SUPPORTI NG PARENTS

Anxiety and depression in parents of sick neonates: a hospital-based

study
Li-Ping Kong, Yan Cui, Yu-Fang Qiu, Shu-Ping Han, Zhang-Bin Yu and Xi-Rong Guo
Aims and objectives. To investigate the prevalence of anxiety and depression in parents of hospitalised neonates and to ana-
lyse their relationship with other factors such as stress and social support, to provide evidence for targeted clinical interven-
tions.
Background. The perinatal period, a special susceptibility to negative emotions, is a period that women and their spouses
have to face. In this time, the fact that the neonates have to be hospitalised is no doubt a huge psychological stress to their
parents. Little understanding of the hospitalisation environment, lacking awareness of neonatal diseases as well as concerns
about the neonates safety, can easily lead to negative emotions in parents. Under the inuence of negative mood, parents
could become irritable and vulnerable, which may do harm to their physical and mental health, impact family harmony and
even result in ineffective communication with doctors, affecting the care of neonates.
Design. This study applied a cross-sectional study design.
Methods. The psychological status of 600 parents (400 fathers and 200 mothers) was assessed in the rst week of the
hospitalisation of neonates, using the Self-Rating Anxiety Scale, Self-Rating Depressive Scale, Social Support Rating Scale
and Perceived Stress Scale.
Results. The results of the cross-sectional survey showed that 20% of fathers and 24% of mothers had symptoms of anxiety,
while 308% of fathers and 35% of mothers had depressive symptoms. The total scores for anxiety and depression in these
parents were signicantly higher than the normal population (p < 001). The level of social support and perceived stress
were the most important factors relating to parental anxiety and depression.
Conclusion. Parents of hospitalised neonates are more prone to suffer from negative emotions than normal population. Anx-
iety and depression are common emotions in these parents. However, the social support they receive is far from satisfactory,
so timely and effective nursing interventions are essential.
Relevance to clinical practice. Health professionals should understand the mental health of parents with hospitalised
neonates and take measures to reduce their psychological pressure so as to improve their care of the neonates, and help to
maintain the harmony and stability of families and the whole society.
Key words: anxiety, depression, hospitalised neonates, incidence, parents, related factors
Accepted for publication: 11 September 2012
Authors: Li-Ping Kong, RN, MSN, Associate Instructor, School of
Nursing, Nanjing Medical University, Nanjing and Department of
Nursing, Nanjing Health School, Nanjing; Yan Cui, MMEd, Pro-
fessor, School of Nursing, Nanjing Medical University, Nanjing;
Yu-Fang Qiu, MMEd, Associate Chief Physician, Department of
Pediatrics, Nanjing Maternal and Child Health Hospital Afliated
to Nanjing Medical University, Nanjing; Shu-Ping Han, PhD, Asso-
ciate Professor, Department of Pediatrics, Nanjing Maternal and
Child Health Hospital Afliated to Nanjing Medical University,
Nanjing; Zhang-Bin Yu, PhD, Registered Medical Practitioner,
Department of Pediatrics, Nanjing Maternal and Child Health
Hospital Afliated to Nanjing Medical University, Nanjing; Xi-
Rong Guo, PhD, Professor, Department of Pediatrics, Nanjing
Maternal and Child Health Hospital Afliated to Nanjing Medical
University, Nanjing, China
Correspondence: Yan Cui, Professor, No. 140 Han-Zhong Road,
Nanjing 210029, China. Telephone: +86 025 86862801.
E-mail: cyan@njmu.edu.cn;
Yu-Fang Qiu, Associate Chief Physician, No.123 Tian Fei Xiang,
Mo Chou Road, Nanjing 210004, China.
E-mail: qiuyufang0298@126.com
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 11631172, doi: 10.1111/jocn.12090 1163
Introduction
With the transformation of the modern medical model and
the establishment of humanistic nursing, nursing care is not
related purely to illness, but also extends to psychological,
social and family nursing. Furthermore, nursing care
extends to family members of patients and healthy people
(Fang et al. 2009).
In recent years, the mental health of parents with hospi-
talised neonates has been of increasing concern for clinical
paediatric workers. The perinatal period, a special suscepti-
bility to negative emotions, is a period that women and
their spouses have to face (Feng & Wang 2010). Hospitali-
sation is not only a serious physiological stress for neo-
nates, but also produces psychosomatic stress in their
parents, including anxiety, depression and other negative
emotions. The negative moods experienced by the parents,
such as irritability, bad temper and impulsive behaviour
(Wu & Cheng 2006), may inuence the quality of care for
their children, or even lead to doctorpatient conicts.
