The Experiences of Parents in the Neonatal Intensive Care Unit: An Integrative Review of Qualitative Studies Within the Transactional Model of Stress and Coping

Quality of couple relationship and associated factors in parents of NICU-cared infants during the first year after birth

OBJECTIVE

To describe factors associated with quality of couple relationships among parents of infants cared for in neonatal intensive care units (NICUs) 1 year after birth and examine the trajectory of the relationship quality compared to parents from maternity units (MUs).

STUDY DESIGN

Longitudinally comparative cohort design. Parents answered surveys during the first year after discharge about the couple relationship, social support, and depressive symptoms.

RESULTS

Better social support and a hospital stay of 7-14 days were positively associated with the couple relationship in NICU mothers, whereas not having slept together with the partner and infant during hospitalization were negatively associated. Depressive symptoms were negatively associated with the relationship among NICU fathers. There were no differences in trajectory of the relationship quality between NICU and MU parents.

CONCLUSION

To strengthen couple relationships, it could be important to improve social support, facilitate space and time for support, and enable togetherness during hospitalization.

Factors affecting parental role adaptation in parents of preterm infants after discharge: a cross-sectional study

Background

Parenting a preterm infant can be incredibly challenging and stressful, particularly in the first year after discharge. Desirable parental role adaptation leads to appropriate parenting behaviors and parent-infant interaction, which are essential to child health and development.

Aim

To investigate the level of parental role adaptation and its influencing factors among parents of preterm infants in the first year after hospital discharge according to Belsky's parenting process model among parents of preterm infants in the first year after hospital discharge.

Methods

A cross-sectional study design was adopted using convenience sampling. Data were collected using the Parental Role Adaptation Scale (PRAS) in parents with preterm infants, the Perceived Social Support Scale (PSSS), the Coping Adaptation Processing Scale (CAPS-15), and a sociodemographic questionnaire. Descriptive statistics, non-parametric tests, Spearman correlation analyses, and multivariate linear regression were used to analyze the data.

Results

In total, 300 Chinese parents were included in the analysis. In the multivariate analysis, first-time parent (p = 0.003), master's degree and above (p = 0.042), coping adaptation processing (p = 0.000), residence location (towns: p = 0.019, city: p = 0.028), monthly family income (6000-10,000: p = 0.000, >10,000: p = 0.000), and perceived social support (p = 0.001) were all significant predictors of parental role adaptation and collectively accounted for 56.8% of the variation in parental role adaptation of parents with preterm infants (F = 16.473, p < 0.001). Coping adaptation processing mediated the relationship between perceived social support and parental role adaptation (95% bootstrap CI = 0.022, 0.130).

Conclusion

Chinese parents of preterm infants experience a moderate level of parental role adaptation when their child is discharged from the hospital to home. Parents who are not first-time parents, have master's degrees or above, live in towns or cities, have higher coping and adaptation abilities, have high monthly family income, and greater perceived social support have a higher level of parental role adaptation. Healthcare providers should pay more attention to parents with low socioeconomic status and encourage them to improve their coping and adaptation abilities and to utilize their formal and informal social support networks.

Nurses' and Parents' View on Neonatal Intensive Care Unit Diaries: A Qualitative Study and Framework Conceptualization

OBJECTIVE

The birth of a premature or critically ill newborn can be a traumatic event for the entire family. In these situations, the neonatal intensive care unit (NICU) diary is a relevant coping intervention to support family members. However, a profound theoretical concept is lacking, and there is little evidence about how it is applied by nurses in clinical practice. Therefore, this study aims to investigate how NICU diaries are used by nurses to support family members cope with their experiences and to develop an evidence-guided and theory-based framework for conceptualizing diary usage in the NICU.

STUDY DESIGN

A qualitative study design containing 12 narrative interviews with nurses from six different hospitals and two focus group interviews with nine parents from two different hospitals was chosen. The qualitative data were analyzed via content analysis inductively and separately and brought together via graphical coding in a second step.

RESULTS

Four main categories emerged from the analyzed data to describe the NICU diary in nursing practice. Regarding diary (1) "usage," three different types of NICU diaries were identified, which seem to be established largely intuitive. The (2) "content" is constituted by the diary's title, introduction, textual, and nontextual components. Taking into account the diary (3) "function" for the parental coping process, three subcategories emerge: (a) strengthening the parental role, (b) supporting understanding of events, and (c) bringing joy and normality to the situation. (4) "Challenges" address an appropriate writing style, the reading of parental entries by nurses and limited resources. Based on these results and taking into account relevant literature, a framework for conceptualizing NICU diaries was developed.

CONCLUSION

NICU diaries show great potential to support the parental coping process. Nevertheless, diary conceptualization should be based on a theoretical framework to clarify its usage for nurses and parents.

KEY POINTS

· NICU diaries are an established intervention used by nurses to support parental coping.. · In nursing practice, different types of NICU diaries emerge.. · Writing styles, content, and reading of entries are reported heterogeneously.. · A conceptualizing framework for NICU diaries is needed..

Parental stress, depression, anxiety and participation in care in neonatal intensive care unit: a cross-sectional study in Italy comparing mothers versus fathers

BACKGROUND

This study aimed at documenting the levels of stress, depression, anxiety and participation in care among mothers versus fathers of newborns hospitalised in a third-level neonatal intensive care unit (NICU) in Northern Italy.

METHODS

Parental stress, depression and anxiety were assessed by the Parental Stressor Scale in NICU (PSS:NICU), the Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI). Participation in care was evaluated with the Index of Parental Participation. Differences between mothers and fathers were assessed with the Mood's median test and z-test, respectively for continuous and discrete variables. Multivariate analyses controlling for potential confounders were performed to confirm gender differences.

