Effect of Nursing Support on Perceived Stress among Parents of Preterm Infants in South-East of Iran

Sedigheh Iranmanesh, Sakine-Sadat Hosseini*, Masoud Rayyani, Farideh Razban,

Batool Pooraboli

Razi Faculty of Nursing and Midwifey, Kerman University of Medical Sciences, Kerman, Iran

Corresponding Author Email: sadathosseini32@gmail.com

ABSTRACT

Objective: When a premature infant is hospitalized, parents experience lots of stresses. So, nursing support is needed to reduce parent’s stresses. Specifying parent’s stress and nursing support can be useful for improving quality of care. Thus the current study was conducted to examine the relationship between parental stress and nursing support.

Methods: In this study descriptive correlational design was employed. Using NPST (Nurse Parent Support Tool) and PSS (Parent Stressor Scale) questionnaires perceived nursing support and parenteral stress of 154 parents (77mothers and 77 fathers) of hospitalized premature infants in NICU of Afzalipur hospital in Kerman – Iran was evaluated. Data analysis was done with spss19.

Findings: Results showed that there was a negative correlation between nursing support and stress in category of “emotional support and parental role alteration“(P=0.009, r=0.209). Results revealed that in all categories of NPST mothers received more nursing support than fathers. While, in all category of PSS except “infant‘s appearance and behavior” fathers stress was more than mothers. Generally, fathers experienced more stress and receive less support.

Conclusion: According to the results nursing support can reduce parental stress. Hence, to providing high quality care it is necessary for nurses to be aware of individual differences and stressors of newborn parents’ in neonatal intensive care unit.

KEY WORDS: Premature infant, nursing support, parental stress, neonatal intensive care unit.3.

INTRODUCTION:

Approximately 12% of the infants are born prematurely which means that they are born before 37 completed weeks of gestation. Premature birth confronts infants with an extended range of dangers and problems and hospitalization of premature newborns is inevitable most of the time (Valizadeh et al., 2012). Hospitalization and the infants ill health can interrupt the mother-infant attachment process and cause great stress for the family involved (Kearvell and Grant, 2010). Stress is psychological and physical strain or tension generated by physical, emotional, social, economic, or occupational circumstances, events, or experiences that are difficult to manage or endure (Steedman, 2007

).

While parents come at Neonatal Intensive Care Unit (NICU) and see their little one surrounded by monitors, and variable noises and lots of tubes, find themselves helpless to care for their infant, which looks to be very delicate (Blanch D'Souza et al., 2009). That specific environmental are stress producing for parents of neonates (Jackson et al., 2006).

This situation creates a need for practices that support parents during the acute phase of their infant’s hospitalization in NICU (Aagaard and Hall, 2008). Nurses are in a unique position to help parents, as they provide care not only for the sick infant but also for the stressed parents (Mok and Leung, 2006). Nursing support for parents is" a set program of support and information to parents of hospitalized children helps in alleviating parental stress" (Blanch D'Souza et al., 2009). By being provided the appropriate support and the needed information about their child, parents can successfully overcome these challenges and, in turn, provide appropriate support to their children and fulfill their multiple roles within the family (Sanjeri et al., 2009).

