The fragile dialogue: communication barriers, authority and adaptive strategies in NICU parent-healthcare worker relationships.

Introduction: Preterm birth profoundly impacts both the infant's health and the family's psychosocial well-being. In NICUs, communication between professionals and parents unfolds in contexts of high emotional stress, technical complexity and structural power asymmetries. Whilst effective dialogue supports family well-being, some structural and contextual factors in the studied NICUs often prevent it. This study, part of the e-ParWelB project, examines healthcare staff's perspectives on structural barriers, the role of digital technologies, and authority dynamics, especially strategies for managing high-uncertainty communication with preterm parents. Materials and methods: We conducted 76 semi-structured expert interviews with a maximum variation sample of NICU staff across four Italian hospitals. Focused ethnographic observations complemented interviews. Data were analysed using a concept-driven coding strategy in NVivo 15. Results: Barriers extend beyond language and ethnicity, including vertical (educational) and horizontal (disciplinary) gaps. Digital technologies increase parental assertiveness but also fuel misunderstandings, anxiety and mistrust. Parents' peer group chats offer support but can amplify stress and conflict. Clinicians respond with varied, individualised strategies, especially pedagogical explanations and emotional support. In a landscape where their authority requires continual negotiation, they struggle to preserve their professional legitimacy whilst providing the best possible care for newborns and cultivating relationships with parents. Discussion: NICU communication is shaped by structural inequality, shifting authority and digital mediation. Healthcare staff broadly agree on an increased emphasis on relationships with parents compared to the past. Nonetheless, implicit and explicit challenges to professional authority often manifest in expectations that parents legitimise their involvement by demonstrating commitment through constant presence in the NICU and compliance with staff directives. Enhancing relational competence, embedding cultural mediation and institutionalising collaboration with parent associations could help reframe these dynamics into trust-based and inclusive forms of care, to the benefit of both families and healthcare workers.