Understanding the psychological status of these parents,
and working to reduce their stress levels, will not only help
to improve the care quality of the neonates (Wu & Cheng
2006), but might also help to maintain the harmony and
stability of families and society as a whole.
Anxiety is an unpleasant and common experience of
external events or internal thoughts, and it involves a series
of emotional reactions of varying severity, manifested as
tension, fear, nervousness, accompanied by the functional
hyperthyroidism of autonomic nervous system and the feel-
ing of an uncertain future (Wang 2007). Depression is the
most common emotional response to psychological stress,
about 103% of the normal population suffer from depres-
sion, feeling obvious weary when doing slightly things,
upset, lower self-condence, despair, sleep disorder, loss of
appetite are common symptoms (Goldney et al. 2010).
Severe depression will seriously trouble the patients life
and work, imposing a heavy burden to families and the
society. There is some variation in the reported prevalence
of anxiety and depression worldwide in parents of hospita-
lised neonates. This is most likely due to the differences
between measurement tools, survey standards and living
environments. Miles et al. (2007) investigated 102 mothers
of premature infants and found that 63% of mothers had
depressive symptoms during their childrens hospitalisation.
Another study showed that 33% of mothers of premature
and low birth weight infants had depressive emotions
(Poehlmann et al. 2009). Carter et al. (2005) investigated
the psychological status of parents with neonates in the
neonatal intensive care unit (NICU) and parents of normal
term newborns. The results revealed that the incidence of
anxiety and depression in fathers of NICU neonates was 11
and 6%, respectively, while the incidence of anxiety was
18% and depression was 22% in mothers; NICU parents
had a higher incidence of anxiety and depression than par-
ents of normal term neonates. Vanderbilt et al. (2009)
found that 39% of NICU mothers met the screening criteria
for postpartum depression, compared with 22% of mothers
of normal neonates.
In some Chinese researches, Zhang and Liu (2009) found
that the prevalence of depression in mothers of preterm
infants was 579%. Cao et al. (2007) reported that the inci-
dence of postpartum anxiety and depression in mothers sep-
arated from their babies was 683 and 450%, respectively.
Fang et al. (2009) indicated that the incidence of anxiety
was 312% and depression was 547% in NICU parents.
Yin et al. (2010) found that the anxiety levels of NICU
mothers were higher than those of mothers of normal new-
borns within 24 hours to one week postnatally. In a study
by Wang et al. (2009), the incidence of postpartum depres-
sion in mothers separated from their newborns was 155%.
Long and Wan (2008) found that anxiety and depression
were signicantly higher for NICU parents than parents of
non-NICU hospitalised children. In summary, the existing
researches show that parental anxiety and depression are
widespread in parents of hospitalised neonates, and the
prevalence rate is higher than that of parents with normal
newborns.
The experience of negative emotions in parents has been
associated with multiple physiological and psychological
factors. For instance, the survey by Carter et al. (2005)
showed that fathers of preterm infants with a gestational
age of <33 weeks were more likely to experience anxiety
and depression. In another study, the length of the hospital
stay and the gender of the neonates were the main factors
affecting the occurrence of maternal anxiety, wherein moth-
ers of male babies were more prone to anxiety (Erdem
2010). In addition, parents misunderstanding of the risk of
neonatal morbidity and the severity of the neonates condi-
tion at admission are also major inuencing factors in the
experience of negative emotions (Fang et al. 2009). Davis
et al. (2003) also found that higher education can reduce
the likelihood of depression in mothers of very low birth
weight infants.
Negative parental emotions have been linked with a vari-
ety of adverse outcomes, including acute stress disorder
(ASD) and post-traumatic stress disorder (PTSD) in parents
(Lefkowitz et al. 2010), and thoughts of suicide or harming
their babies (Miller 2002). In addition, infants may grow up
with poor social adaptability (Luoma et al. 2001), low IQ
2013 Blackwell Publishing Ltd
1164 Journal of Clinical Nursing, 22, 11631172
L-P Kong et al.
and learning difculties (Hay et al. 2001). Maternal perinatal
depression is a major risk factor for paternal postpartum
depression (Goodman 2004). Moreover, the fathers support
can affect emotional communications between mothers and
preterm infants after discharge (Holditch-Davis et al. 2007).
Both studies indicate interactions between parents unhealthy
emotions. These multiple and often reciprocal avenues of
adverse effects underscore the importance of understanding
severe parental distress.