RESULTS

191 parents (112 mothers and 79 fathers) were enrolled. Mothers reported significantly higher median scores for stress (2.9 vs 2.2, p<0.001) and trait anxiety (37 vs 32, p=0.004) and higher depression rates (EPDS ≥12: 43.8% vs 19.0%, p<0.001). 'High stress' (PSS:NICU ≥3) was reported by 45.5% of mothers compared with 24.1% of fathers (p=0.004). The frequency of the three conditions simultaneously was significantly higher among mothers (20.0% vs 3.8%, p=0.016), with the vast majority of mothers (76.0%) suffering from at least one condition compared with less than half of fathers (45.3%, p<0.001). Participation in care was more frequent in mothers (median score: 19 vs 15, p<0.001), with the exception of activities related to advocacy (median 5 vs 4, p=0.053). In a multivariate analysis, gender differences in mental health outcomes did not change.

CONCLUSIONS

Routine screening of mental distress among parents of infants in NICU is warranted, and gender differences need to be acknowledged in order to deliver tailored support and to promote collaboration with the family of vulnerable newborns. Knowledge and skills on how to prevent and cope with mental distress of parents should be part of the core curriculum of staff working in NICU.

A Systematic Review of Psycho-Spiritual Interventions in the NICU: Supporting Parents' Mental Health and Psychological Well-Being

BACKGROUND

The presence of psychospiritual supports and interventions for neonatal intensive care unit (NICU) parents is unclear.

PURPOSE

This systematic review examines the psychological and medical literature for psychospiritual interventions designed to support parents' mental health and psychological well-being during or after the NICU experience.

DATA SOURCES

Data sources include PubMed, PsycINFO, and Cochrane Library (Cochrane Database of Systemic Reviews, Cochrane Central Register of Controlled Trials) with peer-reviewed studies published between 2013 and 2023.

STUDY SELECTION

Peer-reviewed studies that included spiritual and psychological intervention components focused on supporting parents during or after the NICU were included for this systematic review. There were 42 records located in 3 databases ultimately yielding 4 peer-reviewed studies that met inclusion criteria. Articles must have been written in English and evaluate parents'/caregivers' mental health/psychological well-being in relation to a psychospiritual intervention.

DATA EXTRACTION

Because of the small number of studies, article summaries are provided within the results section and were written by the first author with approval by the second and third authors.

RESULTS

Results indicated that when psychological (focus on coping) and spiritual components were included psychological and well-being outcomes were better for NICU parents.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The inclusion of psychological and spiritual aspects of coping and supportive care is necessary for the best family-centered NICU care. More work needs to be done to develop psychospiritual supports and include fathers in these endeavors as most work occurs with mothers. Nurses need support and training to facilitate family-centered care with a focus on parents' psychospiritual needs.

Exploring Parent Experiences With Early Palliative Care Practices in the NICU

BACKGROUND

The anxiety and uncertain outcome of an admission of a seriously ill infant to the neonatal intensive care unit (NICU) can cause great stress for parents and contribute to poor mental health outcomes. Early implementation of family-centered palliative care (PC) may provide support for NICU parents. Key concepts of early PC in the NICU include shared decision-making, care planning, and support for coping with distress.

PURPOSE

The purpose of this study was to explore parent experiences during their child's NICU admission with the early PC practices of shared decision-making, care planning, and coping with distress.

METHODS

Qualitative descriptive methodology was used. Strategies of reflexive journaling, peer debriefing, and data audits were used to enhance trustworthiness. Parents (N = 16) were interviewed, and data were analyzed by conventional content analysis. Targeted recruitment of fathers occurred to ensure they comprised 25% of sample.

RESULTS

Parents' descriptions of decision-making were contextualized in gathering information to make a decision, the emotional impact of the decision, and influences on their decision-making. In experiences with care planning, parents described learning to advocate, having a spectator versus participant role, and experiencing care planning as communication. Key themes expressed regarding parental coping were exposure to trauma, survival mode, and a changing support network.

IMPLICATIONS FOR PRACTICE AND RESEARCH

These findings highlight key areas for practice improvement: providing more support and collaboration in decision-making, true engagement of parents in care planning, and encouraging peer support and interaction in the NICU and in online communities.

Phenomenological Study of Women's Experiences of Neonatal Transport After Childbirth in Korea

OBJECTIVE

To explore the experiences of women in Korea who were separated from their newborns when they were transported to neonatal intensive care units (NICUs) to receive treatment.

DESIGN

Phenomenological.

SETTING

A university hospital with approximately 600 beds in Seoul, Korea.

PARTICIPANTS

Women who experienced neonatal transport after childbirth from March to May 2021 (N = 9).

METHODS

We collected data through individual in-depth interviews and analyzed them using Colaizzi's procedure.

RESULTS

We extracted four overarching themes that represented the experiences of participants: Outsider Left Alone, Enduring in a Different World, The Lost Starting Line, and Running Together.

CONCLUSION

Our findings captured the unique experiences of women whose newborns were transported from the hospitals where they were born to NICUs at other hospitals to receive treatment. It is necessary to develop and apply tailored nursing interventions, such as assessment and support for postpartum blues or depression, to ensure that postnatal care and healthy maternal transition are not hindered.

NANN Membership Recommendations: Opportunities to Advance Racial Equity Within the Organization

BACKGROUND

Neonatal care has advanced significantly in recent years, yet racial health inequities persist in the neonatal intensive care unit (NICU), with infants from racial and ethnic minority groups less likely to receive recommended treatment. Healthcare providers acknowledge that there are steps that can be taken to increase knowledge and awareness regarding health inequities.

PURPOSE

To better understand current health equity-related initiatives in the neonatal community and solicit feedback from National Association of Neonatal Nurses (NANN) membership about advancing racial equity within the organization.

METHODS

A cross-sectional survey was conducted in January 2021. The anonymous, onetime survey was distributed to active NANN members via SurveyMonkey and included questions related to racial equity initiatives, recommendations, and demographics. Data analysis was conducted using an exploratory approach using descriptive statistics, and thematic analysis was used to summarize responses to open-ended questions.

RESULTS

There were 325 members who completed the full survey, of whom were White (83%), female (96%), staff nurses (42%), and those with more than 16 years of experience (69%), and most (69%) were familiar with NANN's racial equity position statement. Recommendations were summarized into the following themes: (1) research, (2) education, (3) workforce diversity, (4) communication, (5) scholarships, (6) resources, and (7) community outreach.