It seems that there is a relationship between nursing support and perceived stress among parents of preterm infants. Reviewing literature revealed that there are a few studies that showed correlation between these two topics. Tandberg et al., (2013) in Norway evaluated experiences of parental stress and nursing support in parents of preterm infants using Nurse Parent Support Tool (NPST) and the Parental Stressor Scale (PSS: NICU). They reported parents experienced high stress levels in relation to the infant’s appearance and evaluated nursing support as positive (Tandberg et al., 2013). Blanch D’Souza et al in 2009 also assessed parenteral stress and nursing support by use of same questionnaires in India and reported that nursing support reduced stress (Blanch D’Souza et al., 2009). In Iranian context three studies found that examined nursing support, using NPST. In a study conducted by Valizadeh et al., (2012) NICU nurses claimed more importance for nursing support and rated the provided support higher in comparison with mothers who did not think so. Seyedamini et al., (2011) stated that in their study mothers of hospitalized children received the most caring support and the least informational support from nurses. Sanjari et al, (2009) reported that parents of hospitalized children received a high level of nursing support. Valizadeh et al., (2009) examined stressors affecting mothers with hospitalized premature newborn in some NICUs of Tabriz- Iran using PSS: NICU. Results showed that "parental relationship and parent's role" was the most stressful dimension (Valizadeh et al., 2009). In the context of Iran no study was found to assess both parental stress and nursing support and their correlation. This study thus was conducted to fulfill that goal in South-East of Iran.

METHODS:

Design

The study carried out based on a descriptive correlational design. In order to collect data an approval was taken from Kerman University of Medical Science and the head of Afzalipur hospital which is supervised by the university.

Background information

At first, a questionnaire was designed in order to obtain background information which was assumed to have influence on parental stress and nursing support. It was developed based on two categories including: (1) infants’ characteristics like gender, gestational age, birth weight, being twin or singleton, length of stay in hospital (2) parental characteristics like age, education level and employment status.

Instruments

To examine parental stressors the Parental Stressor Scale (PSS: NICU) was used. This questionnaire was developed by Margaret Miles (2002). The PSS: NICU was designed to determine parental perception of stressors arising from the physical and psychosocial environment in the NICU. The instrument consist of 34 items and evaluates stress within the following dimensions; the sight and sound of the NICU (6 items), the infant’s appearances/behavior (17 items), and the parental role alterations (11 items). The scores in this scale ranged between 0 and 5 (0= being not experience, 5=extremely stressful).

To evaluate the perceived nursing support of parents whose infants is admitted to the NICU, the nurses' parental support tool (NPST) (Miles et al., 1999) was used. The tool includes 21 items classified into four dimensions including communication and informational support (7items), emotional support (5 items), parental esteem support (4 items), and instrumental support (5 items). The NPST is a five point likert scale with responses ranged between 1 and 5 (1 =almost never; 5=almost always).

Reliability, validity

For translation of the questionnaires from English into Farsi, the standard forward–backward procedure was applied. The initial translation was done by two authors (S.I., B.P) who are nurse educators, and clinically experienced in neonatal intensive care unit (NICU) wards. Their native language is Farsi and their second language is English. S.I. has had the experience of living and becoming educated about nursing in a Western country for 5 years. Therefore, she has knowledge about nursing in both Eastern and Western cultures. A helpful reference at this stage was the Haiiem English–Farsi dictionary. As the study aim was to use the questionnaires with parents of preterm infants in NICU, the items were discussed with two physicians working in NICUs. The translation was revised according to their comments. A teacher of English at Razi Faculty of Nursing and Midwifery then translated the questionnaire back. Both versions were compared by S.I. and B.P. for any discrepancies. Afterward, a pilot group of 10 parents from the study were asked to read the questionnaire and make their comments on it. Each item was discussed.

The validity of scales were assessed through a content validity, 10 Faculty members in Razi Nursing and Midwifery School have reviewed the content of the scales from cultural aspects. These experts were also asked to rate each item based on relevance, clarity, and simplicity on a four-point scale. The researchers analyzed the results, content validity index for PSS and NPST respectively were 85% and 88%. To evaluate the reliability of the scale, alpha coefficients of internal consistency (n=30) were computed. The alpha coefficient for PSS was 0.88 and for NPST was 0.92. So these scales presented acceptable reliability and validity.