Parental anxiety and depression have gradually been
attracting paediatric workers attention, but their incidence
is inadequately reported, and sample sizes are too small
and therefore not representative. The aims of the current
study were to (1) investigate the psychological status (men-
tal health) of parents with hospitalised neonates and study
the epidemiological characteristics of parental anxiety and
depression, and (2) measure the stress levels and social sup-
port of parents and understand how they correlate with
anxiety and depression, (3) explore the associations and
potential predictors of parental anxiety and depressive
symptoms, so as to provide theoretical support for effective
psychological interventions.
Methods
This study applied a cross-sectional study design using some
certain questionnaires to investigate the subjects anxiety,
depression, stress level and social support status during a
certain time. The cross-sectional study design is the method
that is used to observe the disease and health status as well
as its associated factors of the target population in some
time point. In this study, parents of hospitalised neonates
were investigated by four questionnaires including the Self-
Rating Anxiety Scale (SAS), Self-Rating Depressive Scale
(SDS), Social Support Rating Scale (SSRS) and the Perceived
Stress Scale (PSS) in the rst week of the neonates hospital-
isation. We chose the sixth day of the rst week to be the
observation time point, and all the investigators were
trained before the study so as to keep the consistency of the
research.
Participants
The study was carried out at the Department of Pediatrics
in Nanjing Maternal and Child Health Hospital in the
Peoples Republic of China. The parents of neonates were
recruited during the rst week that their newborn babies
were being observed or treated in the Department of Pedi-
atrics, from JanuarySeptember 2011. The inclusion crite-
ria were (1) parental age of 18 years old, with
sufcient ability to communicate and read, (2) parents
with no serious physical illness or mental disorder, and
(3) parents informed consent, with no medical conicts,
(4) neonates were treated in the hospital for more than
24 hours.
Ethical consideration
This research was approved by the Ethics Committee of
Nanjing Maternal and Child Health Hospital afliated to
Nanjing Medical University. The strategies to approach and
gain consent from all parents were approved. All partici-
pant data were made anonymous and stored in a password-
protected computer program.
Study procedures
Convenience sampling was used for this cross-sectional
study. First, the investigator selected parents who met the
inclusion criteria, making sure that they had certain reading
abilities. Then, one parent or both parents completed a
demographic information questionnaire, along with ques-
tionnaires assessing anxiety, depression, perceived stress and
social support in one week after the delivery of sick babies.
Every questionnaire was completed in full, and the suspicious
answers were claried timely at the scene.
Data collection measures
Demographic information questionnaire
Parents reported on their own gender, income, highest level
of education and so on. Mothers completed items about
birth and pregnancy histories (i.e. history of previous preg-
nancies, miscarriages, children in NICU and infant medical
problems identied during pregnancy).
The Zung Self-Rating Anxiety Scale (SAS) and Zung Self-
Rating Depressive Scale (SDS)
The SAS and SDS were specically developed to assess the
presence and degree of anxiety and depression in adults
(Wang et al. 1999). Each scale has 20 items presented in a
multiple-choice format. Each item is given a severity score
from 1 (a little of the time) to 4 (most of the time). The
maximum total SAS or SDS score is 80; the higher
the score, the more severe the depression or anxiety. For
the SAS, a score of more than 50 is considered an anxious
state. Anxiety is divided into mild anxiety (5059), moder-
ate anxiety (6069) and severe anxiety (>60). For the SDS,
the cut-off score is 53; depression is divided into mild
depression (5362), moderate depression (6372) and
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 11631172 1165
Supporting parents Parental anxiety and depression
severe depression (>72). Both the SAS and SDS have been
extensively validated, and psychometric evaluations have
been performed in the Chinese general population.
Social Support Rating Scale (SSRS)
The SSRS is a 10-item self-report questionnaire divided into
three dimensions: objective support, subjective support and
the utilisation of support (Wang et al. 1999). This scale
was developed to assess the social support and social rela-
tions of those completing the questionnaire and to enable
the analysis of correlations between health and different
sources of support. The maximum total SSRS score is the
sum of the item scores, and the higher the score is, the
more social support the parents have.
Perceived Stress Scale (PSS)
The PSS scale, which is used to assess how unpredictable,
uncontrollable and overloaded ones life is, was developed
by Cohen in 1983 (Cohen et al. 1983). It has 10 items, and
every item includes ve grades (04). The total score ranges
from 040, with higher scores indicating higher perceived
stress.
