1. Background
Most deaths in newborns without congenital disorders have been reported due to prematurity. Approximately 10 - 12% of neonates worldwide are born prematurely; however, the rate is gradually rising (1). The principal prematurity consequences are neonatal sepsis, pneumonia, bronchopulmonary dysplasia, perinatal death, cerebral palsy, and intraventricular hemorrhage (2). The hospitalization of premature neonates in the neonatal intensive care unit (NICU) reduces the mortality rate of neonates, although it can be a stressful and unanticipated event for parents (3).
The NICU is a site of medical treatment for premature and critically ill infants. Parents of infants admitted to this ward experience disruptions to parent-infant bonding (4-6). Admitting premature neonates to the NICU would be a traumatic stressor, especially for a long time (7, 8). Therefore, NICU admission impairs parents’ ability to think (9-11). The lack of preparation for parenthood and hospitalization itself, along with grief and isolation, all contribute to a challenging emotional situation for parents. Parents are exposed to a mixture of emotions, such as anxiety, worry, fear, guilt, and helplessness, associated with premature birth (12, 13). The disruption of the parent-infant emotional attachment during hospitalization is the major factor in parents’ distress (5). The barriers to parenting and reactions to the environment might negatively influence the parent-infant relationship (14, 15).
Previous studies have reported that disruption of parents’ relationship with the treatment staff is common (16, 17). The therapeutic relationship between the treatment staff and parents is crucial to ensure the health of neonates (17). Sometimes, neonates’ appearance and unfamiliar technological devices and equipment attached to the neonates might adversely affect parents (18, 19). The stress level of parents will be reduced by providing the necessary information through nurses (17).
Parental stress has been reported in different ways. In a study, the negative effects (e.g., the level of stress) in mothers have been reported more than in fathers (20). Shaw et al. showed the levels of posttraumatic stress disorder at 33% and 9% in fathers and mothers, respectively (21). Parental stress due to hospitalizing neonates at the NICU has been widely investigated (22-27). In this regard, Lindberg and Ohrling demonstrated a significant level of anxiety and depression during prematurity and hospitalization in some parents who did not expect to have a premature neonate (28). The link between NICU hospitalization and anxiety has been described due to lack of parental control over the neonate health situation (29). Moreover, the main cause of anxiety in parents of premature neonates has described strange situations and loss of control over neonates in Iran (30).
2. Objectives
Parental stress might negatively influence neonates’ social, behavioral, and functional development (31). Parental support is an integral part of family-centered care at the NICU. Nurses should recognize the stress-boosting factors in parents and remove their needs to improve the neonate’s developmental outcome (27). For this reason and the lack of studies in this regard, this study aimed to assess the stressors in parents of premature neonates admitted to the NICU at Ali-Ibn-Abitaleb Hospital of Rafsanjan, Kerman, Iran, within November 2020 to September 2021.
3. Methods
This cross-sectional descriptive study was conducted on 204 parents aged 18 - 44 years with premature neonates admitted to the NICU of Ali-Ibn-Abitaleb Hospital of Rafsanjan, Kerman, located in the southeast of Iran, using convenience sampling. All parents met the inclusion criteria, including the gestational age under 37 weeks, parents’ desire to participate, neonate hospitalization of more than 3 days without congenital disorders or abnormalities, and no need for neonate surgery. The parents who avoided filling in the questionnaires were excluded. The data collection tool was a demographic data form, including age, education, occupation, wealth status, number of children, gestational age, spending time with the neonate, and neonate’s birth and health status, and the Parental Stress Scale: Neonatal Intensive Care Unit (PSS: NICU).
The Parental Stress Scale: Neonatal Intensive Care Unit, developed in 1993 by Miles et al. (32), with three domains, including “neonate’s behavior and appearance” (13 items), “sights and sounds” (6 items), and “parental role alterations” (10 items), was used to measure sources of parents’ stress. All the stress items were completed in a self-reported way through a Likert scale rating (0 = not exposed to sources of stress, 5 = extremely stressful). The participants marked only the part related to their experiences in each item. The Iranian validity and reliability of the PSS: NICU have been confirmed by the studies of Borimnejad et al. (33) and Valizadeh et al. (34). Cronbach’s alpha coefficients were reported as 0.78 and 0.86, respectively, based on the assessment of the PSS: NICU in both studies. Cronbach’s alpha coefficient in this study was 0.81.
The current study was approved by the Ethics Committee of Rafsanjan University of Medical Sciences (IR.RUMS.REC.1398.005). It should be noted that all parents were informed of the confidentiality of the data.
