Research in Nursing & Health, 1992, 15, 261 -269
The Stress Response of Mothers Fathers of Preterm Infants Margaret Shandor Miles, Sandra G. Funk, and Mary Ann Kasper
Differences in neonatal intensive care unit (NICU) environmental stress, uncertainty, and anxiety of 23 mothers and fathers (couples) whose premature infants were hospitalized in an NICU were explored. Alterations in the parental role were found to be stressful for both mothers and fathers, with mothers reporting significantly greater stress in this area than did fathers. Stress and uncertainty decreased significantly over time. Mothers and fathers did not differ in level of anxiety. Findings suggest that both mothers and fathers are distressed by the admission of a premature to an NICU; however, mothers may be more distressed by certain aspects of the experience.@ 1992 John Wiley 8 Sons, Inc.
It is well documented that the birth and hospitalization of a preterm infant are very distressing for parents. Feelings of disappointment, fears regarding the child’s survival, and altered parental experiences, including separation and reduced opportunities to interact with the infant, are all difficult for parents (Affleck, Tennen, & Rowe, 1991; Benfield, k i b , & Reuter, 1976; Gennaro, 1988; Philipp, 1983; Trause & Kramer, 1983). Another source of stress for parents is the environment of the neonatal intensive care unit (N1CU)-the sights and sounds of the unit, the infant’s physical appearance, the equipment, and relationships with health care personnel in the unit (Miles, 1989; Miles, Funk, & Kasper, 1991; Paludetto, Faggiano-Perfetto, Asprea, De Curtis, & Margara-Paludetto, 1981; Yu, Jamieson, & Astbury, 1981). It is thought that these experiences of parents of preterm infants may seriously delay successful attainment of the parental role and may influence later parent-infant interactions (Easterbmks, 1988; Goldberg, 1978; Harrison, 1990; Jeffcoate, Humphrey, & Lloyd, 1979; Trause & Kramer, 1983; Yogman, 1987).
Most early studies of preterm parents focused on mothers or on both parents without considering the differences in parental roles. Since the late 1970s, however, a number of investigators have begun examining the responses of fathers to the birth and care of preterm infants (Jeffcoate et al., 1979; Marton, Minde, & Perrotta, 1981; Parke & Anderson, 1987; Yogman, 1987). This may reflect increasing interest in the role of the father during infancy (Berman & Mersen, 1987; Lamb, 1987; LaRossa, 1988). Several investigators have compared the emotional responses of mothers and fathers of preterm infants, and all found that mothers were more distressed than fathers. Benfield et al. (1976) found that mothers of critically ill infants reported more sadness, loss of appetite, guilt, anger, disbelief, depression, and crying than fathers. Philipp (1983) found that mothers retrospectively recalled more anxiety than fathers, although their later perceptions of the child did not differ. Jeffcoate et al. (1979) and Trause and Kramer (1983) found mothers of both preterm and normal newborn infants more distressed than fathers immediately after birth.
Margaret Shandor Miles, PhD, RN, and Sandra G. Funk, PhD, are professors in the School of Nursing at the University of North Carolina at Chapel Hill. Mary Ann Kasper, EdD, RN, is an associate professor in the School of Nursing at the University of Kansas. This study was supported by Grant No. NU01284 from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Public Health Service. The authors thank Cindy Garrett, John Carlson, and Elizabeth Tornquist for their assistance. This article was received on February 18, 1991, was revised, and accepted for publication January 14, 1992. Requests for reprints can be addressed to Dr. Margaret S. Miles, Department of Women’s and Children’s Health, School of Nursing, CB#7460 Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460. 0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/040261-09 $04.00
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M e c k et al. (1991) recently reported that mothers had a higher overall mood disturbance at NICU discharge than did fathers. Findings on maternal and paternal visiting patterns and interactionswith the infants in the hospital setting are mixed, perhaps reflecting cultural differences in the subjects studied. Marton and associates (1981), for example, found that fathers of premature infants in midwestern Canada visited more often than mothers right after birth and were more likely to engage in nurturant behaviors during the first hospital visit, but the difference did not persist over time. Thurman and Korteland (1989) found that mothers responded to their infants in the NICU more intimately than fathers, though both mothers and fathers were more intimate when visiting alone than when together. Brown, York, Jacobsen, Gennaro, and Brooten (1989) found that mothers were the primary visitors and callers during their infants’ hospitalization in the NICU. In an Israeli study, Levy-Shiff, Sharir, and Mogilner (1989) found that mothers visited more and engaged in more caregiving, talking, and holding behaviors during initial hospitalization than fathers. However, with the exception of caretaking, differences between maternal and paternal interactions decreased with time. In a follow-up study, these investigators found that more visiting was significantly correlated with more extensive and positive fathering after discharge (Levy-Shiff, Hoffman, Mogilner, Levinger, & Mogilner, 1990). While both mothers and fathers are distressed by the birth and hospitalization of a preterm infant, mothers appear to be more distressed than fathers, and they are also generally more involved with the infant. What is not known is how the differing responses of mothers and fathers to the infant may be influenced by their response to the NICU environment and to the uncertainty of the infant’s situation. Although the responses of mothers and fathers have been compared, no study has systematically assessed the stress engendered by the NICU environment and the level of uncertainty experienced, and compared mothers’ and fathers’ responses. Furthermore, most studies were done retrospectively or only at discharge, and most collected data only one time. It is important to evaluate the responses of mothers and fathers at the time of admission, when parents are initially adjusting to the infant’s birth and admission to the NICU, and after a period of time when adjustments to the situation have been made. More information on the stress of mothers and fathers within the NICU environment is vital to providing intervention to both mothers and fathers during the infant’s hospitalization.
Therefore, differences in the responses of mothers and fathers with a premature infant in an NICU were explored in this study. Stress is a multifaceted phenomenon encompassing both stressors (sources of stress) and the stress response (Magnusson, 1982). Stressors in this study were considered to encompass the perceived stress arising from various dimensions of the NICU environment, and the level of uncertainty related to the infant’s illness and related treatment; the stress response was considered to be the level of anxiety experienced by the parent (Miles & Carter, 1983). The following research questions were examined: (a) Is there a difference in the perception of NICU environmental stress, levels of uncertainty, and anxiety between mothers and fathers; (b) How do these responses change over time; and (c) What is the relationship between selected aspects of NICU environmental stress and anxiety in mothers and in fathers?
METHOD This study was part of a larger study that explored parental responses to the hospitalization of a premature in the NICU (Miles & Funk, 1987). Parents were interviewed first within a week of their infants’ admission (Time 1) and again approximately a week later (Time 2).
