This project sought to communicate messages about early parent-child relationships and child development by transforming the organizational culture of maternity and pediatric units at a large, urban, teaching hospital. We employed Schein's theory of organizational culture (11), which has been widely used within healthcare organizations to catalyze cultural change (12–14). This theory posits that organizational culture exists on three levels. The first, the most visible, consists of physical artifacts, or the observable aspects of culture. These reflect the second level, which consists of values and beliefs, at least as articulated by individuals. These, in turn, are informed by basic underlying assumptions, the third level of organizational culture. These are the widely accepted beliefs about human nature and reality that may be unconscious and/or unstated.

Change that is not rooted in culture can often be transient. Schein suggests that every culture has strengths that can be drawn upon and reframed to be supportive of the desired change. In this way, new behaviors and values can be tied to existing assumptions and values, given legitimacy, and made more acceptable and less threatening. Over time, these new behaviors are tried, and if people recognize that they work well to bring about desired results, new assumptions arise to articulate the cultural lessons learned.

The Environmental Transformation Project was designed to change parents' and children's experiences of health care by targeting all three levels of the organizational culture surrounding caregivers and children aged 0–5 at our hospital. Consequently, the project entailed not only transforming the physical environment but also the values and assumptions held by all staff who interact in any way with caregivers of children in that age group. Physicians themselves were targeted in a separate, more intensive medical education curriculum initiative focusing on well child care. The underlying goal was to ensure that the messages being shared with patients through visible artifacts were reinforced through patients' interactions with all types of hospital staff. We now describe how that goal was achieved.

Figure 1 depicts the three stages of project development. In the first step, a multidisciplinary team identified “touchpoints” throughout six units within the hospital for transformation: the Prenatal Clinic, Labor and Delivery, Postpartum Units, Neonatal Intensive Care, Pediatric Primary Care Clinic, and Pediatric Emergency Department. The Pediatric Inpatient Unit was not included because it does not specifically target young children. This involved, first, identifying all hospital staff who engage with infants and children up to age 5 and their parents. Staff represented food services, housekeeping, transport, and security, in addition to traditional non-physician clinical roles such as nurses, lactation consultants, and medical assistants. Second, the team identified the physical locations, such as elevator banks, front desks, mirrors, and hand sanitizers, which were most visible to families.

In the second step, the team created staff- and family-facing messages in English and Spanish to promote SSNRs and child development. These messages were intended to serve as prompts for interactions between caregivers and children and between staff members and caregivers. Unit staff and families from the hospital's Patient Advisory Committee reviewed the content for relevance and tone. Staff focus groups explored the feasibility and ease of integrating these messages into healthcare interactions, while family focus groups provided feedback on messages' content, inclusivity, and relatedness.

An expert design team created over 100 images to support the approved messages. A multidisciplinary panel then reviewed the final illustrated messages. They all shared a similar format. They each begin with “Did you know?” and then offer a piece of information about how children develop, followed by “Have you tried?” and a specific activity to encourage engagement between caregivers and children, followed by “It's science!” and a brief scientific explanation about why the activity is important. Messages focused on themes such as the rapid development of a young child's brain, the importance of everyday interactions with caregivers, and how professionals in all roles can support positive parenting by modeling, discussing, and praising (Figure 2). All messages were framed in a strengths-based fashion (i.e., building on families' existing competencies), which reflected the foundational values of respect and dignity, information-sharing, and participation in family-centered care (15). Whenever possible, messages were tied into the surrounding environment, e.g., meals served to postpartum mothers were set on a paper placemat messaging the importance of mealtimes as opportunities for caregivers to discuss family traditions with children.

The third step of the intervention was the creation and delivery of staff training forums. Shortly after the messages were installed, staff in the six selected units were invited to participate in a 45-minute training designed to teach any staff member, clinical or not, who interacts with caregivers and children how they can use existing opportunities in their workflow to promote SSNRs and early child development. A 10-minute introductory video explained early brain development and described specific parenting behaviors that support healthy child development. Following the video, facilitators encouraged staff to identify the ways they could apply these concepts to their specific role in the hospital. At the conclusion of the session, each participant identified a specific moment in their work (e.g., greeting families, making beds, delivering meals) when they could share messaging from the project, and committed to one action they would take in the future. Locke and Latham's (16) goal setting theory of motivation suggests that the formulation of this specific and clear intention may be linked to enhanced performance in practice. Two weeks after the training, an e-learning module was sent to staff to reinforce the training. In addition, monthly newsletters and frequent unit visits from project staff were also conducted to maintain engagement and awareness.

We conducted an evaluation to examine whether the environmental messaging and staff training shifted staff's self-reported knowledge, attitudes, and behaviors in the healthcare setting. Data collection first occurred between June 2019 through September 2020. There was a pause from March to August 2020 due to the COVID-19 pandemic, and data collection resumed in September 2020. The authors' Institutional Review Board deemed the study exempt.

The pre-intervention survey was completed by 356 staff across the six units, and the post-intervention survey was completed by 320 staff across the six units. There were no differences in terms of role and unit between the pre- and post-intervention survey respondents, with the exception of the Labor and Deliver unit, where the proportion of respondents who were nurses was higher in the post-intervention sample (see Appendix A for roles of participants).

Results showed that compared to before the intervention, after the intervention, staff scored statistically significantly higher on all attitude questions, and on four out of the five knowledge questions (Table 1). Staff were also statistically significantly more likely after the intervention than before to engage in all behaviors that promote early learning during interactions with caregivers (Table 2). They were also statistically significantly more likely to communicate all messages that promote early learning to caregivers.

Further, after the intervention, staff were more confident than before in their ability to engage in behaviors that promote SSNRs and early child development; more likely to believe that it was part of their role to routinely do so; and more likely to consider doing so feasible (Table 3). This was true of all three behaviors: praising caregivers, demonstrating positive adult-child interactions, and sharing information or messages. Further, 95% of staff reported that they were successful in making the change in practice they had resolved to make at the end of their training (not shown).

We asked participants in the post-intervention survey to reflect on the impact of the project both on their perception of their role and on the hospital environment. Most staff (89%) agreed or strongly agreed that as a result of the project, they were more patient- and family-centered in their interactions (not shown); most (88%) agreed or strongly agreed that they felt more empowered in their work; and most (89%) agreed or strongly agreed that the hospital environment had become a friendlier place for parents and families.