Data analyses
Statistical analysis was performed using SPSS, version 13.0
for Windows (SPSS Inc., Chicago, IL, USA). Missing values
were handled according to the guidelines given in the man-
uals of the questionnaires. All quantitative variables were
expressed as mean SD and median. The prevalence of
parental mental health problems (anxiety, depression) was
then calculated. Pearson correlation analyses were per-
formed to identify the correlations between stress level,
social support and parental mental health. Risk factors
were identied using univariate regression analysis. T-tests
or F-tests were conducted to compare anxiety and depres-
sion with regard to specic characteristics of parents and
neonates. Finally, a multivariate regression analysis was
performed with an entry signicance level for risk factors
of p < 005 in the univariate analysis. All tests were per-
formed at a signicance level of 5% (p < 005).
Results
Socio-demographic data
A total of 600 parents with hospitalised neonates met the
eligibility criteria for this study from JanuarySeptember
2011. The socio-demographic and neonatal illness-related
data for the 600 parents are reported in Table 1.
Mental health problems in parents
Anxiety
The SAS revealed that, of 600 parents, 2133% were in an anx-
ious state, including mild anxiety (1617%), moderate anxiety
(35%) and severe anxiety (167%). Twenty per cent of fathers
and 24% of mothers met the criteria for anxiety (Table 2). As
can be seen in Table 3, the overall score of anxiety in parents
(4073 1059) was much higher than that of Chinese normal
population with signicant difference (p < 001).
Table 1 Demographic and clinical background of parents and neo-
nates
Fathers (n = 400)
Mothers
(n = 200)
Age, years
(mean SD)
3076 460 2853 406
Average married
years
(mean SD)
317 278 330 313
Level of education,
n (%)
Primary school 4 (1) 1 (05)
Senior high school 36 (9) 23 (115)
Junior high school 67 (1675) 48 (24)
College or higher 293 (7325) 128 (64)
Household income,
Yuan per month,
n (%)
<5000 269 (6725) 168 (84)
5000~10,000 92 (23) 25 (125)
>10,000 39 (975) 7 (35)
Area of residence,
n (%)
Urban 307 (7675) 155 (78)
Rural 93 (2325) 45 (22)
Number of family
members
(mean SD)
301 133 302 130
Medical insurance,
n (%)
Yes 276 (69) 110 (55)
No 124 (31) 90 (45)
Childs gender,
n (%)
Male 232 (58) 112 (56)
Female 168 (42) 88 (44)
Gestational age in
weeks
(mean SD)
3709 316 3663 334
Birth weight in
grams
(mean SD)
305190 102888 292670 93775
Age in days
(mean SD)
727 548 871 618
2013 Blackwell Publishing Ltd
1166 Journal of Clinical Nursing, 22, 11631172
L-P Kong et al.
Depression
The SDS revealed that, of 600 parents, 3217% were in a
depressive state, including mild depression (2317%), mod-
erate depression (717%) and severe depression (183%).
3075% of fathers and 35% of mothers reported possible
clinical depression (Table 2). As can be seen in Table 3,
parents scored signicantly higher on the clinical score for
depression (4434 1344) compared with the Chinese
national norm (p < 001).
Social support
The SSRS showed that scores for objective support
(922 284), utilisation of support (783 188) and the
total social support (3967 719) were signicantly lower
than the Chinese norm (p < 001) (Table 3).
Pressure level
The parental level of perceived stress was in the medium
range (Table 3).
Risk factors for anxiety and depression in parents
Univariate analysis
Factors that may affect parental anxiety and depression were
examined using Pearson correlation analysis; any meaningful
variables were screened using F- or t-tests (Table 4). In total,
nine factors were shown to correlate with parental anxiety
and depression, including education, health insurance, area
of residence, family income, total social support, subjective
and objective support, utilisation of support and stress level.
Parents with lower educational levels scored signicantly
higher for anxiety and depression than those with higher
educational levels (p < 001). Parents with no medical
protection scored signicantly higher for both anxiety and
depression than those who had medical protection
(p < 001). Parents living in rural areas scored higher for
both anxiety and depression than those living in cities
(p < 001). Parents whose monthly family income was
<5000 Yuan per month had more serious depression than
parents whose monthly income was over 5000 Yuan per
month (p < 001). In addition, stress levels, social support
and its subcomponents were signicantly correlated with
anxiety and depression in parents (p < 001) (Table 5).
Multivariate analysis
A multiple stepwise regression analysis in Table 6 showed that
the main factors affecting parental anxiety and depression
were objective support and stress level, which suggests that the
more objective support and the less psychological stress the
parents have, the less anxious and depressed they will feel.
