1. Background
Having a newborn in the intensive care unit (ICU) is a frightening experience for parents, with each infant undergoing an average of 10 to 16 painful procedures per day (1, 2). Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, and it is always a subjective concept (3). Pain is a destructive and distressing experience for newborns and can remain in the memory of the baby (4). Painful therapeutic procedures in the neonatal intensive care unit (NICU) can lead to a series of physiological, learning, and behavioral disorders, attention problems, and hormonal imbalances in newborns, causing neurodevelopmental changes in premature infants who are hospitalized for extended periods (5, 6). The neurobiological vulnerability of premature babies to pain is attributed to their low pain threshold, sensitivity to repeated and continuous pain, and the presence of underdeveloped systems to maintain body balance (7-9). Therefore, special attention to pain control and developmental care is crucial (10).
As premature newborns are born and hospitalized in the NICU, parents require guidance from health care providers to mitigate their initial shock of seeing the NICU environment and to alleviate concerns about the department’s specific policies (11, 12). The involvement of family in the pain management of infants is limited compared to other aspects of care, and few studies have investigated this area (13). Studies in the NICU indicate that insufficient information on painful procedures, inadequate pain management, long waits for pain relief, lack of parental involvement in pain care, and staff’s failure to address parents’ concerns are significant stressors for parents (14, 15). Effective pain management in the NICU cannot be achieved without a thorough understanding of parents’ expectations, awareness, involvement, and consent regarding neonatal pain management (11). It is essential for health professionals to understand parents’ perspectives on infant pain before designing interventions to enhance their participation in this area (9).
2. Objectives
Considering that no information was found about the relationship between parents’ perceptions of pain management and parental stress in Iran, this study aims to clarify the association between parents’ perspectives on pain management and the stressors experienced by parents of newborns hospitalized in NICUs.
3. Methods
A cross-sectional descriptive study design was used in this study. Sampling was conducted using the convenience sampling method among the parents of hospitalized newborns in the NICUs of Emam Khomeini and Amir-Al-Momenin hospitals of Khoy University of Medical Sciences in 2023, with a sample size of 180. The inclusion criteria were a minimum of one visit to the NICU and reading and writing literacy. Exclusion criteria included a previous history of a hospitalized child in the NICU and a history of experiencing stressful factors during the past year.
The data collection tool consisted of three parts:
1. Demographic characteristics: Information about the newborns and parents.
2. Parental Stressor Scale (PSS): Neonatal intensive care unit: Developed by Miles et al. in 1993, this tool has 45 items and four subscales, including sights and sounds, infant appearance, parent-infant relationship, and staff. Each item is scored on a 6-point Likert scale, with scores ranging from 0 (not applicable) to 5 (extremely stressful). A higher score indicates more stress (16, 17).
3. Pain Questionnaire Neonatal Intensive Care: Designed by Franck in 2005, this instrument contains 28 questions based on pain assessment and management, satisfaction with the performance of the treatment staff, satisfaction with providing information to parents of newborns, and how parents participate in pain management. It has both quantitative and qualitative parts. The scores of parents’ opinions about their baby’s pain (quantitative part) range from 0 (minimum pain) to 10 (maximum pain). The qualitative part includes yes/no questions and Likert scale questions (18).
To collect data, after obtaining permission from the ethics committee of Khoy University of Medical Sciences (Iran), the researchers were present at the hospital to explain the study's objectives and provide informed consent forms to participants. The questionnaires were then given to the parents to complete, taking approximately 20 minutes.
The content validity of the PSS: Neonatal intensive care unit was confirmed by Akbarbegloo et al. in Tabriz, Iran, with reliability assessed using Cronbach’s alpha coefficient (α = 0.86) (19). The validity of the Pain Questionnaire Neonatal Intensive Care was confirmed by Mehrnoush et al., with a Cronbach’s alpha coefficient for reliability of 0.84 (20).
Descriptive statistics, including mean and standard deviation, were used to analyze quantitative data, and frequency (%) was used for qualitative variables. Pearson’s correlation test and chi-square test were used to evaluate the relationship between parents’ views on pain management and parental stressors. Analysis of covariance (ANCOVA) was used to control the effect of confounders. Data analysis was conducted using SPSS version 19, with a significance level of P < 0.05.
