Investigation of stress and nursing support in mothers of
preterm infants in neonatal intensive care units
Sevinc Akkoyun
Msc(Nurse)1andFatma Tas Arslan
PhD(Professor)21Konya Eregli State Hospital, Konya, Turkey and2Nursing Department, Selcuk University Faculty of Health Science, Konya, Turkey
Scand J Caring Sci; 2019; 33; 351–358
Investigation of stress and nursing support in mothers of preterm infants in neonatal intensive care units
Background: The birth and hospitalisation of a premature infant in a neonatal intensive care unit (NICU) are stress-ful experiences for the mother and the family. The sup-port of neonatal nurses is necessary to control and reduce the stress of mothers. And nurse–parent support may play a role in effective stress management and make a positive contribution to the health of mothers.
Aim: To determine the correlation of stress and nurse– parent support levels with mothers’ age and educational status, number of children, gestational week of the infant and the hospitalisation period of the infant among moth-ers of premature infants hospitalised in the NICU. Methods: This descriptive and cross-sectional study was conducted in the NICUs of two medical faculties. The study was conducted between March and June 2017 with the participation of 106 mothers with hospitalised premature infants. The data of the study were collected using a ‘mother information form’, Parental Stressor Scale: Neonatal Intensive Care Unit and Nurse-Parent
Support Tool. Number, percentage, mean, standard devi-ation, t-test, analysis of variance test, Pearson’s correla-tion and multiple regression analysis were used to analyse the data.
Results: It was determined that the stress levels were high in mothers regarding their PSS: NICU parental role sub-scale. The stress levels of mothers with infants connected to mechanical ventilation and fed parenterally were high (p< 0.05). The nurse support levels of mothers with middle- and low-income status were high. Multiple regression analysis, mechanical ventilation was deter-mined to be effective in the use of the PSS:NICU total score (p< 0.05).
Conclusions: As a result, it was determined that mechani-cal ventilation and parenteral nutrition of the infant increased the stress level of mothers. Furthermore, in the study, the Nurse-Parent Support score of the mothers with middle- and low-income status was higher.
Keywords: neonatal intensive care unit, nursing support, preterm infant, stress, mother.
Submitted 9 May 2018, Accepted 9 October 2018
Introduction
Infants born before the 37th-gestational week+ 7 days are called preterm infants (1, 2). Preterm birth is a global problem, and it is estimated that approximately 15 mil-lion infants are born prematurely each year (2). It was stated in ‘Born Too Soon: The Global Action Report on Preterm Birth’, published by the World Health Organiza-tion, that premature birth rates vary between 5 and 18% in the world. The premature birth rate is reported as 11.9% in Turkey (3). Preterm birth in Turkey is within world average and important.
The birth of a premature infant, the hospitalisation of the infant in neonatal intensive care unit (NICU) and
having special care needs (4–9) are an unexpected condi-tion and a stressful experience for parents (9–11). It is reported in the literature that the stress levels of mothers of premature infants hospitalised in the NICU are higher than mothers of hospitalised term infants, (12–15) and the stress levels of the mothers among parents of prema-ture infants are higher than in the fathers (9, 16–18).
Mothers are confronted with many stress factors dur-ing this process (16, 19). Havdur-ing a preterm infant, the appearance of the infant, the infant’s uncertain and changing health status, the physical environment, bright lights, noise, odour, tools and equipment, equipment and tubes connected to the infant, physical and emotional separation from the infant, failure to breastfeed, changes in the maternal role, communication between parents and distortion of family routines contribute to the stress of mothers (8, 10, 14, 20–25).
The high level of stress prevents mothers from making the right decisions and participating in the care of their
Correspondence to:
Fatma Tas Arslan, Akademi Mahallesi Yeni _Istanbul Caddesi Alaeddin Keykubat Kamp€us€u 299/1 Selcßuklu, Konya, Turkey. E-mail: fatmatas61@hotmail.com
infants (25). Mothers expect support from people around them to cope with stress (16), and nurse support has an important effect in this process (13). Nursing care and support are needed to reduce or control the stress of the mothers. Nurse–parent support is a part of care in paedi-atric nursing (26, 27). In the context of caregiving roles, nurses are in a strategic position to support parents and assist them in defining their roles (28). In this process, the nurse should support the family physically, socially and emotionally through effective communication with the mother (21). The support provided to mothers has various beneficial effects such as reducing stress, as well as strengthening the parenting role (7). This support starts with the birth in the hospital environment and continues in the neonatal unit and after discharge. In this context, the evaluation of nurse support and stress levels in mothers of premature infants by neonatal nurses is important. Nurses will find opportunities to provide nurs-ing interventions in accordance with these results. These interventions and practices may have a positive effect on the health of premature infants and mothers.
