Parental stress and nurse-parent support in the neonatal intensive care unit: a cross-sectional study (2024)

Background

Admission of a preterm infant to the Neonatal Intensive Care Unit (NICU) is highly stressful for parents. NICU nurses play a crucial role in providing support, positively impacting health and aiding effective stress management during this challenging period. This study assesses stress and nurse-parent support for parents with preterm infants in the NICU, exploring connections between stress, support, and various parental and infant variables.

Methods

This descriptive cross-sectional study was conducted between January and July 2019 on a total of 150 parents (75 mothers and 75 fathers) with preterm infants in a private hospital’s NICU in Ankara, Turkey. Data were collected using the Parent and Infant Information Form, Parental Stressor Scale: NICU (PSS: NICU), and Nurse-Parent Support Tool (NPST).

Results

There was no significant correlation between PSS: NICU and NPST scores (p > 0.05). However, a significant difference was observed in the overall NPST score (p = 0.036) and its emotional support subscale (p = 0.013). Mothers’ PSS: NICU was influenced by infant information (p = 0.027) and marital duration ((p = 0.002), while fathers’ was influenced by number of children (p = 0.040) and infant care participation (p = 0.001). NPST was affected by number of children (p = 0.004) and infant respiratory status (p = 0.011) for mothers and number of children for fathers (p = 0.038). Since parents require informational, emotional, and care-related support, nurses should continuously enhance their professional and communication skills to establish effective communication with parents and provide targeted support.

Conclusion

This study found mothers received greater nurse support than fathers. Mothers with one child had higher nurse support, while mechanical ventilation for mothers and having more than one child for fathers were linked to reduced support. Lower stress levels were noted in mothers married for 6–10 years, those informed about the infant, and fathers actively participating in infant care with more than one child.

Preterm births, occurring before 37 weeks of gestation, pose a global health concern. According to the Global Action Report on Preterm Birth, approximately 13.4million infants were born preterm in 2020, with national rates ranging from 4 to 16.2%. Complications from preterm births contribute to 20% of under-5 deaths, making it a leading cause. Remarkably, 75% of these deaths could be prevented with cost-effective interventions [1]. Turkey’s preterm birth rate of 15% emphasizes its significant global impact [2].

Admitting a premature infant to the neonatal intensive care unit (NICU) poses a significant challenge for parents, given the unexpected and uncertain nature of their infant’s health. Parental stress stems from multiple sources, including the premature birth itself, the unfamiliar NICU environment, complex medical equipment, changes in parental roles, lack of information, and poor communication. This emotional upheaval triggers various parental responses, from shock and frustration to occasional anger upon NICU admission. Importantly, factors like separation from infants, the inability to partake in crucial activities like breastfeeding and touching, and an overarching fear of losing their infants intensify parental stress [3,4,5,6]. Hendy et al. (2024) found that the majority of parents experienced high levels of stress related to sight and sound (80.3%), the appearance of their infants (69%), and the parent-infant relationship (81.4%). Additionally, the study reported that approximately three-quarters of parents (73.6%) experienced overall high stress, with an average score of 167.56 (21.3) [7]. In their study evaluating stress among parents of newborns admitted to the neonatal intensive care unit, Ganguly et al. (2020) reported that parents experienced extremely high levels of stress (mean ± sd: 3.71 ± 0.70), with the greatest stress observed in the areas of sight and sound (3.23 ± 0.41), and in the relationship with the infant and parental role (2.46 ± 0.30) [8]. Çekin and Turan (2018) also reported that parents of premature infants experienced high levels of stress in their study involving 101 parents in the NICU of a university hospital [9]. In the study by Adama et al. (2022), which examined the support needs of parents in the neonatal intensive care unit, it was reported that parents expressed the need for information regarding their infant’s health status, care, treatment, and post-discharge processes. They emphasized the importance of continuity of care, the need for NICU staff to demonstrate empathy, active participation in their infant’s care, ensuring comfort for their baby, receiving support in utilizing coping mechanisms, and having their opinions and perspectives respected [10]. Effectively managing stress and anxiety requires substantial support from healthcare providers, involving guidance through the complexities of care, active involvement in infant care, and fulfilling parental roles. In NICUs, nurses play a pivotal role in caring for preterm infants and supporting their families. Adopting a family-centered approach, NICU nurses are essential in the comprehensive assessment and care of infants, spanning from birth through post-discharge. This approach involves meeting the informational needs of parents, providing multifaceted support across physical, emotional, and social dimensions, and offering counseling services to alleviate heightened stress levels. NICU nurses’ critical responsibility places them in a uniquely significant role within the healthcare continuum [3, 6, 9].

