Understanding parenting occupations in
Critical review
neonatal intensive care: application of the
Person-Environment-Occupation Model
Deanna Gibbs,1 Kobie Boshoff 2 and Alison Lane 3
Key words:
Neonatology, parenting,
occupation.
1 Bartsand the London NHS Trust, London.
2 University of South Australia, Adelaide,
Australia.
3 The Ohio State University, Columbus, Ohio,
United States.
Corresponding author: Deanna Gibbs,
Research Consultant – Nursing, Midwifery
and AHP, Healthcare Governance,
Barts and the London NHS Trust, 4th Floor,
John Harrison House, Royal London Hospital,
London E11BB.
Email: Deanna.Gibbs@bartsandthelondon.nhs.uk
Reference: Gibbs D, Boshoff K, Lane A (2010)
Understanding parenting occupations in
neonatal intensive care: application of the
Person-Environment-Occupation Model.
British Journal of Occupational Therapy,
73(2), 55-63.
DOI: 10.4276/030802210X12658062793762
© The College of Occupational Therapists Ltd.
Submitted: 3 December 2008.
Accepted: 15 September 2009.
Downloaded from bjo.sagepub.com at UNIVERSITE LAVAL on May 4, 2016
The adoption of family-centred care principles within neonatal intensive care,
including support for the development of the parental role, has been increasing
in profile over the past decade. During this period, occupational therapy has also
had an emerging role in the provision of services within neonatal intensive care.
However, there has been limited exploration of the concept of parenting as an
occupation as a means of supporting parental role development within the neonatal
intensive care unit (NICU). In accordance with the philosophy of family-centred
care, opportunities exist to determine how the occupational efforts of parents
and preterm infants can best be supported.
This paper provides a review of the current literature and its application to the
Person-Environment-Occupation (PEO) Model as a framework for illuminating the
acquisition of parenting occupations in the NICU. Illustration is provided of how
the application of the PEO Model can be used to direct occupational therapy
practice to incorporate a focus on family-centred care and the development of an
occupation-based approach through which practice can be enhanced, ensuring
that both the infant’s and the family’s needs are recognised and addressed.
Introduction
Increasing survival rates for infants born preterm and recognition of the
importance of parent-infant attachment in this vulnerable client group has
resulted in a growing profile of the benefits of adopting family-centred
care principles in the neonatal intensive care unit (NICU). However, a
range of barriers continues to have an impact on the uptake of family-centred
care in this highly complex setting. The aim of this literature review was
to consider this ongoing issue from an occupational performance
perspective, through a description of the application of the Person-
Environment-Occupation (PEO) Model (Law et al 1996) to support the
provision of family-centred care in the NICU. A significant amount of
neonatal intensive care research and practice literature is focused on the
viability and survival of the premature infant and on decreasing the
potential for neurodevelopmental sequelae. This paper considers the
issues surrounding the admission of an infant to an NICU from a new
occupation-based context and seeks to promote improved understanding of
parental involvement in neonatal intensive care through the consideration
of parenting occupations.
Background context
Occupational therapy services in NICU
Occupational therapy has had an emerging role in service provision to
premature infants and their families for over 10 years (American Occupational
Therapy Association [AOTA] 1993, Gorga 1994, Vergara et al 2006). However,
British Journal of Occupational Therapy February 2010 73(2) 55
Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model
the specific role attributes of occupational therapists working
within NICUs often differ between facilities and also differ
between countries. These geographical and facility-based
inconsistencies in service delivery make this an area of
practice within which the occupational therapy role and
unique contributions are difficult to articulate to other
professions in this highly complex setting.
Over the past decade, occupational therapy services
within NICUs in the United States and parts of the United
Kingdom have become increasingly established, with
clearly defined roles and competencies forming part of the
professional literature (Vergara et al 2006). The specific
occupational therapy role attributes within NICUs vary, but
service provision may include:
■ Guidance on positioning of infants to support neuro-
behavioural regulation (for example, habituation to
external stimuli, motor responses and consolidation of
and transition between sleep/wake states) and prevent
postural sequelae. Supportive positioning helps to
promote infants’ self-regulation of their autonomic and
motor systems and reduces the risk of muscle imbalance
leading to, for example, shoulder retraction and hip
external rotation.
