MATERNAL & NEONATAL HEALTH

Effect of nursing interventions on stressors of parents of premature infants in neonatal intensive care unit
zbek Tu bakkal and S enay O rkan Turan, Zu mru t Bas

Aim. This study was planned for the purpose of determining the effect of stress-reducing nursing interventions on the stress levels of mothers and fathers of premature infants in a Neonatal Intensive Care Unit (NICU). Design. Randomised intervention. Background. The physical and psychosocial environment of the NICU is a major factor in the stress experienced by the family. Method. Interviews were conducted with the parents of premature infants who agreed to participate in the research. An approximately 30-minute educational programme about their infant and the intensive care unit was held for the mothers and fathers in the intervention group within the rst week after their infant was admitted to the intensive care unit. Then they were introduced to the unit and personnel. They were given the information they requested and their questions were responded to. The parents in the control group received nothing in addition to the routine unit procedures. The mothers and fathers stress scores were measured for both groups after their infants 10th day in the NICU with the Parental Stress Scale: NICU (PSS:NICU). Results. The difference between the intervention group and the control group mothers mean stress score was found to be statistically signicant (t = 405, p < 005). It was determined that the stress scores for the fathers in the treatment group in this research were lower, but the difference between the two groups was not found to be statistically signicant (p > 005). Conclusion. It has been determined that parents experience very high stress levels when their infants are admitted to an NICU and that there are nursing interventions which can be implemented to decrease their levels of stress. Relevance to clinical practice. Determining the sources of stress experienced by parents can help NICU nurses use appropriate interventions in cooperation with other members of the team to decrease the stress that parents experience. Key words: children, neonates, nurses, nursing, parenting, stress
Accepted for publication: 1 December 2007

Introduction
For the last few years, premature infants have been cared for in highly technological Neonatal Intensive Care Units (NICU) (Riper 2001, Butler & Galvin 2003). It is extremely stressful for families to put their infants in an NICU. When premature infants are admitted to the NICU, parents think they have lost control because of an unfamiliar environment. My attention has been directed to the reaction of families whose infants
Authors: Tu rkan Turan, PhD, RN, Assistant Professor, School of Nursing, Pamukkale University, Denizli, Turkey; Zu bakkal, mru t Bas PhD, RN, Associate Professor, Department of Child Health Nursing, _ zmir, Turkey; S zbek, RN, Neonatal Intensive enay O Ege University, I Care Unit, Pamukkale University, Education, Training and Research Hospital, Denizli, Turkey

have been in the NICU for a long time. The physical environment is a major source of stress with bright lights, noisy life-support machines, monitoring equipment and chemical odours. Monitors, alarm noises and ventilators can be frightening. In particular, tubes and monitors attached to or next to the incubators and infants can increase the stress of families (Mc Grath & Conliffe-Torres 1996). However, the greatest source of stress often cited by these parents is loss of their expected and desired parental role. They report feeling
Correspondence: Tu rkan Turan, Assistant Professor, School of Nursing, Pamukkale University, Denizli, Turkey. Telephone: +90 258 241 0576. E-mail: turkanturan@pau.edu.tr

2856

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866 doi: 10.1111/j.1365-2702.2008.02307.x

Maternal & neonatal health

Parenting the premature infant

so disappointed and frustrated that they cannot perform the normal parenting tasks (e.g., feeding) as they had expected and also a feeling of extreme distress and helplessness about not being able to protect them (Miles et al. 1992, 1993). Communication with NICU nurses is vital for the adaptation of families to the new environment and to the new language and terminology as they form new relationships during this period of time (Raeside 1997). Parents emotional reactions to the NICU experience include disappointment, guilt, sadness, depression, hostility, anger, fear, anxiety, grief, helplessness, sense of failure and loss of self-esteem (Bennett & Slade 1990, Afeck & Tennen 1991, Miles et al. 1992, 1993, Hughes et al. 1994, Als & Gilkerson 1997, Miles & Davis 1997, Kussano & Maehara 1998, Singer et al. 1999, Caplan et al. 2000, Brazy et al. 2001, Lau & Morse 2001, Eriksson & Pehrsson 2002). Similar results were reported in studies conducted in Turkey with mothers of infants in NICUs (Yavuzarslan 1995, Cimete 1996, Aks it & Cimete 2001).

