Parental Stress and Mental Health Symptoms in the NICU: Recognition and Interventions

Parental stress and nurse-parent support in the neonatal intensive care unit: a cross-sectional study

BACKGROUND

Admission of a preterm infant to the Neonatal Intensive Care Unit (NICU) is highly stressful for parents. NICU nurses play a crucial role in providing support, positively impacting health and aiding effective stress management during this challenging period. This study assesses stress and nurse-parent support for parents with preterm infants in the NICU, exploring connections between stress, support, and various parental and infant variables.

METHODS

This descriptive cross-sectional study was conducted between January and July 2019 on a total of 150 parents (75 mothers and 75 fathers) with preterm infants in a private hospital's NICU in Ankara, Turkey. Data were collected using the Parent and Infant Information Form, Parental Stressor Scale: NICU (PSS: NICU), and Nurse-Parent Support Tool (NPST).

RESULTS

There was no significant correlation between PSS: NICU and NPST scores (p > 0.05). However, a significant difference was observed in the overall NPST score (p = 0.036) and its emotional support subscale (p = 0.013). Mothers' PSS: NICU was influenced by infant information (p = 0.027) and marital duration ((p = 0.002), while fathers' was influenced by number of children (p = 0.040) and infant care participation (p = 0.001). NPST was affected by number of children (p = 0.004) and infant respiratory status (p = 0.011) for mothers and number of children for fathers (p = 0.038). Since parents require informational, emotional, and care-related support, nurses should continuously enhance their professional and communication skills to establish effective communication with parents and provide targeted support.

CONCLUSION

This study found mothers received greater nurse support than fathers. Mothers with one child had higher nurse support, while mechanical ventilation for mothers and having more than one child for fathers were linked to reduced support. Lower stress levels were noted in mothers married for 6-10 years, those informed about the infant, and fathers actively participating in infant care with more than one child.

Mental health of parents with infants in NICU receiving cooling therapy for hypoxic-ischaemic encephalopathy

BACKGROUND

Parents cuddling their babies during intensive care to promote parent-infant bonding is usual practice in the neonatal intensive care unit (NICU). However, babies undergoing cooling therapy and intensive care are not routinely offered parent-infant cuddles due to concerns of impacting the cooling process or intensive care. We developed the CoolCuddle intervention to enable parents to cuddle babies safely during cooling therapy. We investigated whether CoolCuddle impacted parent-infant bonding and parent's mental health.

METHODS

We conducted parental interviews and compared mental health and bonding measures in two cohorts of parents; one with access to CoolCuddle and the other where CoolCuddle was not available.

RESULTS

Ten tertiary NICUs in England and Wales from 2019 to 2023 were involved and 107 families. There were high levels of post-delivery depression amongst all parents. However, at discharge mothers in the CoolCuddle group had significantly less depression, lower EPDS scores, and higher MIBS scores (consistent with better mother-infant bonding) than those where CoolCuddle was not available. All measures appeared similar when re-measured at 8 weeks. Parents reported they were not ready to access psychological support or information whilst on NICU and stressed the need of mental health support following discharge, which was not offered or available.

CONCLUSION

The CoolCuddle intervention was associated with a lower prevalence of depression and enhanced bonding scores for mothers at discharge compared to those who did not cuddle their babies. Parents highlighted increased levels of postnatal depression following the sudden and traumatic admission of their infant to NICU after birth asphyxia.

Mental health screening for parents following surgical neonatal intensive care unit (NICU) discharge