Data collection and analysis

The study sample comprised parents of preterm infants who were hospitalized in NICU of Afzalipur hospital supervised by Kerman University of Medical Science. Afzalipur is a general hospital with 364 active beds, and one 30-bed NICU. This hospital is in Kerman city in the center of Kerman province and provides medical services for all parts of the province. Parents required having infants with gestational age (GA) less than 37 weeks, without congenital malformations and length of stay in NICU more than7days. Parents participated in this study were required to have no depression, were able to read, speak and write Persian, and come in or stay at NICU during their infant’s hospitalization.

Accompanied by a letter including some information about the aim of the study, the questionnaires were handed out by the third author to 154 parents during four months (March/Jun 2007). Some oral information about the study was also given as well by the third author. Participation in the study was voluntary and anonymous. 154 sets of questionnaires were distributed with a drop out of 4. In all collected data, 90 % of all questions were answered. Data from the questionnaires were analyzed using the Statistical Package for Social Scientists (SPSS). A Kolmogorov-Smirnov test indicated that the data were sampled from a population with normal distribution. Descriptive statistics of the sample and measures that were computed included frequencies, means and reliability. Pearson’s correlation coefficient was used to examine the correlation between the parenteral stress and nursing support scores in addition to correlation of theses tow variables and some demographic factors such as parents’ age, infant’s birth weight, infants’ gestational age, infants’ length of hospital stay. The independent T-test was used to examine correlations between PSS: NICU as well as NPST scores and some other demographic factors, including parents' employment status, location of interview, history of previous hospitalization of the infants, and number of infants (twin or singleton). One-way ANOVA was used to assess the association between PSS: NICU and NPST scores with parents' education level. The significance level was set at 0.05

RESULTS:

Participants

154 parents of preterm infants (77 fathers, 77 mothers) participated in this study. A descriptive analysis of background information of parents of preterm infants (Table 1) revealed that 60.3% of fathers were aged from 30 to 40 years (60.3%) and 48.1% of mothers aged between 20 to 30 years. 39% of fathers and 42.8% of mothers had Diploma. Some of them had bachelor degree or more (33.7% of fathers, 35.1% of mothers). Majority of fathers had non-professional job (63%). Mothers were mainly unemployed (73.4%). Most of mothers participated in this study when they were staying in tap rooms (56%) whereas most of fathers answered to questionnaire while they were moving around the settings (100%). The majority of mothers (62.3%) had a cesarean section delivery. Participants have equal number of female and male infants (77 boys and 77 girls). As illustrated in table 1 the infants were aged from 30 to 34 weeks and majority of them were singletons (85.7%). Most of infants had not previous hospitalization (95%). Majority of them had 1500 to 2500 gr weight of birth (96%), and were stayed in hospital between 7 to 22 days (72.1%).

Figur1. Parental Stressor Scale (PSS: NICU) score and Nurse Parent support tool (NPST) scores

Descriptive Findings

According to figure 1, parents experienced moderate level of parental stress (mean 2.61; SD 0.69) and nursing support (mean 2.71; SD 0.78). The highest mean score in PSS: NICU belonged to the category of "environmental stress" and in NPST belonged to the category of "quality care".

According to table 3, mothers experienced more stress related to the appearance and behavior of their infants compare to fathers. Parents who answered to the questionnaires while were staying in tap rooms reported higher stress level in category of "infants appearance and behavior" compare to those who questioned while were moving around the setting. Parents, who had no experience of previous hospitalizations of the infant, expressed more level of stress in the category of “environmental stress" compared to those who had not such an experience.

Findings showed (table 3) that compared to the fathers, mothers received more nursing support in categories of "emotional support", " communication and information " and "self-confidence". Parents who answered the questionnaire while they were staying in tap room received more nursing support in categories of "emotional support" and "self-confidence" compared to those moving around the setting. Parents who had boy infants reported more nursing support in the category of “Communications - information” than those who had girl infant. Findings also indicated the more infants' hospitalization days, the more nursing support in category of "emotional support" and "quality care" parents received. Mothers who had multiple pregnancies received more information and communication support compare to those had only one pregnancy. As it shown in table 4, there was a negative significant correlation between nursing support in the category of "emotional support "and parental stress in categories of "parental role alterations"(p <0.01).