Nursing interventions: promoting positive parenting

Many parents rst look at the life support equipment in an NICU causes them shock and anxiety. It has been determined that mothers feel overwhelmed by the incubators and other instruments in the NICU and the nurses who comfortably take care of sick infants so that the mothers feel themselves as guests. Parents feel that the nurses need to ask permission to touch their infants and care for them. Parents perceive that the environmental stressors increasing their stress are also harming their infants. However, it has also been determined that when parents learn the function of this equipment and its role in keeping their infant alive, they no longer perceive it to be stressful (Miles & Davis 1997). Giving injections to their infant, inserting tubes, intravenous lines and taking blood have been shown to be the procedures which cause parental stress. It is important for nurses to explain the purpose of these needles, tubes and procedures (Board & Wenger 2003). Nurses can boost parental self-esteem and condence in the NICU. Encouraging visiting, teaching parents how to care for their child and involving them in decision making are all important aspects of this process (Mok & Leung 2006). Parents may not visit for many reasons, including nancial difculties, transportation problems, work schedules and feelings of fear or anxiety. Parents who have difculty in visiting are perceptive about how nurses treat them; therefore, non-supportive nursing behaviours cause them to visit even less (Hummel 2003). In one study, the effectiveness of parent-to-parent peer support for mothers of very preterm infants in an NICU was

evaluated (32 mothers were recruited for the intervention group, 28 mothers were recruited for the control group). Mothers and infants in both groups received medical treatment and social work services as usual. Mothers in the intervention group participated in a support programme; those in the control group did not receive any peer support intervention. The support programme primarily consisted of educational parental support-group meetings and the parent buddy programme. The parent buddy programme consisted of individual parent-to-parent support, primarily telephone support given by a parent experienced with the NICU to a parent of a very preterm infant in the NICU. The mothers who participated in the parent buddy programme reported less stress, state anxiety and depression than the mothers in the control group. The difference between the mean parental stressor scale scores for the intervention and control groups was 139 at four weeks (Preyde & Ardal 2003). The aim of another study was to assess mothers perceptions of stressors related to the NICU environment. Mothers reported that a tour of the NICU was a stressful event; some mothers stated that they were shocked at the size of some of the very preterm infants. These ndings imply that, despite being stressful, a tour of the unit was benecial to mothers. The neonatal unit information booklet was given to 75% of the mothers in the study. All of those who received the booklet found it helpful (Raeside 1997). In another study, 147 parents of preterm infants were allocated to the creating opportunities for parent empowerment (COPE) programme, which comprised audiotaped and written information on infants behaviour and parental roles. Mothers who participated in the COPE programme had less parental stress in the NICU than mothers who received usual care, while fathers in the two groups did not differ (Melnyk et al. 2006). Parents describe non-supportive nursing actions as delaying answer to questions, responding with annoyance, giving false or misleading information, avoiding parents and using overly technical language. Other factors cited as being nonsupportive include limited parental contact/visiting, speaking to parents in unpleasant tones and implying that the parents are incompetent (Hummel 2003, Miles & Davis 1997). Since the earliest days of neonatal care, healthcare professionals have sought to reduce these negative effects by encouraging parents to visit frequently, breast-feeding, holding their infants and interacting with them in a developmentally appropriate manner (Franck et al. 2005). Healthcare professionals should be aware that the needs of parents vary over time as they adapt to their role. An ongoing open and honest relationship will encourage the dialogue necessary to meet parents unique needs as parents to their infant. Although most healthcare professionals agree that these
2857

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

T Turan et al.

principles are important, it is often difcult to translate them into day-to-day practice because of barriers such as time constraints, severity and complexity of long-term illness and increased workload in an intensive-care setting. In addition, some nurses nd the shift from the more traditional roles of helper and caregiver to that of educator, coach and consultant challenging. Efforts to develop a trusting, collaborative relationship with parents will establish a foundation for promoting parental involvement and improved condence in the ability to care for an infant (Beal 2000, Mc Allister & Dionne 2006). No previous study has examined the stress-reducing nursing interventions in Turkey. It is necessary for NICU nurses to be aware of the needs of parents during this sensitive time and to implement stress-reducing nursing interventions for the family. This research was planned for the purpose of determining the effect of stress-reducing nursing interventions on the stress levels of mothers and fathers of premature infants in an NICU.

Method
The data were collected in a 15-bed NICU of Pamukkale University Hospital in Denizli. Seven nurses and four physicians work in the unit. The nurses work is patientcentred. There are two nurses working at a time on day shift and night shift. Because of the heavy workload and small number of nurses, it is not standard for information to be given to the parents of infants in the unit; however, their questions are answered. The research population was comprised of all mothers and fathers of infants admitted to the newborn intensive care unit. Mothers and fathers of infants with a gestational age from 2437 weeks, whose infant did not have a congenital anomaly, who did not have previous experience with the newborn intensive care unit and who agreed to participate in the research comprised the sample. Twenty premature infants mothers and fathers were in the control group and 20 premature infants mothers and fathers were in the experimental group. One father in the control group and three fathers in the experimental group were not able to be reached during the rst interview and a total of 36 fathers were included in the study. The NICU team was requested to notify the researcher as soon as possible after the infants were admitted to the NICU. Within one to two days after an infant was admitted to the unit, the demographic data form and trait anxiety inventory were administered. The rst three weeks after an infant has been admitted to an NICU is a period of time when parents stress level is high
2858