■ Assessment and guidance regarding the infant’s neuro-
behavioural state – this includes key working with parents
in understanding their infant’s neurobehavioural cues
and preparing parents for interaction with their infant
■ Early identification and implementation of supportive
practice and /or intervention for infants identified as
at risk of significant neurodevelopmental sequelae (for
example, intraventricular haemorrhage and periven-
tricular leukomalacia, which may lead to motor, sensory
and cognitive dysfunction)
■ Assessment and support of feeding development (within
North America)
■ Follow-up assessment and /or intervention for infants
born below 1000 grams birth weight, before 29 weeks’
gestation or the presence of other risk factors for neuro-
developmental sequelae.
The type and frequency of services provided is often dependent
on the multidisciplinary team structure within individual
NICUs and on historical role delineation for individual
professions within the team.
During this period, there has also been ongoing discus-
sion in the literature regarding the skills and competencies
required by therapists working in this area (AOTA 1993,
Hyde and Jonkey 1994, Dewire et al 1996, Hunter 1996,
Gorga et al 2000, Vergara et al 2006), resulting in the
publication of position papers detailing the knowledge and
skills requirements for occupational therapists in neonatal
intensive care (Vergara et al 2006). For occupational therapists
providing services in an NICU, this suggests the need to
establish a balance between acquiring detailed knowledge
and skills regarding specific assessment and intervention
practices, gaining an understanding of neonatal health
issues and their required management, and consideration
of the underlying occupational issues for these infants and
56 British Journal of Occupational Therapy February 2010 73(2)
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their families. This period has also seen an increasing
focus on understanding the implications for parents of
preterm infants during the intensive care admission
(Lawhon 2002, Browne 2003, Gavey 2007, Howland 2007,
Thomas 2008), which has served to give more prominence
to the consideration of parental role and support require-
ments. Therefore, in addition to knowledge of application
and theory regarding infant neurodevelopment, there is
also an opportunity to consider occupational performance
as a means of identifying how both parents’ and infants’
occupational efforts can be supported.
To date, there has been limited exploration of the concept
of parenting as an occupation as a means of supporting
parental role development within the NICU. Although the
birth of a preterm infant that requires admission to an NICU
represents a major crisis for parents that may influence the
acquisition of their parental role and engagement in parent-
ing occupations, only one study from within the field of
occupational therapy has specifically investigated parental
stress within the NICU and the potential influence on
parent and infant characteristics (Dudek-Shriber 2004).
With the study results indicating that the most stressful
aspect of having an infant in an NICU is related to altered
parental role and relationship with their infant, recommen-
dations were made for an ongoing focus of the occupational
therapy profession in facilitating a positive parent-infant
relationship and providing intervention that focuses on
supporting the parents’ occupational role (Dudek-Shriber
2004). Although this research highlights the contribution
that supporting parental occupational role performance may
have in reducing stress, and facilitating engagement in
their infant’s care, there is still limited understanding and
research on how the concept of occupation may be used to
explore and understand parental experiences in the NICU
and what implications this may have for occupational
therapy practice in this setting.
Family-centred care
In recognition of the importance of parent-infant attachment,
there has been increasing advocacy for the adoption of
principles of family-centred care in the NICU environment
(Harrison 1993, McGrath and Conliffe-Torres 1996, Sweeney
1997, Hurst 2001, Moore et al 2003). Many neonatal units
have adopted a family-centred approach to caregiving, in
which promotion of the parent-infant relationship and family
involvement in the infant’s care are of central importance
(Franck and Spencer 2003). Johnson et al (1992) have defined
family-centred care as a philosophy of care, which:
■ Recognises and respects the crucial role of the family
in relation to the infant’s care
■ Supports families by building on their strengths and
encouraging them to make the best choices
■ Promotes normal patterns of living during a child’s
illness and recovery.