Subjects and Settings Subjects for this article were the 23 couples who participated in the larger study and were available to be interviewed at both Time 1 and Time 2. Criteria for admission to the study were that: (a) at the time of the first interview, the infant had been in the NICU for at least 12 hr but no longer than 5 days; (b) the infant had been diagnosed as premature by the admitting neonatologist; (c) the parents were able to speak English; and (d) the infant was not unduly unstable nor were the parents unusually upset at the time of the interviews. The status of the infant and parents was assessed through consultation with the charge nurse, the nurse caring for the infant, or the physician. If the infant was unduly unstable or the parents unusually upset at the time of the first interview, the situation was explored daily and parents were entered into the study when the situation was more stable. The settings for the study were a 14-bed Level 111 NICU and a 14-bed intermediary care nursery in a Southeastern university medical center, a 26-
NICU STRESS / MILES ET AL.
bed Level 111 NICU in a midwestern university medical center, and a 24-bed Level 11 NICU in a midwestern community hospital. All of the nurseries cared for seriously ill premature infants; however, only the Level III NICUs admitted infants who were on respirators. In all of the nurseries, infants were hospitalized in one large room and there were open visiting hours for parents. Developmental care had not yet been instituted in any of the units at the time of this study; thus, all units had continuous florescent lighting and the noise level of the monitors and monitor alarms was loud and random. There were no sound absorbent dividers in the units, nor was there a quiet time in the nurseries. The major differences between the units were in the number of beds and in the number of windows; in one unit there were no windows, while the remaining three units had three or more windows.
Data Collection Methods Instruments for data collection included the Parental Stressor Scale: NICU, the Parent Perception of Uncertainty tool, the State-Trait Anxiety Inventory, and a personal family and illness-related data sheet. Selected data from the infants’ hospital charts also were used. The Parental Stressor Scale: NICU (PSS:NICU), adapted from the Parental Stressor Scale: Pediatric Intensive Care Unit (PSS:PICU) (Carter & Miles, 1989), was used to evaluate the NICU environmental stress experienced by parents. Based on observations made in the NICU, interviews with parents, consultation with a parent self-help group, and a review of relevant research, the PSS:PICU was modified for use in the NICU. To establish content validity, the revised instrument was evaluated by professionals who work with parents of infants in the NICU and by parents of infants recently discharged from an NICU. The PSS:NICU consists of 26 items grouped into three dimensions that assess parental perception of stress related to aspects of the NICU environment. The dimensions were identified by principal components analysis (Miles, Funk, & Carlson, 1991). Parental Role Alterations (7 items) measures stress related to changes in the expected parental role with an infant, as well as stress imposed on the parenting role by the child’s illness and treatments. Infant’s Appearance (13 items) measures stress resulting from the appearance and behavior of the sick infant. Sights and Sounds (6 items) measures stress arising from the appearance and sounds of the physical environment of the NICU.
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A fourth dimension, stress related to staff relationships, was experienced so infrequently that it has been dropped from the tool. Internal consistency reliability coefficients for the dimensions were: Parental Role Alteration (31); Infants’ Appearance (.79); and Sights and Sounds (.66)(Miles & Funk, 1987). For each of the 26 items on the PSS:NICU, parents are asked whether or not they have experienced the situation. Those who have experienced it are asked to rate its stressfulness on a scale from 1 (nor at all stressful) to 5 (extremely stressful). Three scorings are available for each of the three scales: the number of stressors experienced, the stress those particular experiences generated, and the overall level of stress experienced by the parent across all items on the scale. In this last scoring, those not experiencing the situation an item represents receive a score of I , indicating that no stress was experienced since the eventhtem did not occur. Although this scoring system results in lower mean stress scores, it was chosen for analyses in this article to provide a common base of comparison between mothers and fathers who may not have experienced exactly the same aspects of the NICU environment. Scores for each of the three scales are calculated by averaging responses to the items on the scale. The Parent Perception of Uncertainty Scale (PPUS) developed by Mishel (1983) is a 31-item scale that measures four dimensions of uncertainty: Multi-attributed Ambiguity-absence of cues about the child’s care; Lack of Clarity-confusing information about the child’s care; Lack of Information-absence of information about the child’s diagnosis and illness; and Unpredictability-inability to predict the child’s outcome. In this study, these aspects of uncertainty were considered situational stimuli that could produce stress in parents during their infant’s hospitalization. The PPUS is a modified version of the Mishel Uncertainty in Illness Scale (MUIS) developed for use with adult patients (Mishel, 1983). The modified instrument was reviewed by a panel of pediatric nurses for content validity. Item responses are provided on a 5-point Likert scale; subscale scores were calculated by averaging item responses that had been corrected for directionality. Cronbach’s alpha for the total scale was .91 with subscale alphas of .87, .8 1, .73, .72, respectively. Coefficient theta results were identical. In factor analysis, the four hypothesized dimensions of uncertainty emerged (Mishel, 1983). Alpha coefficients for subjects in this study were adequate except for one scale: Ambiguity (.83), Lack of
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Clarity (.79), Lack of Information (.57), and Unpredictability (.70). Spielberger’s State-Trait Anxiety Inventory (STAI) was used to assess parents’ propensity for anxiety (trait anxiety), and their current level of anxiety (state anxiety). The two scales on the STAI each contain 20 statements of feelings. To assess trait anxiety, subjects are asked to rate on a 4-point scale how they usually feel; to assess state anxiety, they are asked to rate how they presently feel. Validity and reliability of the STAI are well established (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Alpha coefficients on the STAI for subjects in this study were high: State Anxiety- .95 and Trait Anxiety-.93.
Data Collection Procedures Parents were informed of the purpose of the study; if they agreed to participate, they signed an IRB approved consent form. All interviews were conducted by data collectors who were nurses and who followed a set interview protocol. The protocol specified what to tell parents, how to ask the questions, and how to respond to difficulties or questions raised by parents in understanding the interview. It also included procedures for debriefing parents following data collection to allow them an opportunity to share any concerns, feelings, or questions that may have arisen during the interview. All interviews were done in a private location in the hospital, and mothers and fathers were interviewed separately.
RESULTS
Description of the Sample Mothers and fathers of 23 infants were interviewed at Time 1 and Time 2. Although most of the couples were married (91%), a few (9%) were unmarried. The majority of the parents were Caucasian (87%). The mean age of the mothers was 27 years, with a range from 17 to 39; mean age for fathers was 29, with a range from 20 to 4 1. Both mothers and fathers had an average of 14 years of education. All fathers and the majority (61%) of the mothers were employed outside the home. Mean trait anxiety scores for both mothers (43.22) and fathers (39.83) were somewhat higher than means reported for working adults in the same age range, but similar to means for college students (Spielberger et al., 1983).
All infants had been diagnosed as premature by the attending physician. Most (65%) were admitted to the NICU for complications of prematurity; the mean number of complications was 2.0, with a range from 0 to 4. Gestational ages at birth ranged from 24 to 36 weeks (M = 31). The mean birth weight was 1722 grams, with a range from 690 to 3930 (3 infants weighed more than 2500 grams, the standard definition for preterm infants; it is not known whether they were LGA). Most of the infants (91%) were inborn, and slightly over half (57%) were born by Caesarean section. The majority of the infants were male (65%). Both mothers and fathers rated the infant’s condition at admission to be quite severe (means of 4.0 on a 5-point scale where 5 = the most serious condition possible). The mean age at the time of the first interview was 2.7 days, with a range of I to 5 days; 44% were on respirators. At the time of the first interview, mothers’ and fathers’ ratings of severity had decreased somewhat (M = 3.45 and 2.82, respectively). At the second interview, mean infant age was 13.5 days and 17% remained on respirators. Mothers’ and fathers’ severity ratings had decreased further, to means of 2.73 and 2.18, respectively.