The data were analyzed using SPSS software (version 22). The frequency (percentage) and the mean ± standard deviation were applied for the categorical and quantitative variables, respectively. The one-sample t-test was utilized to compare the subscales’ scores of mothers and fathers as common parents.
4. Results
Out of 204 parents, 99 mothers and 84 fathers responded to the demographic items. Tables 1 and 2 show the demographic characteristics of parents and neonates. The mean age of mothers and fathers were 29.88 ± 5.39 and 33.84 ± 4.69 years, respectively (Table 1). In this study, 57% and 18% of the mothers were within the age range of 26 - 35 and older than 35 years, respectively. Furthermore, 85.3% of the mothers were homemakers. A high level of education was reported for 78.4% of mothers. Moreover, 50% and 30.4% of the fathers were within the age range of 26 - 35 and older than 35 years, respectively; however, 82.4% of the fathers were self-employed. A high level of education (≥ diploma) was reported for 59.8% of the fathers.
Table 1.Demographic Characteristics of Parents
| Characteristics | Mothers (n = 99) | Fathers (n = 84) |
|---|---|---|
| Age (y) | ||
| 18 - 25 | 24 (23.5) | 2 (2) |
| 26 - 35 | 57 (55.9) | 51 (50) |
| 36 - 45 | 18 (17.61) | 31 (30.4) |
| Mean ± standard deviation | 29.88 ± 5.39 | 33.84 ± 4.69 |
| Education | ||
| < Diploma | 22 (21.6) | 36 (35.3) |
| Diploma | 49 (48) | 35 (34.3) |
| > Diploma | 31 (30.4) | 26 (25.5) |
| Occupation | ||
| Homemaker | 87 (85.3) | - |
| Employee | 15 (14.7) | - |
| Self-employed | - | 84 (82.4) |
| Governmental | - | 17 (16.7) |
| Gestational age (week) | ||
| < 28 | 2(2) | |
| 28 - 36 | 89 (87.3) | |
| 37 - 42 | 3 (2.9) | |
| Social Wealth Index | Common | |
| Low income | 14 (13.7) | |
| Middle income | 68 (66.7) | |
| High income | 16 (15.7) | |
| Child number | ||
| 1 or 2 | 80 (78.4) | |
| 3 or 4 | 22 (21.6) | |
| Dead child | ||
| Yes | 13 (12.7) | |
| No | 82 (80.4) |
Table 2.Demographic Characteristics of Premature Neonates
| Characteristics | Neonates (n = 102) |
|---|---|
| Gender | |
| Male | 45 (44.1) |
| Female | 54 (52.9) |
| Age (day) | |
| Mean ± standard deviation (min-max) | 25.31 ± 49.91 (3 - 244) |
| Child number | |
| The first | 44 (43.1) |
| The second | 34 (33.3) |
| The third | 15 (14.7) |
| The fourth | 4 (3.9) |
| Connected to ventilator | |
| Yes | 66 (64.7) |
| No | 30 (29.4) |
| Weight (g) | |
| Mean ± standard deviation (min - max) | 2019.02 ± 555.12 (880 - 2600) |
| Hospitalized days | |
| Mean ± standard deviation (min - max) | 10.52 ± 10.82 (1 - 88) |
Two-thirds of the parents’ Social Wealth Index (SWI) (66.7%) were in the middle. Moreover, 80 responders (78.4%) had 1 or 2 children at home. Additionally, most parents (80.4%) had no dead neonate. The most frequent gestational age (87.3%) was 28 - 36 weeks at birth (Table 1); nevertheless, 52.9% of the neonates were female (Table 2). Regarding neonates, 43.1% were born as the first child. The mean of hospitalized days was reported as 10.52 ± 10.82 (range: 1 - 88 days), and almost half of the neonates (64.7%) were eligible to use the breathing support by a ventilator (Table 2).
The comparison of parental stress scores in the total scale for mothers and fathers was performed using the one-sample t-test as they had a common neonate. Table 3 shows the comparison for various subscales of the PSS: NICU. Mothers had higher stress scores in the “sights and sounds” and “neonate’s behavior” domains; nevertheless, the stress score of the “parental role alterations” domain was higher in fathers. None of these items showed a significant difference.