IMPLICATIONS FOR PRACTICE AND RESEARCH

NANN members offered clear and actionable recommendations to advance health equity within the neonatal community and organization, which included offering more diversity, inclusion, and equity education at the annual conferences, in ANC articles, and newsletters, and the creation of scholarships or reduced membership fees to encourage diverse enrollment in the organization.

Ethnic minority fathers' experiences of the Neonatal Care Unit: barriers to accessing psychological support

BACKGROUND

The Neonatal Care Unit is a challenging environment for parents. Previous literature documents the need for increased and more specialised understanding of support for fathers. There remains a dearth of literature on the experiences of ethnic minority fathers in particular, who may be less likely to access psychological support available.

METHOD

This project aimed to understand the barriers ethnic minority fathers face when accessing psychology support at a Neonatal Care Unit in England. Seven fathers from ethnic minority backgrounds participated in semi-structured interviews after their babies were discharged.

RESULTS

Data were analysed using a Reflexive Thematic Analysis approach. Three main themes were identified: 'Psychology is a Threat', 'It's Not Really Talked About in our Culture', and 'A Space for Mum, Not Me'. These themes are discussed in reference to the extant literature, and recommendations are provided to improve access to support in this neonatal unit.

CONCLUSIONS

There is a need to recognise interacting influences of gender and cultural norms in supporting these fathers, including understanding the role of psychology, consideration of stigma, and knowing families in relation to their cultural context.

Fetal Anomaly: Family Experiences and Preferences for Care: An Integrative Review

BACKGROUND

The prenatal diagnosis of a fetal anomaly is unexpected, creating a family crisis. Expectant parents are at an increased risk for perinatal depression and traumatic stress. Prior reviews examined parents' experiences when terminating but not continuing the pregnancy. This review synthesized qualitative research to describe the experiences, emotional responses, and needs of families continuing their pregnancy.

METHODS

An integrative review was performed using the Whitemore and Knafl methodology and PRISMA guidelines. A systematic review of peer-reviewed articles published between 2000 and 2200 on the experiences of fetal anomaly was performed using 5 databases. Eligible articles included qualitative studies describing families' experiences with a fetal anomaly diagnosis who elected to continue their pregnancy. Methodological quality was evaluated using the Critical Skills Appraisal Program checklist.

RESULTS

Of the 678 article results, 16 met inclusion criteria. There were 298 participants from 5 countries. The major overarching theme of Response to the Diagnosis of Fetal Anomaly was identified. The major categories were emotional response, coping strategies, influences, health care experiences, and family needs. Uncertainty and grief were the most common emotions.

DISCUSSION

Parents choosing to continue pregnancy benefit from compassionate, sensitive care, and accurate, concise information, provided in tailored instruction using multiple styles.

Trauma Informed Care in the Neonatal Intensive Care Unit

Parents who have a baby receiving care in the Neonatal Intensive Care Unit (NICU) likely all experience emotional distress and are at elevated risk of experiencing trauma. The NICU environment is a potential source of traumatic stress for parents and often the risk for neonatal death is substantial. While the stressors facing parents are considerable, the effects can be minimized through implementation of trauma-informed care. The Family Guidance Tool was developed to help parents and healthcare professionals in a NICU setting utilize a strengths-based approach to create an atmosphere of mutual trust and understanding while encouraging the family to be the guide. This practical tool shows promise to mitigate stress often experienced by parents in a NICU setting.

Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations

BACKGROUND AND OBJECTIVES

To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made.

METHODS

Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach.

RESULTS

Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways.

CONCLUSIONS

Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.

Family Resilience as an Emerging Concept in Neonatology: Evidence From a Metasummary Review

BACKGROUND

Family resilience can be observed through specific resilience-promoting processes, namely, shared belief systems, communication, and organizational processes, but the concept remains mostly unstudied in neonatology. This metasummary aims to evaluate the frequency of family resilience processes in qualitative scientific literature to illustrate how family resilience is exhibited in the neonatal intensive care unit (NICU) setting.

METHODS

A search among 4 databases yielded 7029 results, which were reviewed for inclusion. Following Sandelowski and Barroso's qualitative metasummary method, findings from each study were independently coded and frequency effect size was calculated.

RESULTS

Forty-six primary qualitative studies published between 2016 and 2022 conducted with parents of preterm infants who discussed their NICU hospitalization experience were included in this metasummary. All 9 of Walsh's family resilience processes were identified in the literature, and their frequency effect size ranged from 4% to 91%. Four additional themes emerged pertaining to specific family resilience behaviors exhibited by NICU families.

CONCLUSION

This analysis sheds new light on the most recent qualitative evidence of parents' experiences in the NICU by analyzing it through the lens of family resilience and posits family resilience as a promising concept in relation to the predominance of the family-centered care philosophy in neonatal units.

Lived experience caring for a child with Covid-19 disease: A phenomenological study

Background

Caregivers of COVID-19 patients, including mothers with an infected child, are affected by adverse physical and psychological effects. Since mothers perform an important role in caring for a child with Covid-19, explaining their challenges and experiences positively affects the health conditions of children and society, in general.

Aim

This study aimed to explain mothers' experiences with children diagnosed with COVID-19, who were referred to Bandar Abbas Children's Hospital.

Method

The present study was qualitative and used the Van-Manen method. The statistical population included 13 mothers with children hospitalized for coronary heart disease and COVID-19, who were selected by purposive sampling. Semi-structured interviews were implemented to collect data until saturation. Data analysis was performed using MAXQDA 10 software. Lincoln and Guba's criteria were used to evaluate the data's accuracy and strength.

Results

The mean age of mothers participating in the study was 37.92 ± 4.87. On the other hand, the mean age of children was 5.15 ± 2.07 years. Three main themes and 13 sub-themes were extracted from the data analysis. The main themes were "Inability to Caring", "Mental and Physical drain" and "Conflict of Roles and Responsibilities". In this study, when a child develops COVID-19 disease, the mother experiences a series of negative emotions, which lead to feelings of helplessness and inability to care for the child.

Conclusion

Mental and physical manifestations strains were the most important issues that the mothers experienced. The majority of the participants need psychological support to cope with the disease. Therefore, it is recommended to make a proper design to psychologically and socially support these mothers, while alleviating the physical manifestations of their children's disease.