While existing research has primarily concentrated on maternal stress within NICUs, fathers’ experiences and needs have been relatively overlooked [11,12,13]. This study seeks to bridge this gap by comprehensively examining stress levels and nurse-parent support experiences among both mothers and fathers of preterm infants within the NICU. The research aims to uncover nuanced correlations between stress, nurse-parent support, and various parent and infant-centric variables, including age, educational attainment, duration of marriage, number of living children, gestational age, respiratory and nutritional status of infants, information disclosure to parents, participation in infant care, and the timing of the first visit to the infant. By exploring the experiences of both parents, this research aims to pinpoint factors influencing stress levels, providing healthcare practitioners, especially NICU nurses, with specific insights to deliver effective support. Additionally, it seeks to contribute to the improvement of nursing care practices and ultimately promote the holistic well-being of parents and their premature infants within the complex boundaries of the NICU environment.

Study design and participants

This descriptive cross-sectional study was conducted in the Neonatal Intensive Care Unit (NICU) of a private hospital providing tertiary intensive care services in Ankara, Turkey. A private hospital was selected for this study due to its possession of a level 3 NICU, advanced medical facilities, bed capacity, and specialized care for premature infants. Additionally, private hospitals typically have a lower nurse-to-patient ratio, which can influence the level of individualized care and create an ideal setting to explore the dynamics of nurse-parent interactions. The hospital’s resources enabled a comprehensive examination of parental experiences and support systems. At the institution where the study was conducted, an approach that supports parental involvement and parent-infant bonding allows parents to see their infants daily, participate in kangaroo care, and take part in feeding and caregiving. To foster parent-infant bonding at the time of discharge, the family is provided with a room where they can stay with their infant for 24h. This period may be extended or shortened depending on the condition of both the parents and the infant. The unit also provides comfort amenities for parents, such as seating areas, during their infant’s hospital stay.

Preterm infants admitted to the NICU typically range from 23 to 37 weeks of gestation. Common diagnoses include low gestational age, low birth weight, congenital anomalies, respiratory distress syndrome, neonatal jaundice, and infections. Each nurse is responsible for the care of a maximum of three infants.

The research design involved a comparison of two independent sample groups, utilizing a Post Hoc value for detailed research problem analysis. G.Power-3.1.9.2, a robust statistical tool, was used to calculate the required sample size at a 95% confidence level. The minimum sample size, determined with precision for α = 0.05, featured a standardized effect size of 0.5068, signifying a moderate effect. Mean values, with standard deviations, were 11.7 ± 2.7 and 10 ± 3.9 for the respective groups, with a statistical power of 0.8694, according to parameters defined by Cohen (1988) [14]. A total of 150 participants, comprising 75 mothers and 75 fathers, were included in the study. The sample was raised using simple random sampling technique.

The inclusion criteria were carefully established, ensuring a homogeneous study population. Specific conditions included having a baby born before 37 weeks of pregnancy, having only one baby at birth, no surgical procedures undergone by the baby, the absence of congenital anomalies or genetic disorders, no previous preterm infant or NICU experience for the parents, and the baby staying in the NICU for 5 days or more. Data collection took place between January and July 2019, targeting parents meeting these inclusion criteria. Before participating in the data collection process, both mothers and fathers were provided with preliminary information about the study during their visits to the NICU. Parents who expressed a willingness to participate received detailed information about the study in a private room adjacent to the NICU after their baby’s visit. Parents were provided with an information sheet detailing the study’s purpose, procedures, and their right to withdraw at any time. They were given time to ask questions, and written informed consent was obtained from those who agreed to participate. Parents were asked to complete the survey forms. The data were collected under the supervision of the researcher. Filling out the data collection forms took approximately 20min.

Data collection tools

Parent and infant information form

The researchers developed the form based on existing literature [3, 9], comprised 33 inquiries. It covered diverse aspects, including parents’ age, education level, income, employment situation, length of marriage, number of children, NICU visit frequency, information received, participation in care, and the infant’s characteristics (gender, gestational week, birth weight, nutritional and respiratory status, pregnancy type, delivery mode, and hospital stay length).