Table 4 shows descriptive information for the subscales of PSS: NICU scores. The most stressful component in the “sights and sounds” domain was related to “sudden alarm noises” in fathers; however, “other sick neonates” was the least stressful component in the “sights and sounds” domain. “Sudden alarm noises” and “a large number of staff members” were reported as the most and least stressful items in mothers, respectively. Moreover, the highest score of stress in the “neonate’s behavior” domain was reported in “needles and tubes put in” for both, followed by “the neonate seemed to be in pain” for fathers and “sadness” for mothers. The major causes of stress in “parental role alterations” subscales were relevant to “feeling helpless about how to help neonate” and “being separated from neonate” in fathers and mothers, respectively. “Not being able to care for my neonate myself” and “feeling that staff is closer to my neonate” included the least stressful causes in fathers and mothers, respectively.
Table 4.Level of Stress in Parents Measured by the Parental Stress Scale: Neonatal Intensive Care Unit (n = 102) a
| Subscales and Components | Fathers | Mothers | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No Exposure | Exposure (Stress Level) | No Exposure | Exposure (Stress Level) | |||||||||
| 1 | 2 | 3 | 4 | 5 | 1 | 2 | 3 | 4 | 5 | |||
| Sights and Sounds | ||||||||||||
| Presence of monitors and equipment | 10 (9.8) | 18 (17.6) | 22 (21.6) | 19 (18.6) | 23 (22.5) | 10 (9.8) | 11 (10.8) | 6 (5.9) | 22 (21.6) | 32 (31.4) | 24 (23.5) | 7 (6.9) |
| Noise of monitors and equipment | 16 (15.7) | 13 (12.7) | 19 (18.6) | 21 (20.6) | 21 (20.6) | 12 (11.8) | 11 (10.8) | 8 (7.8) | 17 (16.7) | 31 (30.4) | 26 (25.5) | 9 (8.8) |
| Sudden alarm noises | 20 (19.6) | 8 (7.8) | 17 (16.7) | 11 (10.8) | 28 (27.5) | 18 (17.6) | 12 (11.8) | 1 (1) | 14 (13.7) | 21 (20.6) | 33 (32.4) | 21(20.6) |
| Other sick neonates | 18 (17.6) | 31 (30.4) | 8 (7.8) | 29 (28.4) | 13 (12.7) | 3 (2.9) | 15 (14.7) | 22 (21.6) | 18 (17.6) | 24 (23.5) | 18 (17.6) | 5 (4.9) |
| A large number of staff members | 9 (8.8) | 21 (20.6) | 22 (21.6) | 29 (28.4) | 11 (10.8) | 10 (9.8) | 14 (13.7) | 35 (34.3) | 18 (17.6) | 29 (28.4) | 6 (5.9) | 0 (0) |
| Connected to a ventilator to breathe | 12 (11.8) | 26 (25.5) | 16 (15.7) | 30 (29.4) | 12 (11.8) | 6 (5.9) | 16 (15.7) | 17 (16.7) | 18 (17.6) | 32 (31.4) | 13 (12.7) | 6 (5.9) |
| Neonate’s Behavior | ||||||||||||
| Tubes and equipment | 11 (10.8) | 18 (17.6) | 32 (31.4) | 32 (31.4) | 16 (15.7) | 17 (16.7) | 10 (9.8) | 9 (8.8) | 17 (16.7) | 18 (17.6) | 35 (34.3) | 13 (12.7) |
| Bruises | 19 (18.6) | 3 (2.9) | 17 (16.7) | 21 (20.6) | 17 (16.7) | 25 (24.5) | 12 (11.8) | 11 (10.8) | 14 (13.7) | 12 (11.8) | 33 (32.4) | 20 (19.6) |
| Neonate’s color | 29 (28.4) | 4 (3.9) | 20 (19.6) | 18 (17.6) | 13 (12.7) | 18 (17.6) | 13 (12.7) | 9 (8.8) | 14 (13.7 | 24 (23.5) | 19 (18.6) | 23 (22.5) |
| Labored breathing | 23 (22.5) | 8 (7.8) | 15 (14.7) | 21 (20.6) | 13 (12.7) | 22 (21.6) | 19 (18.6) | 6 (5.9) | 13 (12.7) | 16 (15.7) | 28 (27.5) | 20 (19.6) |
| Size | 17 (16.7) | 20 (19.6) | 17 (16.7) | 15 (14.7) | 19 (18.6) | 14 (13.7) | 12 (11.8) | 10 (9.8) | 20 (19.6) | 22 (21.6) | 18 (17.6) | 20 (19.6) |