Admission to the surgical neonatal intensive care unit (sNICU) is a stressful experience. Care is often complex, with inherent risks and potential complications. This study describes the implementation of an outpatient mental health screening process for parents of infants admitted to a sNICU. Parents of infants aged >34 weeks gestation with a congenital anomaly requiring neonatal surgery participated in this prospective observational study. Standardised measures to screen for parenting stress (Parenting Stress Index™ Fourth Edition Short Form) and depressive symptoms (Center for Epidemiologic Studies Depression Scale) were administered at the first outpatient visit scheduled when the infant's corrected gestational age was 4 months. A triage algorithm was developed, to review the initial screening results prompting appropriate action and intervention. Positive screens were triaged as evaluate (assess within 48 h), targeted information (email contact), or escalate response (same day risk assessment). Demographic factors associated with parental stress and depressive symptoms were explored. Forty parents (response rate: 88 %) participated in screening. A high portion of parents (52.5 %) required secondary screening, for parenting stress (n = 10), depressive symptoms (n = 5) or both stress and depressive symptoms (n = 6). Socioeconomic disadvantage was positively associated with parenting stress (p = 0.02) and greater depressive symptoms with parent education levels (p = 0.01). Results indicate screening of parent mental health in the outpatient setting is feasible. Use of a triage algorithm helped prioritise parent follow-up and facilitate workflows. Parent mental health screening should be prioritised within and beyond the sNICU to support family and infant outcomes during this critical period of development.

Management and Clinical Outcomes of Neonatal Hypothermia in the Newborn Nursery

OBJECTIVES

Neonatal hypothermia has been shown to be commonly detected among late preterm and term infants. In preterm and very low birth weight infants, hypothermia is associated with increased morbidity and mortality. Little is known about the clinical interventions and outcomes in hypothermic late preterm and term infants. This study fills this gap in the evidence.

METHODS

Single-center retrospective cohort study using electronic health record data on infants ≥35 weeks' gestation admitted to a newborn nursery from 2015 to 2021. Hypothermia was categorized by severity: none, mild (single episode, 36.0-36.4°C), and moderate or recurrent (<36.0°C and/or 2+ episodes lasting at least 2 hours). Bivariable and multivariable logistic regression examined associations between hypothermia and interventions or outcomes. Stratified analyses by effect modifiers were conducted when appropriate.

RESULTS

Among 24 009 infants, 1111 had moderate or recurrent hypothermia. These hypothermic infants had higher odds of NICU transfer (adjusted odds ratio [aOR] 2.10, 95% confidence interval [CI] 1.68-2.60), sepsis evaluation (aOR 2.23, 95% CI 1.73-2.84), and antibiotic use (aOR 1.73, 95% CI 1.15-2.50) than infants without hypothermia. No infants with hypothermia had culture-positive sepsis, and receipt of antibiotics ≥72 hours (surrogate for culture-negative sepsis and/or higher severity of illness) was not more common in hypothermic infants. Hypothermic infants also had higher odds of blood glucose measurement and hypoglycemia, slightly higher percent weight loss, and longer lengths of stay.

CONCLUSIONS

Late preterm and term infants with hypothermia in the nursery have potentially unnecessary increased resource utilization. Evidence-based and value-driven approaches to hypothermia in this population are needed.

Parenting Stress Following a Neonatal Intensive Care Unit Hospitalization: A Longitudinal Study of Mothers and Fathers

A neonatal intensive care unit (NICU) hospitalization can add significant stress to the postpartum period. Parents experience isolation and uncertainty, which can affect their capacity to bond with their new baby. Understanding how stress is shaped by and changes following a NICU experience will help in developing supports for these families. We examined patterns of parenting stress over the first year of life following a NICU stay to better understand changes in stress, differences in maternal and paternal stress, and how medical and developmental variables impact parent stress. Parents of infants (n = 51) who had experienced a NICU hospitalization and met criteria for California's High-Risk Infant Follow-Up program completed assessments at 6, 9, and 12 months. A comparison group (n = 38) from a historic dataset included parents of infants born full term without medical complications. NICU parents reported higher levels of parenting stress at 6 months, but not 12 months, with mothers and fathers reporting similar stress levels. Parenting-related stress was found to be relatively stable and consistent over this period. Among NICU parents, lower developmental level at 12 months was associated with more distress in interacting with their child. These findings highlight the importance of monitoring parenting stress following discharge from the NICU and developing interventions for supporting parents of NICU graduates showing developmental delays.

Best Practices to Support Maternal Mental Health During the Transition from Neonatal Intensive Care Unit to Home: A Scoping Review

Mothers with an infant hospitalized in the neonatal intensive care unit (NICU) are at an increased risk of mental health concerns, including depression and anxiety. Successful mental health support during the critical time of transition from hospital to home requires careful consideration of the mothers' mental health beginning during the NICU stay. Major themes from a scoping review to identify best practices to support maternal mental health include (1) comprehensive evaluation of needs and continuity of care, (2) key role of in-person support, and (3) the potential to use technology-based support to increase mental health support.