Parental perceptions and experiences of care in the surgical neonatal intensive care unit

BACKGROUND

Parents endure significant stress when their newborns require surgery while in the neonatal intensive care unit (NICU). Our study aims to explore the surgical NICU experience from the parents' perspective and identify areas that may improve this experience. A secondary objective was to integrate their feedback to refine the implementation strategy of the neonatal enhanced recovery after surgery (ERAS®) guideline.

METHODS

In December 2019, five surgical NICU parents participated in a focus group. Conversation surrounded parents' perspectives and experiences of the surgical NICU. Inductive analysis was performed to identify data, themes, and concepts that emerged from the discussion.

RESULTS

Participants identified four major interrelated themes that impacted the surgical parents' NICU experience. These themes include (1) parental state, both physical and emotional, (2) the altered parental caregiver role which necessitates identifying alternative meaningful parental experiences, (3) the care team dynamic, incorporating consistency and effective communication, and (4) the discharge process which may be significantly eased through graduated, hands-on training.

CONCLUSION

Key elements of the neonatal ERAS® guideline address major themes and stressors identified by parents. The parental perspective may help clinicians appreciate the parent surgical NICU experience and assist in improving family-centered care to surgical infants and their families.

Experiences of Mothers of Preterm Infants in the Neonatal Intensive Care Unit During the COVID-19 Pandemic

BACKGROUND

The neonatal intensive care unit (NICU) stay following the birth of a preterm infant can be stressful and traumatic for families. During the COVID-19 pandemic, the NICU environment changed precipitously as infection control and visitor restriction measures were implemented.

PURPOSE

Our study aimed to examine the impact of the pandemic policies on the experiences of mothers of preterm infants during their stay in the NICU.

METHODS

Semistructured interviews were conducted with mothers of preterm infants hospitalized in a Canadian tertiary-level NICU. Informed by interpretive description methodology, interview content was transcribed and analyzed using a thematic analysis approach. The identified themes were validated, clarified, or refined using investigator triangulation.

RESULTS

Nine English-speaking mothers, aged 28 to 40 years, were interviewed. Four themes emerged from the analysis of their experiences: (1) disrupted family dynamic, support, and bonding; (2) physical and emotional isolation; (3) negative psychological impact compounded by added concerns, maternal role change, and survival mode mentality; and (4) positive aspects of the pandemic management measures.

IMPLICATIONS FOR PRACTICE

During the pandemic, the way that care was provided in the NICU changed. This study helps to explore how neonatal clinicians can foster individual and organizational resilience to keep patients and families at the center of care, even when the healthcare system is under intense stress.

IMPLICATIONS FOR RESEARCH

: Our results show that these changes heightened mothers' distress, but also had a modest positive impact. Further research about long-term consequences of pandemic policies on the mother and preterm infant after NICU discharge is warranted.

Effects of maternal stress and/or anxiety interventions in the first 1000 days:Systematic review of reviews

OBJECTIVE

Effective interventions are needed to mitigate effects of stress and anxiety from conception and up to two years postpartum (the first 1000 days), but it is unclear what works, for what populations and at what time points. This review aimed to synthesise evidence from existing reviews of the effects of stress and anxiety interventions.

METHODS

A systematic review of systematic reviews was conducted. PsycINFO, CINAHL, MEDLINE and the Cochrane databases were searched (inception to January 2020). Reviews were eligible if they examined effects of interventions during the first 1000 days on women's stress and/or anxiety. Extracted data were narratively synthesised. Review quality was assessed using existing recommendations including the AMSTAR tool .

RESULTS

Thirty-four reviews were eligible for inclusion; 21 demonstrated high methodological quality. Cognitive behavioural therapy demonstrates some beneficial effects for anxiety across the first 1000 days for general and at-risk populations. Support-based interventions demonstrate effects for stress and anxiety for at-risk mothers in the postpartum. Music, yoga and relaxation demonstrate some effects for stress and anxiety, but studies are limited by high risk of bias.

CONCLUSION

Existing evidence is inconsistent. Cognitive behavioural therapy and support-based interventions demonstrate some benefits. Further methodologically and conceptually robust research is needed.

Implementing genomics in the neonatal period: An assessment of parental decision making and anxiety

As uptake of rapid genome sequencing (GS) in the neonatal period steadily increases, a clinical genetics service that is optimized to the needs of parents becomes increasingly important. We aimed to investigate factors that influence decision making about rapid GS by parents of infants admitted to neonatal intensive care units (NICU) and explore their experiences of decisional conflict and anxiety during this time. Parents of neonates suspected of having a genetic disorder and offered rapid GS in the NICU completed a questionnaire measuring experience with GS counseling, decisional conflict, and anxiety level. Our results demonstrate that despite a largely positive GS experience (70%; 21/30) among the survey respondents, 50.0% (14/28) experienced moderate to severe anxiety measured using the GAD-7 scale, and 34.6% (9/26) experienced decisional conflict measured using the SURE scale. We also showed that prematurity may be a modifier of anxiety in this group of parents and although not statistically significant, distance lived away from the hospital site could have practical significance. Open-ended responses to survey questions highlighted that feeling overwhelmed, the types of engagements parents had with healthcare providers, and the timing of information provision also influenced parental decision making in this setting. We suggest that the GAD-7 scale for generalized anxiety and SURE scale for decisional conflict could be incorporated by genetic counselors into routine care of parents of neonates who have been offered rapid GS to identify those who may need additional support (resources, information, or psychological). These tools may inform ways that communication between patients and providers can be improved and enhanced and clinical genetics services in the NICU can be optimized. We suggest that integrating genetic counselors into the NICU care team could increase access for this population and ensure delivery of optimized patient education and counseling.

