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ORIGINAL ARTICLE
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Estimation of stress amongst the parents of neonates admitted to neonatal intensive care unit


1 Department of Pediatrics, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
2 Psychiatry, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
3 Department of Community Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
4 Department of Obstetrics and Gynaecology, Uma Nath Singh Autonomous State Medical College, Jaunpur, Uttar Pradesh, India
5 Department of Paediatrics, Uma Nath Singh Autonomous State Medical College, Jaunpur, Uttar Pradesh, India
6 Department of Paediatrics, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
7 Department of Business Administration, University of People, Pasadena, USA

Date of Submission12-Jul-2022
Date of Acceptance08-Dec-2022
Date of Web Publication21-Jan-2023

Correspondence Address:
Richa Rathoria,
Department of Obstetrics and Gynaecology, Uma Nath Singh Autonomous State Medical College, Jaunpur, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_132_22

  Abstract 


Introduction: The admission of the baby to the neonatal intensive care unit (NICU) can be a stressful predicament for parents. This study aims to evaluate parental stress levels and the factors impacting them. Materials and Methods: This cross-sectional study was conducted in the NICU of a tertiary care centre for 3 months. Data were collected using a questionnaire consisting of demographic characteristics of parents, neonates and Parental Stressor Scale: NICU (PSS: NICU) to measure parental stress. The data were analysed using descriptive statistics and an independent t-test. Results: P ≤ 0.05 was considered statistically significant. Most of the parents reported medium stress levels (3–3.9). The mean total parental stress score of parents was 3.31 (0.36). Amongst the PSS: NICU subscales, the NICU sight and sound caused maximum stress to the parents (mean = 3.35 [0.48]) followed by the relationship with the baby and parental role (mean = 3.34 [0.44]). Mothers felt more stressed as compared to fathers (mean = 3.60 [0.23] vs. 3.08 [0.28]; P < 0.05). Conclusion: Higher parental stress levels were seen in lower age group (18–25 years), less than high school education, unemployed and previous history of neonatal death, outborn deliveries, pre-term (gestational age <37 weeks), birth weight <1500 g, longer duration of respiratory support (>3 days), intubated with ventilatory support, not started on feeds and not given kangaroo mother care. Parents of NICU-admitted neonates are under significant stress, and there is a necessity to provide family-centred care.

Keywords: Neonatal, neonatal intensive care unit, parental stress, Parental Stressor Scale



How to cite this URL:
Sisodia P, Khan H, Shukla NK, Rathoria R, Rathoria E, Bansal U, Shukla R. Estimation of stress amongst the parents of neonates admitted to neonatal intensive care unit. Adv Hum Biol [Epub ahead of print] [cited 2023 Feb 2]. Available from: https://www.aihbonline.com/preprintarticle.asp?id=368369




  Introduction Top


In recent decades, the global as well as the Indian, neonatal mortality rate has declined. More pre-mature and critically ill infants are being treated in the neonatal intensive care unit (NICU) with the advancing medical technology.[1] The parent–infant bonding formed during the newborn period is vital for a lifelong relationship. Still, this process got hampered by NICU admission for various indications adversely affecting the child's emotional development.[2] Maternal feelings get negatively affected by the sense of exclusion and lack of interaction in the NICU.[3] During the NICU stay of their infant, apart from their characteristics and situations, parents get affected by the newborn's condition, NICU environmental factors, communication skills and the behaviour of the staff.[4]

Parents of neonates admitted to the NICU experience a great deal of stress, thus making it essential for healthcare providers to identify and act on the source of this stress.[5] Parents of pre-term babies get separated from their babies both physically and psychologically by the artificial environment of the NICU and experience the fragility of their babies in the NICU.[6],[7] Parents do not get opportunities to participate in parenting during NICU admission, leading to misunderstanding of their baby's behavioural clues after being discharged from NICU.[8] The parents of sick babies, especially mothers, have difficulty transitioning into parenthood, leading to negative feelings in them such as anxiety, depression, anger, helplessness and confusion.[9] Stress in mothers caused by the critical condition of the baby can be the risk factor for mother–infant bonding, which can negatively affect the future developmental outcomes of the neonate.[10]