Table 1. Background characteristics of parents and their infants

Variable	Fathers N (%)	Mothers N (%)	Variable	Infants N (%)
Age (years)			Birth weight
20-30	42 (27.3%)	74 (48.1%)	< 1500gr	34 (22.1%)
30-40	93 (60.3%)	70 (45.4%)	1500-2500gr	96 (62.3%)
40-50	16 (10.4%)	10 (6.5%)	≥ 2500gr	24 (15.6%)
50-60	3 (1.9%)	-----	Gestational age (weeks)
Education level			26-30	31 (20.1)
Illiterate	8 (10.4%)	4 (5.2%)	30-34	76 (49.4 %)
Primary education	13 (16.9%)	13 (16.9%)	34-37	47 (30.5%)
Diploma	30 (39%)	33 (42.8%)	Length of hospital stay (days)
bachelor degree or more	26 (33.7%)	27 (35.1%)	7-22	111 (72.1%)
Employment status			22-37	33 (21.4%)
Professional job	54 (35%)	24 (15.6%)	37-50	10 (6.5%)
Non-professional job	97 (63%)	17 (11%)	History of previous hospitalization
unemployed	3 (1.9%)	113 (73.4%)	Yes	7 (4.5%)
Location of interview			No	147 (95.5%)
While staying in tap room	0 (0.00%)	56 (72.8%)	Number of infants
While moving around the setting	77 (100%)	21(27.2%)	Singleton	132 (85.7%)
Type of infant delivery			Twin	22 (14.3%)
Natural vaginal delivery		……….
Cesarean section delivery		() 62.3%

Table2. Correlation between Parental Stressor Scale (PSS: NICU) score and Nurse Parent support tool (NPST) with some parents background information

		Parental Stressor Scale (PSS: NICU)				Nurse Parent support tool (NPST)
		Environ mental	Appearance /behavior	Parental role alterations	Emotional support		Information communication	Self- confidence	Quality Care
		Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)		Mean (SD)	Mean (SD)	Mean (SD)
Parents (T-test)	Mother	2.92 (0.99)	2.57 (0.91)*	2.50 (0.88)*	2.83 (0.90)**		2.92 (1.3) *	2.83 (0.97)**	3.16 (0.90)
	Father	3.09 (0.79)	2.26 (0.85)*	2.83 (0.75)*	2.19 (0.66)**		2.50 (0.72)*	2.12 (0.64)**	3.08 (0.71)
Location of interview (T-test)	While staying in tap room	2.94 (1.009)	2.68 (0.98)**	2.56 (0.96)	2.78 (0.91) **		2.81 (0.78)	2.88 (1.008) **	3.11 (0.97)
	While moving around the setting	3.04 (.083)	2.26 (0.80)**	2.72 (0.75)	2.35 (0.78) **		2.65 (1.21)	2.24 (0.73) **	3.12 (0.71)
Experience of previous hospitalization of the infant (T-test)	No	3.04 (0.89)^*	2.41 (0.90)	2.68 (0.84)	2.49 (0.85)		2.69 (0.71)	2.45 (0.89)	3.11 (0.82)
	Yes	2.24 (0.82)^*	2.45 (0.72)	2.18 (0.38)	3.10 (0.83)		3.33 (1.17)	3.08 (0.76)	3.20 (0.74)
Gender of infant (T-test)	Boy	3.03 (0.90)	2.47 (0.98)	2.58 (0.92)	2.60 (0.94)		2.89 (1.31) *	2.56 (1.01)	3.20 (0.88)
	Girl	2.97 (0.90)	2.36 (0.80)	2.75 (0.74)	2.42 (0.74)		2.53 (0.73) *	2.40 (0.75)	3.04 (0.73)
length of hospitalization(days) ANOVA test	7-22	3.03 (0.87)	2.42 (0.92)	2.65 (0.87)	2.42 (0.81) *		2.67 (1.15)	2.42 (0.87)	3.19 (0.82) **
	22-37	3.01 (1.01)	2.39 (0.73)	2.71 (0.71)	2.86 (0.84) *		2.99 (0.74)	2.66 (0.79)	3.08 (0.73) *
	37-50	2.68 (0.85)	2.41 (1.15)	2.63 (9.75)	2.30 (1.07) *		2.18 (0.83)	2.57 (1.35)	2.52 (0.76)*
Multiple pregnancy (T-test)	Singletons	2.95 (0.92)	2.41 (0.90)	2.66 (0.85)	2.48 (0.80)		2.62 (0.71)*	2.42 (0.83)	3.08 (0.78)
	twins	3.30 (0.71)	2.43 (0.78)	2.66 (0.77)	2.70 (1.11)		3.23 (2.25)*	2.80 (1.18)	3.39 (0.94)