Stressful Experiences of Parents in the Paediatric Intensive Care Unit: Searching for the Most Intensive PICU Stressors

Hospitalization of a child in the paediatric intensive care unit (PICU) is extremely stressful, both for the child and for his or her family. The purpose of this study was to gain deeper insight into the stressful experiences of parents of children hospitalized in the PICU. This study included 96 parents. The data were collected using a translated and standardized scale "The Parental Stressor Scale: Paediatric Intensive Care Unit (PSS: PICU)". This study confirms high exposure of parents to numerous PICU stressors. The most intense PICU stressor for parents was child's breathing depending on the ventilator (4.22 ± 1.17), and the least intense was child's demanding behaviour (1.17 ± 0.33). A significant positive correlation between the level of parents' perceived stress and the number of their children was recorded (r = 0.240, p = 0.02), while there was no significant correlation between the level of stress and other sociodemographic variables. A significantly higher level of stress was experienced by parents with primary school education (p = 0.032) and parents who are not healthcare professionals (p < 0.01). It is necessary to establish a system that will enable continuous assessment of parents' stress levels and timely prevention of stressful experiences for parents in the PICU.

CUIDAR-MaPre scale validation: A tool to measure the caregiving competence of mothers of premature infants

OBJECTIVE

To determine the validity and reliability of the CUIDAR instrument in mothers of premature infants.

METHOD

Cross-sectional validation study. The study was conducted in two stages. First stage: literature review, semantic adequacy, and judgement with 7 experts to establish content validity. In the second stage, the psychometric properties of the instrument were evaluated by exploratory factor analysis after its application to 207 mothers of premature infants.

RESULTS

In the expert's judgment, the content validity index was higher than 0.8, which indicated adequate representativeness of the items. Agreement between judges was moderate with a Fleiss Kappa of 0.51. The exploratory factor analysis established the adequacy of the sample with a Kaiser-Mayer-Olkin statistic of 0.859 and Bartlett's test of sphericity 2953.9 (p = 0.000). After considering various scenarios, a 7-dimensional, 33-item model explained 57.9% of the variance, with an overall Cronbach's alpha of 0.852 and adequate goodness-of-fit indices. The goodness-of-fit tests allowed us to establish through statistical significance χ² = 0.01, CFI = 0.92, BIC ≥ 10 and RMSEA = 0.05 indicating that the model has a good fit.

CONCLUSIONS

A new model was identified based on the items and dimensions of the CUIDAR instrument, which allows us to assess the competence of mothers to care for their premature children in a valid and reliable way.

Stress and Wellbeing during the COVID-19 Pandemic: A Mixed-Methods Exploration of Frontline Homelessness Services Staff Experiences in Scotland

Staff working in homelessness services often find the work rewarding yet challenging, and the sector experiences high levels of staff burnout and staff turnover. During the COVID-19 pandemic, staff working in these services faced particularly stressful working conditions. This study explored the experiences of stress and wellbeing among those working in frontline homelessness service roles during the early stages of the pandemic in Scotland. Semi-structured interviews were conducted with 18 participants, 11 of whom completed the Maslach Burnout Inventory (MBI). Qualitative data were analysed using Framework Analysis in NVivo, informed by the Revised Transactional Model of occupational stress and coping. MBI data were analysed using descriptive statistics. The COVID-19 pandemic positively and negatively impacted participants’ lives and roles. Organisational culture acted as a magnifying glass for pre-pandemic practices: for some, the pandemic brought teams and staff closer together, creating a better working environment. For others, it led to fragmentation and frustration. Participants discussed coping strategies and recommendations for the future to protect staff wellbeing. Quantitative data suggested that participants were not experiencing burnout, although some were at heightened risk. Future research should explore the longer-term impact of the pandemic on homelessness service staff outcomes.

Assessment of parent understanding in conferences for critically ill neonates

OBJECTIVES

This study aimed to characterize the use and impact of assessments of understanding in parent-clinician communication for critically ill infants.

METHODS

We enrolled parents and clinicians participating in family conferences for infants with neurologic conditions. Family conferences were audio recorded as they occurred. We used a directed content analysis approach to identify clinician assessments of understanding and parent responses to those assessments. Assessments were classified based on an adapted framework; responses were characterized as "absent," "yes/no," or "elaborated."

RESULTS

Fifty conferences involving the care of 25 infants were analyzed; these contained 374 distinct assessments of understanding. Most (n = 209/374, 56%) assessments were partial (i.e. okay?); a minority (n = 60/374, 16%) were open-ended. When clinicians asked open-ended questions, parents elaborated in their answers most of the time (n = 55/60, 92%). Approximately three-quarter of partial assessments yielded no verbal response from parents. No conferences included a teach-back.

CONCLUSIONS

Although common, most clinician assessments of understanding were partial or close-ended and rarely resulted in elaborated responses from parents. Open-ended assessments are an effective, underutilized strategy to increase parent engagement and clinician awareness of information needs.

PRACTICE IMPLICATIONS

Clinicians hoping to facilitate parent engagement and question-asking should rely on open-ended statements to assess understanding.

Lived experiences of stress of Black and Hispanic mothers during hospitalization of preterm infants in neonatal intensive care units

OBJECTIVE

To characterize the lived experiences of stress associated with having a preterm infant hospitalized in the NICU among Black and Hispanic mothers.

METHODS

We performed a qualitative content analysis of secondary data from two prior studies that included 39 in-depth interviews with Black and Hispanic mothers of preterm infants at 3 U.S. NICUs. We used a constant comparative method to select important concepts and to develop codes and subsequent themes.

RESULTS

Black and Hispanic mothers described stressors in the following domains and categories: Individual (feeling overwhelmed, postpartum medical complications, previous stressful life events, competing priorities); Hospital (perceived poor quality of care, provider communication issues, logistical issues); Community (lack of social supports, lack of financial resources, work challenges).

CONCLUSIONS

The findings of this study suggest that stressors both inside and outside of the hospital affect the lived experiences of stress by Black and Hispanic mothers during NICU hospitalization.

Parents' pandemic NICU experience in the United States: a qualitative study

Background

Prior to the COVID-19 pandemic, parents of infants in the Neonatal Intensive Care Unit (NICU) frequently reported high levels of stress, uncertainty, and decreased parenting confidence. Early research has demonstrated that parents have had less access to their infants in the hospital due to restrictions on parental presence secondary to the pandemic. It is unknown how parents have perceived their experiences in the NICU since the beginning of the COVID-19 pandemic. The purpose of this study was to describe the lived experience of parents who had an infant in the NICU in the context of the COVID-19 pandemic to inform healthcare providers and policy makers for future development of policies and care planning.

