1. Background
Deliveries based on the number of gestational weeks can occur preterm, term, and post-term. Preterm and post-term deliveries may negatively affect the neonate's health and pose a concern for global health (1, 2). Globally, the birth rate of preterm infants is estimated at 5% to 18%, and in Iran, it is estimated at 10%. Most of these infants require admission to a neonatal intensive care unit (NICU) (3, 4).
Neonatal intensive care units (NICUs) treat and provide care for vulnerable infants, including preterm neonates and newborns with congenital malformations (5). The NICU hospitalization of infants affects the normal life routine, well-being, and family functioning (6, 7). Parents often face challenges in adapting to their parenting role and bonding with their infant, and their caregiving after discharge is vital to their infant's development and growth (8, 9). It is therefore essential for parents of infants to receive more care to assist them in coping with their current challenges, such as mental health problems and parental barriers during their infant's hospitalization in the NICU, which can continue for many years after the birth of the child (10, 11). For parents, the NICU environment, equipment, alarms, and medical measures provided by health care are sources of stress (12). These stressors physically, mentally, and psychologically disrupt the parent-infant relationship and cause many emotional problems for parents (13).
Hence, identifying family needs reduces stress and emotional problems in parents (14), and nurses have the responsibility to address and guide parental problems as identified by family-centered development care (FCDC) (15). Therefore one of the best and most effective ways to prevent injuries caused by hospitalization is FCDC by nurses and family involvement in infant care (16). In FCDC, the family is considered a significant member of the NICU care team and an important influence on the infant's health and well-being. Its goal is to foster the attachment relationship between the family and infant (15, 17). A first step in implementing FCDC and kangaroo mother care (KMC) is identifying parental needs nurses and applying those needs to the care program (18). A number of efforts are being made to implement the care method in Iran following the recommendations of the international Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Federation (NFI) in the KMC and NIDCAP.
The NICU Family Needs Inventory (NFNI) is a self-report instrument to identify families' real needs during neonates' hospitalization in the NICU, which assesses 5 of the most important dimensions of need (19). In light of these findings, Hashim and Hussin concluded that information, assurance, and proximity to the infant are the most important needs of parents (20). In 2018, Lyu et al. demonstrated that the families of hospitalized children with cancer (chronic illness) required support, comfort, and information (21). A study by Sargent reported that assurance and information were the most important needs from the perspective of mothers (22). Since each parent has unique needs, nurses' understanding of parental needs differs from the actual needs of parents (23). Due to the fact that needs are influenced by culture and that there are various cultures in society, it is possible for parents from various regions and cultures to have different personalities and social characteristics (24). There have been limited studies in Iran on the needs of families in different cultures, so most studies have concentrated on the needs of mothers and those of admission and discharge (25) but have not addressed the needs of parents (mother and father) simultaneously, and their needs during neonatal hospitalization have been ignored. The assessment of needs is felt in different cultures, including in the cities of northern Iran.
2. Objectives
The purpose of this study was to assess the needs of families with neonates in NICUs of some hospitals in northern Iran.
3. Methods
3.1. Design
This cross-sectional study was performed in the NICUs of 4 medical centers affiliated with two universities of medical sciences in northern Iran from 2018 - 2019 using convenience sampling among parents of infants who met the inclusion criteria and were selected randomly.
We recruited parents who had never experienced infant mortality or hospitalization in the neonatal intensive care unit and had infants with gestational ages greater than 30 weeks. Infant mortality was the exclusion criteria for parents.
3.2. Sample Size
The sample size required to assess the needs of the family, assuming the family needs assessment score has a coefficient of variation CV = 0.02, and the error limit is estimated to be d = 0.02 µ, the sample size required at the 95% confidence level is about 360 samples.