Parental stressor scale: neonatal intensive care unit (PSS: NICU)

The scale was initially developed by Miles, Funk, and Carlson (1993) [15] to assess parental perception of stressors originating from the physical and psychological environment of the NICU. It was later adapted into Turkish by Turan and Başbakkal (2006) [16]. The 34-item scale consisted of three dimensions: Sights and Sounds (6 items), Infant’s Appearance and Behaviors (17 items), and Parental Role Alteration (11 items). Respondents rated each item on a five-point Likert scale, ranging from 1 (not at all stressful) to 5 (extremely stressful). The scale provides two scores: Metric 1 measures parental stress related to the infant’s NICU stay, while Metric 2 reflects the overall level of stress. Higher scores indicate higher levels of stress. In the original scale, Cronbach’s alpha was 0.94 for Metric 1 and 0.89 for Metric 2. In this study, Cronbach’s alpha for Metric 1 and 2 were 0.96 and 0.96, respectively.

Nurse-parent support tool (NPST)

The tool was originally developed by Miles et al. (1999) to measure parents’ perception of nursing support during their child’s hospitalization [17]. It was later adapted into Turkish by Turan et al. (2016) [18]. The 21-item Nurse-Parent Support Tool (NPST) consisted of four subscales: information giving and communication support (9 items), emotional support (3 items), esteem support (4 items), and quality caregiving support (5 items). Participants rated each item on a five-point Likert scale, ranging from 1 (almost never) to 5 (almost always). Higher scores indicated greater levels of support. In the original scale, Cronbach’s alpha was 0.95, while in our study, its alpha was 0.96.

Data analysis

The statistical analysis was performed using IBM SPSS version 21.0 (IBM Corp. Released 2012, Armonk NY, USA). Descriptive statistics, including mean, standard deviation, frequency, and percentage, were employed. For intergroup comparison, independent sample t-test, Mann Whitney U test, ANOVA, and post hoc Tukey were used. The correlation between the total scores was assessed using Pearson’s correlation coefficient. Multiple linear regression analysis, employing the enter method, was utilized to identify the independent variables predicting PSS: NICU and NPST scores. Statistical significance was set at p < 0.05.

Table1 reveals that 72% of mothers and 64% of fathers were 35 years old or younger. Additionally, 53.3% of parents held bachelor’s and graduate degrees, 57.3% had a marriage duration of 1–5 years, and 53.3% had one child. Further details show that 28% of mothers and 29.3% of fathers first visited their infants after the initial day of birth. In terms of infant care, 44% of mothers and 20% of fathers participated, while 90.7% of mothers and 92% of fathers received information about their infants.

Table2 details characteristics related to pregnancy, birth, and infants, indicating that 66.7% of births were planned pregnancies, 54.7% were female, 42.7% were born between 29 and 32 weeks gestation, and 36% had a birth weight of 1501–2500g. Additionally, 36% were fed normally, 45.3% exhibited normal breathing, and 66.7% were hospitalized for less than 15 days. The average infant age was 12.9 days, with parents spending an average of 32.7min with their child.

Table3 compares PSS: NICU and NPST scores based on parents. No statistically significant difference was found between fathers and mothers for PSS: NICU (p = 0.598) and its subscales (p > 0.05). However, a statistically significant difference existed for the total NPST score (p = 0.036) and its emotional support subscale (p = 0.013).

Table4 compares PSS: NICU scores for mothers based on their characteristics, revealing significant differences for the number of children (p = 0.010), duration of marriage (p = 0.018), first visit to the infant (p = 0.029), and time spent with the infant (p = 0.004). For NPST scores, significant differences were found in variables other than duration of marriage (p = 0.110) gestational week (p = 0.922), nutritional status (p = 0.711), and time spent with the infant (p = 0.062).

Table5 compares PSS: NICU scores for fathers based on their characteristics, showing significant differences for the number of children (p = 0.043), gestational week (p = 0.047), duration of marriage (p = 0.033), time spent with the infant (p = 0.015), and participation in care (p < 0.001). NPST scores also exhibited significant differences based on the number of children (p = 0.041), first visit to the infant (p = 0.010), time spent with the infant (p = 0.020), and participation in care (p = 0.022).

The results of multiple linear regression analysis in Table6 reveal significant factors influencing parents’ PSS: NICU and NPST scores. For mothers, receiving information (p = 0.027) and duration of marriage (p = 0.002) significantly affected PSS: NICU scores, while the number of children (p = 0.004 and infant respiratory status (p = 0.011) were significant factors for NPST scores. Regarding fathers, the number of children (p = 0.040) and participation in care (p = 0.001) significantly influenced PSS: NICU scores, and the number of children was a significant factor in NPST scores (p = 0.038).