This study was conducted to determine the correlation of stress and nurse–parent support levels with mothers’ age and educational status, number of children, gesta-tional week of the infant and the hospitalisation period of infants among mothers of premature infants hospi-talised in NICU.
The research questions:
1 Does stress indicate any difference in mother and infant variables (educational and employment status; perception of income; pregnancy; form of birth, sex; respiratory and nutritional status of infant and the visit frequency of mothers)?
2 Does nurse support indicate any difference in mother and infant variables (educational and employment sta-tus; perception of income; pregnancy; mode of deliv-ery, sex; respiratory and nutritional status of infant and the visit frequency of mothers)?
3 What is the predictive power of the respiratory and nutritional status on scores of stress?
Methods
Procedure
This descriptive and cross-sectional study was conducted at two NICUs affiliated with two medical faculty hospitals in a large city of Turkey. The sample size was calculated using the G*Power 3.1 programme (29). The size of the samples was calculated for each subscale, considering the mean and SD of the subscales of the Parental Stressor Scale:Neonatal Intensive Care Unit (PSS:NICU) in another study on maternal stress in the NICU (22). The largest sample size was obtained when the calculation was performed with the score of the PSS:NICU Parental
Role Alteration approach. By assuming a common SD of 3.4 in order to define a difference of 3 in sample mean scores on the score of Parental Role Alteration approach with a statistical power of 0.90 and a significance level of 0.05, 97 mothers were required. One hundred six indi-viduals were planned to be included in the study because of anticipated participant attrition and missing responses.
The inclusion criteria were as follows: (i) having infants born within the 24–37 weeks’ interval (ii), having only one infant at birth, (iii) having no premature infant birth history in previous births, (iv) having no congenital anomaly in the infant (v) and having the infant hospi-talised in the NICU for 7 days or more.
Data were collected by visiting the NICU on parent between March and June 2017. Before collecting data, the mothers were informed about the study. Data were collected in an interview room in the NICU under the supervision of a researcher. It took approximately 20 minutes to complete the data collection forms.
Measures
The data were collected using an information form on the sociodemographic and obstetric characteristics of the participants and contained of features the infant, PSS: NICU and Nurse-Parent Support Tool (NPST).
Mother information form
Mother information form was developed by the researcher in accordance with the literature (21, 22, 25, 26). The mother information form involved questions including sociodemographic characteristics (age, educa-tional status, employment status, income status) and fer-tility characteristics (pregnancy, form of birth, number of children) of the mothers and characteristics [sex, gesta-tional age (weeks), birthweight (g), current weight (g), infant length of stay in hospital (days), the time to first seeing the infant (hours), visit frequency, respiratory sta-tus, nutritional status] of the infant.
Parental Stressor Scale: Neonatal Intensive Care Unit The PSS:NICU was developed by Miles et al., in 1993 (30). The Turkish adaptation and validation of the scale were conducted by Turan and Basßbakkal in 2006 (31). The PSS:NICU is a 34-item Likert-type scale, and the scale has three subscales (Subscale of Sights and Sounds with six items, Subscale of Infant Behaviour and Appear-ance with 17 items and Subscale of Parental Role Alter-ations with 11 items). The responses to the scale are scored on a Likert-scale on which the parents can rate the level of stress for each item from 1 (not at all stress-ful) to 5 (extremely stressstress-ful). With higher scale score stress increases.