Comparisons of Mothers and Fathers, Time 1 and l i m e 2 Overall, parents perceived the greatest amount of stress in relation to alterations in the parental role (M = 2.96), the second greatest amount of stress in relation to the sights and sounds of the NICU (M = 2.56), and the least in relation to the infant’s appearance (M = 2.29). To examine the differences between mothers’ and fathers’ perceptions of NICU environmental stress stimuli, a two-way (parental role X time) repeated-measures multivariate analysis of variance (MANOVA) (McCall & Appelbaum, 1973) was performed on the three scales of the PSS:NICU. The mean PSS:NICU scale scores for mothers and fathers at Time 1 and Time 2 are shown in Figure 1; the corresponding significance tests are given in Table 1. The multivariate main effects for both Role and Time were significant, but the interaction between these two factors was not. Overall, mothers reported the NICU environment to be more stressful than did fathers, and both perceived the environment to be more stressful at Time 1 than Time 2. Univariate analyses, performed to further examine these differences, revealed significant role, time, and roleby-time effects for parental role alteration. At both Time 1 and Time 2, mothers reported experiencing
NlCU STRESS / MILES ET AL.
Parental Role Alteration
265
Infant Appearance
24.68
5.0 4.8 4.6 4.4
4.4 4.2 4.0 C
T
2.8 2.6 2.4 2.2
2.6 2.4 2.2 2.0 1.8 1.6 1.4 I1.2 1 .o
I T1
T2
::81.6 1.4
1.2 1 .o
T1
T2
FIGURE 1. Mean PSS:NICU scale scores (+/- 1 standard deviation) by time and parental role. Note: Solid line = mothers' scores; dotted line = fathers' scores.
more stress related to alterations in the expected parental role than did fathers. This difference was most marked at Time 1, where mothers' scores were 40% higher than fathers' scores (M = 3.80 versus M = 2.70, respectively). While role-related stress had decreased by Time 2 for both mothers and fathers, with mothers showing a greater decrease, mothers still reported experiencing more stress in this area than did fathers (M = 2.84 versus M = 2.48). Although stress resulting from the fragile and sickly appearance of the infant decreased significantly from Time 1 to Time 2 (M = 2.43 versusM = 2.15), mothers and fathers did not differ in the stress they perceived in this area. There were no significant differences between mothers and fathers or across time in the perception
of the stress created by the sights and sounds of the unit. Parents reported experiencing the greatest level of uncertainty in the area of unpredictability (M = 3.36), and the least concerning lack of clarity (M = 2.04). The mean levels of uncertainty for mothers and fathers at Time 1 and Time 2 are shown in Figure 2. A two-way (parental role X time) repeated-measures MANOVA revealed no significant multivariate differences between mothers and fathers or between Time 1 and Time 2 in level of uncertainty; the interaction was also nonsignificant (see Table 2). Because the statistical power of the multivariate test was modest, due to the relatively small sample size, the univariate ANOVAs also were examined for patterns across
Table 1. Analysis of Variance for PSS:NICU Scales Source Role (Mother vs. Father) Time (Time 1 vs. Time 2) Role x Time Univariate ANOVAs by PSS:NICU Scale Parental role alteration Role Time Role x Time Infant appearance Role Time Role x Time Sights and sounds Role Time Role x Time
df
F
P
3,20 3,20 3,20
3.57 4.80 2.82
,032 .011 ,065
1,22 1,22 1,22
10.31 9.96 7.67
.004
1,22 1,22 1.22
.41 8.31 1.41
.009
1,22 1,22 1,22
.32 .01 1.74
.577 .929 ,200
,005 ,011 .529 .248
RESEARCH IN NURSING 8 HEALTH
266
Lack of Clarity
Lack of Information 5.0 4.8 4.6 4.4 4.2
4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 -
43:
2
3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.o
x
.E
2 a 2 2 5
r”
-
1.2 1.o T1
1
T2
Ambiguity
6
:x:
.E
2a F 3 =
,
T1
T2
Unpredictability 5.0 4.8 4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.o
5.0 4.8 4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2
=:
1 .o
T1
,
T2
c
1 L.I 3.90
3.78
T1
T2
FIGURE 2. Mean Uncertainty scale scores (+/- 1 standard deviation) by time and parental role. Note: Solid line = mothers’ scores; dotted line = fathers’ scores
the dimensions of uncertainty. Significant reductions in uncertainty from Time 1 to Time 2 were noted in the areas of information, clarity, and ambiguity; mothers differed from fathers only in the area of unpredictability. State anxiety scores for both mothers and fathers fell within the range of “anxious clients” (Spielberger et al., 1983) at Time 1, which was within one week of the infant’s admission. The mean scores for mothers and fathers were 51 (SD = 13.7) and 49 (SD = 12.0), respectively. By Time 2 (approximately one week later), mothers’ scores had fallen to 43 (SD = 13.0), on the average, and fathers’ scores to 40 (SD = 11.9). A roleby-time ANOVA indicated that the decrease in anxiety from Time 1 to Time 2 was significant, F( 1,22) = 16.72, p = .001, but that mothers and
fathers did not differ significantly from each other in their levels of anxiety. Relationship between NlCU Stress and Anxiety
For fathers, anxiety scores were found to correlate significantly with stress related to alterations in the parental role and with lack of clarity at both Time 1 (r = .53, p < .005, and r = .37, p < .M1,respectively) and Time 2 ( r = .53, p < .005, and r = .37, p < .M1, respectively). Although for mothers, anxiety was found to correlate most strongly with parental role alterations at Time 1 (r = .32, p < .068), none of the relationships examined at Time 1 or Time 2 were significant.
267
NICU STRESS / MILES ET AL.