The philosophy of family-centred care provides a contextual
base to the increasing focus within the NICU on supporting
the acquisition of parental occupations.

To facilitate the implementation of family-centred
care within the NICU, a number of principles have been
identified (Harrison 1993, Hurst 2001). First, family-centred
care promotes the encouragement of families to participate
as fully as possible in caring for and making decisions
about their hospitalised infants. Second, it ensures respect
for the diversity of families and their values and beliefs.
This aims to facilitate the development of supportive care
partnerships in the NICU and beyond (Hurst 2001,
Malusky 2005, Griffin 2006).
Despite the adoption of care philosophies that recommend
the use of family-centred care within the NICU, however,
there are still barriers that limit its uptake. Peterson et al
(2004), in a survey of nurses working in NICUs and pae-
diatric intensive care units (PICUs), identified a discrepancy
between the elements of family-centred care that have
been acknowledged as essential and the reality of what is
executed in practice. The respondents to this survey
employed in PICUs rated the importance and implemen-
tation of elements of family-centred care more highly than
those working in NICUs. However, it was also acknowl-
edged that this response is influenced by the realisation
that infants are typically admitted to an NICU shortly
after birth and there is a perception that there is,
therefore, limited time for them to be integrated into the
family structure (Peterson et al 2004). Further, the study
recognised that the amount of time that NICU nurses
spend with these fragile infants and the relationships that
develop over prolonged lengths of hospitalisation may
pose a conflict to the implementation of family-centred
care (Peterson et al 2004).
Qualitative studies that have explored parental percep-
tions of NICU have also served to identify the inconsistencies
in the adoption of family-centred care practices. Cescuti-
Butler and Galvin (2003), in a grounded theory study,
determined that parents felt that they had failed to integrate
into the NICU during their infant’s admission. They were
conscious of an implied burden on staff, identifying feel-
ings of not belonging in the unit and being especially
careful of staff and staff routines (Cescuti-Butler and Galvin
2003). Sweeney (1997), in a personal reflection on an NICU
and PICU experience, identified factors through which the
presence or absence of a family-centred care approach had
a significant impact on the family experience. Issues such
as involvement in decision making, the provision of infor-
mation to orient families to new environments, experiences
or available supports, the necessity of a two-way information
exchange, consistency of caregiving (both caregivers and care
plans) and basic courtesy were experienced as either enabling
or constraining, based on the attitudes and actions of the
health professionals involved (Sweeney 1997).
There has been significant research on and industry
acknowledgement of the barriers to the implementation
of family-centred care, and subsequently the support of
the acquisition of the parental role. However, it remains
a multifaceted problem that needs to be addressed in order
to ensure greater consistency in the implementation of
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Deanna Gibbs, Kobie Boshoff and Alison Lane
family-centred care principles in the provision of neonatal
care. While the barriers to family-centred care provision
exist, it remains difficult for all NICU-based staff to support
parents adequately in the acquisition of the role of parent-
ing. Consideration of this issue through a means that allows
the multifactorial components to be considered in relation
to each other is required given the complexity of the factors,
which may constrain or enable the provision of family-centred
care. Occupational therapists, with their understanding of
core philosophies regarding occupational performance, are
in a key position to explore these multifactorial barriers
and consider how parental occupational performance can
be maximised within this setting.
Understanding parenting
occupations: the Person-
Environment-Occupation
(PEO) Model
The consideration of parenting as an occupational role
acquired by the parents of preterm infants within an NICU
provides a context for exploring the complexities of the
implementation of family-centred care in this environment.
Occupation is a core domain for the occupational therapy
profession. As a result, a number of theoretical paradigms
and frames of reference are in use within the profession to
delineate the complex processes that exist between individuals,
their roles and occupations, and the environments in which
they take place. The Person-Environment-Occupation (PEO)
Model (Law et al 1996) was developed as a framework
within which to examine person-environment processes in
the context of occupational therapy practice.