This study aimed to determine the stress and nurse-parent support levels of parents with preterm babies admitted to NICUs and the relationship between stress, nurse-parent support, and some variables related to parents and infants.

In this study, although the difference between the stress scores of mothers and fathers was not statistically significant, the score was higher for mothers. Additionally, both mothers and fathers received high scores from the infant’s appearance and behaviors and parental role alteration dimensions of the PSS-NICU. In the study conducted by Ganguli et al. (2020), it was reported that parents experienced extremely high levels of stress in general, but no significant difference was found between mothers and fathers in terms of overall stress. The highest level of stress was observed in the sight and sound domains, followed by relationship with the baby and parental role [8]. Similarly, other studies have found that parents experienced increased stress related to the infant’s appearance and behaviors and parental role alteration dimensions [9, 11, 19].

Parental stress was associated with having a single child, 1–5 years of marriage, and spending more time with the infants. Caring for a preterm baby in a hospital setting can induce parental stress. Prolonged hospitalization, fear of losing the infant, changes in parental roles, and the inability to assist with their child all elicit negative emotions and may elevate stress levels [10, 20,21,22]. These factors could result in greater stress levels for parents spending more time with their infant. The impact of 1–5 years of duration of marriage on stress levels may be explained with the assumption that younger couples may experience increased stress due to the unexpected nature of preterm birth and the challenges it poses. Additionally, the presence of only one child seems to increase stress levels for parents. The novelty of parenting, coupled with the uncertainty and unfamiliarity surrounding preterm birth, can lead to heightened stress levels in families with a single child. The absence of prior experience with a preterm infant or NICU setting may contribute to the increased stress observed in these parents. These findings emphasize the importance of targeted support and education for parents with only one child, focusing on stress management strategies and coping mechanisms.

Fathers’ stress levels were found to decrease with higher gestational weeks, whereas mothers’ stress levels were found to decrease when they visited the infant within 30min after birth. Regression analysis revealed that receiving information about the infant reduced maternal stress, whereas participating in the infant’s care was effective in reducing paternal stress. Consistent with the results of this study, Eom and Im (2019) stated that fathers’ involvement in their infants’ care increased their confidence in their paternal roles and reduced their stress levels [23]. In Tilahun’s study (2024), it was also determined that parents experienced high levels of stress during the admission of their premature infants to the NICU, while parents of infants born between 34 and 37 weeks of gestation or in late gestational weeks had lower stress levels [22]. Çekin and Turan (2018) found that parents who had children other than the infant in the NICU and infants with lower gestational weeks had higher levels of stress [9]. Turan et al. (2016) reported that informing the parents and introducing them to healthcare professionals reduced the stress levels of mothers [18]. Mansson et al. (2019) noted that the inability to feed the infant and participate in care is a source of stress for parents [24]. Active involvement in infant care appears to have a protective effect against stress for fathers, aligning with existing literature emphasizing the positive impact of paternal engagement in the NICU setting [13, 15, 23, 25]. Encouraging and facilitating fathers’ participation in caregiving activities can serve as a valuable strategy for alleviating stress and fostering a sense of connection with their infants.

The timing of the first visit to the infant played a significant role in maternal stress levels, with earlier visits correlating with reduced stress. This finding underscores the importance of early parental involvement and interaction with the infant in the NICU, potentially contributing to a sense of control, understanding, and emotional bonding. Healthcare providers, particularly nurses, play a critical role in facilitating timely and meaningful parental visits, offering guidance on how to navigate the NICU environment, and addressing parental concerns promptly.

Concerning nurse-parent support, the study revealed that mothers received more support compared to fathers. This aligns with previous studies indicating that mothers typically perceive and receive greater support than fathers in NICU settings [4, 9]. The emotional support dimension emerged as the most significant contributor to this disparity, with mothers reporting higher scores. Emotional support, encompassing elements like empathy, reassurance, and encouragement, plays a crucial role in alleviating stress and enhancing coping mechanisms, as extensively documented in the literature [12, 13]. In the study by Mariano et al. (2022), mothers reported feeling generally supported by nurses and indicated that their sense of support increased when they observed nurses providing direct nursing care and showing interest in their premature infants [26]. In their study, Lee and Choi (2023) reported that fathers seek support from nurses to cope with the stress caused by their infants being in the NICU. They noted that after participating in tactile and educational interventions, fathers’ attachment significantly increased, and over time, fathers took on multiple roles as protectors, caregivers, and decision-makers for their partners and infants [25]. Healthcare providers, particularly nurses, should be mindful of the distinct needs and experiences of both mothers and fathers, striving to ensure fair and tailored support for both parental units.