DISCUSSION Findings from this study support the previous literature suggesting that the admission of an infant to an NICU is stressful to parents (Benfield et al., 1976; Gennaro, 1988; Miles, 1989; Paludetto et al., 1981; Philipp, 1983; Trause& Kramer, 1983; Yu eta]., 1981). The most stressful aspect of the NICU environment for these parents was alterations in the parental role. The stress related to parental role alterations decreased markedly in the week following the child’s admission; however, it was still the most stressful aspect of the admission for parents. Although both mothers and fathers found parental role changes to be the most stressful aspect of their infant’s admission, mothers were more distressed than fathers by parental role alteration. Mothers’ scores on the parental role alteration subscale were markedly higher at both Time 1 and Time 2 than fathers’ scores. Although both maternal and paternal scores dropped by Time 2, mothers’ scores remained high. Thus, mothers may experience stress uniquely related to the loss of the caretaking role with the infant. These findings support previous research that found that mothers appear to be more concerned about caregiving and nurturing the sick infant than fathers (Brown et al., 1989; Levy-Shiff et a]., 1989; Marton et a]., 1981;Thurman & Korteland, 1989). The findings
also are similar to research that found mothers experienced more stress related to the parental role than fathers when a child is admitted to a pediatric intensive care unit (Miles, Carter, Spicher, & Hassanein, 1985; Riddle, Hennessey, Eberly, Carter, & Miles, 1987). The sights and sound of the unit were moderately stressful for both mothers and fathers, and this did not change over time. These findings are similar to research with parents of children admitted to a pediatric intensive care unit (Miles et a]. , 1985). As pointed out in this previous research, it may be that the public no longer finds the sights and sounds of intensive care units intimidating because of familiarity with ICUs through television and personal experiences. The infant’s appearance and behavior were slightly less stressful for parents than were the sights and sounds of the unit, and this stress decreased significantly over time. These findings may reflect the results of nursing and medical staff discussions that normalize the infant’s unusual appearance and behaviors with parents. The greatest amount of uncertainty experienced by mothers and fathers was in the area of unpredictibility, with mothers reporting greater uncertainty in this area than did fathers. Although all of the uncertainty scores dropped over time for both mothers and fathers, unpredictability decreased the least and remained the greatest source of uncertainty. That lack of information, lack of
Table 2. Analysls of Variance for Uncertainty Scales Source Role (Mother vs. Father) Time (Time 1 vs. Time 2) Role x Time Univariate ANOVAs by Uncertainty Scale Lack of information Role Time Role x Time Lack of clarity Role Time Role x Time Ambiguity Role Time Role x Time Unpredictability Role Time Role x Time
df
F
4,19 4,19 4.19
1.36 2.27 .47
,284 ,099 ,757
P
1,22 1,22 1,22
1.53 5.28 .79
,230 ,032 ,385
1,22 1,22 1,22
1.10 5.96
.oo
,307 ,023 ,966
1,22 1,22 1,22
1.72 5.80 1.24
,203 .025 .277
1,22 1,22 1,22
5.44 .42 .01
.029 .521 ,909
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clarity, and ambiguity scores decreased by Time 2 is not surprising; it would be expected that parents might accumulate information and have a clearer picture about their child’s illness over the first weeks following admission. On the other hand, unpredictability about the course and outcomes for the infant may remain a constant, if not increasing, problem for parents of sicker preterm infants. This area of parental response during an infant’s NICU admission has not been addressed in previous research. Anxiety levels indicated that these parents were highly anxious during the first week after admission but were significantly less anxious a week later. This suggests that the anxiety surrounding the admission of the infant lowers after the initial shock and adjustments have occurred. A limitation of this study, however, may be the way in which anxiety was measured; a more clinically sensitive instrument may be needed to measure the anxiety of parents of hospitalized children. For fathers, anxiety was moderately related to alterations in the parental role and to uncertainty related to lack of clarity regarding the child’s diagnosis and treatment. For mothers, there were no significant relationships between NICU environmental stress dimensions and uncertainty dimensions and anxiety scores. Maternal anxiety may be more diffuse than that experienced by fathers and other sources of anxiety, not included in this study, may need to be examined. A particularly important aspect of anxiety that was not included in this study might be concern about whether the infant might die. In addition, concerns regarding the needs of other children, job responsibilities, and financial strains may influence anxiety. Results of this study have relevance for professionals working with parents of prematures hospitalized in an NICU. Interventions with parents in the NICU should include both mothers and fathers. Particular attention should be placed on the stress related to their altered parental role. Separation from the infant, feelings of helplessness in the parental role, and limitations on their ability to give care are all aspects of the situation that staff should address with parents. Interventions that enhance and support the parental role are especially important. Parents also should receive information about the usual sights and sounds of the NICU; this may reduce the stress they engender in parents. Parents may need assistance in understanding and coping with the unpredictability of their infant’s illness course as well. Allowing parents to discuss the feelings engendered by unpredictability also may help.
Findings of this study should be considered in light of the small sample size. While the multivariate repeated measures design employing 23 dyads used in this study had a power of greater than .70 to detect large effect sizes in PSSNICU scores and a power greater than .80 to detect moderate effect sizes in uncertainty scores, it was not sensitive to smaller differences (Keyes & Muller, 1991). If it is clinically important to identify smaller differences,replication with a larger sample size is recommended. In addition, although a repeated measures design was used, the study was short term in nature; a longitudinal design that follows parents over a longer period of time is needed. No effort was made to explore the responses of parents of infants hospitalized in different units due to the small sample. How differences in the physical and psychosocial aspects of different NICU settings affect parents might be explored in further research. There also is a need to identify the differing responses, level of involvement, and caregiving behaviors of mothers as compared to fathers, and to examine how parental stress influences mothers’ and fathers’ responses to their infant. In addition, research is needed to examine how the stress responses surrounding the infant’s hospitalization affects parents after discharge. Although many studies have been focused on parenting the preterm infant after discharge, there has been little evaluation of how parental stress during hospitalization may affect later parenting of the child.
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Michaels & W.A. Goldberg (Eds.). The transition to parenthood: Current theory and research ( pp. 176-208). New York: Cambridge University Press. Gennaro, S. (1988). Postpartal anxiety and depression in mothers of premature infants. Nursing Research, 3 7 , 82-85. Goldberg, S . (1978). Prematurity: Effects on parent-infant interaction. Journal of Pediatric Psychology, 3 , 137- 144. Harrison, M.J. (1990). A comparison of parental interactions with term and preterm infants. Research in Nursing & Health, 13, 173-179. Jeffcoate, J.A., Humphrey, M.E., & Lloyd, J.K. (1979). Role perception and responses to stress in fathers and mothers following pre-term delivery. Social Science and Medicine, 13A, 139- 145. Keyes, L . , & Muller, K . (1991). IML power program. Software developed under NICHD Mental Retardation Research Center Grant P30-HDO3110-22. Lamb, E. (Ed.). (1987). The father’s role: Crosscultural perspectives. Hillsdale, NJ: Lawrence Erlbaum Association, Publishers. LaRossa, R. (1988). Fatherhood and social change. Family Relations, 3 7 , 45 1-457. Levy-Shiff, R., Hoffman, M.A., Mogilner, S., Levinger, S . , & Mogilner, M.B. (1990). Fathers’ hospital visits to their preterm infants as a predictor of father- infant relationship and infant development. Pediatrics, 86, 289-293. Levy-Shiff, R . , Sharir, H., & Mogilner, M.B. (1989). Mother- and father-preterm infant relationship in the hospital preterm nursery. Child Development, 60, 93- 102. Magnusson, D. (1982). Situational determinants of stress: An interactional perspective. In L. Goldberger & S . Breznitz (Eds.), Handbook ofstress: Theoretical and clinical aspects (pp. 23 1-253). New York: The Free Press. Marton, P., Minde, K., & Perrotta, M . (1981). The role of the father for the infant at risk. American Journal of Orthopsychiatry, 5 1 , 672-679. McCall, R.B., & Appelbaum, M.I. (1973). Bias i n the analysis of repeated-measures designs: Some alternative approaches. Child Development, 4 4 , 401 -415. Miles, M.S. (1989). Parents of critically ill premature infants: Sources of stress. Critical Care Nursing Quarterly, 1 2 ( 3 ) , 69-74. Miles, M.S., & Carter, M.C. (1983). Assessing parental stress in intensive care units. Journal of Maternal Child Nursing, 8 , 354-360. Miles, M.S., Carter, M . C . , Spicher, C . , & Hassanein, R. (1985). Maternal and paternal reactions when a child is admitted to a pediatric ICU. Issues in Comprehensive Pediatric Nursing, 7 , 333342. Miles, M.S., &Funk, S.G. (1987). Parentalstres-