Methods

The study design was a qualitative description of the impact of the COVID-19 pandemic on parents’ experiences of having an infant in the NICU. Free-text responses to open-ended questions were collected as part of a multi-method study of parents’ experiences of the NICU during the first six months of the pandemic. Participants from the United States were recruited using social media platforms between the months of May and July of 2020. Data were analyzed using a reflexive thematic approach.

Findings

Free-text responses came from 169 parents from 38 different states in the United States. Three broad themes emerged from the analysis: (1) parents’ NICU experiences during the COVID-19 pandemic were emotionally isolating and overwhelming, (2) policy changes restricting parental presence created disruptions to the family unit and limited family-centered care, and (3) interactions with NICU providers intensified or alleviated emotional distress felt by parents. A unifying theme of experiences of emotional distress attributed to COVID-19 circumstances ran through all three themes.

Conclusions

Parents of infants in the NICU during the first six months of the COVID-19 pandemic experienced emotional struggles, feelings of isolation, lack of family-centered care, and deep disappointment with system-level decisions. Moving forward, parents need to be considered essential partners in the development of policies concerning care of and access to their infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-03028-w.

Parenting Self-Efficacy in Fathers of Medically Complex Infants: A Longitudinal Study

INTRODUCTION

Infants with medical complexity are have multiple chronic conditions and require specialized intensive care. One important factor in optimizing infant health and development is parenting self-efficacy (PSE). The purpose of this study was to examine parental self-efficacy in fathers over time.

METHODS

A longitudinal survey study was conducted with fathers of medically complex infants. We used the validated Karitane Parent Confidence Scale to assess PSE and multivariable linear regression examined the associations between father and infant characteristics on PSE.

RESULTS

Fathers (n=27) were white (74%), married (85%), high school educated (37%), with incomes ≥ $US50,000 (66%). Father's mean PSE score was 39.28 (±3.9). Hispanic ethnicity and total number of chronic conditions were significant predictors of lower PSE in fathers (p < .03).

CONCLUSIONS

Fathers of medically complex infants reported low PSE. More strategic interventions need to focus on self-efficacy and creating opportunities for connection between fathers and infants.

Parental and staff experiences of restricted parental presence on a Neonatal Intensive Care Unit during COVID-19

Aim

The COVID‐19 pandemic had a significant impact on parental presence in the Neonatal Intensive Care Unit (NICU) during the first wave. The NICU team at the Rosie Hospital, Cambridge, endeavoured to explore the impact on parent and staff experiences of supporting parents throughout the period when visiting was restricted, between 13th August and 11th September 2020.

Methods

Bespoke surveys were designed following the first lockdown to gather information on the impact on staff and parents. The questions were developed in the context of initial observations and conversations with staff and parents.

Results

The findings of this study have illustrated the extent of the restrictions on parental wellbeing and mood, with the restrictions having had an adverse effect on these. In addition, the findings illustrate the adverse effect that the parents reported due to the restricted presence in terms of their babies’ wellbeing, parent‐infant bonding, partners’ wellbeing, parental confidence, the ability to breastfeed confidently and parents’ access to the medical teams.

Conclusion

The findings of this study have a number of clinical implications for parents and staff. Namely, the data supported the decision not to close NICU again during the second and third waves.

Parent's Stress Predictors during a Child's Hospitalization

A child’s illness and hospitalization are particularly difficult and most often an unpredictable situation in a family’s life cycle. The level of stress of a parent of a hospitalized child depends on many factors, such as the psychological characteristics of the child and the parent, the child’s health condition, and support from the family and medical staff. Our research aimed to search for interactions between the stress experienced by the parent and the temperamental variables of both the child and the parent, and the support received from the family and hospital staff. Using three pencil-paper questionnaires—PSS, EAS-D, EAS-C—and interview questionnaire, we tested 203 parent–child dyads at the time of children hospitalization. It was revealed that the most notable moderator of the relationship between temperamental traits and the characteristics of the hospital-related situation is the child’s age. When analyzing the situation of a family with a hospitalized child, particular attention should be paid to parental emotional distress, which, regardless of the child’s age, predicts a high level of parental stress.

Needs and Perceptions Relative to Emotional Support in Parents With Preterm Infants

Objectives of this study were to explore parents' needs for emotional support and how such support could be best delivered during admittance to a neonatal unit. This study took place at 6 neonatal units in Sweden. Forty-two semistructured interviews were analyzed using qualitative content analysis: 26 individual telephone interviews with mothers of preterm infants 6 to 10 months after discharge and 16 face-to-face interviews with parents of preterm infants admitted to neonatal units. The main category to emerge was needs and preferences for emotional support , which consisted of 2 generic categories: emotional needs and preferences for potential support interventions . Emotional needs define the importance of comprehending the new situation, finding meaning, and managing the situation through resources. Preferences for potential support interventions identify possible ways to deliver emotional support in the form of parental group, diary writing, professional counseling, and Internet support. The results highlight the importance of supporting parents' sense of coherence in their situation and parenthood by offering different interventions according to parent preferences. Parental groups could serve as a keystone for emotional support with the possibility to combine with other support mechanisms.

Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants

Objective: This study examined the effect of postpartum administration of depo medroxyprogesterone acetate (DMPA) on milk production, time to onset of secretory activation, lactation duration, and infant consumption of mother's own milk (MOM) in mothers of preterm very low-birth-weight (VLBW) infants. Materials and Methods: We conducted a secondary analysis of data from mothers who delivered infants weighing ≤1,500 g and at ≤32 weeks' gestation. The volume of milk produced was measured on days 1-7, 14, and 21 by weighing all expressed milk on an electronic scale. Time to secretory activation was determined through self-report of a feeling of breast fullness. Information on lactation duration and the percent of feeds consisting of MOM consumed by infants was obtained from the medical records. Results: Mothers who received postpartum DMPA were more likely to be African American (72.4% versus 31.4%; p = 0.0006), unemployed (65.5% versus 44.5%; p = 0.027), and Medicaid eligible (89.7% versus 67.2%; p = 0.019). There were no differences in daily milk production between mothers who received DMPA before hospital discharge (n = 29) compared with those who did not (n = 141). When mothers who reached secretory activation before receiving DMPA were removed from analysis, receiving DMPA was associated with a later onset of secretory activation (103.7 versus 88.6 hours; p = 0.028). There were no statistically significant differences between the study groups in lactation duration or infant MOM consumption. Conclusions: DMPA, when administered postpartum to mothers of preterm VLBW infants, delayed secretory activation, but had no detrimental effect on milk production or lactation duration. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01892085.