The study revealed that mothers with one child received higher nurse support, while fathers’ support decreased when the infant required mechanical ventilation. Hendy et al. (2024), Tilahun (2024), and Akkoyun (2019) found in their studies that mechanical ventilation of the infant increased the stress levels of parents [3, 7, 22]. These findings illuminate the intricacies of nurse-parent interactions and the differential support needs based on parental and infant characteristics. For mothers with only one child, nurses may perceive an increased need for support due to the absence of siblings who can potentially share caregiving responsibilities. Fathers, on the other hand, may experience decreased support when their infants require mechanical ventilation, possibly reflecting the heightened complexity and severity of the infant’s health condition, which could impact the father’s perceived ability to actively participate in caregiving tasks.

Notably, the study did not find a significant relationship between parental stress and nurse-parent support scores. While previous research has highlighted the influential role of nursing support in mitigating parental stress [3, 26, 27], the current study suggests that these two constructs may not be directly correlated. The nuanced nature of stressors and support mechanisms within the NICU context necessitates a comprehensive understanding of the multifaceted factors influencing parental well-being.

Limitataions

This study offers valuable contributions to existing literature, but certain limitations must be acknowledged. Conducted in a single private hospital in Ankara, Turkey, the findings may not be widely applicable. Future research should span diverse healthcare settings and cultural contexts for a more comprehensive understanding of parental experiences and support needs. Additionally, reliance on self-report measures introduces the potential for social desirability bias, suggesting that incorporating objective measures, like physiological indicators of stress, could enhance the validity of the findings.

Implications for practice

This study unveils the complex dynamics of parental stress and nurse-parent support for preterm infants in the NICU. Elevated stress levels, especially among mothers, highlight the deep emotional impact of preterm birth. These stressors emanate from various sources, including the infant’s appearance and behaviors, alterations in parental roles, and the broader challenges associated with NICU hospitalization. Crucially, the study highlights the importance of tailored support interventions for mothers and fathers, recognizing their unique experiences and needs. Mothers, often at the forefront of caregiving responsibilities, may benefit from targeted emotional support, information dissemination, and strategies to alleviate stress related to the infant’s appearance and behaviors. Fathers, while also grappling with stressors, may derive significant benefits from active participation in infant care, fostering a sense of involvement and connection. The identification of specific factors influencing stress levels, such as the number of children, duration of marriage, and the timing of the first visit, offers valuable insights for healthcare providers. These factors can guide the development of targeted interventions aimed at addressing the diverse needs of parents navigating the challenges of preterm birth. Additionally, the study emphasizes the crucial role of nurses in providing emotional support, guidance, and information to parents, highlighting the need for ongoing training and education to enhance the quality of nurse-parent interactions.

NICU:

Neonatal Intensive Care Unit

PSS:

Parental Support Scale

NPST:

Nurse-Parent Support Tool

Authors and Affiliations

1. Gulhane Faculty of Nursing, Department of Pediatric Nursing, University of Health Sciences Turkey, Ankara, Turkey

   Dilek Konukbay,Mürşide Vural&Dilek Yildiz

2. Sağlık Bilimleri Üniversitesi, Gülhane Hemşirelik Fakültesi Gn. Tevfik Sağlam Cad., Etlik, 06018, Ankara, Turkey

   Dilek Konukbay

Contributions

Study conception and design, DK, MV, DY. Data collection, DK, MV, DY. Data analysis and interpretation, DK, MV, DY. Drafting of the article and Critical revision of the article, DK, MV, DY.

Corresponding author

Correspondence to Dilek Konukbay.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the University of Health Sciences Gülhane Scientific Research Ethics Committee (Approval No. 2019/01.18/370.46418926). Institutional permission was secured from the hospital where the study was conducted. Also permissions were obtained to utilize the data collection tools. The research was conducted in accordance with the Declaration of Helsinki. All of the participants were informed about the purpose of the study and their written informed consents were obtained. Participation was voluntary and without compensation. The anonymity of the participants was maintained throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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