The PEO Model has been used as a tool to examine
complex occupational performance issues in hospital,
community, academic and research settings (Strong et al
1999). Because of the significant impact that the physical
and social NICU environment has had on the provision
of family-centred care, the PEO Model was selected for
use to explore parental occupational performance in this
environment. Strong et al (1999) described the PEO Model
as providing therapists with a practical, analytical tool to
assist in the analysis of problems in occupational perfor-
mance, to guide intervention planning and evaluation and
to communicate clearly occupational therapy practice.
The PEO Model (Law et al 1996) considers human
functioning and learning as a product of complex person,
environment and occupation interactions. The model is
conceptualised as the person and his or her environments
and occupations interacting dynamically over time (Fig. 1,
Law et al 1996). Law et al (1996) defined occupations as
clusters of activities in which individuals engage in order
to meet their intrinsic needs for self-maintenance,
expression and fulfilment. Occupations are then carried
out within the context of individual roles and capacities,
and multiple environments (Law et al 1996). Occupational
British Journal of Occupational Therapy February 2010 73(2) 57
Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model

Fig. 1. Person-Environment-Occupation (PEO) Model.* when considering the parents of

preterm infants experiencing care
in an NICU. Person in this context
may relate to both the infant and
the family caregivers, which can
include the mother and father of
the preterm infant, both individ-
ually and as a dyad, in addition
to wider extended family contexts
(for example, the involvement of
siblings or grandparents).
In general terms, preterm
infants have limited capabilities
to tolerate stressful or overstimu-
lating environments and they
typically respond in a disorganised
manner (McGrath and Conliffe-
Torres 1996). In infancy, Whitfield
(2003) described preterm infants
as being generally more difficult
to settle, more irritable, and
having less predictable sleep
patterns and poorer emotional
regulation. They have difficulty
*Source: Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L (1996) The Person-Environment-Occupation in focusing attention selectively
Model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), and are less likely to orient to or
9-23. Reprinted with kind permission of CAOT Publications ACE. spend time exploring novel
stimuli, habituate less efficiently
to visual stimuli, and encode
performance is the outcome of the transaction between the information less efficiently when compared with term-born
person, the environment and the occupation. The extent infants (Whitfield 2003). Therefore, the NICU experience
of the congruence of this transaction is represented by the may be a significant factor disrupting the development of
degree of overlap between the three spheres of the model the infant’s ability to self-regulate his or her autonomic, motor
(Strong et al 1999). and state systems. For example, preterm infants may exhibit
The PEO Model can therefore provide a framework physiological disorganisation (for example, colour change,
within which to consider the acquisition of parenting increased respiratory effort, poor temperature regulation and
occupations in the NICU by understanding the person- disturbed visceral and digestive functioning), difficulties
environment congruence (Law et al 1996). There are a with sustaining relaxed tone and posture, and difficulties
number of interrelated barriers identified in the literature in habituating to their environment (Brazelton and Nugent
that can influence the uptake of family-centred care within 1995). The disruption of self-regulation may result in
the NICU. From these it can be determined that varying subsequent difficulties for parents when trying to establish
factors within an NICU admission may have a constraining opportunities for engaging with their infant.
effect on occupational performance, resulting instead in a Previous studies have also indicated that an infant’s
person-environment incongruence. admission to an NICU can be a period of intense stress for
parents arising from the premature birth and medical
sequelae. Hughes et al (1994), in a phenomenological study,
Occupational analysis of identified common stressors for parents of preterm infants,
including infant appearance, health and course of hospital-
parenting occupations isation, separation from their infant and not feeling like a
From a review of the literature that has explored the uptake of parent, and communication with staff. A qualitative study
family-centred care in NICU, it is apparent that the issues iden- by Wereszczak et al (1997) enabled further identification that
tified within the current body of knowledge can be attributed stress experienced by parents during an NICU admission is
to either a person, environment or occupation factor. attributed to varying sources. These included environmental
stressors such as the infant’s appearance and behaviour,
Person staff behaviour and communication, the sights and sounds
The grounding of the PEO Model in the tenets of client- of the environment and alteration in parental role. Situational
centred care (Strong et al 1999) supports its applicability stressors such as uncertainty, the perception of severity of

58 British Journal of Occupational Therapy February 2010 73(2)

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their infant’s illness and prenatal events also contributed
to parent-identified stress within the NICU.