Table 2 Incidence of anxiety and depression in parents of hospitalised neonates (%)
Parents (n = 600) Father (n = 400) Mother (n = 200)
n % n % n %
Anxiety 128 2133 80 2000 48 2400
Mild anxiety 97 1617 61 1525 36 1800
Moderate anxiety 21 35 10 250 11 550
Severe anxiety 10 167 9 225 1 050
Depression 193 3217 123 3075 70 3500
Mild depression 139 2317 93 2325 46 2300
Moderate depression 43 716 27 675 16 800
Severe depression 11 183 3 075 8 400
Table 3 A comparison between parents anxiety, depression and social support, and the Chinese national norm
Parents (n = 600) Fathers (n = 400) Mothers (n = 200) Chinese norm (n = 1158)
Anxiety 4073 1059* 4042 1076* 4135 1026* 2978 1001
Depression 4434 1344* 4353 1319* 4595 1382* 3346 855
Total social support 3967 719* 3961 714* 3980 731* 4438 838
Subjective support 2263 506 2260 516 2270 486 2381 475
Objective support 922 284* 935 289* 897 271* 1268 347
Utilisation of support 783 188* 766 187* 817 186* 938 240
Stress level 1419 649 1416 653 1425 643
*p < 001.
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 11631172 1167
Supporting parents Parental anxiety and depression
Discussion
Epidemiology of anxiety and depression in parents of
hospitalised neonates
In the present study, anxiety and depression were widespread
in parents of hospitalised neonates. Twenty per cent of
fathers and 24% of mothers met the criteria for anxiety, and
3075% of fathers and 35% of mothers reported possible
clinical depression. Parents scored signicantly higher in the
clinical range of anxiety and depression than the Chinese
normal population. Our ndings regarding parental mental
health problems are consistent with previous studies. In sum-
mary, the mental health of parents with hospitalised neonates
is far from positive, and this should be a cause of concern
and attention for clinicians.
The most common manifestations of anxiety are fatigue,
loss of appetite and sleep, nervousness, irritability, panic
and other symptoms, which may lead to the inadequate
attendance of neonates (Wu & Cheng 2006). The hospital
environment not only brings serious physiological and
psychological stress to infants, but also results in varying
degrees of stress in parents. The hospitalisation of neonates
can result in parental anxiety, depression, fear and other
mental health problems. If the negative emotions are not
dealt with in a timely and effective manner, they may gen-
erate a series of physical and mental problems for parents,
inuence family harmony and stability or even result in bar-
riers in communication between doctors and parents. This
suggests that medical professionals should try to understand
parents mental state, communicate with them and encour-
age them to express their feelings. The necessary level of
comfort and encouragement should be provided to help
alleviate the psychological pressures.
Risk factors for anxiety and depression in parents of
hospitalised neonates
Social support is built on the social network of various
aspects including family, friends, comrades, organisations
Table 4 Univariate analysis of anxiety and depression in parents of hospitalised neonates
Anxiety t/F p Depression t/F p
Gender
Father 4042 1076 0295 0768 4353 1319 1631 0103
Mother 4135 1026 4595 1382
Age (years)
<20 4280 893 F = 0953 0414 4860 841 F = 2526 0057
20~29 4095 1037 4527 1336
30~39 3956 1074 4244 1338
40 4181 1247 4094 1296
Level of education
Primary School 4660 1043 1031 0000 4900 1251 9825 0000
Senior High School 4508 1049 4708 1275
Junior High School 4335 1084 4928 1287
College or higher 3901 1013 4233 1321
Medical insurance
Yes 3938 992 3531 0000 4279 1321 3458 0001
No 4253 1135 4670 1334
Area of residence
Urban 3099 1048 3581 0000 4373 1336 2764 0006
Rural 4359 1053 4727 1342
Household income (Yuan per month)
<5000 4093 1043 1531 0217 4518 1341 4967 0007
5000~10,000 3968 1040 4215 1296
>10,000 3852 1185 3991 1304
Table 5 Correlational analysis between parental anxiety, depres-
sion, social support and stress levels
Parental anxiety
Parental
depression
r p r p
Total social support 0126 0002 0121 0003
Subjective support 0235 0000 0237 0000
Objective support 0144 0000 0140 0000
Utilisation of support 0236 0000 0259 0000
Stress level 0547 0000 0599 0000
2013 Blackwell Publishing Ltd
1168 Journal of Clinical Nursing, 22, 11631172
L-P Kong et al.
and societies moral and material support. Social support
is positively related to the subjective experience of the
individual (Du & Wu 2004). When faced with the same
intensity of stress, individuals who lack or cannot make
good use of their social support system will differ signi-
cantly in terms of their psychological and physiological
reactions. Good social support can provide protection for
individuals under stress, and it has an important role in
the maintenance of a positive emotional outlook (Wang &
Jiao 2010).