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sors in the neonatal intensive care unit. Grant report submitted to the Division of Nursing, HRSA, DHHS. Miles, M.S., Funk, S . G . , & Carlson, J. (1991). The Parental Stressor Scale: Neonatal Intensive Care Unit.Manuscript submitted for publication. Miles, M.S., Funk, S .G., & Kasper, M. A. (I99 1). The neonatal intensive care unit environment: Sources of stress for parents. AACN Clinical Issues in Critical Care Nursing, 2 , 346-354. Mishel, M. (1983). Parents’ perception of uncertainty concerning their hospitalized child. Nursing Research, 3 2 , 324-330. Paludetto, R., Faggiano-Perfetto, M., Asprea, A.M., De Curtis, M . , & Margara-Paludetto, P. (1981). Reactions of sixty parents allowed unrestricted contact with infants in a neonatal intensive care unit. Early Human Development, 5 , 401-409. Parke, R.D., & Anderson, E.R. (1987). Fathers and their at-risk infants: Conceptual and empirical analyses. In P.W. Berman & F.A. Pedersen (Eds.), Men’s transition to parenthood (pp. 149- 162). Hillsdale, NJ: Lawrence Erlbaum and Associates, Publishers. Philipp, C. (1983). The role of recollected anxiety in parental adaptation to low birthweight infants. Child Psychiatry and Human Development, 13, 239-248. Riddle, I . I . , Hennessey, J . , Eberly, T.W., Carter, M.C. & Miles, M.S. (1987). Stressors in the paediatric intensive care unit as perceived by mothers and fathers. In C . Barnes (Ed.), Recent advances in nursing (Vol. 16): Nursing care of children in health and illness (pp. 149-162). London: Churchill-Livingston. Spielberger, C.D., Gorsuch, R.L., Lushene, R., Vagg, P.R., &Jacobs, G.A. (1983). Manualfor the State-Trait Anxiety Inventory (Form Y ) . Palo Alto, CA: Consulting Psychologists Press, Inc. Thurman, S.K., & Korteland, C. (1989). The behavior of mothers and fathers toward their infants during neonatal intensive care visits. Children’s Health Care, 18, 247-252. Trause, M.A., & Kramer, L. (1983). The effects of premature birth on parents and their relationships. Developmental Medicine and Child Neurology, 2 5 , 459-465. Yogman, M.W. (1987). Father-infant caregiving and play with preterm and full-term infants. In P.W. Berman & F.A. Pedersen (Eds.), Men’s transition to parenthood (pp. 175- 195). Hillsdale, NJ: Lawrence Erlbaum and Associates, Publishers. Yu, V.Y.H., Jamieson, J . , & Astbury, J . (1981). Parents reactions to unrestricted parental contact in the intensive care unit nursery. The Medical Journal of Australia, 1 , 294-296.
The Stress Response of Mothers Fathers of Preterm Infants Margaret Shandor Miles, Sandra G. Funk, and Mary Ann Kasper
Differences in neonatal intensive care unit (NICU) environmental stress, uncertainty, and anxiety of 23 mothers and fathers (couples) whose premature infants were hospitalized in an NICU were explored. Alterations in the parental role were found to be stressful for both mothers and fathers, with mothers reporting significantly greater stress in this area than did fathers. Stress and uncertainty decreased significantly over time. Mothers and fathers did not differ in level of anxiety. Findings suggest that both mothers and fathers are distressed by the admission of a premature to an NICU; however, mothers may be more distressed by certain aspects of the experience.@ 1992 John Wiley 8 Sons, Inc.
It is well documented that the birth and hospitalization of a preterm infant are very distressing for parents. Feelings of disappointment, fears regarding the child’s survival, and altered parental experiences, including separation and reduced opportunities to interact with the infant, are all difficult for parents (Affleck, Tennen, & Rowe, 1991; Benfield, k i b , & Reuter, 1976; Gennaro, 1988; Philipp, 1983; Trause & Kramer, 1983). Another source of stress for parents is the environment of the neonatal intensive care unit (N1CU)-the sights and sounds of the unit, the infant’s physical appearance, the equipment, and relationships with health care personnel in the unit (Miles, 1989; Miles, Funk, & Kasper, 1991; Paludetto, Faggiano-Perfetto, Asprea, De Curtis, & Margara-Paludetto, 1981; Yu, Jamieson, & Astbury, 1981). It is thought that these experiences of parents of preterm infants may seriously delay successful attainment of the parental role and may influence later parent-infant interactions (Easterbmks, 1988; Goldberg, 1978; Harrison, 1990; Jeffcoate, Humphrey, & Lloyd, 1979; Trause & Kramer, 1983; Yogman, 1987).
Most early studies of preterm parents focused on mothers or on both parents without considering the differences in parental roles. Since the late 1970s, however, a number of investigators have begun examining the responses of fathers to the birth and care of preterm infants (Jeffcoate et al., 1979; Marton, Minde, & Perrotta, 1981; Parke & Anderson, 1987; Yogman, 1987). This may reflect increasing interest in the role of the father during infancy (Berman & Mersen, 1987; Lamb, 1987; LaRossa, 1988). Several investigators have compared the emotional responses of mothers and fathers of preterm infants, and all found that mothers were more distressed than fathers. Benfield et al. (1976) found that mothers of critically ill infants reported more sadness, loss of appetite, guilt, anger, disbelief, depression, and crying than fathers. Philipp (1983) found that mothers retrospectively recalled more anxiety than fathers, although their later perceptions of the child did not differ. Jeffcoate et al. (1979) and Trause and Kramer (1983) found mothers of both preterm and normal newborn infants more distressed than fathers immediately after birth.
Margaret Shandor Miles, PhD, RN, and Sandra G. Funk, PhD, are professors in the School of Nursing at the University of North Carolina at Chapel Hill. Mary Ann Kasper, EdD, RN, is an associate professor in the School of Nursing at the University of Kansas. This study was supported by Grant No. NU01284 from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Public Health Service. The authors thank Cindy Garrett, John Carlson, and Elizabeth Tornquist for their assistance. This article was received on February 18, 1991, was revised, and accepted for publication January 14, 1992. Requests for reprints can be addressed to Dr. Margaret S. Miles, Department of Women’s and Children’s Health, School of Nursing, CB#7460 Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460. 0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/040261-09 $04.00
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M e c k et al. (1991) recently reported that mothers had a higher overall mood disturbance at NICU discharge than did fathers. Findings on maternal and paternal visiting patterns and interactionswith the infants in the hospital setting are mixed, perhaps reflecting cultural differences in the subjects studied. Marton and associates (1981), for example, found that fathers of premature infants in midwestern Canada visited more often than mothers right after birth and were more likely to engage in nurturant behaviors during the first hospital visit, but the difference did not persist over time. Thurman and Korteland (1989) found that mothers responded to their infants in the NICU more intimately than fathers, though both mothers and fathers were more intimate when visiting alone than when together. Brown, York, Jacobsen, Gennaro, and Brooten (1989) found that mothers were the primary visitors and callers during their infants’ hospitalization in the NICU. In an Israeli study, Levy-Shiff, Sharir, and Mogilner (1989) found that mothers visited more and engaged in more caregiving, talking, and holding behaviors during initial hospitalization than fathers. However, with the exception of caretaking, differences between maternal and paternal interactions decreased with time. In a follow-up study, these investigators found that more visiting was significantly correlated with more extensive and positive fathering after discharge (Levy-Shiff, Hoffman, Mogilner, Levinger, & Mogilner, 1990). While both mothers and fathers are distressed by the birth and hospitalization of a preterm infant, mothers appear to be more distressed than fathers, and they are also generally more involved with the infant. What is not known is how the differing responses of mothers and fathers to the infant may be influenced by their response to the NICU environment and to the uncertainty of the infant’s situation. Although the responses of mothers and fathers have been compared, no study has systematically assessed the stress engendered by the NICU environment and the level of uncertainty experienced, and compared mothers’ and fathers’ responses. Furthermore, most studies were done retrospectively or only at discharge, and most collected data only one time. It is important to evaluate the responses of mothers and fathers at the time of admission, when parents are initially adjusting to the infant’s birth and admission to the NICU, and after a period of time when adjustments to the situation have been made. More information on the stress of mothers and fathers within the NICU environment is vital to providing intervention to both mothers and fathers during the infant’s hospitalization.