The Experiences of Parent Dyads in the Neonatal Intensive Care Unit: A Qualitative Description

Background The hospitalization of an infant in the neonatal intensive care unit (NICU) is a distressing and often unexpected event for parents. Parents have risk for depression, anxiety, and posttraumatic stress, which can adversely impact them and their relationship. The hospitalization and subsequent stress may affect parents' capability to connect with and parent their child. Purpose Describe parents' experiences and ability to cope with the NICU; identify experiential and coping differences between mothers and fathers; examine the effect of the NICU hospitalization on the parent dyad relationship. Methods A qualitative descriptive design with dyadic interviews examined parents' experiences and coping skills, and subsequent effects on the parental relationship. Data collection continued until saturation was achieved and no new themes emerged. Through content analysis, an accurate description of parents' experiences in the NICU was rendered. Findings Nine themes from eight dyad interviews emerged and were categorized within the six domains of the transactional theory of stress and coping. The major themes were: Deeply Distressing, Unexpected and Unprepared, Expecting to Hear and Be Heard, Becoming Parents, Stronger Together, Support is Key, Parents Want Better Communication, and Adjusting to the NICU. Implications for practice Support from professionals and family, and clear and consistent communication from the treatment team helped alleviate parents' anxiety about their infant. Implications for research Research regarding the impact of a NICU hospitalization on the relationship between parent dyad members, specifically longitudinal studies, may lead to a better understanding of the long-term effects of this specific stressor on parents.

Impacts of Neonatal Hospitalization on Families during the 2019 Coronavirus Pandemic

OBJECTIVE

Limited data are available regarding family and financial well-being among parents whose infants were hospitalized during the 2019 coronavirus (COVID-19) pandemic. The study objective was to evaluate the family and financial well-being of parents whose infants were hospitalized in the neonatal intensive care unit (NICU) during COVID-19.

STUDY DESIGN

Parents were recruited for this online, cross-sectional survey via support groups on social media. Data collection was completed between May 18, 2020 and July 31, 2020. The final sample consisted of 178 parents, who had an infant hospitalized in an NICU between February 1, 2020 and July 31, 2020. The primary outcomes were impact on family life and financial stability, as measured by the Impact on Family scale, an instrument that evaluates changes to family life as a result of infant or childhood illness.

RESULTS

Of the 178 parent respondents, 173 (97%) were mothers, 107 (59.4%) were non-Hispanic White, and 127 (69.5%) of the infants were born prematurely. Parents reported significant family impact and greater financial difficulty. Extremely premature infants, lower household income, parent mental health, and lower parental confidence were predictive of greater impacts on family life.

CONCLUSION

Parents reported significant family and financial impacts during their infant's hospitalization amid COVID-19. Further studies are needed to guide clinical practice and inform family-supportive resources that can mitigate consequences to family well-being.

KEY POINTS

· Impact of infant hospitalization in the context of COVID-19 is largely unknown.. · In a cohort of NICU parents during COVID-19, they reported changes to family life and finances.. · Greater impacts were reported by parents with lower income, confidence, and very premature infants..

Parental protective factors and stress in NICU mothers and fathers

OBJECTIVE

Evaluate the effect of parental protective factors on parental stress at time of NICU admission and prior to discharge.

STUDY DESIGN

Parents of infants born at <35 weeks gestation were approached at a single level III NICU. Consenting parents completed a questionnaire on admission and prior to infant's discharge of demographic information and three validated instruments: (1) parental stress (PSS:NICU), (2) Parents' Assessment of Protective Factors (PAPF), and (3) health literacy (PHLAT-8).

RESULTS

Mean PSS:NICU Total score was 2.8 ± 0.9 (Time 1) and 2.6 ± 1.1 (Time 2). Mean PAPF scores in all subcategories were high (means >3, ±0.3-0.5) (Time 1, Time 2). There was no clinically significant association between PSS:NICU scores and PAPF or any of the other measured variables.

CONCLUSION

PAPF and other commonly implicated factors were not associated with perceived self-reported parental stress at time of NICU admission and prior to discharge.

Parental experiences of their infant's hospital admission undergoing cardiac surgery: A systematic review

AIM

To explore parents' experiences of parenting a child hospitalised with congenital heart disease (CHD) and undergoing surgery.

METHODS

Five electronic databases were systematically searched for articles describing the experiences of parents with a child with a CHD. A thematic analysis approach was used to identify the most common themes.

RESULTS

A total of 188 articles were identified. Eight studies were included in the review. Four themes emerged, including balancing the parental role, experiencing anticipatory grief, decreasing parental stress using coping strategies and professional support.

CONCLUSION

Having a child with CHD undergoing heart surgery is a stressful experience due to, among other things, the different situation-related parenting role during the hospital stay and feelings of anticipatory grief. Healthcare professionals in the PICU have an essential role in supporting parents and understanding the needs that are crucial for the parents in order to provide better support and reduce stress and anxiety. More qualitative research regarding the pathway from the prenatal diagnosis through the early childhood period is warranted.

Beliefs and needs of fathers of newborns hospitalised in a neonatal unit: A descriptive correlational study

BACKGROUND

Transition to parenthood is a wonderful yet stressful period especially when it involves the newborn's hospitalisation. To support and facilitate this transition, it is essential to understand parental beliefs and needs. The father's perspective remains an understudied yet fundamental question.