(Hughes et al. 1994). The parents in the intervention group were met with as soon as possible and a meeting time was arranged that would occur within the rst week of their infants admission to NICU. The data collection period was from JanuaryJune 2004. The parents were given education in the education room one-on-one, face-to-face for approximately 30 minutes. The contents of the education included the introduction of the NICU, information about the personnel caring for their infant, technical equipment the parents might see when they enter the unit (monitors, respiratory support equipment, phototherapy lights, etc.) and situations related to their care (medications or nutrition given into the vein, feeding tubes such as nasogastric tubes, blood transfusions, etc.), information about the appearance of a premature infant, feelings that parents may experience during this period of time, visiting the unit, participating in the care of their infant, breast-feeding, weight gain, discharging and medical terminology. Their questions were answered and topics that they did not understand were repeated. Meanwhile, an educational booklet prepared by the researchers about these topics was given to them. Then the charge nurse was asked if the situation in the unit was appropriate, the mother and father were taken together or singly into the NICU. The parents were given information by the researcher, which included introducing the family to the unit personnel, acquainting them with the unit, the equipment being used with their infant, information about their infants condition and treatments that may be used with their infant. The parents were told that sharing their feelings with their spouse, relatives and healthcare personnel would help to decrease their concerns; when possible they were encouraged to share their feelings with the parents of other NICU infants, to ask the nurses questions about things they were curious about and they were supported in doing this without any hesitation. The parents in the control group received nothing in addition to the routine unit procedures. In the NICU where the research was conducted, the parents were taken to see their infant once a day when the situation in the unit was appropriate. After their infants had been in the NICU for approximately 10 days, the parents of both groups were asked to complete the PSS:NICU. Then the infants age in days, the number of times their infant had been visited and the infants ventilator status were evaluated.

Instruments
The infants medical records, demographic data form, trait anxiety inventory, and PSS:NICU were used as research data collection tools. The demographic data form included the

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

Maternal & neonatal health

Parenting the premature infant

mothers age, education, fathers age, education, current number of living children, someone to help with child care, had experienced a stressful life event last year, infants gender, gestational age, birth weight, method of delivery, Apgar scores (ve minutes), current major medical problems in the infant, infants age in days, number of visits of their infants in the NICU and information about whether or not their infants were attached to a ventilator. Trait anxiety inventory The STAI (State-Trait Anxiety Inventory) is a 40-question tool that was developed by Spielberger et al. (1970) and ner and LeCompte (1985). Twenty adapted to Turkish by O of the questions are related to level of state anxiety and 20 to level of trait anxiety. Trait anxiety is an individuals predisposition to experience anxiety. This can also be explained as individuals generally having the tendency to perceive or interpret stressful situations. There are four choices of responses to the statements of the trait anxiety inventory: almost never (1), sometimes (2), often (3), almost always (4). Statements 21, 26, 27, 30, 33, 36 and 39 on the inventory are reversed. In the evaluation, the points from the reversed statements are subtracted from the total score of the direct statements and the total is added to the number 35 to obtain the trait anxiety score. The internal consistency for the trait anxiety tool of the STAI is between ner & LeCompte 1985). 083087 (O Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) The PSS:NICU was developed to measure situations that can cause stress in the NICU. For each item, points from 1 (not stressful)5 (extremely stressful) or 0 (not experienced). Each item was scored using a Likert scale from 1 (not stressful)5 (extremely stressful) or 0 (not experienced) were given. They were told to only mark variables that they had experienced; and from the tool, two separate scores were obtained. Metric 1 is the level of stress experienced by the parents and marked on the tool. For example, if the infants colour changes suddenly and the family marked this as 3 (moderate level of stress) on the tool, three points were given for this evaluation. In addition, if the infants colour does not change suddenly and the family has not experienced this, then no points are given with this scoring system. To be able to comprehend better the degree of stress for every item that is a result of the NICU environment, these points were used. Metric 2 was giving one point to variables that were not experienced by parents; it was scored assuming that this variable did not cause any kind of stress. For example, if the infants colour changes suddenly and the family marked this