Therefore, differences in the responses of mothers and fathers with a premature infant in an NICU were explored in this study. Stress is a multifaceted phenomenon encompassing both stressors (sources of stress) and the stress response (Magnusson, 1982). Stressors in this study were considered to encompass the perceived stress arising from various dimensions of the NICU environment, and the level of uncertainty related to the infant’s illness and related treatment; the stress response was considered to be the level of anxiety experienced by the parent (Miles & Carter, 1983). The following research questions were examined: (a) Is there a difference in the perception of NICU environmental stress, levels of uncertainty, and anxiety between mothers and fathers; (b) How do these responses change over time; and (c) What is the relationship between selected aspects of NICU environmental stress and anxiety in mothers and in fathers?
METHOD This study was part of a larger study that explored parental responses to the hospitalization of a premature in the NICU (Miles & Funk, 1987). Parents were interviewed first within a week of their infants’ admission (Time 1) and again approximately a week later (Time 2).
Subjects and Settings Subjects for this article were the 23 couples who participated in the larger study and were available to be interviewed at both Time 1 and Time 2. Criteria for admission to the study were that: (a) at the time of the first interview, the infant had been in the NICU for at least 12 hr but no longer than 5 days; (b) the infant had been diagnosed as premature by the admitting neonatologist; (c) the parents were able to speak English; and (d) the infant was not unduly unstable nor were the parents unusually upset at the time of the interviews. The status of the infant and parents was assessed through consultation with the charge nurse, the nurse caring for the infant, or the physician. If the infant was unduly unstable or the parents unusually upset at the time of the first interview, the situation was explored daily and parents were entered into the study when the situation was more stable. The settings for the study were a 14-bed Level 111 NICU and a 14-bed intermediary care nursery in a Southeastern university medical center, a 26-
NICU STRESS / MILES ET AL.
bed Level 111 NICU in a midwestern university medical center, and a 24-bed Level 11 NICU in a midwestern community hospital. All of the nurseries cared for seriously ill premature infants; however, only the Level III NICUs admitted infants who were on respirators. In all of the nurseries, infants were hospitalized in one large room and there were open visiting hours for parents. Developmental care had not yet been instituted in any of the units at the time of this study; thus, all units had continuous florescent lighting and the noise level of the monitors and monitor alarms was loud and random. There were no sound absorbent dividers in the units, nor was there a quiet time in the nurseries. The major differences between the units were in the number of beds and in the number of windows; in one unit there were no windows, while the remaining three units had three or more windows.
Data Collection Methods Instruments for data collection included the Parental Stressor Scale: NICU, the Parent Perception of Uncertainty tool, the State-Trait Anxiety Inventory, and a personal family and illness-related data sheet. Selected data from the infants’ hospital charts also were used. The Parental Stressor Scale: NICU (PSS:NICU), adapted from the Parental Stressor Scale: Pediatric Intensive Care Unit (PSS:PICU) (Carter & Miles, 1989), was used to evaluate the NICU environmental stress experienced by parents. Based on observations made in the NICU, interviews with parents, consultation with a parent self-help group, and a review of relevant research, the PSS:PICU was modified for use in the NICU. To establish content validity, the revised instrument was evaluated by professionals who work with parents of infants in the NICU and by parents of infants recently discharged from an NICU. The PSS:NICU consists of 26 items grouped into three dimensions that assess parental perception of stress related to aspects of the NICU environment. The dimensions were identified by principal components analysis (Miles, Funk, & Carlson, 1991). Parental Role Alterations (7 items) measures stress related to changes in the expected parental role with an infant, as well as stress imposed on the parenting role by the child’s illness and treatments. Infant’s Appearance (13 items) measures stress resulting from the appearance and behavior of the sick infant. Sights and Sounds (6 items) measures stress arising from the appearance and sounds of the physical environment of the NICU.
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A fourth dimension, stress related to staff relationships, was experienced so infrequently that it has been dropped from the tool. Internal consistency reliability coefficients for the dimensions were: Parental Role Alteration (31); Infants’ Appearance (.79); and Sights and Sounds (.66)(Miles & Funk, 1987). For each of the 26 items on the PSS:NICU, parents are asked whether or not they have experienced the situation. Those who have experienced it are asked to rate its stressfulness on a scale from 1 (nor at all stressful) to 5 (extremely stressful). Three scorings are available for each of the three scales: the number of stressors experienced, the stress those particular experiences generated, and the overall level of stress experienced by the parent across all items on the scale. In this last scoring, those not experiencing the situation an item represents receive a score of I , indicating that no stress was experienced since the eventhtem did not occur. Although this scoring system results in lower mean stress scores, it was chosen for analyses in this article to provide a common base of comparison between mothers and fathers who may not have experienced exactly the same aspects of the NICU environment. Scores for each of the three scales are calculated by averaging responses to the items on the scale. The Parent Perception of Uncertainty Scale (PPUS) developed by Mishel (1983) is a 31-item scale that measures four dimensions of uncertainty: Multi-attributed Ambiguity-absence of cues about the child’s care; Lack of Clarity-confusing information about the child’s care; Lack of Information-absence of information about the child’s diagnosis and illness; and Unpredictability-inability to predict the child’s outcome. In this study, these aspects of uncertainty were considered situational stimuli that could produce stress in parents during their infant’s hospitalization. The PPUS is a modified version of the Mishel Uncertainty in Illness Scale (MUIS) developed for use with adult patients (Mishel, 1983). The modified instrument was reviewed by a panel of pediatric nurses for content validity. Item responses are provided on a 5-point Likert scale; subscale scores were calculated by averaging item responses that had been corrected for directionality. Cronbach’s alpha for the total scale was .91 with subscale alphas of .87, .8 1, .73, .72, respectively. Coefficient theta results were identical. In factor analysis, the four hypothesized dimensions of uncertainty emerged (Mishel, 1983). Alpha coefficients for subjects in this study were adequate except for one scale: Ambiguity (.83), Lack of
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Clarity (.79), Lack of Information (.57), and Unpredictability (.70). Spielberger’s State-Trait Anxiety Inventory (STAI) was used to assess parents’ propensity for anxiety (trait anxiety), and their current level of anxiety (state anxiety). The two scales on the STAI each contain 20 statements of feelings. To assess trait anxiety, subjects are asked to rate on a 4-point scale how they usually feel; to assess state anxiety, they are asked to rate how they presently feel. Validity and reliability of the STAI are well established (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Alpha coefficients on the STAI for subjects in this study were high: State Anxiety- .95 and Trait Anxiety-.93.