Dudek-Shriber (2004), in a quantitative study using a
parental self-report instrument with 162 parents, confirmed
that the stress experienced by parents during their infant’s
NICU admission may often be diffuse, with a range of factors
contributing to it. However, the results also indicated that
the subscale in which they reported the greatest stress was
related to an altered parental role and relationship with
their baby. In addition, the degree of stress experienced
by parents needs to be considered. For some parents, their
response in the NICU situation has been aligned with post-
traumatic stress reactions (Holditch-Davis et al 2003).
Contributing to experiences of parental stress are the limita-
tions to the development of situational control, with parents
wanting and needing to be given opportunities to experience
a sense of ownership and control within the intensive care
unit in relation to their infant rather than remaining on
the periphery of his or her care (Fenwick et al 2001).
The parents of preterm infants all present with individ-
ualised experiences, which bring them to a common point
of their infant’s admission to an NICU. So, although
guidelines for the implementation of family-centred care
have been developed, they may not take into account the
journey that these individuals have experienced in becoming
the parent of a preterm infant and, therefore, the need for
the implementation of a care model that supports their
individualised needs as parents and a family.
Environment
The PEO Model considers the environment as the context
within which the occupational performance of an individual
takes place. Environmental contexts are not static and can
have an enabling or constraining effect on occupational
performance (Law et al 1996). Therefore, the addition of
an unanticipated technological environment such as the
NICU, in which occupational role development occurs
may have a significant influence on how the occupation of
parenting is acquired and performed. In this context, the
environment may include not only the physical aspects of
the environment, including the design of the unit, lighting
and medical equipment, but also the staff with which parents
may interact as a key component of that environment.
The physical environment of the NICU is a significant
source of stress for preterm infants and their families. The
NICU is a milieu in which infants consistently encounter
overwhelming stimuli, including bright lights, loud noises,
excessive handling by multiple caregivers and intrusive
and uncomfortable treatment interventions (McGrath and
Conliffe-Torres 1996). It involves a barrage of factors for
which the preterm infant is not developmentally prepared.
Factors influencing the infant’s status include illness
severity, noise, light, repetitive pain, exposure to analgesia,
sedation and other drugs, and separation from normal
maternal interaction, including touch, smell, sucking and
voice (Whitfield 2003). Prematurity disrupts the normal
growth and development of the brain and nervous system.
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Deanna Gibbs, Kobie Boshoff and Alison Lane
Beginning shortly after conception and continuing into
childhood, the brain and nervous system experiences a
period of rapid growth and maturation between 25 and
40 weeks’ gestation. For preterm infants, this period of
development coincides with a time when the infant is
likely to be exposed to various environmental stressors
that are developmentally inappropriate and potentially
harmful to the infant’s sensory systems (McGrath and
Conliffe-Torres 1996).
Families also experience the stress of the highly tech-
nological environment. They encounter life-sustaining
equipment, monitors, multiple tubes and intravenous lines,
intrusions by multiple caregivers and an overwhelming
fear of the unknown, which can serve to create physical and
emotional barriers between a preterm infant and his or
her family (McGrath and Conliffe-Torres 1996, Miles and
Holditch-Davis 1997, Byers 2003). These environmental
stressors can prove an immediate barrier in enabling
parents to engage readily with their infants.