as 3 (moderate level of stress) on the tool, then this is given three points in the evaluation. In addition, if the infants colour does not change suddenly and the family has not experienced this, in this scoring system one point is given, assuming that this factor has not caused any stress. These scores were used to determine the level of stress experienced by the parents. The tool has three subscales; Infants Appearance and Behaviours (17 items), Sights and Sounds (six items), Parental Role Alteration (11 items). Miles et al. (1993) tested this tool with 115 mothers and 75 fathers of infants in an NICU and found a Cronbach alpha value of 094 for Metric 1 and 089 for Metric 2. The Cronbach alpha values for the subscales varied between 073092 (Miles et al. 1993). In another research study that was conducted by Reid and Bramwell (2003) in England, there were 40 mothers of premature infants who were admitted to the NICU and in a moderate risk group. In the results, the PSS:NICU scales Cronbach alpha value for sights and sounds subscale was 081; it was 085 for infants appearance and behaviours subscale and was 083 for changes in parental role subscale (Reid & Bramwell 2003). Based on the recommendations of the author, three new items were added, the tool was translated into Turkish and used with the parents of 123 premature infants, and was found to be valid and reliable. The alpha coefcient for all subscales was within acceptable limits (>070). The Cronbach alpha coefcient for the total tool was 089 for Metric 1 and 090 for Metric 2. The subscale Cronbach alpha values were in the range of 078088 (Turan & Bas bakkal 2006).

Ethics procedures
A written permission was taken from the Medical Director of the Pamukkale University Hospital. Besides this, before parents were interviewed, they were informed about the purpose of the research, the benets that would be obtained from the research and the length of time the interview would take; and their verbal permission was received.

Data analysis
Chi-square test and t-test were used to determine the intervention and control groups in terms of demographic and infant characteristics or outcome measure taken at baseline (trait anxiety inventory). The mean stress scores for the mothers and fathers in the intervention and control groups were examined. To examine the correlation between the dependent and independent variables, the MannWhitney U-test was used for paired groups that do not have normal
2859

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

T Turan et al.

distribution and the KruskalWallis test was used for groups that have more than two.

they were found to have a moderate level of stress with no signicant difference between the two groups (Table 1).

Results
There were no statistical differences (p > 005) between the intervention and control groups in terms of demographic and infant characteristics (Table 1). Because the trait anxiety level could have an effect on the scores, mothers and fathers received PSS:NICU. The trait anxiety levels of intervention and control group mothers and fathers were examined, and

Findings related to the mothers PSS:NICU total and subscale scores

As can be seen in Table 2, the Sights and Sounds subscale mean score for the mothers in the intervention group was 203 and for the mothers in the control group was 256. The difference between the two groups for this section was found to be statistically signicant (t = 278, p < 005). The

Table 1 Baseline characteristics of mothers and fathers and their preterm infants in the intervention group and the control group Characteristics Mothers Mean age (and SD), year Education Primary school Middle school University level Occupation Housewife Working Trait anxiety inventory Fathers Mean age (and SD), year Education (and %) Primary school Middle school University level Trait anxiety inventory Infants Mean birth weight (and SD), kg Mean gestational age (and SD), week Mean Apgar score at ve minutes (and SD) Age (and SD) Six to seven days Eight to nine days 10 days and above Caesarean delivery Mechanical ventilation (and %) SD = Standard deviation. *p > 005. Table 2 Comparison of the mothers PSS:NICU total and subscales mean scores Intervention group (n = 20) Subscales Sights and sounds Infants appearance and behaviours Parental role alteration Total n 20 20 20 20 X 203 311 336 314 SD 070 036 037 051 Intervention group Control group v2 t p

247 44 10 (50) 6 (30) 4 (20) 16 (80) 4 (20) 437 (87) 285 44 5 (294) 8 (471) 4 (20) 418 (88) 146 (3809) 3105 (26) 70 (1) 9 (450) 9 (450) 2 (100) 13 12 (60)

250 52 11 (55) 8 (40) 1 (5) 16 (80) 4 (20) 445 (118) 297 53 8 (421) 8 (421) 3 (158) 402 (40) 145 (4173) 3145 (29) 71 (12) 5 (250) 13 (650) 2 (100) 15 13 (65)

0168 2133

0686* 0372*

0000 0244 0223 1428

1000* >005 0732* 0276*

0740 022* 106* 038* 209*

>005

180* 039*

Control group (n = 20) n 20 20 20 20 X 256 332 423 337 SD 073 054 045 057 df 38 38 38 38 t 278 144 661 405 p-value 0008 0157 0000 0000

2860

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

Maternal & neonatal health

Parenting the premature infant

45 4 35 3 25 2 15 1 05 0 Sights and sounds Infants appearance and behaviours Parental Role alteration TOTAL

Infants Appearance and Behaviours subscale mean score for the mothers in the intervention group was 311 and for the mothers in the control group was 332. The difference between the two groups for this section was not found to be statistically signicant (t = 144, p > 005). The parental role subscale mean score for the mothers in the intervention group was 336 and for the mothers in the control group was 423. The difference between the two groups for this section was found to be statistically signicant (t = 661, p < 005). The general mean score for the mothers in the intervention groups was 314 and for the mothers in the control group was 337. The difference between the two groups was found to be statistically signicant (t = 405, p < 005).