3.3. Measuring Instrument
The data were collected using the NICU Family Needs Inventory designed by Ward (19) and a demographic questionnaire for the parents (age, education, type of delivery, job, number of births) and neonates (gender, diagnosis, gestational age, birth order). The instrument is an edited version of the Critical Care Family Needs Inventory (CCFNI) designed by Molter (26). In addition to the 56 items on the questionnaire, the questionnaire assesses family needs in terms of comfort (getting hope and an honest response regarding treatment outcomes), proximity to infants (parental presence at the infant's side), information (information about the neonate's condition), assurance and support (getting professional assistance and social support to cope with stress as well as getting emotional and social support from others). A total of 56 questions were asked, including infant proximity (8 items), assurance (12 items), support (18 items), information (11 items), and comfort (7 items). Questions are scored on a Likert scale of 1 to 4 (not important, slightly important, important, and very important). The importance of needs was determined based on the parent's responses to the items in the questionnaire. According to Cronbach's alpha, this questionnaire had acceptable validity and reliability in the population of Iran in the Aemmi et al. study for mothers (0.8) and nurses (0.98) (27) and in the Mirjalili study for the dimensions of support 77%, comfort 66%, information 70%, proximity to infant 53%, assurance 72%. Also, the reliability of the questionnaire was reported in Ward's study by calculating Cronbach's alpha coefficient of 91% (19), and in Sargent's study, the alpha coefficient for subscales was reported from 61% to 87% (22). In the present study, to determine the validity of the questionnaire, after translation, ten nursing faculty members, subspecialists in infants, head nurses, NICU staff, and parents were given a written explanation, and changes were made using their comments and corrective guidance. Cronbach's alpha was calculated to determine reliability at 0.92. For each dimension of need, the reliability coefficient was calculated using Cronbach's alpha method of assurance (0.66), proximity to infants (0.65), information (0.78), comfort (0.67), and support (0.84).
3.4. Data Collection
The researcher started collecting data after obtaining ethical approval from the University of Medical Sciences and observing ethical considerations (explaining the study's aims to the participants, participating voluntarily in the study, and keeping the information confidential).
As the mother might be absent in the first few days after delivery, the questionnaire was provided to parents from the third day to 24 hours before the baby was discharged from the hospital.
Both parents completed the self-report questionnaire simultaneously. Parents had the opportunity to complete the questionnaire and return it to the researcher 24 hours before discharge.
3.5. Data Analysis
After collecting the final data, SPSS 23 was used to analyze the data. Kolmogorov-Smirnov test was used to determine if the data had a normal distribution. In order to investigate the correlation between family dimensions and some quantitative and qualitative variables, Pearson and Spearman correlation coefficients were used. In order to compare the dimensions of the needs of families with newborns hospitalized with some of their individual and social characteristics (job, education, gestational age, birth order), the independent statistical t-test was applied, and P < 0.05 was considered as significant level. Because the dimensions of family needs in the questionnaire had different scores, standardization was done to calculate the dimensions of family needs based on importance to parents. The dimensions were calculated using a scale of one hundred.
4. Results
In this study, 360 parents were enrolled in the study. Most of the participating mothers had a non-academic education (50.2%) and were housewives (90.3%), and most of the participating fathers had a non-academic education (53%) and were self-employed (80.9%). The majority of the newborns were term (51.9%), male (54.4%), first children (50.8%), and delivered by cesarean section (71.1%). In total, 36% of infants were hospitalized for respiratory distress syndrome, 19% for prematurity, 14% for icterus, and 31% for other illnesses.
Frequency distribution of the dimensions of needs according to the parents' importance suggested that proximity to the infant, information, assurance, comfort and support were (93.59%), (90.53%), (89.18%), (86.70%) and (80.78%), respectively.
The results related to dimensions of family needs showed that the maximum mean (± standard deviation) score in between the five dimensions related to the support dimension and its minimum was about comfort (Table 1).
Table 1.Mean and Standard Deviation of Needs Dimensions in Neonatal Intensive Care Unit
| Needs Dimensions | Mean ± SD |
|---|---|
| Proximity | 29.95 ± 7.4 |
| Information | 39.83 ± 8.51 |
| Assurance | 42.81 ± 5.82 |
| Comfort | 20.81 ± 11.34 |
| Support | 54.93 ± 11.42 |
According to the results of the comparison of dimensions of family needs with some variables of parents and infants, the mean assurance was higher in multiparous parents (90.27 ± 6.08) than in primiparous parents (88.12 ± 5.38), and the mean comfort was higher in parents of term infants (88.03 ± 11.03) than in those of preterm infants (85.30 ± 11.53), showing that this difference is statistically significant (P < 0.05). There was no significant difference between mothers' needs concerning education and employment (P > 0.05) (Tables 2 and 3).