4. Results
The findings indicated that the mean age of mothers was 25.57 ± 5.6 years, and the mean age of fathers was 27.63 ± 4.1 years. Approximately 60.49% of deliveries were cesarean. A total of 85.64% of parents had no previous NICU experience. The majority of neonates (55.2%) were the first child. The mean birth weight was 1685 ± 614 grams, and the average NICU hospitalization was 18 days (Table 1).
Table 1.Distribution of Demographic Characteristics of Parents and Neonates
| Characteristics of Parents and Neonates | No (%) |
|---|---|
| Gestational age (wk) | |
| 28 | 83 (46.6) |
| 30 | 56 (31.2) |
| 32 | 35 (20.1) |
| 34 | 5 (2) |
| 36 | 1 (0.1) |
| Neonate’s gender | |
| Girl | 93 (51.4) |
| Boy | 87 (48.6) |
| Neonate’s birth weight (gr) | |
| 2500 > | 167 (92.9) |
| 2500 < | 13 (7.1) |
| Birth rank | |
| First child | 99 (55.2) |
| Second child | 64 (35.7) |
| The third child | 15 (8.2) |
| Fourth child and above | 2 (0.9) |
| Wife’s education | |
| Illiterate | 2 (1.02) |
| Elementary | 89 (49.62) |
| Diploma | 77 (42.9) |
| University | 12 (6.46) |
| Mother’s job | |
| Employed | 11 (5.87) |
| Housekeeper | 169 (94.13) |
| Type of delivery | |
| NVD | 71 (39.51) |
| Cesarean | 109 (60.49) |
| History of NICU admission | |
| Yes | 26 (14.36) |
| No | 154 (85.64) |
| History of low-birth-weight newborn | |
| Yes | 3 (1.87) |
| No | 177 (98.3) |
| Family income | |
| Low | 99 (54.83) |
| Average | 78 (43.7) |
| A lot | 3 (1.47) |
| Mother’s education | |
| Illiterate | 3 (1.6) |
| Elementary | 78 (43.16) |
| Diploma | 87 (48.26) |
| University | 12 (6.98) |
| Wife’s job | |
| Worker | 36 (19.65) |
| Employee | 13 (7.14) |
| Farmer | 8 (4.16) |
| Free | 118 (64.81) |
| Unemployed | 4 (1.95) |
| Other jobs | 1 (0.41) |
Abbreviation: NICU, neonatal intensive care unit.
The results of the PSS showed that "Presence of monitors and equipment" (64.5%) and "Sudden noises of monitor alarm" (55.7%) were the most significant stressors caused by the sights and sounds of the NICU. There was a difference between the stressful domains for parents (P = 0.047), with the mean of the parent-infant relationship stressors being higher than other areas (Table 2).
Table 2.Comparison of Domains Stressors of Parents with Hospitalized Baby in Neonatal Intensive Care Unit
| PSS: NICU | Mean ± SD | Analysis of Variance |
|---|---|---|
| Sights and sounds stressors | 3.12 ± 0.62 | df = 2.1; P = 0.047 |
| Infant appearance stressors | 2.81 ± 0.68 | |
| Parent-infant relationship stressors | 2.95 ± 0.88 | |
| Staff stressors | 1.73 ± 0.56 |
Abbreviations: PSS, Parental Stressor Scale; NICU, neonatal intensive care unit.
According to the parents, the mean pain score felt by the baby was 3.74 ± 3.03. The maximum amount of pain felt by newborns was 6.44 ± 3.5. There was a significant relationship between the maximum amount of pain and parental stress (r = 0.43, P < 0.01) (Table 3).
Table 3.Parents’ View About the Pain Management of Newborns Hospitalized in Neonatal Intensive Care Unit (Quantitative Variables)
| Variables | Mean ± SD | Parental Stressor |
|---|---|---|
| How much pain you think your baby is feeling at this moment? | 3.74 ± 3.03 | r = 0.01; P = 0.91 |
| The worst pain you think your baby has felt since admission to the NICU. | 6.44 ± 3.5 | r = 0.43; P = 0.01 |
| The least pain you think your baby has felt since admission to the NICU. | 2.24 ± 2.03 | r = 0.23; P = 0.89 |
| How much pain you expected your baby would have while in the NICU? | 2.39 ± 2.79 | r = 0.13; P = 0.34 |
| How much did you expect your baby's pain to be relieved in NICU? | 1.83 ± 2.05 | r = 0.33; P = 0.57 |
Abbreviation: NICU, neonatal intensive care unit.