Parenting Expectations, NICU Experiences, and Maternal Psychological Outcomes: An Exploratory Mixed-Methods Study

BACKGROUND

Infant neonatal intensive care unit (NICU) hospitalization increases maternal risk for psychological distress. However, no universal screening standards exist and predicting maternal risk remains challenging. Reconceptualizing maternal distress in relation to differences between parenting expectations and NICU experiences may illuminate commonalities across a range of experiences.

PURPOSE

This study explored parenting expectation-experience differences (EEDs) among NICU mothers and assessed correlations between EED scores and psychological outcomes 1 to 5 years post-NICU hospitalization.

METHODS

A 3-phase explanatory sequential mixed-methods design was used. Pearson's correlation coefficients were used to measure relationships between EED scores and maternal psychological outcomes. Reflexive thematic analysis of one-on-one, semi-structured interviews contextualized EED scores.

RESULTS

Most participants (92.9%) reported negative EED scores, indicating NICU experiences fell short of parenting expectations. Significant inverse correlations were found between EED scores and maternal outcomes, including depression ( r = -0.25, P < .01), anxiety ( r = -0.25, P < .01) and posttraumatic stress disorder symptoms ( r = -0.41, P < .001), and perceived parenting self-efficacy ( r = -0.28, P < .01). Major qualitative themes included unexpected versus prepared, lost parenting experiences, and surviving and thriving. Data synthesis contextualized EED scores and revealed key differences in meaning ascribed to unmet parenting expectations.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Preparing mothers for infant NICU hospitalization and creating a NICU parenting environment, which better supports mothers and their engagement in parenting tasks, may help to reduce differences between parenting expectations and NICU experiences. Further research is needed to elucidate the impacts of parenting EEDs in this population.

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.

Parent and grandparent neonatal intensive care unit visitation for preterm infants

OBJECTIVE

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes.

STUDY DESIGN

Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared.

RESULTS

Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%).

CONCLUSION

Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Mother's mental health and the interaction with her moderate preterm baby in the NICU

INTRODUCTION

Moderate preterm infants, born between 320/7 and 336/7 weeks, represent a significant number of preterm-born infants; however, they remain a poorly studied group despite their vulnerability. The objective of this correlational study is to describe the impact of having a moderate preterm infant hospitalised in the NICU on the mothers' mental health and how this relates to the interaction between the dyad.

METHOD

During the hospitalisation period, 85 moderate preterm mother-infant dyads participated in this study. The participants provided self-reports of depression, parental stress, and skin to skin and breastfeeding practices. Also, mother-infant interaction was assessed in the NICU with an observational scale.

RESULTS

Mothers evidenced high levels of stress and depressive symptoms during the hospitalization. The stress experienced by these women was significant, although weakly, associated with the interaction with their babies; and mothers of small for gestational age babies showed difficulties in this area.

CONCLUSIONS

The results of this study could represent a contribution to a better understanding of the relation between the characteristics of moderate preterm babies, maternal emotional wellbeing, and the quality of mother-infant interactions in NICU settings.

Randomized Controlled Trial on the Effect of the Neonatal Nurse Navigator Program on Maternal Stress and Neonatal Cortisol Levels

OBJECTIVE

To assess the effect of the Neonatal Nurse Navigator Program (NNNP) compared to usual care on maternal stress and neonatal salivary cortisol level (SCL) in the NICU.

DESIGN

Randomized control trial.

SETTING

NICU in a tertiary health care hospital in Manipal, Udupi District, Karnataka, India.

PARTICIPANTS

Neonates between 34 and 36 weeks gestation and their mothers (N = 120 dyads).

METHODS

We used block randomization to assign dyads to the intervention or control group. We measured maternal stress using the Parental Stress Scale: Neonatal Intensive Care Unit, and we estimated neonatal stress by measuring SCLs within 24 hours of NICU admission and before discharge from the unit. We conducted a descriptive analysis on participant characteristics and reported maternal stress levels using means and standard deviations. We used the analysis of covariance change score test to determine the difference in maternal and neonatal stress levels between the intervention and control groups.