A score was derived for each subscale and each parent by adding all of the ratings for each question in each sub-scale. According to Miles, the PSS:NICU can be scored in two ways. Metric 1: Stress Occurrence Level is the level of stress experienced in a particular situation. Those who report the experience receive a score and those who do not are coded as missing. The total denominator is the number of parents who experienced the particular stress. Metric 2: Overall stress level is the stress from the total NICU environment. Parents who do not report a score on an item are given a score of 1. The total denominator is the number of items on the scale. Metric 2, as outlined by Miles et al., best describes the levels of parental stress due to the total NICU environment. Metric 2 was used because this study was assessing parental experience of stress and support.
The Cronbach’s alpha value of the original version of the scale was found as 0.89 in the study performed by Miles et al., the Turkish version also showed good psy-chometric properties and its Cronbach’s alpha coefficient was 0.89 (Metric 1) and 0.90 (Metric 2) (31). In the pre-sent study, the Cronbach’s alpha coefficient for the PSS: NICU was 0.92.
Nurse-Parent Support Tool
The NPST was developed by Miles et al., in 1999. The Turkish adaptation and validation of the tool were con-ducted by Turan et al. (26). The tool evaluates the paren-tal perception of nursing support of their infants at the end of hospitalisation (32).
The NPST consists of a Likert-type scale with 21 items. The tool has four subscales; information giving and com-munication support (nine items); emotional support (three items); esteem support (four items) and quality caregiving support (five items). The NPST is a 5-point Likert-type scale ranging from 1 (almost never) to 5 (al-most always). With higher scale score nurse–parent sup-port increases.
The Cronbach’s alpha value of the original version of the tool was found as 0.95 in the study by Miles et al. The internal consistency of the Turkish version of NPST is high, and its Cronbach’s alpha coefficient was 0.92 (26). In the present study, the Cronbach’s alpha coeffi-cient for the NPST was 0.91.
Data analysis
The Statistical Package for the Social Sciences version 22.0 (IBM Corporation, New York, NY, USA) was used. The data are represented as number, percentages, mean and standard deviation, and the comparisons between the groups were performed using Student’s t- and F-tests. In order to determine the effect of respiratory and nutritional status on the PSS:NICU, multiple regression
analysis was performed. Regarding independent variables found as significant after performing bivariate analyses, the following variables such as respiratory status (1= mechanical ventilation, and 0 = not mechanical ventilation) and nutritional status (1= parenterally, and 0= enterally) were inserted into logistic regression analy-sis. For all analyses, p< 0.05 was considered to be significant.
Ethical considerations
Before starting the study, ethics committee approval from the Non-invasive Clinical Trials Ethics Committee (2017/ 03) and the related permission from hospitals were obtained. In addition, permission was obtained from the authors for the availability of the scales. All participants were informed, and each provided written informed consent.
Results
It was determined that 34.9% of the mothers had high school or higher education, 85.8% were unemployed, and 73.6% had middle–low income. Pregnancies of 94.3% occurred spontaneously and 85.8% gave birth through caesarean section. It was found that 60.4% of newborns were male, 17.9% were breathing with venti-lator support, 12.3% were fed parenterally, and 83% of the mothers visited their infants every day (Table 1).
It was found that the average age of the mothers was 29.08 6.54 years, the number of children was 2.30 1.43, the average gestational week of the infants was 32.01 3.66, their mean birthweight was 1787.24 828.25 grams (g), their average current weight was 2029.61 805.41 g, their average length of hospital stay was 22.73 23.9 days, and the time to first seeing the infant for the mother was 30.58 24.75 hours. The mothers’ mean PSS:NICU sub-scale scores were 2.67 0.89 for the subscale of sights and sounds, 2.77 0.87 for the subscale of infant beha-viour and appearance, and 3.28 0.87 for the subscale of parental role alterations. The PSS:NICU total score was 2.92 0.72. The mean NPST score was 3.85 0.64 (Table 2).
In the study, the Nurse-Parent Support score of the mothers with middle- and low-income status was higher (t= 2.160 p = 0.03). In the study, Sights and Sounds subscale and PSS:NICU total scores of the mothers whose infants were connected to ventilators were significantly higher than the other groups (p< 0.05). The subscale Sights and Sounds, the subscale Infant Behaviour and Appearance and PSS:NICU total scores of mothers with parenterally fed infants were significantly high (p< 0.05). Mothers’ characteristics of educational, employment, and income status, mode of birth, sex of
the infant, visit frequency, and their PSS:NICU subscale scores and the total scores were similar (p> 0.05). There was no difference between the mothers’ educational and employment status, mode of birth, sex of the infant, visit frequency, respiratory and nutritional characteristics and their NPST scores (p> 0.05) (Table 3).