The majority of parents (78.4%) stated that if their baby feels pain, they may have immediate medical problems. Additionally, 55.1% of parents did not receive any information about pain control, but in most cases, nurses explained how to pat or rock the baby (58.4%). Nearly 64.4% of parents reported that during painful procedures, no one asked them if they wanted to be with the baby.
There was a significant relationship between worrying about urgent medical problems when the baby has pain (χ2 = 163.7, df = 138, P = 0.04), receiving information about pain (χ2 = 163.7, df = 92, P = 0.04), using pain relief methods (χ2 = 130.4, df = 92, P = 0.05), reducing the baby’s pain with medication (χ2 = 159.4, df = 124, P = 0.003), supporting the staff (χ2 = 192.8, df = 128, P = 0.05), and being next to the baby when it is in pain (χ2 = 195.2, df = 173, P = 0.03) with parental stressors in the NICU (Table 4).
Table 4.Association Between Parents’ Stressors and Parents’ Views on Hospitalized Newborns Pain Management in Neonatal Intensive Care Unit (Qualitative Variables)
| Pain Questionnaire-NIC | No. (%) | Parental Stressor |
|---|---|---|
| If you believe that your baby has felt pain while in the neonatal unit, were you worried that your baby might? a | X2 = 163.7; df = 138; P = 0.04 | |
| Have immediate medical problems | 141.12 (78.4) | |
| Have later medical problems | 38 (21.2) | |
| Remember having pain | 8 (4.3) | |
| React to pain differently when he/she is older | 12 (6.3) | |
| I was not worried about any of these things. | 6 (3.5) | |
| How much verbal information about pain control for your baby have you received? | X2 = 154.7; df = 138; P = 0.15 | |
| A lot | 80 (44.7) | |
| Some | 50 (27.5) | |
| A little | 30 (16.5) | |
| None | 20 (11.3) | |
| How much written information about pain control for your baby have you received? | X2 = 163.7; df = 92; P = 0.04 | |
| A lot | 53 (29.2) | |
| Some | 18 (10.2) | |
| A little | 10 (5.5) | |
| None | 99 (55.1) | |
| If you have received either verbal or written information about pain control for your baby, please tell us when you received this information. a | X2 = 158.6; df = 163; P = 0.110 | |
| On admission | 61 (34.1) | |
| Daily | 31 (17.3) | |
| Before procedures | 3.6 (2) | |
| Occasionally | 82 (45.9) | |
| I did not receive any information. | 17 (9.4) | |
| Who have you received information from about pain control for your baby? a | X2 = 121.9; df = 92; P = 0.02 | |
| Nurse | 146 (81.2) | |
| Doctor | 24 (13.7) | |
| Family/friends | 5 (2.7) | |
| Internet | 17 (9.4) | |
| Other healthcare person | 7 (4.3) | |
| No one | 17 (9.4) | |
| How satisfied have you been with the amount of information you have received about pain control for your baby? | X2 = 102.9; df = 92; P = 0.2 | |
| Very satisfied | 36 (20.2) | |
| Satisfied | 54 (29.8) | |
| Somewhat satisfied | 56 (31.3) | |
| Somewhat unsatisfied | 8 (4.4) | |
| Unsatisfied | 15 (8.3) | |
| Very unsatisfied | 11 (6) | |
| The nurses have shown me how to look for signs of pain in my baby. | X2 = 144.2; df = 163; P = 0.34 | |
| Yes | 33 (18.1) | |
| No | 147 (81.9) | |
| The nurses have shown me how to make my baby more comfortable by: a | X2 = 130.4; df = 92; P = 0.05 | |
| Positioning | 82 (45.9) | |
| Pacifier | 53 (29.4) | |
| Swaddling | 24 (13.7) | |
| Feeding | 89 (49.4) | |
| Patting or rocking | 105 (58.4) | |
| Music/toys | 0 (0) | |
| The nurses did not show me. | 20 (11) | |
| How do you think these ways of comforting your baby have helped your baby's pain? | X2 = 124.8; df = 163; P = 0.03 | |
| Went away | 20 (11.3) | |
| Decreased a lot | 83 (46) | |