Data Collection Procedures Parents were informed of the purpose of the study; if they agreed to participate, they signed an IRB approved consent form. All interviews were conducted by data collectors who were nurses and who followed a set interview protocol. The protocol specified what to tell parents, how to ask the questions, and how to respond to difficulties or questions raised by parents in understanding the interview. It also included procedures for debriefing parents following data collection to allow them an opportunity to share any concerns, feelings, or questions that may have arisen during the interview. All interviews were done in a private location in the hospital, and mothers and fathers were interviewed separately.
RESULTS
Description of the Sample Mothers and fathers of 23 infants were interviewed at Time 1 and Time 2. Although most of the couples were married (91%), a few (9%) were unmarried. The majority of the parents were Caucasian (87%). The mean age of the mothers was 27 years, with a range from 17 to 39; mean age for fathers was 29, with a range from 20 to 4 1. Both mothers and fathers had an average of 14 years of education. All fathers and the majority (61%) of the mothers were employed outside the home. Mean trait anxiety scores for both mothers (43.22) and fathers (39.83) were somewhat higher than means reported for working adults in the same age range, but similar to means for college students (Spielberger et al., 1983).
All infants had been diagnosed as premature by the attending physician. Most (65%) were admitted to the NICU for complications of prematurity; the mean number of complications was 2.0, with a range from 0 to 4. Gestational ages at birth ranged from 24 to 36 weeks (M = 31). The mean birth weight was 1722 grams, with a range from 690 to 3930 (3 infants weighed more than 2500 grams, the standard definition for preterm infants; it is not known whether they were LGA). Most of the infants (91%) were inborn, and slightly over half (57%) were born by Caesarean section. The majority of the infants were male (65%). Both mothers and fathers rated the infant’s condition at admission to be quite severe (means of 4.0 on a 5-point scale where 5 = the most serious condition possible). The mean age at the time of the first interview was 2.7 days, with a range of I to 5 days; 44% were on respirators. At the time of the first interview, mothers’ and fathers’ ratings of severity had decreased somewhat (M = 3.45 and 2.82, respectively). At the second interview, mean infant age was 13.5 days and 17% remained on respirators. Mothers’ and fathers’ severity ratings had decreased further, to means of 2.73 and 2.18, respectively.
Comparisons of Mothers and Fathers, Time 1 and l i m e 2 Overall, parents perceived the greatest amount of stress in relation to alterations in the parental role (M = 2.96), the second greatest amount of stress in relation to the sights and sounds of the NICU (M = 2.56), and the least in relation to the infant’s appearance (M = 2.29). To examine the differences between mothers’ and fathers’ perceptions of NICU environmental stress stimuli, a two-way (parental role X time) repeated-measures multivariate analysis of variance (MANOVA) (McCall & Appelbaum, 1973) was performed on the three scales of the PSS:NICU. The mean PSS:NICU scale scores for mothers and fathers at Time 1 and Time 2 are shown in Figure 1; the corresponding significance tests are given in Table 1. The multivariate main effects for both Role and Time were significant, but the interaction between these two factors was not. Overall, mothers reported the NICU environment to be more stressful than did fathers, and both perceived the environment to be more stressful at Time 1 than Time 2. Univariate analyses, performed to further examine these differences, revealed significant role, time, and roleby-time effects for parental role alteration. At both Time 1 and Time 2, mothers reported experiencing
NlCU STRESS / MILES ET AL.
Parental Role Alteration
265
Infant Appearance
24.68
5.0 4.8 4.6 4.4
4.4 4.2 4.0 C
T
2.8 2.6 2.4 2.2
2.6 2.4 2.2 2.0 1.8 1.6 1.4 I1.2 1 .o
I T1
T2
::81.6 1.4
1.2 1 .o
T1
T2
FIGURE 1. Mean PSS:NICU scale scores (+/- 1 standard deviation) by time and parental role. Note: Solid line = mothers' scores; dotted line = fathers' scores.
more stress related to alterations in the expected parental role than did fathers. This difference was most marked at Time 1, where mothers' scores were 40% higher than fathers' scores (M = 3.80 versus M = 2.70, respectively). While role-related stress had decreased by Time 2 for both mothers and fathers, with mothers showing a greater decrease, mothers still reported experiencing more stress in this area than did fathers (M = 2.84 versus M = 2.48). Although stress resulting from the fragile and sickly appearance of the infant decreased significantly from Time 1 to Time 2 (M = 2.43 versusM = 2.15), mothers and fathers did not differ in the stress they perceived in this area. There were no significant differences between mothers and fathers or across time in the perception
of the stress created by the sights and sounds of the unit. Parents reported experiencing the greatest level of uncertainty in the area of unpredictability (M = 3.36), and the least concerning lack of clarity (M = 2.04). The mean levels of uncertainty for mothers and fathers at Time 1 and Time 2 are shown in Figure 2. A two-way (parental role X time) repeated-measures MANOVA revealed no significant multivariate differences between mothers and fathers or between Time 1 and Time 2 in level of uncertainty; the interaction was also nonsignificant (see Table 2). Because the statistical power of the multivariate test was modest, due to the relatively small sample size, the univariate ANOVAs also were examined for patterns across
Table 1. Analysis of Variance for PSS:NICU Scales Source Role (Mother vs. Father) Time (Time 1 vs. Time 2) Role x Time Univariate ANOVAs by PSS:NICU Scale Parental role alteration Role Time Role x Time Infant appearance Role Time Role x Time Sights and sounds Role Time Role x Time
df
F
P
3,20 3,20 3,20
3.57 4.80 2.82
,032 .011 ,065
1,22 1,22 1,22
10.31 9.96 7.67
.004
1,22 1,22 1.22
.41 8.31 1.41
.009
1,22 1,22 1,22
.32 .01 1.74
.577 .929 ,200
,005 ,011 .529 .248
RESEARCH IN NURSING 8 HEALTH
266
Lack of Clarity
Lack of Information 5.0 4.8 4.6 4.4 4.2
4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 -
43:
2
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x
.E
2 a 2 2 5
r”
-
1.2 1.o T1
1
T2
Ambiguity
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:x:
.E
2a F 3 =
,
T1
T2
Unpredictability 5.0 4.8 4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.o
5.0 4.8 4.6 4.4 4.2 4.0 3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2
=:
1 .o
T1
,
T2
c
1 L.I 3.90
3.78
T1
T2
FIGURE 2. Mean Uncertainty scale scores (+/- 1 standard deviation) by time and parental role. Note: Solid line = mothers’ scores; dotted line = fathers’ scores
the dimensions of uncertainty. Significant reductions in uncertainty from Time 1 to Time 2 were noted in the areas of information, clarity, and ambiguity; mothers differed from fathers only in the area of unpredictability. State anxiety scores for both mothers and fathers fell within the range of “anxious clients” (Spielberger et al., 1983) at Time 1, which was within one week of the infant’s admission. The mean scores for mothers and fathers were 51 (SD = 13.7) and 49 (SD = 12.0), respectively. By Time 2 (approximately one week later), mothers’ scores had fallen to 43 (SD = 13.0), on the average, and fathers’ scores to 40 (SD = 11.9). A roleby-time ANOVA indicated that the decrease in anxiety from Time 1 to Time 2 was significant, F( 1,22) = 16.72, p = .001, but that mothers and
fathers did not differ significantly from each other in their levels of anxiety. Relationship between NlCU Stress and Anxiety
For fathers, anxiety scores were found to correlate significantly with stress related to alterations in the parental role and with lack of clarity at both Time 1 (r = .53, p < .005, and r = .37, p < .M1,respectively) and Time 2 ( r = .53, p < .005, and r = .37, p < .M1, respectively). Although for mothers, anxiety was found to correlate most strongly with parental role alterations at Time 1 (r = .32, p < .068), none of the relationships examined at Time 1 or Time 2 were significant.