Table 2.Comparison of Different Needs of Families with Infants Hospitalized in NICU Based on Gestational Age, Multiparous and Primiparous a
| Variables/Needs Dimensions | Primipara | Multipara | t-Test Result | Preterm | Term | t-Test Result | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| t | df | P-Value | t | df | P-Value | |||||
| Proximity | 94 ± 6.49 | 93.5 ± 7.56 | 1.52 | 346 | 0.25 | 93.64 ± 6.64 | 93.53 ± 7.40 | 0.146 | 358 | 0.884 |
| Information | 90.83 ± 7.81 | 90.22 ± 9.20 | 0.687 | 344 | 0.492 | 90.13 ± 8.56 | 90.89 ± 8.46 | -0.849 | 358 | 0.396 |
| Assurance | 88.12 ± 5.38 | 90.27 ± 6.08 | -3.358 | 358 | 0.001 | 89.05 ± 5.87 | 89.29 ± 5.80 | -0.390 | 358 | 0.697 |
| Comfort | 87.14 ± 10.67 | 86.30 ± 12.03 | 0.699 | 358 | 0.485 | 85.30 ± 11.53 | 88.03 ± 11.03 | -2.291 | 358 | 0.023 |
| Support | 80.24 ± 10.85 | 81.34 ± 11.99 | -0.913 | 358 | 0.362 | 80.04 ± 10.94 | 81.45 ± 11.84 | -1.168 | 358 | 0.243 |
a Values are expressed as mean ± SD.
Table 3.Comparison of Different Needs of Mothers with Infants Hospitalized in Neonatal Intensive Care Unit Based on Education and Occupational Status a
| Variables/Needs Dimensions | Academic Education | Non-academic Education | t-Test Result | Housewife | Employee | t-Test Result | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| t | df | P-Value | t | df | P-Value | |||||
| Proximity | 93.45 ± 6.97 | 93.71 ± 7.11 | -0.353 | 358 | 0.724 | 93.52 ± 7.16 | 94.10 ± 5.85 | -0.641 | 358 | 0.645 |
| Information | 90.29 ± 8.99 | 90.75 ± 8.02 | -0.511 | 358 | 0.61 | 90.53 ± 8.66 | 90.45 ± 7.11 | 0.055 | 358 | 0.956 |
| Assurance | 89.09 ± 5.93 | 82.26 ± 5.73 | -0.271 | 358 | 0.787 | 89.17 ± 5.96 | 89.16 ± 4.48 | 0.012 | 358 | 0.99 |
| Comfort | 87.05 ± 11.55 | 86.39 ± 11.15 | 0.554 | 358 | 0.58 | 86.55 ± 11.66 | 88.33 ± 7.74 | -1.22 | 358 | 0.228 |
| Support | 80.49 ± 12.11 | 81.06 ± 10.72 | -0.469 | 358 | 0.64 | 80.72 ± 11.61 | 81.3 ± 9.54 | -0.284 | 358 | 0.776 |
a Values are expressed as mean ± SD.
The relationship between dimensions of parental need with some qualitative and quantitative variables (age, education, number of childbirths, birth order) demonstrated that there was a significant direct relationship between assurance with paternal and maternal ages, number of childbirths, and birth order (P < 0.05). It indicates that the need for assurance rose with the increasing age of parents, the number of births, and birth order. Moreover, there was a significant inverse relationship between paternal education and assurance and between maternal education and proximity (P < 0.05). The needs for proximity and assurance were lower in parents with increasing maternal and paternal education, respectively (Table 4).
Table 4.Correlation Between Needs dimensions of Families with Infants hospitalized in Neonatal Intensive Care Unit and Some Quantitative and Qualitative Variables
| Variables/Dimensions Need As | Paternal Age | Maternal Age | Number of Childbirths | Birth Order | Paternal Education | Maternal Education | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| r | p | r | p | r | p | r | p | r | P | r | p | |
| Assurance | 0.160 | 0.002 | 0.139 | 0.008 | 0.218 | < 0.01 | 0.242 | < 0.01 | -0.129- | 0.015 | -0.061 | 0.249 |
| Proximity | -.015 | 0.779 | -0.029 | 0.588 | -0.061 | 0.249 | -0.047 | 0.375 | 0.090- | 0.087 | -0.063 | 0.023 |
| Information | 0.046 | 0.379 | -0.003 | 0.958 | -0.019 | 0.714 | 0.002 | 0.937 | -0.070 | -0.184 | -0.024 | 0.652 |
| Comfort | -0.034 | 0.514 | -0.001 | 0.982 | -0.015 | 0.776 | -0.012 | 0.825 | 0.053 | 0.316 | 0.008 | 0.886 |
| Support | 0.018 | 0.729 | 0.043 | 0.413 | 0.036 | 0.490 | 0.042 | 0.431 | -0.067 | 0.205 | -0.038 | 0.474 |
5. Discussion
The results of the present study indicated that parents’ needs range from more important to less important in terms of proximity to their infant, information, assurance, comfort, and support. Like the current study, Wang et al. found that parents prioritized infant proximity more than any other dimension of need (28). Consistent with the results of the current study, Aemmi et al. (27) concluded that the need for proximity to infants was more important among mothers. Cleveland acknowledge that nurses should have a positive attitude toward mothers who are able to care for their infants with their supervision, which contributes to a closer bond between mother and child (29). Guillaume et al. have demonstrated that nurses' caring attitude and regular communication according to parents' needs are essential prerequisites for greater parental involvement in the NICU (30).