Multiple regression analysis was used in the study to evaluate the effect of the variables of being connected to mechanical ventilation and parenteral nutrition on PSS: NICU total score. According to the analysis conducted with the Backward method, being connected to a mechanical ventilation, which is in the last part in the model, was found to be p= 0.003. This variable deter-mined the contribution of total PSS:NICU as 8% (Table 4).
Discussion
This study was conducted to determine of stress and nurse–parent support levels with mothers’ age and
educational status, number of children, gestational week of the infant and the hospitalisation period of infants among mothers of premature infants hospitalised in NICU. Stress prevents mothers from participating in the care of their infants (25). Care and support of neonatal nurses are needed to reduce or control the stress of mothers.
It was found in the study that the stress related to the parenting roles of the mothers was higher and other sub-scales. In the literature, mothers with infants staying in the NICU are reported to experience stress about parental roles (5, 15, 20, 22, 24, 33, 34), and infant behaviour and appearance (8, 10, 23). In the literature, interven-tions such as providing information, ensuring that par-ents take an active role in care and encouraging parpar-ents to express their feelings are recommended to reduce stress levels (21). It is thought that causes such as the mother’s separation from the infant, failure to breastfeed or giving care contribute to high stress depending on the parental role. It is considered that the stress expressed by mothers can be reduced by supporting situations such as allowing mothers to see their infants whenever they want, being involved in their care and breastfeeding when appropriate.
The NPST level in the study was found as 3.85 0.64. In the study by Mok and Leung (35), the mean NPST score was 3.84, showing similarity with the present study. The mean NPST score is higher in the literature than the present study (9, 22, 32, 36, 37) a study found a lower mean NPST score in their study (26). The NPST score of the mothers was lower in the present study com-pared with studies conducted abroad. There can be many reasons for this difference. It is thought that sufficient support cannot be provided to mothers in Turkey due to reasons including the number of nurses working in the
Table 1 The mothers’ and the infants’ characteristics (n= 106)
Variables n % Educational status Primary school 35 33.0 Secondary school 34 32.1 High school 23 21.7 University 14 13.2 Employment status Employed 15 14.2 Unemployed 91 85.8 Income status High 28 26.4
Middle and low 78 73.6
Pregnancy Spontaneous 100 94.3 Medical methodsa 6 5.7 Mode of delivery Vaginal 15 14.2 Caesarean section 91 85.8 Sex Female 42 39.6 Male 64 60.4 Respiratory status Mechanical ventilation 19 17.9
Breathing with oxygen 34 32.1
Spontaneous breathing 53 50.0 Nutritional status Parenterally 13 12.3 Enterally 93 87.7 Visit frequency Everyday 88 83.0 Twice a week 10 9.4 Once a week 8 7.6 a
Medical methods: inoculation (n= 2), in vitro fertilisation (n = 4).
Table 2 The mothers’ and the infants’ characteristics and the moth-ers’ PSS:NICU and NPST scores
Variables Mean SD
Average age of the mothers (years) 29.08 6.54
Mean number of children 2.30 1.43
Gestational age (weeks) 32.01 3.66
Birth weight (g) 1787.24 828.25
Current weight (g) 2029.61 805.41
Infant’s length of hospital stay (days) 22.73 23.9 The time to first see the infant (hours) 30.58 24.75 PSS:NICU
PSS:NICU sights and sounds 2.67 0.89
PSS:NICU infant behaviour and appearance 2.77 0.87 PSS:NICU parental role alterations 3.28 0.87
PSS:NICU total 2.92 0.72
NPST total 3.85 0.64
NPST, nurse-parent support tool; PSS:NICU, Parental Stressor Scale: Neonatal Intensive Care Unit; SD, standard deviation.
NICU (38) and insufficient number of experienced or cer-tified nurses, and fast nurse circulation. NICUs are clinics with a heavy workload. By keeping the number of neonatal nurses working in these clinics at optimal rates, nurses can allocate enough time for mothers, establish effective communication, support the mother and give information about the infant more effectively. These practices can help increase the support given by nurses.