RESULTS

The NNNP group exhibited significantly lower maternal stress scores before discharge than the control group, and we observed reductions across all three subscales of the Parental Stress Scale: Neonatal Intensive Care Unit. Mean neonatal salivary cortisol levels were significantly lower in the interventional group than in the control group, F(1.117) = 24.03, 95% confidence interval [7.9, 18.6], p < .001.

CONCLUSION

Use of the NNNP reduced maternal stress SCLs in high-risk neonates by actively engaging mothers in the care of their neonates in the NICU. We recommend adoption of the NNNP model as a standard care policy in NICUs throughout India.

Application of Trauma-Informed Care Principles to Care Needs Identified by Mothers of NICU-Hospitalized Children

Systematic uptake of family-centered care (FCC) interventions remains challenging and frequently suboptimal in many neonatal intensive care units (NICUs). Across NICUs in the United States, integrating family members as partners in infant caregiving and decision-making has not been well supported and routine screening and provision of psychological support for parents remains inadequate. Trauma-informed care (TIC) may offer a more comprehensive approach to NICU care which can encompass FCC principles and promote family recovery and resilience by recognizing and responding to the traumas experienced by NICU infants and families. The current paper aimed to understand needs identified by mothers of NICU-hospitalized children and reports a focused analysis of one-on-one interview data (n = 13 mothers) collected during a larger mixed methods study. Reflexive thematic analysis was used to understand needs identified by mothers and to explore how these needs aligned with TIC principles. Six themes were identified and subsequently examined in the context of the principles of TIC: I Just Had No Control, That Really Caught Us Off Guard, So Much Was Already Taken Away, We're People and There Needs To Be More Support and Practices Which Helped. Mothers' care needs were found to align with TIC principles. Findings suggest that implementation of TIC principles in NICU settings can support parental presence, participation in infant care, and mental health and support the potential of TIC as a more comprehensive approach to meeting the needs of NICU parents.

Supporting Disclosure of Unmet Mental Health Needs among Parents of Critically Ill Infants

OBJECTIVE

To characterize (1) the prevalence of mental health discussion and (2) facilitators of and barriers to parent disclosure of mental health needs to clinicians.

STUDY DESIGN

Parents of infants with neurologic conditions in neonatal and pediatric intensive care units participated in a longitudinal decision-making study from 2018 through 2020. Parents completed semi-structured interviews upon enrollment, within 1 week after a conference with providers, at discharge, and 6 months post-discharge. We used a conventional content analysis approach and NVIVO 12 to analyze data related to mental health.

RESULTS

We enrolled 61 parents (n = 40 mothers, n = 21 fathers) of 40 infants with neurologic conditions in the intensive care unit. In total, 123 interviews were conducted with 52 of these parents (n = 37 mothers, n = 15 fathers). Over two-thirds of parents (n = 35/52, 67%) discussed their mental health in a total of 61 interviews. We identified two key domains when approaching the data through the lens of mental health: (1) self-reported barriers to communicating mental health needs: parents shared uncertainty about the presence or benefit of support, a perceived lack of mental health resources and emotional support, and concerns about trust; (2) self-reported facilitators and benefits of communicating mental health needs: parents described the value of supportive team members, connecting to peer support, and speaking to a mental health professional or neutral third party.

CONCLUSIONS

Parents of critically ill infants are at high risk of unmet mental health needs. Our results highlight modifiable barriers and actionable facilitators to inform interventions to improve mental health support for parents of critically ill infants.

'It turned my life upside down': Parents' emotional experience of the transition with their preterm infant from birth to discharge Home-A qualitative study

BACKGROUND

A smooth transition from the neonatal intensive care unit (NICU) to home is critical for establishing parents' competence as primary caregivers and ensuring infant health. In the clinical context with a restrictive visiting policy, family-centred care is challenging to implement, prohibiting a smooth transition of care for the families. According to Meleis' Transition Theory, parents might experience emotional change initiated by critical events during this transition.

OBJECTIVES

The aim of this study was to understand parents' emotional experience of their preterm infant's birth to discharge home from the NICU to facilitate the care transition better.