| Wrinkled appearance | 27 (26.5) | 13 (12.7) | 12 (11.8) | 21 (20.6) | 15 (14.7) | 14 (13.7) | 22 (21.6) | 11 (10.8) | 24 (23.5) | 15 (14.7) | 11 (10.8) | 19 (18.6) |
| Needles and tubes put in | 10 (9.8) | 4 (3.9) | 6 (5.9) | 21 (20.6) | 21 (20.6) | 40 (39.2) | 9 (8.8) | 5 (4.9) | 8 (7.8) | 22 (21.6) | 22 (21.6) | 36 (35.3) |
| Neonate fed by tube | 20 (19.6) | 7 (6.9) | 9 (8.8) | 18 (17.6) | 19 (18.6) | 29 (28.4) | 21 (20.6) | 10 (9.8) | 7 (6.9) | 10 (9.8) | 31 (30.4) | 23 (22.5) |
| Neonate seemed to be in pain | 17 (16.7) | 4 (3.9) | 12 (11.8) | 25 (24.5) | 22 (21.6) | 22 (21.6) | 22 (21.6) | 5 (4.9) | 6 (5.9) | 15 (14.7) | 16 (15.7) | 38 (37.3) |
| Sadness | 16 (15.7) | 4 (3.9) | 18 (17.6) | 19 (18.6) | 20 (19.6) | 25 (24.5) | 14 (13.7) | 4 (3.9) | 6 (5.9) | 13 (12.7) | 26 (25.5) | 39 (38.2) |
| Limp and weak | 9 (8.8) | 20 (19.6) | 17 (16.7) | 17 (16.7) | 13 (12.7) | 26 (25.5) | 18 (17.6) | 8 (7.8) | 6 (5.9) | 16 (15.7) | 24 (23.5) | 30 (29.4) |
| Movement | 24 (23.5) | 4 (3.9) | 16 (15.7) | 19 (18.6) | 15 (14.7) | 24 (23.5) | 20 (19.6) | 3 (2.9) | 10 (9.8) | 15 (14.7) | 23 (22.5) | 31 (30.4) |
| Cry | 33 (32.4) | 11 (10.8) | 18 (17.6) | 22 (21.6) | 16 (15.7) | 2 (2) | 27 (26.5) | 11 (10.8) | 15 (14.7) | 10 (9.8) | 30 (29.4) | 9 (8.8) |
| Parental Role Alterations | ||||||||||||
| Being separated from neonate | 15 (14.7) | 2 (2) | 7 (6.9) | 30 (29.4) | 17 (16.7) | 31 (30.4) | 11 (10.8) | 4 (3.9) | 7 (6.9) | 14 (13.7) | 28 (27.5) | 38 (37.3) |
| Not feeding my neonate myself | 18 (17.6) | 8 (7.8) | 15 (14.7) | 32 (31.4) | 16 (15.7) | 13 (12.7) | 13 (12.7) | 12 (11.8) | 16 (15.7) | 17 (16.7) | 19 (18.6) | 25 (24.5) |
| Not being able to care for my neonate myself | 24 (23.5) | 12 (11.8) | 15 (14.7) | 36 (35.3) | 11 (10.8) | 4 (3.9) | 20 (19.6) | 11 (10.8) | 15 (14.7) | 22 (21.6) | 21 (20.6) | 13 (12.7) |
| Not being able to hold my neonate when I want | 19 (18.6) | 14 (13.7) | 7 (6.9) | 38 (37.3) | 14 (13.7) | 10 (9.8) | 22 (21.6) | 11 (10.8) | 14 (13.7) | 19 (18.6) | 20 (19.6) | 16 (15.7) |
| Feeling helpless and unable to protect the neonate | 12 (11.8) | 4 (3.9) | 11 (10.8) | 37 (36.3) | 18 (17.6) | 20 (19.6) | 18 (17.6) | 6 (5.9) | 14 (13.7) | 14 (13.7) | 19 (18.6) | 31 (30.4) |
| Feeling helpless about how to help neonate | 15 (14.7) | 6 (5.9) | 5 (4.9) | 37 (36.3) | 22 (21.6) | 22 (16.7) | 12 (11.8) | 13 (12.7) | 18 (17.6) | 13 (12.7) | 26 (25.5) | 20 (19.6) |
| Not having time to be alone with neonate | 12 (11.8) | 3 (2.9) | 25 (24.5) | 30 (29.4) | 15 (14.7) | 17 (16.7) | 22 (21.6) | 12 (11.8) | 22 (21.6) | 19 (18.6) | 17 (16.7) | 10 (9.8) |
| Not being able to share neonate with other family members | 12 (11.8) | 10 (9.8) | 20 (19.6) | 36 (35.3) | 12 (11.8) | 12 (11.8) | 10 (9.8) | 8 (7.8) | 20 (19.6) | 21 (20.6) | 29 (28.4) | 14 (13.7) |
| Fear of touching or hugging my neonate | 12 (11.8) | 14 (13.7) | 12 (11.8) | 20 (19.6) | 19 (18.6) | 25 (24.5) | 19 (18.6) | 17 (16.7) | 14 (13.7) | 16 (15.7) | 26 (25.5) | 10 (9.8) |
| Feeling that the staff is closer to my neonate than I am | 21 (20.6) | 8 (7.8) | 21 (20.6) | 31 (30.4) | 14 (13.7) | 7 (6.9) | 30 (29.4) | 14 (13.7) | 23 (22.5) | 19 (18.6) | 9 (8.8) | 7 (6.9) |
a Values are expressed as No. (%).