T-test and ANOVA test significance was at the level of P≤0.05* and P≤0.01**

Table3. Correlation between the parental stressor and nursing support

Parental Stressor Nursing support	Environmental r (P)	Appearance /behavior r (P)	Parental role alterations r (P)
Emotional support	-0.118 )0.14(	0.070 (0.39(	-0.209) 0.009)^**
Information and communication	-0.07) 0.39(	0.061) 0.45(	-0.062 (0.44)
Self-confidence(esteem)	0.070 (0.39)	0.105 (0.19)	-0.139 (0.087)
Instrumental support(Quality Care)	0.127 (0.12)	-0.028 (0.73)	- 0.042 (0.60)

Correlation was significant at the level of P≤0.05* and P≤0.01**

DISCUSSION:

The result of this study indicated a negative significant correlation between nursing support in the category of "emotional support "and parental stress in categories of "parental role alterations" in parents of preterm infants hospitalized in NICU in South-East Iran(p <0.01). It means nursing emotional support decreases parents’ experience of stress induced by parental role alterations. Likewise, Blanch D’Souza et al., (2009) reported mild negative correlation between parental stress and nursing support. Montirosso et al., (2010) stated that although support from the NICU staff diminished stress produced by the infant’s appearance and behavior, support from the NICU staff did not completely relieve stress related to the alteration of the parental role (Montirosso et al., 2012). The results of this study highlights that nursing support are essential in the care of premature infants and their parents to reduce parental stress.

The results indicated that the participants experienced moderate level of stress during hospitalization of their preterm infant (total mean score 2.72 out of 5). Respectively, the highest mean scores in PSS: NICU belonged to the categories of “environmental stresses” (mean 3), “parental role alteration” (mean 2.66) and then “appearance and behavior of infants” (mean 2.41). This is consistent with the findings of Tichy et al., (1988) that point out specific environmental stimuli such as noise, lights, and the fast pace of the setting are stress creating for parents of neonates. Inconsistently, two studies (Blanch D’Souza et al., 2009; Tandberg et al., 2013) reported that participants experienced higher stress in category of “parental role alternation” and “infant’s appearance /behavior”, than “environmental stresses”. In addition, Valizadeh et al., (2009) found that highest level of stress experienced by Iranian parents respectively was in categories of “parental role alternation”, “infant’s appearance and behavior” and in the end “environmental stresses”. Moreover, Montirosso et al. (2012) found that among Italian mothers of preterm infants, the alteration in the parental role was the most important source of NICU-related stress. This contradiction may be due to different designing and constructing of NICUs. In NICU that this study conducted, the space assigned for infants and medical equipment was very close to nursing station and this made the NICU more noisy and crowded. So it requires that health care professionals pay more attentions in participate effectively in the design, construction, and occupancy of NICUs.