267
NICU STRESS / MILES ET AL.
DISCUSSION Findings from this study support the previous literature suggesting that the admission of an infant to an NICU is stressful to parents (Benfield et al., 1976; Gennaro, 1988; Miles, 1989; Paludetto et al., 1981; Philipp, 1983; Trause& Kramer, 1983; Yu eta]., 1981). The most stressful aspect of the NICU environment for these parents was alterations in the parental role. The stress related to parental role alterations decreased markedly in the week following the child’s admission; however, it was still the most stressful aspect of the admission for parents. Although both mothers and fathers found parental role changes to be the most stressful aspect of their infant’s admission, mothers were more distressed than fathers by parental role alteration. Mothers’ scores on the parental role alteration subscale were markedly higher at both Time 1 and Time 2 than fathers’ scores. Although both maternal and paternal scores dropped by Time 2, mothers’ scores remained high. Thus, mothers may experience stress uniquely related to the loss of the caretaking role with the infant. These findings support previous research that found that mothers appear to be more concerned about caregiving and nurturing the sick infant than fathers (Brown et al., 1989; Levy-Shiff et a]., 1989; Marton et a]., 1981;Thurman & Korteland, 1989). The findings
also are similar to research that found mothers experienced more stress related to the parental role than fathers when a child is admitted to a pediatric intensive care unit (Miles, Carter, Spicher, & Hassanein, 1985; Riddle, Hennessey, Eberly, Carter, & Miles, 1987). The sights and sound of the unit were moderately stressful for both mothers and fathers, and this did not change over time. These findings are similar to research with parents of children admitted to a pediatric intensive care unit (Miles et a]. , 1985). As pointed out in this previous research, it may be that the public no longer finds the sights and sounds of intensive care units intimidating because of familiarity with ICUs through television and personal experiences. The infant’s appearance and behavior were slightly less stressful for parents than were the sights and sounds of the unit, and this stress decreased significantly over time. These findings may reflect the results of nursing and medical staff discussions that normalize the infant’s unusual appearance and behaviors with parents. The greatest amount of uncertainty experienced by mothers and fathers was in the area of unpredictibility, with mothers reporting greater uncertainty in this area than did fathers. Although all of the uncertainty scores dropped over time for both mothers and fathers, unpredictability decreased the least and remained the greatest source of uncertainty. That lack of information, lack of
Table 2. Analysls of Variance for Uncertainty Scales Source Role (Mother vs. Father) Time (Time 1 vs. Time 2) Role x Time Univariate ANOVAs by Uncertainty Scale Lack of information Role Time Role x Time Lack of clarity Role Time Role x Time Ambiguity Role Time Role x Time Unpredictability Role Time Role x Time
df
F
4,19 4,19 4.19
1.36 2.27 .47
,284 ,099 ,757
P
1,22 1,22 1,22
1.53 5.28 .79
,230 ,032 ,385
1,22 1,22 1,22
1.10 5.96
.oo
,307 ,023 ,966
1,22 1,22 1,22
1.72 5.80 1.24
,203 .025 .277
1,22 1,22 1,22
5.44 .42 .01
.029 .521 ,909
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clarity, and ambiguity scores decreased by Time 2 is not surprising; it would be expected that parents might accumulate information and have a clearer picture about their child’s illness over the first weeks following admission. On the other hand, unpredictability about the course and outcomes for the infant may remain a constant, if not increasing, problem for parents of sicker preterm infants. This area of parental response during an infant’s NICU admission has not been addressed in previous research. Anxiety levels indicated that these parents were highly anxious during the first week after admission but were significantly less anxious a week later. This suggests that the anxiety surrounding the admission of the infant lowers after the initial shock and adjustments have occurred. A limitation of this study, however, may be the way in which anxiety was measured; a more clinically sensitive instrument may be needed to measure the anxiety of parents of hospitalized children. For fathers, anxiety was moderately related to alterations in the parental role and to uncertainty related to lack of clarity regarding the child’s diagnosis and treatment. For mothers, there were no significant relationships between NICU environmental stress dimensions and uncertainty dimensions and anxiety scores. Maternal anxiety may be more diffuse than that experienced by fathers and other sources of anxiety, not included in this study, may need to be examined. A particularly important aspect of anxiety that was not included in this study might be concern about whether the infant might die. In addition, concerns regarding the needs of other children, job responsibilities, and financial strains may influence anxiety. Results of this study have relevance for professionals working with parents of prematures hospitalized in an NICU. Interventions with parents in the NICU should include both mothers and fathers. Particular attention should be placed on the stress related to their altered parental role. Separation from the infant, feelings of helplessness in the parental role, and limitations on their ability to give care are all aspects of the situation that staff should address with parents. Interventions that enhance and support the parental role are especially important. Parents also should receive information about the usual sights and sounds of the NICU; this may reduce the stress they engender in parents. Parents may need assistance in understanding and coping with the unpredictability of their infant’s illness course as well. Allowing parents to discuss the feelings engendered by unpredictability also may help.
Findings of this study should be considered in light of the small sample size. While the multivariate repeated measures design employing 23 dyads used in this study had a power of greater than .70 to detect large effect sizes in PSSNICU scores and a power greater than .80 to detect moderate effect sizes in uncertainty scores, it was not sensitive to smaller differences (Keyes & Muller, 1991). If it is clinically important to identify smaller differences,replication with a larger sample size is recommended. In addition, although a repeated measures design was used, the study was short term in nature; a longitudinal design that follows parents over a longer period of time is needed. No effort was made to explore the responses of parents of infants hospitalized in different units due to the small sample. How differences in the physical and psychosocial aspects of different NICU settings affect parents might be explored in further research. There also is a need to identify the differing responses, level of involvement, and caregiving behaviors of mothers as compared to fathers, and to examine how parental stress influences mothers’ and fathers’ responses to their infant. In addition, research is needed to examine how the stress responses surrounding the infant’s hospitalization affects parents after discharge. Although many studies have been focused on parenting the preterm infant after discharge, there has been little evaluation of how parental stress during hospitalization may affect later parenting of the child.
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