The SSRS divides social support into three factors:
objective support, subjective support and utilisation of
support. Objective support is concerned mainly with actual
contacts between individuals and the society (Du & Wu
2004). Support provided by health care workers should be
the most important source of support for parents. However,
this study shows that the level of perceived social support
received by parents, especially objective support (as
revealed by the SRSS score), was signicantly lower than
the national norm, indicating that support for parents psy-
chological needs was not sufcient in terms of timeliness or
effectiveness. Furthermore, in this study, the researchers
found that parents were unsatised with the support
provided by the nursing staff. The lack of parental
understanding regarding the hospital environment, or the
absence of timely informed knowledge regarding diagnosis/
prognosis, may have limited the objective support felt by
parents.
Mounts (2009) pointed out that if nursing support was
reduced by one point, the risk of depression in parents
would increase by 6% (Mounts 2009). This is in line with
the current study, which revealed that parents anxiety and
depression scores were negatively correlated with the over-
all status of social support and each subcomponent; the
lower the level of social support, the more serious the level
of parental anxiety and depression. In recent years, in addi-
tion to traditional psychotherapy, a number of targeted
social support measures have been studied, such as informa-
tion support and group intervention (Melnyk et al. 2006,
Wu et al. 2007). There has been some success for these
measures; the research indicates that support, understand-
ing and help from family members, relatives, friends, co-
workers and organisations contribute to improving parents
mental health.
Undue stress can generate a series of negative emotional
reactions. Studies have shown that maternal postpartum
depression is related to the level of stress (Wang & Chen
2006). Jackson et al. (2007) found that stress levels were
higher in parents of preterm infants with a gestational age
of 2530 weeks, and there was still pressure on the parents
of such infants at 18 months of age. In the current study,
psychological stress was common in parents. Furthermore,
parental anxiety and depression were closely related to
stress levels.
The main causes of parents psychological stress may be
attributable to some or all of the following factors: (1) the
neonatal wards are a closed environment; other family
members cannot directly come into contact with sick
babies and are informed about the neonatal situation via
video during visiting times. The maternalchild separation,
combined with environmental isolation, is a relatively
strong factor affecting mental health. (2) Parents often
lack the proper knowledge and are prone to have great
mental stress associated with worries regarding the disease
and treatment outcomes, and the prognoses. (3) If the
family economic situation is not ideal, the childrens medi-
cal care expenses will be a heavy burden on parents, caus-
ing considerable psychological stress. According to the
above points, we are making some improvement programs
as follows: (1) Some certain parents are allowed to come
into the ward to touch their babies under the condition
that the neonates are in a very serious disease status. (2)
Panels and posters could be exhibited outside the ward to
introduce the disease knowledge to all parents. (3) If the
family indeed could not be able to afford the medical
expense, we would call on some social organisations to
help them and try the best to lighten their economical
burden.
We uphold that medical staff should have compassion
and communication skills so as to understand the parents
Table 6 Summary of linear regression analyses and the predictors of anxiety and depression
Variable Partial regression coefcient Standard error Standardised regression coefcients t p
Anxiety
Objective support 0479 0121 0128 3944 0000
Stress level 0757 0054 0466 14056 0000
Depression
Objective support 0698 0148 0148 4709 0000
Stress level 1068 0066 0518 16212 0000
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 11631172 1169
Supporting parents Parental anxiety and depression
feelings and strengthen exchanges with parents, guiding
them to express their feelings, taking the initiative to give
comfort and encouragement, and so help to ease the
psychological pressure. In addition, if the circumstances
allow, simple decompression exercises such as some
relaxation trainings could be applied to reduce mental
stress.
Conclusions
The current study examined the mental health of parents
with hospitalised neonates and revealed the prevalence of
negative emotions like anxiety and depression; stress level
and social support were the leading factors to those emo-
tions. However, there are limitations within the studies
reported, such as sample constraints and the limited
amount of interventional research. Further epidemiological
surveys on the incidence of negative emotions and their
related risk factors are recommended for systematic, effec-
tive psychological interventions. Parents negative mood
may affect not only their own physical and mental health,
but may also have an adverse impact on family harmony
and stability, subsequently affecting the quality of care
received by their children. Overall, the research indicates
that health care professionals urgently need to address the
concerns of parents and their emotional reactions, be posi-
tive with communication exchanges, encourage parents to
seek help, enhance parents capability to positively explore
the sources of social support and fully mobilise all social
forces to ease psychological pressure, in an attempt to grad-
ually ameliorate negative emotional disturbances.