MOTHERS FATHERS

Figure 1 Comparison of the mothers and fathers PSS:NICU total and subscales mean scores.

Findings related to the fathers PSS:NICU total and subscale scores

The comparison of the PSS:NICU mean scores obtained by the intervention and control group fathers is shown in Table 3. The sights and sounds subscale mean score for the fathers in the intervention group was 209 and for the fathers in the control group was 248. There was no statistically signicant difference found between the two groups for this section (t = 200, p > 005). The Infants Appearance and Behaviours subscale mean score for the fathers in the intervention group was 302 and for the fathers in the control group was 312. The difference between the two groups for this section was not found to be statistically signicant (t = 048, p > 005). The parental role subscale mean score for the fathers in the intervention group was 397 and for the fathers in the control group was 407. The difference between the two groups for this section was not found to be statistically signicant (t = 026, p > 005). The general mean score for the fathers in the intervention groups was 303 and for the fathers in the control group was 322. The difference between the two groups was not found to be statistically signicant (t = 115, p > 005). Although there was no statistically signicant difference in the subcategory scale mean scores between the mothers and

fathers, there was a statistically signicant difference in the total mean scores, with the fathers having higher mean scores than the mothers (t = 247, p < 005) (Fig. 1).

Findings related to the factors affecting the mothers PSS:NICU score means
The intervention group mothers PSS:NICU scores were not found to be different according to their age, whether or not they had experienced a stressful life event last year, infants gestational age, birth weight and number of times they visited their infants in the NICU (p > 005). The control group mothers age, whether or not they had experienced a stressful life event last year, infants gestational age, birth weight, number of times they visited their infants in the NICU, were found to affect the scores received from the PSS:NICU (p < 005) (Table 4). It was determined that the intervention and control group mothers PSS:NICU scores were not affected by their education, number of living children, whether or not there was someone to help with child care, infants gender, method of delivery, ve-minute Apgar scores, number of major problems, age (in days) (p > 005), but affected whether or not their infant was on the ventilator (p < 005) (Table 4).

Table 3 Comparison of the fathers PSS:NICU total and subscales mean scores Intervention group (n = 17) Subscales Sights and sounds Infants appearance and behaviours Parental role alteration Total N 17 17 17 17 X 209 302 397 303 SD 054 061 042 048

Control group (n = 19) N 19 19 19 19 X 248 312 407 322 SD 060 064 047 052 df 34 34 34 34 t 200 048 026 115 p-value 0053 0628 0793 0256

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

2861

T Turan et al. Table 4 Distribution of mothers PSS:NICU scores according to factors that affected their PSS:NICU score means PSS:NICU scores Intervention group (n = 20) Variables Mothers age* 1519 2024 2529 30 and above Stressful life event last year Yes No Infants gestational age* 2628 weeks 2932 weeks 3337 weeks Infants birth weight 1500 gr. 1500 gr. > NICU visits* 12 34 5 and above Mechanical ventilation Yes No Education* Number of living children Someone to help with child care Infants gender Method of delivery Apgar score (ve minutes) Number of major problems* Age (days)* *KruskalWallis test. MannWhitney U-test. n X SD p-value Control group (n = 20) n X SD p-value

2 7 8 3 4 16 4 9 4 12 5 2 10 8 12 8

9200 8928 8437 8233 8900 8593 9850 8977 8925 9433 8540 8900 8400 8912 9091 8000 8641 8643 8648 8655 8643 8564 8472 8925

1131 851 787 404 1157 730 655 1501 1875 1293 1663 989 498 1056 707 396 820 755 696 817 706 938 634 655

>005

1 11 4 4 6 14 4 8 7 11 8 8 7 5 13 7

12500 10700 9500 8475 11016 9714 11325 9662 8614 10118 8950 11112 9514 9320 10746 8914 10239 9927 10153 10097 10067 10493 10262 9960

934 616 1192 858 1388 970 1376 1142 1523 1368 1058 1088 1347 1079 1051 1343 1473 1318 1389 1424 1206 1326 1192

<005

>005

<005

>005

<005

>005

>005

>005

<005

<005 >005 >005 >005 >005 >005 >005 >005 >005

<005 >005 >005 >005 >005 >005 >005 >005 >005

Findings related to the factors that affected the fathers PSS:NICU score means
The intervention group fathers PSS:NICU scores were not found to be different according to their infants gestational age (p > 005), but found to be different according to whether or not they had experienced a stressful life event last year (p < 005). The control group fathers age, whether or not they had experienced a stressful life event last year and infants gestational age were found to affect the scores received from the PSS:NICU (p < 005) (Table 5). It was determined that the intervention and control group fathers PSS:NICU scores were not affected by their education, number of living children, whether or not there was someone to help with child care, infants gender, method of
2862

delivery, birth weight, ve-minute Apgar scores, number of major problems, age (in days), number of times they visited their infants in the NICU and whether or not their infant was on the ventilator (p > 005) (Table 5).