In the current study, the Sights and Sounds subscale scores and PSS:NICU total scores of the mothers with infants connected to mechanical ventilation were found to be higher than the scores of mothers whose infants could breathe with oxygen and spontaneously. In some studies, no significant result was found between the breathing of infants with mechanical ventilation and PSS: NICU (8, 9, 20, 39, 40). On the other hand, the stress
Table 3 Comparison of PSS:NICU and NPST scores in terms of the mothers’ and the infant’s characteristics (n= 106)
Variables Sights and sounds
Infant behaviour and appearance
Parental role
alterations PSS:NICU total NPST total
Educational status Primary school 15.65 0.94 46.68 2.53 34.62 1.69 96.97 4.37 83.17 2.47 Secondary school 16.82 0.90 49.41 2.27 37.50 1.50 103.73 3.76 80.61 2.24 High school 15.26 1.18 41.47 3.03 34.69 2.06 91.43 5.22 79.82 2.60 University 16.35 1.32 51.71 4.54 39.35 2.60 107.42 6.94 78.00 3.95 F 0.468 1.884 1.218 1.777 0.579 p 0.706 0.137 0.300 0.156 0.630 Employment status Employed 15.93 1.25 43.66 3.86 32.60 2.70 92.20 6.23 76.20 3.84 Unemployed 16.04 0.57 47.65 1.55 36.78 0.98 100.49 2.60 81.72 1.39 t 0.006 0.933 2.470 1.447 2.135 p 0.936 0.336 0.110 0.232 0.147 Income status High 16.00 0.92 47.57 3.18 36.39 2.03 99.96 5.12 76.25 2.35
Middle and low 16.05 0.63 46.92 1.60 36.11 1.05 99.08 2.73 82.62 1.56
t 0.040 0.190 0.130 0.160 2.160 p 0.960 0.844 0.896 0.870 0.030 Mode of birth Vaginal 15.40 1.57 49.93 4.55 36.40 2.57 101.73 7.18 86.93 3.34 Caesarean section 16.14 0.55 46.62 1.50 36.15 1.00 98.92 2.55 79.95 1.42 t 0.243 0.638 0.008 0.164 3.446 p 0.623 0.426 0.927 0.686 0.066 Sex Female 15.42 0.77 46.64 2.37 36.61 1.60 98.69 3.96 78.69 2.48 Male 16.43 0.70 47.39 1.81 35.90 1.14 99.73 3.04 82.42 1.45 t 0.880 0.064 0.130 0.170 0.045 p 0.348 0.800 0.710 1.913 0.833 Visit frequency Everyday 15.79 0.59 47.26 1.62 36.29 1.05 99.35 2.72 80.30 1.52
1 or 2 times per week 17.22 1.05 46.27 3.04 35.66 1.94 99.16 5.12 84.05 2.27
t 1.024 0.255 0.252 0.029 1.063
p 0.308 0.799 0.802 0.977 0.290
Respiratory status
Mechanical ventilation 20.10 1.65 54.21 3.62 40.26 2.09 114.57 6.48 82.00 2.43
Breathing with oxygen 15.17 0.80 44.79 2.08 34.73 1.13 94.70 3.06 80.17 2.56
Spontaneous breathing 15.13 0.60 46.01 2.13 35.66 1.51 96.81 3.51 81.05 1.91 F 7.390 2.831 2.220 4.778 0.111 p <0.001 0.060 0.110 0.010 0.895 Nutritional status Parenterally 21.23 2.15 56.15 4.27 41.00 2.59 118.38 8.12 81.61 2.18 Enterally 15.31 0.47 45.82 1.49 35.52 0.98 96.65 2.39 80.85 1.48 t 3.960 2.400 1.950 3.070 0.189 p <0.001 0.018 0.054 0.030 0.850
levels of mothers with infants connected to ventilators were reported to be high in some studies (41–44). In line with these results, mothers with infants connected to mechanical ventilation in the NICU experienced more stress in our study. The technical equipment applied to infants with mechanical ventilation support can be vari-ous and numervari-ous. The uncertainty of this equipment and the presence of many cables connected to the infant were observed to increase the stress of mothers about Sights and Sounds in particular. Moreover, infants con-nected to ventilators are generally followed up at the 3rd level in NICUs and evaluated as critically ill patients. Obscurity about the course of the infant’s condition and the fact that the infant is critically ill were concluded to increase the stress of the mothers. In addition, infant care at this level is provided by nurses and parents only see the infants during visiting hours. It can be asserted that not being able to see an infant whenever the mother wants and not being involved in their care significantly contributes to the mother’s stress.