| Decreased a little | 71 (39.5) | |
| Made no difference | 2 (1.2) | |
| Made it a little worse | 2 (0.8) | |
| Made it a lot worse | 0 (0) | |
| Don’t know | 2 (1.2) | |
| I feel confident that the staff can tell when my baby is in pain. | X2 = 163.7; df = 92; P = 0.09 | |
| Strongly agree | 48 (26.6) | |
| Agree | 31 (17.3) | |
| Somewhat agree | 42 (23.1) | |
| Somewhat disagree | 11 (6.3) | |
| Disagree | 31 (17.3) | |
| Strongly disagree | 17 (9.4) | |
| Have you ever disagreed with either the nurses or doctors about whether your baby was feeling pain? | X2 = 97.3; df = 56; P = 0.39 | |
| Yes | 45 (25) | |
| No | 135 (75) | |
| I am satisfied that the nurses make my baby more comfortable. | X2 = 181.4; df = 150; P = 0.05 | |
| Strongly agree | 118 (65.7) | |
| Agree | 26 (14.2) | |
| Somewhat agree | 30 (16.9) | |
| Somewhat disagree | 2 (0.8) | |
| Disagree | 3 (2) | |
| Strongly disagree | 1 (0.4) | |
| My baby has received medicine for pain. | X2 = 159.8; df = 46; P = 0.09 | |
| Yes | 46 (25.8) | |
| No | 58 (32.2) | |
| Don’t know | 76 (42) | |
| Sometimes my baby didn’t have pain, but received other medications to make him/her calm. | X2 = 173.8; df = 45; P = 0.35 | |
| Yes | 18 (10.3) | |
| No | 96 (53.2) | |
| Don’t know | 66 (36.5) | |
| If your baby has received medicine for pain, in what way do you think the medicine has helped your baby’s pain? | X2 = 173.8; df = 45; P = 0.35 | |
| Went away | 35 (19.6) | |
| Decreased a lot | 75 (41.9) | |
| Decreased a little | 50 (28) | |
| Made no difference | 2 (0.8) | |
| Made little worse | 0 (0) | |
| Made lot worse | 0 (0) | |
| Don’t know | 18 (9.7) | |
| No | 155(86.1) | |
| Very unsatisfied | 1 (0.4) | |
| If you felt like the medication did not help your baby’s pain, did you tell anyone? | X2 = 191; df = 130; P = 0.42 | |
| Yes | 25 (13.88) | |
| No | 155 (86.11) | |
| If you did tell someone, how long did it take before a member of staff did something to help relieve your baby’s pain? | X2 = 130.4; df = 128; P = 0.05 | |
| Less than 10 minutes | 144 (79.9) | |
| 11 - 20 minutes | 18 (10.2) | |
| 21 - 30 minutes | 3 (2) | |
| 31 - 60 minutes | 0 (0) | |
| More than 1 hour | 2 (0.8) | |
| I asked but my baby didn’t receive it. | 1 (0.4) | |
| I never asked for help. | 12 (6.7) | |
| When my baby received pain medication, I was worried that he/she would: a | X2 = 186.2; df = 128; P = 0.04 | |
| Become addicted | 60 (33.3) | |
| Stop breathing | 33 (18.4) | |
| Be very sleepy | 46 (25.9) | |
| Was terminally ill | 24 (13.7) | |
| Not get enough | 12 (6.7) | |
| I was not worried. | 40 (22.4) | |
| The staff have been supportive with my concerns about my baby's pain. | X2 = 192.8; df = 128; P = 0.05 | |
| Strongly agree | 96 (53.1) | |
| Agree | 32 (17.7) | |
| Somewhat agree | 37 (20.9) | |
| Somewhat disagree | 2 (1.2) | |
| Disagree | 10 (5.5) | |
| Strongly disagree | 3 (1.6) | |
| Have you been present with your baby while they were undergoing a painful procedure? | X2 = 178.3; df = 92; P = 0.96 | |
| Never | 75 (41.6) | |
| Sometimes | 68 (38) | |
| Often | 31 (17.3) | |
| Always | 6 (3.2) | |
| Have you been present with your baby while they were undergoing a painful procedure? | X2 = 177.4; df = 86; P = 0.39 | |
| Never | 116 (64.4) | |
| Sometimes | 35 (19.4) | |
| Often | 13 (7.5) | |
| Always | 16 (8.7) | |
| When a painful procedure was being done on my baby I would most often prefer to: | X2 = 195.2; df = 173; P = 0.03 | |
| Stay at my baby’s bedside | 9 (5.1) | |
| Stay and assist by providing comfort | 93 (51.4) | |
| Leave the room | 78 (43.5) |
Abbreviation: NICU, neonatal intensive care unit.