Discussion
The sights and sounds subscale mean score obtained by the mothers in the intervention group was found to be statistically different from that of the control group (p < 005). Researchers have found that parents in the NICU have clearly different, unique experiences from normal birth. In the beginning, they are taken into the NICU environment equipped with machines and monitors for which no one is prepared (Miles et al. 1992, Hughes et al. 1994). Knowing

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

Maternal & neonatal health

Parenting the premature infant

Table 5 Distribution of fathers PSS:NICU scores according to factors that affected their PSS:NICU score means PSS:NICU scores Intervention group (n = 17) Variables Stressful life event last year* Yes No Infants gestational age 2628 weeks 2932 weeks 3337 weeks Age Education Number of living children* Someone to help with child care* Infants gender* Method of delivery* Birth weight* Apgar score (ve minutes)* Number of major problems Age (days) NICU visits Mechanical ventilation* *MannWhitney U-test. KruskalWallis test. n X SD p-value Control group (n = 19) n X SD p-value

5 12 4 9 4

7780 9750 9850 8977 8925 9068 9279 9307 9085 9178 9470 8986 8935 8997 9259 9432 8925

1023 1144 655 1501 1875 1664 1320 1341 1507 1441 1500 1478 1595 1160 1502 964 513

<005

5 14 4 8 7

10760 9221 11325 9662 8614 9650 9725 9542 9561 9615 9677 9534 10562 10045 9553 9622 9311

838 1546 970 1376 1142 1620 1783 1530 1624 1595 1630 1445 609 1738 1274 1650 1017

<005

>005

<005

>005 >005 >005 >005 >005 >005 >005 >005 >005 >005 >005 >005

>005 >005 >005 >005 >005 >005 >005 >005 >005 >005 >005 >005

the sources of environmental-related stress can help to decrease parents stress. For example, when parents are given an explanation about the reason why monitors are used and about the meaning of alarms and when the monitor alarms are adjusted to appropriate limits, their stress will decrease (Board & Wenger 2003). The highest mean scores for mothers in the intervention and control groups in this research were in the parental role alteration subscale and the greatest difference between the groups was also seen in this subscale. Miles et al. (1992) examined the level of stress of mothers of 23 premature infants and determined that, as a subscale, changes in the mothers roles were the most stressful. Not being able to meet their infants needs of basic care is a clear cause for stress in families. Inexperienced mothers feelings of stress and helplessness may be increased by comparing themselves with personnel who have the ability to care for their infants (Miles et al. 1992, Nottage 2002). At the conclusion of the research, a statistically signicant difference was found between the PSS:NICU total mean scores for the intervention and control group mothers (t = 405, p < 005). In a study conducted by Preyde and Ardal (2003), it was determined that mothers whose infants are in an NICU and who are given a supportive intervention

had lower PSS:NICU stress scores than the mothers not given the intervention. No statistically signicant difference was found between the PSS:NICU subscale or general score means for the intervention and control group fathers (t = 115, p > 005). However, when the mean scores are looked at one by one, it can be seen that the intervention group fathers had lower stress scores. The fathers stress score means were similar to the research results of Miles and Brunssen (2003). Mothers and fathers, when their infants are admitted to an NICU, perceive their preparation as very important. In one study, mothers reported that a tour of the NICU was a stressful event; some mothers stated that they were shocked at the size of some of the very preterm infants. However, ndings show that, although it is stressful, acquainting mothers with the NICU is benecial (Raeside 1997). All of the parents who had received the neonatal unit information booklet found it helpful. The researchers believe that the nding of the intervention group mothers and fathers low stress score was a result of the effectiveness of the stressreducing nursing interventions. When the mothers and fathers score means were examined, it was seen that the fathers stress score mean was higher than the mothers. During the rst days after an infant is
2863

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

T Turan et al.