Psychological stress and anxiety amongst the parents following the birth of a critically ill or pre-term infant can negatively impact both of them during their NICU stay and after discharge as it can increase the risk of adverse developmental, cognitive, academic and mental outcomes in the infant. The use of well-validated screening tools can help identify parents who are at risk for psychological distress.[11] Interventions addressing NICU parent stress, depression and anxiety have been shown to not only improve parent outcomes but infant outcomes as well.[12]

Each parent has their way of reacting to their NICU environment. NICU staff needs to know about the parental reactions to the NICU environment, identify the source of stress and understand the risk factors and plan accordingly.[13] Parental Stressor Scale (PSS):NICU has been widely used in the Western population to measure the parental stress response due to the admission of their newborn into NICU.[14]

This study was conducted in our setup to estimate the magnitude of stress and its significant sources amongst the parents of neonates admitted to NICU and to identify the demographic parameters that influence the stress level.


  Materials and Methods Top


Research design

The present cross-sectional study was conducted in the NICU of a tertiary care centre situated at Safedabad, Lucknow, Uttar Pradesh, over 3 months from January to March 2022. The approval of the institutional ethical committee was obtained before the start of the study.

Setting and relevant context

The study was planned amongst parents of neonates admitted to NICU using a pre-designed and pre-tested semi-structured validated interview-based questionnaire consisting of PSS:NICU.

Inclusion criteria

Parents of all the inborn and outborn neonates irrespective of gestational age and diagnosis admitted to the NICU for more than 24 h were included.

Exclusion criteria

Parents of those neonates who expired before the questionnaire, had a congenital malformation, were admitted for less than 24 h, parents with previous psychiatric or cognitive pathologies and drug addiction and who were not willing to take part in an interview, were excluded from the study.

Sample

The study population included parents (mothers and fathers) of neonates admitted into the NICU during the study period. Purposive sampling was used, and all the eligible parents were approached inside the NICU within 7 days of their newborn's admission during their visit time. There were a total of 128 parents (64 mothers and 64 fathers) with their newborns admitted to the NICU during the study period. However, 38 parents were excluded as their newborns stayed in NICU for a duration of fewer than 24 h. Twelve mothers and five fathers refused to participate. We took either the mother or the father of the neonate in our study, and 73 eligible parents (40 fathers and 33 mothers) were finally enrolled in the study.

Measurement

The quantitative information was measured using a self-administered questionnaire which included the demographic characteristics of parents and neonates, and the PSS:NICU. Parental stress was measured using PSS:NICU. It was a 46-item instrument developed by Miles et al. that measures parents' perception of stress within the NICU.[14] The scale consisted of 4 subscales that measured stress related to (a) sights and sounds of the unit (5 items), (b) appearance and behaviours of the infant (19 items), (c) impact on the parent's role and relationship with the baby (10 items) and (d) staff behaviours and communication (11 items). It also had a general stress-level question that summarises the parent's overall feeling of stress related to having an infant in the NICU. The feeling of anxiousness, upset or tension was defined as stress. The responses to each PSS:NICU subscale were scored on a 5-point Likert scale. Scale points 1, 2, 3, 4 and 5 were not at all stressful, a little stressful, moderately stressful, very stressful and extremely stressful, respectively. The overall stress level was classified according to points on the Likert scale as low (1–2.9), medium (3–3.9) and high (4–5).[12]

Data collection

All the eligible parents were interviewed using the structured questionnaire of PSS:NICU in the four subscales after taking informed written consent. The data collected on demographic characteristics of parents included gender, age, education, occupation, socioeconomic status, parity, history of the previous stillbirth, risk factors, previous history of neonatal death and previous newborn admission to NICU. Data collected on the infant's demography and clinical characteristics included their place and mode of delivery, gestational age (weeks), birth weight (grams), gender of baby, respiratory support, length of respiratory support, intubated with ventilator support, feeding with breast milk and kangaroo mother care (KMC). After the interview, a dedicated psychological counsellor did appropriate counselling sessions for all the parents to mitigate their stress levels.