a Selecting more than one option was allowed.
5. Discussion
The findings of the present study showed that the most significant stressors for parents were the sights and sounds of the NICU, followed by the parent-infant relationship. These findings are consistent with the study by Ganguly et al., which confirmed that the most significant stressors were the sights and sounds of the NICU, such as alarms, monitors, and other hospitalized infants (21, 22). This environment not only directly affects the premature infant but also indirectly affects the child through the caregiver’s stress and their ability to provide adequate care (21, 23). These factors impact the ability of parents to care for and communicate with their baby, potentially leading to a loss of the parenting role (24).
This study demonstrates a significant relationship between parental stressors and parents' views on pain management in many cases (Table 3). Research also indicates that among many stressful factors, such as hunger, excessive stimulation through noise and light, or separation from parents, pain is the main cause of physical and psychological discomfort that affects the quality of life of parents (25). There was a statistical relationship between parents’ stress and their views on creating urgent medical problems when the newborn is in pain. A preliminary study conducted by Petteys indicated no significant difference in stress levels between the palliative care and usual care groups. However, it is important to note that infants referred to palliative care are more critically ill and have higher mortality than other NICU infants, leading to higher stress scores among their parents (26).
The use of methods to calm the infant during pain had a significant relationship with parental stress. Research has determined that the most effective ways for parents to reduce the pain of premature infants are skin-to-skin care (27) and facilitated tucking (8). According to the results, parents' satisfaction when the infant’s pain was controlled by the care team had a significant relationship with parental stress, with greater satisfaction reducing stress. In the Petteys et al.’s study, all parents whose infants received palliative care to reduce pain reported high satisfaction with the care, suggesting that palliative care may reduce stress in parents of the most vulnerable infants (26).
The findings revealed that from the parents' perspective, receiving information and support during the infant’s pain, as well as the use of pain relievers, were related to parental stress. Consistent with the results of the present study, Alburaey presented that increasing parents’ information about infant pain encourages cooperation in pain control and reduces stress (28). In other studies, more than half of the nurses allowed parents to relieve the baby’s pain and taught them about the signs of pain on the infant’s face (28-31). Based on the parents’ perspective, a quick response to relieve the infant’s pain and parents staying with the infant during pain were associated with reduced parental stress. According to the results, the presence of parents with babies, the availability of nurses to answer questions and concerns, honesty in caregiving, and education during discharge had a positive effect on reducing stress and providing non-pharmacological methods of pain control (32, 33).
5.1. Conclusions
Considering that the pain of newborns has negative effects on the healing process of infants and can increase hospitalization duration as well as parental stress, it is recommended that the Department of Newborn Health take basic measures to improve performance in this area. Additionally, a guideline should be formulated for evaluating pain as a fifth vital sign. More attention should be given to the role of parents as the best pain relievers for infants. As infant pain control is an interdisciplinary task, the training of all members of the treatment team should be prioritized. Special attention should be given to infant pain control methods in the curriculum for nurses, neonatologists, and pediatricians.
5.2. Limitations
One limitation that could introduce bias or imprecision was the participant selection limited to hospitals in Khoy city, which may not generalize to the broader population. To mitigate this limitation, sampling was done with maximum variety to increase generalizability. The data were self-reported, which may introduce recall bias or social desirability bias. Participants may not accurately remember past events (recall bias) or may answer in a way they believe is socially acceptable rather than truthful (social desirability bias). To reduce this bias, the researcher was present with the participants while completing the questionnaires and answered their questions.