admitted to an NICU, the fathers have to assume more responsibility because of the mothers health status. This may be the reason why the fathers stress score mean was higher than the mothers. There was a statistically signicant difference in the control group mothers stress scores according to the mothers age. Younger mothers had signicantly increased stress. In a study conducted with adolescent mothers who had infants in an NICU, it was determined that the most stressful situations were parental role changes and the infants appearance and behaviours (Christopher et al. 2000). The intervention group mothers stress scores were not signicantly different according to their age. The reason why the young mothers in this group did not have a clear increase in their stress scores shows the stressreducing nursing interventions implemented by the researchers. There was a statistically signicant difference in the control group mothers stress scores according to the gestational age and birth weight of their infants. The appearance of their infants, their medical care needs and length of stay in the unit vary according to gestational age. The nding that the mothers of infants who had a young gestational age experienced more stress was an expected nding. In a study conducted with the mothers of 12 premature infants, the mothers of infants with birth weight less than 1500 g had higher stress scores than mothers whose infants had birth weights greater than 1500 g (Raeside 1997). There was no statistically signicant difference in the intervention group mothers stress scores according to their infants gestational age and birth weight. The stress scores of the mothers who visited their infants a small number of times was higher than that of the mothers who visited their infants more often. Nurses need to help increase the self-respect and condence of parents in the NICU. The foundations of this process are to encourage them to visit, and to teach them how to care for their infants. Lack of understanding and support being shown to mothers and fathers who experience difculty with visiting may be a cause for their coming to visit less often (Dobbins et al. 1994, Miles & Davis 1997). There was no statistically signicant difference in the stress scores of intervention group mothers according to the number of times they visited their infants in the NICU. Control group fathers who had experienced a stressful life event last year had higher PSS:NICU scores than fathers who had not. The reason for this result may be because the control group fathers in this research had positive gains from their past experiences with stressful events or they had exhausted their strength with the previous event. Interven2864

tion group fathers who had experienced a stressful life event last year had lower PSS:NICU scores than the fathers who had not. Stressful life events can have positive and negative effects on individuals. Individuals who experience back-toback or intensely stressful life events may have exhausted their strength and may have even more severe anxiety when they encounter new stressful life events. In contrast to this, an individual who has experienced a previous stressful life event can use the coping methods that they developed during that time and successfully overcome new events (Aks it & Cimete 2001). This result may be what had happened in this phase of the research with the intervention group fathers. A statistically signicant difference was found in the stress scores for fathers in the control group according to their infants gestational age. Fathers whose infants had lower gestational ages had more stress in the NICU, which is an expected result. There was no statistically signicant difference between the intervention group fathers stress scores according to their infants gestational age. The reason why none of these variables, which are thought to have an effect on the mothers and fathers stress scores from the PSS:NICU, had no effect on mothers and fathers in the intervention group is thought to be the effect of the education and stress-reducing interventions given to the intervention group.

Conclusion
The admission of their infant to a newborn intensive care unit is a stressful event for the parents. Within 10 days of admission of their premature infant to the newborn intensive care unit, the parents in the experimental group were administered the stress-reducing nursing interventions. As a result, the parents in this group were found to have lower PSS:NICU scores than the control group. In addition, the mothers in the control group whose age was younger, who had experienced another stressful life event within the last year and whose infants gestational age was less were found to have higher PSS:NICU stress scores. Family-centred nursing practice is very important. It is suggested that it would be appropriate for written documents to be prepared, which provide information for parents when their infants are admitted to an NICU about the unit and how their infants needs will be met. In conclusion, there is a need for supportive nursing interventions, such as being with parents during their rst visits to the NICU, explaining about their infants condition, answering their questions, giving condence by supporting them emotionally, encouraging them to come and visit

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

Maternal & neonatal health

Parenting the premature infant Franck LS, Cox S, Allen A & Winter I (2005) Measuring neonatal intensive care unit related parental stress. Journal of Advanced Nursing 49, 608615. Hughes M, McCollum J, Sheftel D & Sanchez G (1994) How parents cope with the experience of neonatal intensive care. Child Health Care 23, 114. Hummel P (2003) Parenting the high-risk infant. Newborn and Infant Nursing Reviews 3, 8892. Kussano AC & Maehara S (1998) Japanese and Brazilian maternal bonding behaviour towards preterm infants. Journal of Neonatal Nursing 4, 2328. Lau R & Morse CA (2001) Parents coping in the neonatal intensive care unit: a theoretical framework. Journal of Psychosomatic Obstetric & Gynecology 22, 4147. Mc Allister M & Dionne K (2006) Partnering with parents: establishing effective long-term relationship with parents in the NICU. Neonatal Network 25, 329337. Mc Grath JM & Conliffe-Torres S (1996) Integrating family centered developmental assessment and intervention in to routine care in the neonatal intensive care unit. The Nursing Clinics of North America 31, 367386. Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, Stone PW, Small L, Tu X & Gross SJ (2006) Reducing premature infants length of stay and improving parents mental health outcomes with the creating opportunities for parent empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics 118, 14141427. Miles SM & Brunssen SH (2003) Psychometric properties of the parental stressor scale: infant hospitalization. Advances in Neonatal Care 3, 189196. Miles MS & Davis DH (1997) Parenting the prematurely born child: pathways of influence. Seminars in Perinatology 21, 254 266. Miles MS, Funk SG & Kasper MA (1992) The stress response of mothers and fathers of preterm infants. Research in Nursing Health 15, 261269. Miles MS, Funk SG & Carlson J (1993) Parental stressor scale: neonatal intensive care unit. Pediatric Nursing 42, 148152. Mok E & Leung SF (2006) Nurses as providers of support for mothers of premature infants. Journal of Clinical Nursing 15, 726734. Nottage SL (2002) The Effects of Parental Stress on Hospital Supportive Service Utilization. Unpublished Dissertation, August 26, Faculty of The Chicago School of Professional Psychology, USA, pp. 4456. ner N & LeCompte A (1985) Durumluk-Su O rekli Kayg Envanteri El Kitab (State-Trait Anxiety Inventory Handbook), 2th edn. _ niversity Press, Istanbul. Bog i U azic Preyde M & Ardal F (2003) Effectiveness of a parent buddy program for mothers of very preterm infants in a neonatal intensive care unit. CMAJ 15, 969973. Raeside L (1997) Perceptions of environmental stressors in the neonatal unit. British Journal of Nursing 6, 914923. Reid T & Bramwell R (2003) Using the parental stressor scale: NICU with a British sample of mothers of moderate risk preterm infants. Journal of Reproductive and Infant Psychology 21, 279291. Riper MV (2001) Family-provider relationships and well-being in families with preterm infants in the NICU. Heart and Lung 30, 7482.