Statistical analysis

Descriptive analysis of data was done using SPSS version 20.0 for Windows (IBM, Armonk, NY, USA). Demographic data and stress levels of the parents were evaluated statistically using descriptive statistics. The overall stress levels for each of the four subscales were compared with the sociodemographic and clinical characteristics of the parents and infants using independent t-tests. P ≤ 0.05 was considered statistically significant.


  Results Top


The mean age of parents was 28.53 (3.8) years. The sociodemographic and clinical details of the parents and their neonates are summarised in [Table 1] and [Table 2], respectively.
Table 1: Demographics and clinical parameters of parents (n=73)

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Table 2: Demographics and clinical characteristics of newborns (n=73)

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The mean score of sights and sounds, neonatal appearance and behaviours, parent's role and relationship and staff behaviour and communication subscales was 3.35 (0.48), 3.22 (0.49), 3.34 (0.44) and 3.33 (0.51), respectively. The mean total parental stress score of parents was 3.31 (0.36). The association of stress levels of parents with sociodemographic and clinical characteristics of both parents and neonates were analysed using the independent t-test for each variable and those with significant association (P < 0.05) are represented in [Table 3] and [Table 4], respectively.
Table 3: Parental stress levels in relation to sociodemographic and clinical characteristics of parents (n=73)

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Table 4: Parental stress levels in relation to sociodemographic and clinical characteristics of neonates (n=73)

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  Discussion Top


The parental stress levels in relation to most of the sociodemographic and clinical parameters of parents and neonates demonstrated medium stress levels in the present study. When the four subscales were considered, the NICU sight and sound is what most stresses the parents, followed by the relationship with the baby and parental role in our study which was consistent with the findings of a study by Ganguly et al.[15] Miles et al. reported in their study that changes in parental role caused by the infant's illness caused the maximum stress, followed by the infant's appearance and behaviour.[16] High-stress levels in the sight and sound subscale and parental role subscale can be explained by the fact that a common layman parent who is emotionally attached to their baby, visiting NICU for the first time, can get stressed by seeing the rush of the nursing staff, monitors and equipment of the NICU, ventilators, intravenous tubes and infusion pump devises and listening to continuous alarm noises. The least stress was experienced in the subscale of appearance and behaviour of neonates which was similar to the previous study by Ganguly et al.[15] The least stress in the subscale of appearance and behaviour of neonates may be due to brief visiting hours and limited visible access of the newborns due to clinging sheet and nesting, which was insufficient to create a bond or notice the baby's behaviour.

When the four subscales and total parental stress scores were compared with the gender of parents, the mean scores were higher in mothers in all the subscales (P < 0.05) except in the staff behaviour and communication subscale. The higher mean scores in mothers in our study indicate that they felt more stressed which was in accordance with a study done by Matricardi et al., which reported more stress in mothers as compared to fathers.[17] Similarly, Carter et al. concluded in their study that the NICU environment was more stressful for mothers as compared to fathers.[18]

The stress levels of parents in the NICU sight and sound subscale (e.g., alarms, monitors and other admitted neonates) were significantly more in the 18–25 years' age group while there was no significance reported in other subscales in the present study. This was comparable to a study done by Dudek-Shriber., who reported that younger parents in their study had experienced greater stress levels which may be due to being parents for the first time or not knowing what to expect or do.[19]

The stress levels of parents with education of less than high school were significantly higher in NICU sights and sounds, neonatal appearance and behaviour subscales and total parental stress scales in the present study (P < 0.05). The stress levels of parents who were unemployed were significantly higher in NICU sights and sounds, neonatal appearance and behaviours, parent's role and relationship subscales and total parental stress scales in the present study (P < 0.05). This was equipollent to a study done by Ganguly et al., which reported that stress levels were found to be higher in parents who were less educated or uneducated and unemployed.[15] This could be explained by their inability to comprehend the information given to them, as well as their lack of familiarity with the NICU environment. Wormald et al., in their study too, found higher stress levels in parents with unemployment and lower education level.[20]