Study limitations
In this study, as time was limited, the researchers took con-
venience sampling method in collecting data, and only
investigated parents of hospitalised neonates in one tertiary
hospital of Nanjing, so the conclusions of the study may
not so representative.
Relevance to clinical practice
Existing studies have found some related factors that inu-
ence the mental status of parents of hospitalised neonates, for
example, the severity of the neonates illness, limited time to
watch and touch the babies during hospitalisation, and insuf-
cient social support. In these studies, mothers are the most
common investigated subjects; however, these researchers are
less concerned about the fathers of hospitalised infants, so
this study investigated anxiety and depression in fathers and
mothers, respectively. Determining the psychological status
and related factors of bad emotions experienced by parents
of hospitalised neonates can help clinical workers use appro-
priate interventions to decrease stress and improve mental
health of parents with sick babies.
Acknowledgement
This work was supported by grants from the Medical
Innovation Team and Leading Talent of Jiangsu Province
(Grant No. LJ201109), Key Medical Personnel Foundation
of Jiangsu Province (Grant No. RC2011021) and the
Nanjing Medical Science and Technique Development Foun-
dation, Nanjing, Jiangsu, China (Grant No. YKK11054).
Contributions
Study design: YC, Y-FQ, X-RG; data collection and
analysis: S-PH, L-PK, YC and manuscript preparation: L-
PK, Z-BY.
Conict of interest
The authors have no conict of interest to declare.
References
Cao Y, Gao W, Zheng Y & Fan KC
(2007) Study on the psychological
state and nursing interventions of
high-risk pregnancy mothers after
being separated from their newborns.
Maternal and Child Health Care of
China 22, 179180.
Carter JD, Mulder RT, Bartram AF &
Darlow BA (2005) Infants in a neona-
tal intensive care unit: parental
response. Archives of Disease in
Childhood-fetal and Neonatal Edition
90, 109113.
Cohen S, Kamarck T & Mermelstein R
(1983) A global measure of perceived
stress. Journal of Health and Social
Behavior 24, 385396.
Davis L, Edwards H, Mohay H & Wollin
J (2003) The impact of very premature
birth on the psychological health of
mothers. Early Human Development
73, 6170.
Du WD & Wu AQ (2004) Medical Psy-
chology. Jiangsu Peoples Publishing
House, Nanjing, China, pp. 7193.
Erdem Y (2010) Anxiety levels of mothers
whose infants have been cared for in
unit level-I of a neonatal intensive care
unit in Turkey. Journal of Clinical
Nursing 19, 17381747.
Fang JB, Li YH, Zhang L & Qiu CJ
(2009) Study on anxiety, depression
conditions and inuencing factors of
2013 Blackwell Publishing Ltd
1170 Journal of Clinical Nursing, 22, 11631172
L-P Kong et al.
Parents of NICU infant patients. West
China Medical Journal 17, 4244.
Feng C & Wang X (2010) Classication of
postpartum depression phenomena and
the corresponding risk factors. Chinese
Journal of Birth Health & Heredity 18,
145146.
Goldney RD, Eckert KA, Hawthorne G &
Taylor AW (2010) Changes in the
prevalence of major depression in an
Australian community sample between
1998 and 2008. The Australian and
New Zealand Journal of Psychiatry
44, 901910.
Goodman JH (2004) Paternal postpartum
depression, its relationship to maternal
postpartum depression, and implica-
tions for family health. Journal of
Advanced Nursing 45, 2635.
Hay DF, Pawlby S, Sharp D, Asten P,
Mills A & Kumar R (2001) Intellec-
tual problems shown by 11-year
-old children whose mothers had post-
natal depression. Journal of Child Psy-
chology and Psychiatry 42, 871889.
Holditch-Davis D, Schwartz T, Black B &
Scher M (2007) Correlates of mother-
premature infant interactions. Research
in Nursing & Health 30, 333346.
Jackson K, Ternestedt BM, Magnuson A
& Schollin J (2007) Parental stress
and toddler behavior at age
18 months after pre-term birth. Acta
Paediatrica 96, 227232.