their infant and to touch their infant, teaching them how to care for their infant, informing them about the treatments and procedures being used with their infant, explaining why medical devices are being used and avoiding medical terminology.

Contributions
Study design: TT, ZB; data collection and analysis: TT, S O and manuscript preparation: TT, ZB

References
Affleck G & Tennen H (1991) The effect of newborn intensive care on parents psychological well-being. Child Health Care 20, 614. Aks it S & Cimete G (2001) C ocug un yog un bakm u nitesine kabulu irelik bakmnn annelerin anksiy nde, annelere uygulanan hems ete du zeyine etkisi (Effect on mothers anxiety level of nursing care niversitesi for mothers in admitting child to an ICU). Cumhuriyet U Hems irelik Yu ksekokulu Dergisi 5, 2535. Als H & Gilkerson L (1997) The role of relationship-based developmentally supportive newborn intensive care in strengthening outcome of preterm infants. Seminars in Perinatology 21, 178 189. Beal JA (2000) A nurse practitioner model of practice in the neonatal intensive care unit. The American Journal of Maternal Child Nursing 25, 1823. Bennett DE & Slade P (1990) Reactions of mothers of preterm infants. Midwife Health Visitor & Community Nurse 26, 323326. Board R & Wenger NR (2003) Stressors and stress symptoms of mothers with children in the PICU. Journal of Pediatric Nursing 18, 195201. Brazy JE, Anderson BM, Becker PT & Becker M (2001) How parents of premature infants gather information and support. Neonatal Network 20, 4148. Butler LC & Galvin K (2003) Parents perceptions of staff competency in a neonatal intensive care unit. Journal of Clinical Nursing 12, 752761. Caplan G, Mason EA & Kaplan DM (2000) Four studies of crisis in parent of prematures. Community Mental Health Journal 36, 25 45. Christopher SE, Bauman KE & Meehan KV (2000) Perceived stress, social support and affectionate behaviours of adolescent mothers with infants in neonatal intensive care. Journal of Pediatric Health Care 14, 288296. Cimete G (1996) Sorunlu yenidog etm an ebeveynlerinin stresle bas elerini destekleyici bir hems irelik yaklas m modeli (A nursing care model for supporting coping with stress of parents of ill newborns). Tu ireler Dergisi 46, 28. rk Hems Dobbins N, Bohling C & Sutphen J (1994) Partners in growth: implementing family-centered changes in the neonatal intensive care unit. Child Health Care 23, 115126. Eriksson BS & Pehrsson G (2002) Evaluation of psychosocial support to parents with an infant born preterm. Journal of Child Health Care 6, 1933.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866

2865

T Turan et al. Singer LT, Salvator A, Guo S, Collin M, Lilien L & Baley J (1999) Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant. JAMA 281, 799805. Spielberger CD, Gorsuch RL & Lushene RL (1970) Manual for the State-Trait Anxiety Inventory: STAI (Self-evaluation Questionnaire). Consulting Psychologist Press, Palo Alto, USA. Turan T & Bas bakkal Z (2006) Yenidog an yog un bakm u nitesi anne baba stres o eg erlik ve gu als mas (Study on inin gec lc venirlik c validity and reliability of a Turkish version of the parental stress niversitesi scale: neonatal intensive care unit). Hacettepe U Hems irelik Yu ksekokulu Dergisi 13, 3242. Yavuzarslan F (1995) Prematu re servisinde yaplan planl taburcu eg itiminin bakma etkisi (Effect of Planned Discharge Education on Premature Service). Unpublished Dissertation, University of Hacettepe, Ankara.

2866

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 28562866