The scores of the subscales Sights and Sounds and Infant Behaviour and Appearance and PSS:NICU total scores of mothers with parenterally fed infants were higher than in mothers with enterally fed infants. It was concluded that parenteral nutrition increased the stress in mothers. In a study, Parental Role-related stress of mothers who could not breastfeed their infants was found as high (15). On the other hand, it was reported in another study that the feeding type infants did not increase anxiety and hopelessness (44). Parenterally fed infants are often premature infants who cannot start or tolerate enteral feeding. In addition, because they are not breastfed, mothers’ visits are less frequent and shorter in duration. We believe that causes such as seeing the infant only during visiting hours, not being able to feed the infant enterally and having less interaction with the nurses increased the stress level of mothers.
It was found in the study that NPST score of the moth-ers with middle- and low-income level was higher com-pared with those with a high income. There are no significant results regarding income status and NPST score in the literature (22, 37). In the present study, it was thought that mothers with low-income level likely wanted to ask more questions and obtained more infor-mation from nurses.
When the correlation of the characteristics and NPST scores of the mothers and infants with stress was
evaluated in this study, no significant result was found. However, in different studies in literature, nurse support and characteristics of mothers and infants have been revealed to affect the stress levels of the mothers. It was observed in a study that stress of mothers increased as the gestational week of the infant decreased, (33) and another showed that the stress scores of mothers increased with increased length of stay in the NICU and decreased income statuses (22). In other studies, it was found that the mother’s age and gestational week were correlated with stress (24, 34).
It was observed in the study that infants being connected to mechanical ventilation had an effect on the PSS:NICU total score and accounted for 8% of the stress experienced by the mothers. Many factors about the infant and environment can affect the stress of mothers with preterm infants hospitalised in NICU. In the literature, parent’s age and gestational week have been found to affect the PSS:NICU total score (34).
Conclusion
It was determined that the stress of mothers concerning the parental roles were high. The variables of being con-nected to mechanical ventilation and parenteral nutrition increased the stress level of mothers. Nurse support level of mothers with middle- and low-income status was higher. The status of being connected to mechanical ven-tilation affected the stress scores of mothers.
Neonatal nurses should be guiding in controlling and reducing the stress of mothers, especially those with parenterally fed infants connected to mechanical ventila-tion. Nurses should provide support to mothers by way of giving information, involving them in infant care and allowing them to see their infants at any time. Neonatal nurses should be better prepared and qualified to help mothers with premature infants. In this way, they will play an effective role for the mothers to cope with stress.
Future studies should include interventions to reduce the stress of mothers. In particular, it is recommended to conduct studies to evaluating situations (technical equip-ment, cables) that arise from the environmental com-plexity and the appearance of infants connected to mechanical ventilation.
Limitations
The study was performed in two centres.
Acknowledgements
This study was presented as oral at the 6th National, 1st International Pediatric Nursing Congress, November 29th
Table 4 Multiple regression analysis of risk factors affecting mothers’ PSS:NICU total scores
Risk factors Beta t p
Mechanical ventilation 0.289 3.078 0.003
to December 2nd 2017, Antalya, Turkey. We gratefully thank all the mothers and the team of the translation company.
Conflict of interest
The authors declare no conflict of interest.
Author contributions
Fatma Tas Arslan and Sevinc Akkoyun performed the study design; Sevinc Akkoyun performed that data col-lection. Fatma Tas Arslan and Sevinc Akkoyun analysed
the data. Fatma Tas Arslan and Sevinc Akkoyun drafted that manuscript.
Ethical approval
The study was conducted with approvals from the Non-invasive Clinical Trials Ethics Committee (2017/03) of Medical Faculty at the Selcuk University, and the related permission from hospitals were obtained.
Funding
No financial support was received in the study.
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