METHODS

This qualitative descriptive study using semistructured interviews was conducted between June and August 2020. Purposive sampling was used to recruit 17 parents (6 fathers and 11 mothers) from the NICU of a tertiary hospital in eastern China. Data were analysed using content analysis.

RESULTS

The following three situational themes characterised by three-phase emotions related to 16 critical events were obtained from the data and were used to describe parents' experiences during the transition: Theme 1, Life falling apart; Theme 2, Feeling anxious and struggling with uncertainty; and Theme 3, Feeling both hopeful and inadequate at discharge.

CONCLUSIONS

Parents of preterm infants have distinctive emotional experiences in each phase during their infants' transition from the NICU to home. Awareness of parents' critical events and emotional experiences in each phase could help NICU staff anticipate and provide timely and targeted support for parents. The next step is to develop a family-centred intervention for healthcare providers to better prepare parents for the transition from the NICU to home.

Feasibility of wearable sensors in the NICU: Psychophysiological measures of parental stress

BACKGROUND

Parents report elevated stress during their infant's NICU hospitalization. Real-time measures may improve our understanding of parental stress in the NICU.

AIM

Examine the feasibility of wearable sensors to describe parental stress in the NICU.

STUDY DESIGN

In this prospective feasibility study of 12 parent-infant dyads, parents wore an Empatica E4 wristband to measure psychophysiological stress via electrodermal activity (EDA) during sensory interventions (holding, massage, reading, touch, etc) with their babies. Baseline and intervention periods were delineated during which concurrent monitoring and clinical observations of infant behavior and environmental factors were recorded. Feasibility was assessed by investigating recruitment/enrollment, retention/adherence, acceptability, sensor usability, and changes in EDA waveforms based on potential stressors. For the latter, independent samples t-tests and ANOVA were used to examine differences in EDA from baseline to intervention, and the impact of environmental and infant factors on parent stress were visually analyzed against EDA waveforms.

RESULTS

Wearable sensor use in the NICU appeared feasible as assessed by all methods. Preliminary data analysis indicated that overall parent EDA levels during parent-infant interactions were low, and engagement in sensory intervention(s) led to a non-significant increase in parental EDA, measured by both skin conductance levels and non-specific skin conductance responses. Three main patterns of EDA emerged: a temporary increase in EDA at the beginning of the intervention followed by a decrease and plateau, a plateau in EDA from baseline to intervention, and a gradual rise in EDA throughout intervention. Specific environmental and infant factors, such as infant stress and health care providers entering the room, appeared to impact parent stress levels.

CONCLUSION

Although these preliminary findings provide support for use of EDA in the NICU, future studies are needed.

Addressing caregiver mental health in the neonatal ICU

PURPOSE OF REVIEW

The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals.

RECENT FINDINGS

Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes.

SUMMARY

To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU.

VIDEO ABSTRACT

http://links.lww.com/MOP/A70.

Group trauma focused cognitive behavior therapy for parents of premature infants compared to individual therapy intervention

BACKGROUND

The current study compares results of a group-based intervention developed to reduce symptoms of posttraumatic stress, depression, and anxiety in parents of premature infants with a prior study using an individual version of the treatment manual.

METHODS

26 mothers of preterm infants (25-34 weeks' gestational age; >600 g) received 6 sessions of trauma-focused cognitive behavior therapy (CBT). Outcomes were compared with those of a previously published RCT, which tested an individual therapy based on the same model in a group of 62 mothers. Results were also compared across in-person and telehealth treatment.

RESULTS

From baseline to follow up, the individual intervention showed greater improvement in trauma symptoms assessed with the Davidson Trauma Scale (d = 0.48, p = 0.016), although both conditions showed clinically significant improvement. Similar patterns were found for maternal depression and anxiety. In-person treatment was found to be superior to telehealth treatment administered during the COVID-19 pandemic, although the difference was not significant.

CONCLUSIONS

Group-based trauma focused CBT is an effective treatment modality for parents of premature infants with symptoms of psychological distress but not as effective as individual therapy using the same treatment model.