Supporting parental involvement and promoting family-
centred care approaches can also be significantly influenced
by the social environment that exists within the NICU,
particularly in consideration of the relationships between
parents and health care providers in the NICU. Fenwick
et al (2001), in their study involving 28 mothers of pre-
term infants, described parent-staff interactions as either
facilitative or inhibitive. Staff that provided facilitative
interaction were perceived by mothers as collaborators in
their infant’s care, who provided enhanced opportunities
for them to be with their infants in a meaningful way,
such as through participation in routine caregiving and
opportunities for holding their infant; however, staff who
were perceived as inhibitive displayed behaviours that
restricted maternal efforts to achieve a sense of physical
closeness with their infants (Fenwick et al 2001). Conflict
between parents and staff can result in a variety of parental
behaviours as they attempt to regain some control over
parenting their infant. These may include vigilance in
watching over their baby, safeguarding him or her from
harm, feelings of disaffection as a result of the communi-
cation with staff, a guarding of communication style and a
fear of reprisals or recrimination if they speak out about
their infant’s care (Lasby et al 1994, Fenwick et al 2001).
These studies have begun to explore and articulate commu-
nication styles that facilitate the development of parent-
infant attachment. However, the strategies and recommen-
dations aimed at increasing facilitative interaction are
reported in generalist terms. The transfer of these recom-
mendations into clear guidelines for practice is not yet
evident (Beveridge et al 2001, Peterson et al 2004).
Although research to date has focused predominantly
on parental perceptions of their communication with staff,
a study has also been conducted which investigated health
care staff’s perceptions of the dyadic relationships that are
formed between staff and parents in the NICU. Walker
(1998), in a survey of 298 neonatal nurses, determined that
90% of respondents did not believe that any of the care
British Journal of Occupational Therapy February 2010 73(2) 59
Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model
practices or policies/procedures of the NICU contributed
to the barriers that confronted parents in the acquisition
of parenting roles and skills. This indicates that there is
potential for limitations in understanding the implications
of staff caregiving practices on parental role acquisition,
since the aforementioned studies have indicated clearly that
such an influence exists from the perspective of parents.
Given that health care staff act as gatekeepers in parents’
access to their infants in the NICU, the development of a
positive collaborative relationship between parents and
staff is important in supporting family-centred care.
Occupation
Occupation is defined as ‘groups of self-directed, functional
tasks and activities in which a person engages over the
lifespan … clusters of activities as tasks in which the person
engages in order to meet his/ her intrinsic needs for self-
maintenance, expression and fulfilment’ (Law et al 1996,
p16). The ability to engage in a cluster of activities that are
identifiable as parenting occupations in the NICU may be
necessarily limited due to the infant’s fragility and the nature
of the highly intensive care support that he or she is receiving.
The contrast between actual and anticipated parenting
experiences is an additional constraining factor to parental
involvement in the care of an infant. The parents of pre-
term infants have lost many of the usual rituals that are
associated with the birth of a new baby, such as leaving
hospital with the baby and receiving congratulations on
the baby’s birth. Lasby et al (1994) identified that the loss
of these expected maternal events make it difficult to gain
acknowledgement of motherhood, which creates difficulty
in the establishment of meaningful moments between
parent and infant. Findlay (1997), in her discussion of
the adaptation process experienced by parents of preterm
infants, includes descriptions of parental experience of
pregnancies ending prematurely and the commencement of
a process of adjusting to unanticipated situations. Parents of
preterm infants are subsequently required to develop their
parenting skills in the very public domain of the NICU. This,
in itself, may be problematic due to the acknowledged
barriers that exist to parenting in the NICU, such as the
physical environment, the mismatch between parents and
their infant in terms of readiness for interaction, the
inability to provide all of their infant’s caregiving, and
the support of staff regarding parental competence in
caregiving (Gale and Franck 1998).
Miles and Holditch-Davis (1997), in their development
of a conceptual framework relating to the needs of parents
in an NICU, identified that the loss of the anticipated
parental or caregiving role can leave parents with feelings
of helplessness, struggling for opportunities in which to
exert their parental role. This framework was confirmed
in a subsequent study, in which 25 of 31 mothers who
participated in the study reported that their loss of the
anticipated role contributed to difficulties in developing
positions as advocates and decision makers on behalf of
their children (Holditch-Davis and Miles 2000).