Lefkowitz DS, Baxt C & Evans JR (2010)
Prevalence and correlates of posttrau-
matic stress and postpartum depres-
sion in parents of infants in the
Neonatal Intensive Care Unit (NICU).
Journal of Clinical Psychology in
Medical Settings 17, 230237.
Long W & Wan Q (2008) The impact of
non-critically ill neonates admitted to
neonatal intensive care unit on
psychological status of parents. Journal
of University of South China (Medical
Edition) 36, 676677.
Luoma I, Tamminen T, Kaukonen P,
Laippala P, Puura K, Salmelin R &
Almqvist F (2001) Longitudinal study
of maternal depressive symptoms and
child well-being. Journal of American
Academy of Child and Adolescent
Psychiatry 40, 13671374.
Melnyk BM, Feinstein NF, Gillis AL, Fair-
banks E, Crean HF, Sinkin RA, Stone
WP, Small L, Tu X & Gross J (2006)
Reducing premature infants length of
stay and improving parents mental
health outcomes with the Creating
Opportunities for Parent Empower-
ment (COPE) neonatal intensive care
unit program: a randomized, con-
trolled trial. Pediatrics 118, e1414
e1427.
Miles MS, Holditch-Davis D, Schwartz TA
& Scher M (2007) Depressive symp-
toms in mothers of prematurely born
infants. Journal of Developmental and
Behavioral Pediatrics 28, 3644.
Miller LJ (2002) Postpartum depression.
Journal of American Medical Associa-
tion 287, 762765.
Mounts KO (2009) Screening for maternal
depression in the neonatal ICU. Clin-
ics in Perinatology 36, 137152.
Poehlmann J, Schwichtenberg AJ, Bolt D
& Dilworth-Bart J (2009) Predictors
of depressive symptom trajectories in
mothers of preterm or low birth
weight infants. Journal of Family Psy-
chology 23, 690704.
Vanderbilt D, Bushley T, Young R &
Frank DA (2009) Acute posttraumatic
stress symptoms among urban mothers
with newborns in the neonatal inten-
sive care unit: a preliminary study.
Journal of Development and Behav-
ioral Pediatrics 30, 5056.
Wang XY (2007) Clinical manifestations
and classication of anxiety disorders.
Chinese Community Doctors 23, 46.
Wang SY & Chen CH (2006) Psychosocial
health of Taiwanese postnatal hus-
bands and wives. Journal of Psychoso-
matic Research 60, 303307.
Wang LQ & Jiao WH (2010) Study of the
correlation between mental health and
social support in hospitalised patients
with tuberculosis. Journal of Nursing
Administration 10, 322324.
Wang XD, Wang XL & Ma H (1999)
Mental Health Rating Scale Manual
(updated version). Beijing: Chinese
Mental Health Journal 12, 7238.
Wang L, Wang LH & GUO L (2009) The
inuence of the depression on breast
milk feeding in mothers experienced
mothernewborn separation. Journal
of Clinical Nursing 8, 23.
Wu H & Cheng LP (2006) Relationship
between anxiety and social support in
paterfamilias of Infant Hepatitis Syn-
drome. Journal of Nursing Science 21,
2223.
Wu LP, He Z, Han DR, Zhao H & Li Y
(2007) Effect of informational support
on postpartum anxiety of mothers of
premature infant. Chinese Journal of
Nursing 42, 297300.
Yin Z, Wu YH, Cai CP, Zhu XL & Wang
LQ (2010) Status Analysis of anxiety,
depression and social support in
postpartum women with neonate in
NICU. Nursing Journal of Chinese
Peoples Liberation Army 27, 337
339.
Zhang J & Liu C (2009) Study on the psy-
chological state and its inuencing fac-
tors of high-risk pregnancy mothers
after being separated from their new-
borns. Chinese Journal of Practical
Nursing 25, 1720.
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 11631172 1171
Supporting parents Parental anxiety and depression
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
clinically related scholarship which supports the practice and discipline of nursing.
For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN:
High-impact forum: one of the worlds most cited nursing journals, with an impact factor of 1118 ranked 30/95
(Nursing (Social Science)) and 34/97 Nursing (Science) in the 2011 Journal Citation Reports

(Thomson Reuters, 2011).

One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over
8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).
Early View: fully citable online publication ahead of inclusion in an issue.
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley
Online Library, as well as the option to deposit the article in your preferred archive.
2013 Blackwell Publishing Ltd
1172 Journal of Clinical Nursing, 22, 11631172
L-P Kong et al.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.