Benefits of maternally-administered infant massage for mothers of hospitalized preterm infants: a scoping review

OBJECTIVES

Infant massage (IM) is a well-studied, safe intervention known to benefit infants born preterm. Less is known about the benefits of maternally-administrated infant massage for mothers of preterm infants who often experience increased rates of anxiety and depression in their infants' first year of life. This scoping review summarizes the extent, nature, and type of evidence linking IM and parent-centered outcomes.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for scoping reviews (PRISMA-ScR) protocol was followed using three databases: PubMed, Embase, and CINAHL. Thirteen manuscripts evaluating 11 separate study cohorts met pre-specified inclusion criteria.

RESULTS

Six primary topics related to the influence of infant massage on parent outcomes emerged: 1) anxiety, 2) perceived stress, 3) depressive symptoms, 4) maternal-infant interaction, 5) maternal satisfaction, and 6) maternal competence. Emerging evidence supports that infant massage, when administered by mothers, benefits mothers of preterm infants by reducing anxiety, stress, and depressive symptoms and improving maternal-infant interactions in the short-term, but there is limited evidence to support its effectiveness on these outcomes in longer periods of follow-up. Based on effect size calculations in small study cohorts, maternally-administered IM may have a moderate to large effect size on maternal perceived stress and depressive symptoms.

CONCLUSIONS

Maternally-administered IM may benefit mothers of preterm infants by reducing anxiety, stress, depressive symptoms, and by improving maternal-infant interactions in the short-term. Additional research with larger cohorts and robust design is needed to understand the potential relationship between IM and parental outcomes.

Outcomes of Preterm Infants: Shifting Focus, Extending the View

Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.

Sociodemographic risk factors, parental stress and social support in the neonatal intensive care unit

OBJECTIVE

Investigate relationships among neonatal intensive care unit (NICU) parent demographics, reported stress and social support.

DESIGN

Cross-sectional observation.

SETTING

Tertiary referral NICU in Mid-Atlantic USA.

PATIENTS

Parents (n=300) in the Giving Parents Support trial at enrolment.

MEASURES

Psychometric scales measured general stress, parental stress, NICU stress and social support. Demographic variables included education level, health insurance type, race, relationship status, age and gender. Length of stay was used to control for illness severity. Associations and potential modifying effects were evaluated using linear regression.

RESULTS

Having less than a college degree (b=-2.52, SE=0.91) and female parent gender (b=-3.42, SE=1.47) were associated with lower parental stress scores. Older age in years was associated with higher parental stress scores (b=0.21, SE=0.07) but lower NICU stress scores (b=-0.01, SE=0.01). Greater social support scores were associated with lower scores of general (b=-2.76, SE=0.39) and parental stress (b=-1.71, SE=0.47). Less than a college degree (b=-0.26, SE=0.11), Medicaid insurance (b=-0.43, SE=0.11) and black race (b=-0.56, SE=0.12) were associated with decreased social support scores. Level of social support modified the relationship between education and parental stress, with higher social support decreasing education-based differences in parental stress scores (p=0.049).

CONCLUSION

Sociodemographic risk factors may not infer stress or risk in the anticipated direction. Practice and future research should focus on identifying and supporting NICU families at high risk for stress and low support.

TRIAL REGISTRATION NUMBER

NCT02643472.

The Prevalence of PTSD of Mothers and Fathers of High-Risk Infants Admitted to NICU: A Systematic Review

Admission of a preterm or sick full-term infant to the neonatal intensive care unit (NICU) is a stressful experience for parents. Indeed, the 'NICU experience' may constitute a traumatic event for parents, distinct from other birth-related trauma, leading to significant and ongoing posttraumatic stress disorder (PTSD) symptoms. However, the rates at which this outcome occurs are not well understood. This review aimed to identify the prevalence of PTSD in mothers and fathers of high-risk infants admitted to the NICU, specifically focusing on the NICU experience as the index trauma. The PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were used to conduct this review. We searched PsycINFO, PubMed, Scopus, EMBASE, Web of Science, ProQuest Dissertations and Theses databases, and reference lists of included articles (1980-2021). Two independent reviewers screened titles and abstracts and conducted the full-text screening assessment. Of the 707 records identified, seven studies met the inclusion criteria. In this systematic review, PTSD symptomatology was assessed by self-report measures rather than a clinical interview. We identified significant variations in the methodologies and quality between studies, with a wide variation of reported prevalence rates of PTSD of 4.5-30% in mothers and 0-33% in fathers. Overall, the findings indicate that up to one-third of parents experience PTSD symptomatology related to the NICU experience. These results emphasize the importance of universal routine antenatal and postnatal screening for symptoms of PTSD to identify parents at risk of distress during the NICU experience and after discharge.Trial registration: The study protocol was registered with Prospero registration number CRD42020154548 on 28 April 2020.