To determine the effect of independent variables on the variable of parental stressors, multivariate analysis was performed with multiple linear regression. The independent variables were entered into multivariate analysis using the backward method, and only the gestational age variable was significant in the regression model (P = 0.02, adjusted R-squared = 0.038).
5. Discussion
This study aimed to assess the stressors in parents of premature neonates hospitalized at the NICU in Ali-Ibn-Abitaleb Hospital of Rafsanjan within November 2020 to September 2021. Premature neonates are often admitted to the NICU as high-risk cases to decrease morbidity and mortality (3). Previous studies have identified the NICU experience as a traumatic stressor for parents. Turning the stressful environment of the NICU into a family-centered unit for parents with a hospitalized premature neonate is critical to promote the neonatal healthcare process (7, 35-37). At the NICU, the neonate’s health status and the treatment protocols were the major causes of parental concern (25).
In this study, the parental stress scores were measured in both parents separately in each item and in total. Based on the results, the most stressful source at the NICU was the “neonate’s behavior” followed by “parental role alterations” and “sights and sounds” in both parents. The current study’s results are similar to the results of some previous that reported the “neonate’s behavior” domain as the leading cause of stress (17, 38) and the “sights and sounds” domain as the least significant (5, 39). In contrast, some studies introduced “parental role alterations” as the major cause of stress in both mothers and fathers (21, 24, 40, 41). The appearance of premature neonates is smaller than mature neonates; therefore, their reaction decreases to physical stimulation. Studies have indicated a reduction in parental stress after the physical response of neonates (42). Otherwise, nurses and treatment groups are effective in the control of parental stress by providing information about the situation and behavior of neonates.
In parental role components, “feeling helpless about how to help neonate” and “being separated from neonate” for fathers and mothers were detected as the experienced stressors with the highest scores, respectively. Parents have no awareness of the treatment process and staff’s behavior; they are not also able to care for their neonates by themselves. “Alarm noises” in the NICU atmosphere and “needles and tubes put in” in evaluating the “neonate’s behavior” domain were the most stressful sources for both parents, which is consistent with the findings of Ashwani et al. (39). “Alarm noises” includes sound, light, and care activities of neonates. Nurses should inform parents about the used monitors and setting in the NICU environment to reduce stress.
The measurement of mean scores of the PSS: NICU subscales in both parents showed that mothers experienced higher levels of stress in the “neonate’s behavior” and “sights and sounds” domains; nevertheless, in the “parental role alterations” domain, fathers were more stressed. In this study, there were no significant differences in total stress scores between mothers and fathers; however, mothers experienced much more stress than fathers, which is in line with the results of previous studies (5, 32, 38, 43-45).
The hospitalization of neonates at the NICU is stressful for both parents; nevertheless, fathers might adopt some strategies to reduce the stress level; however, mothers might have a negative evaluation of their neonates’ difficulties (5). Mothers are more concerned about the neonates’ future health and losing the neonate than fathers (25). Parents spend much time and cost to understand the NICU atmosphere, and naturally their feelings overcome after the neonate is hospitalized (46).
The limitation of the current study was the reluctance and the lack of mental and psychological readiness of parents due to their child’s illness. Accordingly, it was tried to minimize this limitation by establishing appropriate communication and explaining the project’s objectives. The convenience sampling method was another limitation that could limit the generalizability of the results. It is suggested to perform other studies similar to this study with a larger sample size.
5.1. Conclusions
Overall, parents are forced to scrimmage with many stressors during the hospitalization time of neonates at the NICU. Nurses are responsible for providing information and respond the parents’ questions about the healthcare process of their neonates in understandable terms. This issue enables nurses to support parents in emotional aspects and encourage them to communicate with their neonates.