Studies such as the ongoing study have reported that the least important need is support (19, 22, 23, 28). This may be due to the fact that health care providers are adequately meeting the support need or that the importance of other needs may make the support need less important.
However, Alsaiari et al. in Saudi Arabia found that assurance, proximity, and information were the most important needs from the perspective of parents, which is different from the results presented in this study (31).
The difference may be due to changes in the questionnaire used for determining parental needs in the above studies. Since it was possible for the participated parents to have unlimited visits to the NICU in Alsaiari et al.’s study (31). Vaskelyte and Butkeviciene stated that parents' primary needs were assurance, proximity to their infants, information, support, and comfort (32), which is inconsistent with the results of the present study. Considering the fact that the questionnaires for the needs assessment were completed in the first days of an infant's hospitalization in the abovementioned study (32), parents in the first days of their infants' hospitalization needed more assurance and confidence about their infant's future, and mothers were unable to provide basic care in the first days due to their high levels of anxiety. In the present study, questionnaires were filled out at different times during the infant's hospitalization, thereby affecting the type of parental needs. According to Sargent, in another study, the mothers' priority needs were assurance, information, infant proximity, comfort, and support, which is in contrast to the results of the present study (22). Our study evaluated both the needs of mothers and fathers of neonates admitted to level II and III neonatal intensive care units, while Sargent's study evaluated only the needs of mothers with neonates admitted to level III neonatal intensive care units.
From the perspective of mothers, Mirjalili et al. found that assurance was their most important need, which is contrary to the findings of the ongoing study (25). This difference may be related to the questionnaire used to determine the maternal need or the time for completing the questionnaire (admission time). The present study found that parents of term infants felt a greater need for comfort. Multiparous parents reported a greater need for assurance than primiparous parents. In terms of academic or non-academic education, there was no significant difference between mothers' needs. As illustrated by Alves et al., parents with a lower level of education have a greater need for comfort and support, whereas parents with higher levels of education have a greater need for assurance and comfort (18). In Mundy's study, no significant difference was found among the dimensions of needs in parents with less than a 12th-grade education. Those with 12th-grade education reported a greater need for support and information, and those with academic education reported a greater need for support. The needs of primiparous and multiparous parents did not differ significantly (23). According to Mirjalili et al., mothers with preterm infants require less information than other mothers (25), which is inconsistent with our results. Maybe the reason is that Mirjalili et al.’s study focused on the needs of infants admission, whereas our study examined parental needs during hospitalization with large sample size. In addition, the questionnaires used in both studies were different (25).
5.1. Conclusions
As indicated by the current study, infant proximity and information are more important to families, while support is less important. Therefore, it is recommended that maternal and neonatal health policymakers should consider the results of this study for providing unlimited or least limited possibilities to attend in the NICU for families in addition to facilitating the emotional bond between infant and parents, parent's mental health, and reducing parents' emotional reactions and reduce the stress parents experience during their infant's hospitalization. The presence of parents in the NICU also fulfills the FCC and NIDCAP care philosophy and influences the continuation of breastfeeding. Furthermore, identifying and meeting the family's real needs can be used as a strategy for improving the health care provided. This also promotes family compatibility during the hospitalization of an infant.
5.2. Limitations
One limitation of our study was the inaccessibility of all the NICUs in Mazandaran province since culture, customs, and beliefs can influence people's needs. In light of the cultural and ethnic diversity, conducting further cultural and social studies with different populations is recommended to identify the needs of different cultures. Additionally, this study is limited by the lack of knowledge regarding the level of parental involvement in completing the questionnaire.