Implementing modified family integrated care in a U.S. neonatal intensive care unit: nursing perspectives and effects on parents

OBJECTIVES

(1) Assess effects of a modified Family Integrated Care (FICare) model on U.S. Neonatal Intensive Care Unit (NICU) parents; (2) Evaluate NICU nurses' perspectives.

DESIGN

Case -control design with parental stress assessed before and after NICU-wide FICare implementation using Parent Stressor Scale: NICU (PSS:NICU) questionnaire. In addition, stratification by degree of participation evaluated associations with parental stress, parental-staff communication and discharge readiness. Questionnaires captured nursing perspectives on FICare.

RESULTS

79 parents (88%) participated prior to FICare; 90 (90%) after. Parent stress was lower (p < 0.001) with FICare. Parents learning 5-15 infant-care skills had lower stress compared to those learning <5 (p = 0.008). Parent utilization of an educational app was associated with improved communication frequency (p = 0.007) and quality (p = 0.012). Bedside NICU nurses reported multiple positive associations of FICare for parents and staff.

CONCLUSIONS

Any degree of FICare participation decreases parental stress; increased participation has multiple positive associations.

Ten Years of Neonatal Intensive Care Adaption to the Infants' Needs: Implementation of a Family-Centered Care Model with Single-Family Rooms in Norway

Ten years ago, the Neonatal intensive care unit in Drammen, Norway, implemented Single-Family Rooms (SFR), replacing the traditional open bay (OB) unit. Welcoming parents to stay together with their infant 24 h per day, seven days per week, was both challenging and inspiring. The aim of this paper is to describe the implementation of SFR and how they have contributed to a cultural change among the interprofessional staff. Parents want to participate in infant care, but to do so, they need information and supervision from nurses, as well as emotional support. Although SFR protect infants and provide private accommodation for parents, nurses may feel isolated and lack peer support. Our paper describes how we managed to systematically reorganize the nurse's workflow by using a Plan-Do-Study-Act (PDSA) cycle approach. Significant milestones are identified, and the implementation processes are displayed. The continuous parental presence has changed the way we perceive the family as a care recipient and how we involve the parents in daily care. We provide visions for the future with further developments of care adapted to infants' needs by providing neonatal intensive care with parents as equal partners.

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.

He Tamariki Kokoti Tau: Families of Indigenous Infants Talk about Their Experiences of Preterm Birth and Neonatal Intensive Care

Māori (Indigenous peoples of Aotearoa New Zealand) bear an unequal burden of poor perinatal health outcomes, including preterm birth. An infant arriving preterm disrupts the birth imaginary of whānau (family collectives) and situates them in a foreign health environment that may not be culturally safe and nurturing. A cross-sectional interpretative phenomenological analysis of first interviews with 19 whānau participating in a Kaupapa Māori (by, with, for Māori) qualitative longitudinal study of preterm birth identified themes from their experiences and the meanings they attributed to them. Preterm birth was an emotional roller coaster, with the birth imaginary and anticipated roles disrupted as health practitioners took over the care of their infants. Whānau expressed the desire to be close to their infants, holding them, loving them, nurturing them, and emplacing them within whakapapa (genealogy, continual layering of foundations) networks. When health practitioners or hospital policies inhibited this intimacy by isolating, excluding, or discriminating, whānau were frustrated. Being familiar with hospital routines, staff, peers, infant cares, and being wrapped in wider whānau support were key for whānau coping. Whakawhanaungatanga (processes of establishing relationships) create safe spaces for whānau to be themselves. This quietens the 'storm' and returns whānau to a sense of calm, through the reclamation of their environment.