60 British Journal of Occupational Therapy February 2010 73(2)
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Christiansen (1999) supported the facilitatory influence
of occupation on the person, with the suggestion that the
performance of occupations is a means of creating and
maintaining identities. This, therefore, is an important
component to consider in relation to parenting within an
NICU. Difficulties exist for parents attempting to consolidate
their self-identity, resulting from limitations in access to
their infant and the restrictions that they encounter in
engaging in activities that they anticipated and identified
as being a parent. Christiansen (1999) introduced the
concept of ‘possible selves’. Possible selves are imagined
views of our future identities and give meaning and
structure to an individual’s thoughts about the future.
This is congruent with parental perceptions of their
NICU experience, where they identify the loss of their
anticipated parenting role (Wereszczak et al 1997); that is,
activities such as feeding, bathing and dressing their
infant that they identified throughout their pregnancy,
which supported their imagined identity of being a parent,
were not available to them. Hammell (2004) suggested
that the loss of the ability to participate in occupations
that are important to individuals can erase perceptions of
capability and competence.
Person-environment-occupation
transactions in an NICU:
implications for practice
In considering the rich information currently available
that delineates the person, environment and occupation
aspects of the NICU experience for preterm infants and
their families, the PEO Model can be used to consider
how the development of occupational performance can
be facilitated. By exploring the transactions that may
occur between each aspect of the model, focusing on the
person-occupation, occupation-environment and person-
environment relationships (Strong et al 1999), it may be
possible for occupational therapists to identify strategies
that could serve to overcome the barriers and support
optimal occupational performance when working with
individual families.
Occupational therapy as a profession is concerned with
assisting individuals to participate in the chosen occupations
that are necessary for health, development and quality of
life (Parham and Primeau 1997). In the critical care
context of an NICU, this perspective can be diminished in
importance owing to the primary focus on components of
infant functioning and survival. Opportunities exist to
determine how both the infants’ and parents’ occupational
efforts can be enabled and supported (Holloway 1998).
The areas of PEO transactions would serve as a starting
point for exploring how parental occupational performance
within the NICU context may be enabled.
The application of the PEO Model in relation to the
context of parenting in the NICU is illustrated in Fig. 2.
 Deanna Gibbs, Kobie Boshoff and Alison Lane

Fig. 2. Analysis of the potential person-environment-occupation transactions in NICU.* can be a significant barrier to
occupational engagement. When
planning care, consideration
also needs to be given to:
■ The availability of opportuni-
ties for parents to be engaged
in caregiving activities
■ Parents’ fear about being
involved in the care of their
infant and not wishing to
harm their baby
■ Parents’ previous experience
and confidence in the perfor-
mance of caregiving activities,
such as bathing and feeding,
and how these can be best
enabled.

NICU = neonatal intensive care unit.
*Source: Adapted from: Strong S, Rigby P, Stewart D, Law M, Letts L, Cooper B (1999) Application of
the Person-Environment-Occupation Model: a practical tool. Canadian Journal of Occupational Therapy,
66(3), 122-33. Adapted and reprinted with kind permission from CAOT Publications ACE.
Occupation-environment transactions
Within the NICU, occupation-environment transactions are
clearly evident. As a result of the intensive medical support
required by the infant, occupational engagement will be
limited by the physical barriers of medical equipment in
the unit, such as the infant being ventilated or nursed in
an incubator. As outlined earlier, the social environment
of the NICU may also have an impact on the fluency of
occupation-environment transactions.
Person-environment transactions
Person-environment transactions can also be present.
These can include the local visiting hours and regulations
for the unit that may inhibit parents’ participation in care-
giving activities. Owing to the tertiary nature of NICUs,
many infants are admitted to units that are geographically
distant to their parents’ home, making regular visiting
difficult. Within the social environment, consideration
needs to be given to the support provided by NICU staff
for parents to assume a caregiving role for their infants.