The findings of the present study indicated that parents received moderate level of nursing support (mean 2.72). Participants received more nursing support respectively in the categories of “quality of care” (mean 3.12), and then “communication- information” (mean 2.71), “emotional support” (mean 2.51), “self- confidence and esteem” (mean 2.48). Likewise, findings of an earlier study in Iran (Valizadeh et al.,2010) showed the most important areas of the nursing support are information-communication and quality of care. Tandberg et al (2013) showed parents were satisfied from support provided by the nurses, especially about the information and quality care aspects, also Blanch D’Souza et al., (2009) in their study stated that parents were satisfied with nursing support in category of communication- information. The results suggest that parents require more attention and support, thus it is essential that nurses improve their knowledge and skill regarding parental support.

Mother and fathers had different experiences regarding parental stress and nursing support. Fathers reported higher level of stress compared to mothers (mean score 2.72 for fathers; means score 2.66 for mothers). It is inconsistent with previous studies (Blanch D’Souza et al., 2009; Frank et al., 2005) that found mothers had more stress level than fathers. Based on researchers’ experience, in the studied population mothers involved in infant care programs more than fathers. This involvement could be effective in reducing their stress. In addition results revealed that mothers received more support than fathers. Insufficient nursing support might lead to more stress in fathers. According to the findings, mothers experienced highest level of stress in category of “infant’s appearance” and fathers mostly experienced stress in the category of “parental role alteration”. It could be due to the NICUs’ visiting policies that do not permit fathers to visit their infants except in visiting hours from 2pm to 4 pm. And there is not specific room for fathers like those assigned for mothers. Therefore, fathers are not able to perform their parental role and this imposes more stress on the fathers. Mothers visited their infants more frequently that fathers so they recurrently observed procedures and treatments that altered their infants appearances and experience more stress in the category of “infant’s appearance”. also it could be due to specific mothers emotional characteristics. Mothers received more support in the categories of “emotional support”, “communication–information” and “self-confidence” compare to fathers. This difference did not report in the study conducted by Tandberg et al., (2013). Fathers attended to the NICU less frequently than mother, for the reason that there were allowed to visit the infants in limited hours and they had financial responsibilities and their employment condition forbid them to spend more time in hospital. So they communicated with nurses less than mothers and received less support. The results might indicate that fathers require different nursing intervention strategies to relieve their stress.

Results showed that parents who had boy infants were given more information and communicate support than those who had girl infant. This finding implied that, in Iranian culture, the gender of offspring still may be important for parents and society. Parents who answered to the questionnaires while were staying in tap rooms reported higher stress level in category of "infants appearance and behavior" compare to those who questioned while were moving around the setting. In addition, parents who answered the questionnaire while they were staying in tap room received more nursing support in categories of "emotional support" and "self-confidence" compared to those moving around the setting. Parents who were staying in tap room were involved more with their infants’ disease and their care. All of participants who were staying in tap room were mothers and due to specific characteristics of mothers, they experienced more stress about infants’ appearance and behavior. They repeatedly encounter with invasive intervention that were performed for their infants.

CONCLUSION:

Both mothers and fathers reported feeling moderate stress during hospitalization of their preterm infant. However fathers’ experienced more stress than mothers maybe because there is less attention to fathers in NICU at hospital research. Parents were not satisfied with the support from the nurses, especially in relation to the confidence and self-esteem dimension and they satisfied of the nursing care dimension.

It is necessary for nurses who work in the neonatal intensive care unit to be aware of individual differences and stressors for parents in NICU and with giving appropriate information help to provide high quality care to infants and parents. Hence teaching nurses working in NICUs the essential skills for identifying causes of stress and ways to reduction stress and providing support to the parents of infants hospitalized is very helpful. Thus providing well support for parents in neonatal intensive care units through supporting an individual parent is an option.

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Received on 25.11.2013 Modified on 08.01.2014

Accepted on 14.01.2014 © A&V Publication all right reserved

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 81-86