Any previous history of neonatal death was significantly associated with higher stress levels of parents in the parent's role and relationship, staff behaviour and communication subscales and total parental stress scale in our study (P < 0.05) while in contrast Ganguly et al., reported higher stress levels in only sight and sound subscale.[15] Umasankar and Sathiadas., discovered significantly higher levels of stress in all components if there has been a previous neonatal death, which is consistent with our findings.[21]

There was no significant relationship noted between the parental stress subscales in relation to parity, history of previous stillbirth, risk factors and history of previous NICU admission which was similar to a study by Ganguly et al.[15]

The present study revealed that there were higher stress levels amongst parents of outborn delivered newborns in all the PSS:NICU subscales while in contrast Palma et al., did not find any statistically significant difference.[22] Neonatal factors such as pre-maturity (gestational age <37 weeks), birth weight less than or equal to 1500 g, newborn on respiratory support for more than 3 days, intubated and on ventilatory support and not starting any mode of feeding with breast milk, were associated with a significantly higher level of parental stress in all subscales and total score scale except staff behaviour and communication subscale in the present study. This was in accordance with a study by Chourasia et al., which revealed that higher stress levels in parents are associated with pre-maturity of baby, longer duration of NICU stay and not being able to directly breastfeed the baby.[23] Accordingly, Varma et al. reported that the lower birth weight of the baby and intubated babies on ventilator support were associated with higher maternal stress levels.[24] Parents who were allowed to provide KMC to their newborns had significantly lower stress levels in all four subscales and total scale in our study. Gooding et al. reported that kangaroo care (skin-to-skin holding care) is one of the most comfortable activities for NICU parents shown to contribute to stress reduction, apart from providing extensive benefits to the infant.[25]

There was no significant relationship noted between the parental stress subscales in relation to mode of delivery and gender of the baby in this study which was similar to a study by Ganguly et al.[15]

The findings of the medium-to-high level of stress amongst parents emphasise the fact that it is vital for healthcare providers in NICU to identify their stressors so that intervention protocols can be started promptly. The parental counselling and interventions taken to reduce parental stress should be focused on the parental role with their newborn. Interventions should be taken to lower the noise level of alarms and set the appropriate alarm limits. According to a study by Gooding et al., educational materials should be available to parents in the NICU including audiovisual materials and lay and medical information about NICU conditions and procedures.[25],[26] A designated family support person should be there to help the parents in the high-risk group.[25] The Ministry of Health and Family Welfare, Government of India created operational guidelines on family participatory care for improving newborn health in July 2017. These guidelines call for including the families of ill and pre-term newborns as partners in caregiving and decision-making in newborn care facilities.[27],[28],[29] The overburdened NICU staff in the public sector in India find very little time to focus on parental stress. High rates of stress amongst NICU parents demonstrate the need to incorporate family-centred care into NICU policies, procedures and culture.

Strength and limitation

The strength of the present study was that a dedicated psychological counsellor did appropriate counselling sessions post-questionnaire for all the parents to mitigate their stress levels. The limitation of the present study was that the sample size was small and the sample was a convenience sample and may not be representative of the population, so the findings cannot be generalised. Furthermore, follow-up was not done to see the effect of counselling sessions on the reduction of parental stress levels. In the future, there is a further need for a study to see the effect of parental counselling and the implementation of family-centred care on the reduction of parental stress in our setting.


  Conclusion Top


The NICU environment is moderately stressful for both mothers and fathers with the highest level of stress in sight and sounds, and parental role alteration. Mothers were more stressed as compared to fathers. Parents of newborns who started feeding with breast milk and provided KMC were significantly less stressed. NICU interventions to implement the practice of family-centred care and providing educational and emotional support to parents may help mitigate the parental stress.

Acknowledgement

The authors would like to acknowledge the faculty members, senior residents, junior residents and all the parents who have participated in this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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