This includes the communication style undertaken by
health care providers and whether this is perceived by
parents as facilitative or inhibitive.
Person-occupation transactions
Within the person-occupation transactional area, the manage-
ment of the infant’s fragile medical status during caregiving
Supporting parental
occupational adaptation
Within each of the elements of
person, environment and occupa-
tion, barriers exist that are diffi-
cult to remediate. For example,
depending on the structure and
operational functioning of an
NICU, the moderation of some
environment factors, such as
unit design and lighting policies,
may be limited. However, bedside
factors, such as the management of incubator covers, alarms
and voice level, are able to be moderated through collaborative
staff efforts. Similarly, the types of medical and technological
intervention required to support the infant are beyond the
control of the occupational therapist. However, what can
be considered is how best to support parents’ occupational
adaptation to this environment. Providing an intervention
approach that includes consistent and understandable
explanations regarding equipment function, clearly identifying
and making available opportunities for parents to participate
in safe but meaningful contact with their infants, and
equipping parents to interpret their infants’ state regulation
in relation to timeliness of interaction can all have a positive
effect on the person-environment transaction and, ultimately,
the parents’ occupational role development.
The development of evidence-based neonatal care
approaches, such as the Newborn Individualised Develop-
mental Care and Assessment Programme (NIDCAP) (Lawhon
2002, Als 2008), has been key in supporting multidiscipli-
nary NICU-based staff in the provision of a highly individ-
ualised developmentally supportive care approach for
preterm infants. The aim of individualised developmentally
supportive care models, such as NIDCAP, is to alter the
focus of neonatal care from the traditional task-oriented or
procedure-oriented approach to a focus on processes and
relationships, including the increased involvement of
families (Westrup 2007). The NIDCAP approach is based

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Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model
on the premise that infants’ own behaviour provides the
necessary information in order to determine their current
capabilities. It is a comprehensive programme, involving
structured behavioural observation of the infant and the
provision of individualised caregiving support of the infant’s
developmental goals (VandenBerg 2007). The ongoing
process of NIDCAP supports continual adjustment of the
environment and caregiving practices in light of the infant’s
and parents’ developmental needs (VandenBerg 2007).
NICUs that have adopted a NIDCAP approach are more
able not only to be truly responsive to the needs of infants
with a resulting impact on developmental outcome but also
to centralise the role of an infant’s family and address the
PEO transactions inherent in the NICU admission. Successful
implementation of individualised developmental care requires
the full commitment of NICU staff at all levels and provides
a significant shift in how health services address the needs of
this client group (VandenBerg 2007, Westrup 2007). However,
like family-centred care, the uptake of NIDCAP and other
developmental care approaches has remained inconsistent.
The PEO Model provides a structure through which an
understanding of how each infant and his or her family
accommodates to the NICU experience can be achieved
and, more specifically, can be used to direct occupational
therapy practice in focusing on family-centred care and
the development of occupational performance. Therefore,
although the types of occupational therapy intervention
outlined at the beginning of this paper are a key element of
neonatal service provision, the use of an occupation-based
approach can provide a means through which practice can
be enhanced by ensuring that both the infant’s and the
family’s needs are recognised and addressed.
Conclusion
The consideration of parenting as an occupational role for
the parents of preterm infants within an NICU would appear
to allow the emergence of an understanding of the person-
environment influences on occupational performance. By
improving understanding of the parental occupations in
the NICU, the provision of facilitatory or enabling service
frameworks may be considered. As outlined, the PEO Model
may therefore provide a new and systematic means of
addressing an ongoing issue in the care of preterm infants
and their families. Through the use of this approach,
occupational therapists working within NICU environments
have the potential both to support significantly the use of
family-centred care approaches and to promote occupational
adaptation with the parents of preterm infants.
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■ The PEO Model provides a structure for considering parenting
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