OBJECTIVES

The objective of the study was to measure beliefs and needs of fathers of newborns hospitalised in a neonatal intensive care unit (NICU) and their correlations with sociodemographic variables.

METHODS

Fathers with a newborn hospitalised for 4-15 days in a level III NICU in Western Switzerland completed the NICU Parental Beliefs Scale and the short form of the NICU Family Needs Inventory. For each item of the NICU Family Needs Inventory, fathers also answered with regard to their satisfaction level. Additional needs were collected with an added open-ended question. Simple linear regressions were used to correlate beliefs, needs, and the sociodemographic data.

RESULTS

Seventy fathers were included. The average score for paternal beliefs was 68.44 (standard deviation = 10.29), indicating a good perception of their role. The majority (77%) considered all needs as very important or important, and 70% were very satisfied or satisfied. Fathers described communication as a very important, but unmet, need. Fathers' beliefs were higher in those who were not first-time fathers (71.88 ± 8.27 vs 66.06 ± 10.97, p = 0.028), who had a paternity leave (72.68 ± 10.19 vs 66.05 ± 9.68, p = 0.014), and who were of foreign nationality (71.86 ± 9.39 vs 63.85 ± 9.80, p = 0.002).

CONCLUSIONS

Fathers with a newborn hospitalised in the neonatal unit had good paternal beliefs. Most of the listed needs were perceived as very important and had a good level of satisfaction. Significant differences between Swiss fathers and fathers of foreign nationality were measured. Reasons of these differences should be explored in a forthcoming study.

Patterns of Parenting Confidence Among Infants With Medical Complexity: A Mixed-Methods Analysis

BACKGROUND

Parenting confidence is an important factor in fostering optimal health and development of infants with medical complexity. However, our understanding of how parents of medically complex infants describe development of confidence is limited. The purpose of this mixed-methods study was to describe the nature and development of parenting confidence.

METHODS

A mixed-method design was used to examine how parents described their level of confidence. Ten parents of infants with medical complexity. Quantitative measures provided patterns of confidence and qualitative data focused on parent descriptions of confidence. Parents completed online surveys at 3 time points: (1) study enrollment, (2) infant discharge from hospital, and (3) 3 months after discharge. Parents were purposively sampled, using their confidence patterns, for qualitative phone interviews.

RESULTS

Our analysis of quantitative findings revealed 3 confidence patterns: (1) increasing, (2) stable, and (3) varying. Parents described their confidence as either (1) a state of being confident or (2) how they behaved in the parenting role. Parents felt both certain and uncertain in their level of confidence and described confidence as being situationally dependent.

IMPLICATIONS FOR PRACTICE

Parenting confidence needs to be cultivated through encouragement and repeated exposure to parenting behaviors. Nurses are well-suited to help identify parents with low confidence to support parents so that they can develop confidence.

IMPLICATIONS FOR RESEARCH

Because there is variability in parent confidence during this critical early period of life, future research should consider a larger cohort of parents that compares confidence in diverse parent groups (ie, married vs living together couples, same-sex couples, and single parents). Research should also examine effective strategies to promote confidence and associated long-term health and developmental outcomes.

Feasibility and efficacy of integrating resiliency training into a pilot nurse residency program

The high stress associated with the nursing profession can negatively affect the health of nurses and the quality of patient care that they provide. This quasi-experimental study aimed to 1) assess the feasibility of integrating a Stress Management and Resiliency Training (SMART) program within a nine-month pilot nurse residency program and 2) assess the effects of the program on participants' stress, anxiety, mindfulness, and resilience relative to a comparison group. A pre- and post-intervention survey design was used, with measurements taken at baseline and at 1, 3, 9, and 12 months after baseline. We enrolled 51 registered nurses (intervention group, n = 23; comparison group, n = 28) at a Midwestern US academic medical center. Nurses in the intervention group had a participation rate of 93%-100% with SMART program events. Despite the relatively limited adherence to the protocol by intervention group participants, significant improvements were noted for stress (P < .001), mindfulness (P < .001), and resilience (P < .001) in the intervention group compared with the comparison group. The SMART program can potentially be successfully integrated into a nurse residency program and positively impact nurse stress, mindfulness, and resilience. Further research is needed to determine the proper dose of the intervention and methods to enhance adherence.

External barriers for including parents of preterm infants in a randomised clinical trial in the neonatal intensive care unit in Sweden: a descriptive study

OBJECTIVES

Performing randomised controlled trials (RCTs) in neonatal intensive care is challenging in many ways. While restrictive inclusion criteria or busy study protocols are obvious barriers, external barriers leading to termination of a study are seldom discussed. The aim of this study was to describe barriers for inclusion of families in neonatal intensive care in an RCT aiming to evaluate the effects of continuous skin-to-skin contact on mood and sleep quality in parents of preterm infants, as well as the quality of parent-infant interaction and salivary cortisol concentrations at the time of discharge.

DESIGN

A descriptive study.

SETTING

Three out of seven tertiary neonatal intensive care units in Sweden participated in a two-arm RCT that was terminated because of low inclusion rate.

PARTICIPANTS

Before termination of the study, 11 out of 242 families assessed for eligibility were included for participation.

RESULTS

The major barriers for inclusion in this RCT were external due to (1) lack of intensive care beds in the neonatal ward, causing medically stable infants to be transferred back to the referring hospital quicker than expected, (2) moving directly from the delivery room to a family room without passing an open bay intensive care room or (3) transferring from one neonatal ward to another with the same care level to increase availability of intensive care beds where needed. Other barriers were the inclusion criteria 'single-birth' and 'Swedish-speaking parent'.

CONCLUSIONS

The major barriers for including participants were external constituted by transferals between neonatal wards and cities due to lack of intensive care beds. This is a multifactorial issue related to organisational structures. However, since this affects the possibilities to perform research this study highlights some suggestions to consider when planning prospective intervention studies within a neonatal setting.

TRIAL REGISTRATION NUMBER

NCT03004677.

Current Resources for Evidence-Based Practice, September 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of “spin” in scientific reporting and its effect on summaries and syntheses of the literature and commentaries on reviews about early versus late amniotomy as part of labor induction protocols and the economic burden associated with maternal morbidity.