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How to cite this article:

Aguiñaga-Zamarripa ML, Reynaga-Ornelas L, Beltrán-Torres A. Estrés percibido por los padres del neonato en estado crítico durante el proceso de hospitalización. Rev Enferm Inst Mex Seguro Soc. 2016; 24(1):27-35.

Perceived stress for parents of critically ill newborns during hospitalization

Ma. de la Luz Aguiñaga-Zamarripa,¹ Luxana Reynaga-Ornelas,² Araceli Beltrán-Torres³

¹Unidad de Medicina Familiar 56, Instituto Mexicano del Seguro Social; ²División de Ciencias de la Salud, Universidad de Guanajuato; ³Unidad Médica de Alta Especialidad Hospital de Gineco-Pediatría 48, Instituto Mexicano del Seguro Social. León, Guanajuato, México

Correspondence: Araceli Beltrán Torres

Email: araceli.beltrant@hotmail.com

Date received: December 17th, 2014

Date judged: May 29th, 2015

Date accepted: July 24th, 2015

Abstract

Introduction: Treatment protocols for family includes identifying stress levels of parents of newborns in critical condition in hospital, enabling care planning, increasing the degree of security and the perceived benefit in improving infant.

Objective: To describe the level of perceived stress for parents of critically ill neonates during hospitalization in a Neonatal Intensive Care Unit (NICU).

Methodology: descriptive correlational study in a NICU parents about their perceptions of interpersonal stress and superpersonal interviewed during hospitalization with “Parenting Stressors Scale: Neonatal Intensive Care Unit”, developed and validated by Dr. Miles, statistical analysis was conducted in SPSS v.8.

Results: The level of stress perceived by parents was referred on five levels: Not stressful 24 %, Little bit stressful 36%, Moderately stressful 25 %, Very stressful 10 %, and Extremely stressful 5 %. The average was little stressful interpersonal stress with superpersonal 2.04 and the stress was moderately stressful to 2.51. The stress factor was highest scoring behavior and communication.

Conclusions: We identified that there is a relationship between interpersonal and extra-personal factors with the level of stress perceived by parents during hospitalization of the newborn in critical condition.

Keywords: Stress; Parents; Critical illness; Newborn.

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Introduction

Regarding family participation in the care of a person during hospitalization, several authors report the development of care protocols for families in which not only the family benefits, as it has been found that the family positively influences the patient’s improvement.¹ There are other studies stating that providing adequate information to relatives facilitates adaptation and recognition strategies.²

Canadian researcher and physiologist Hans Selye in 1935 described the term stress as a syndrome in which there is fatigue in the organism as a result of a stressful situation, generating a response to a physical or emotional demand; that is, it starts with an alarm reaction that is used by the body as a defense mechanism that includes changes in blood components, adrenal glands, the thymus and stomach. The term General Adaptation Syndrome was coined by Selye in 1976, to explain and identify the pattern of physiological changes observed without relating it to stimulus harmful to the organism.

Handling stressful situations depends on the adaptability of the organism, its preparation, needs, expectations, and self-esteem. When a newborn requires medical care from birth because of prematurity, illness, or congenital malformation, this simultaneously presents events that are mostly unexpected and thus overwhelming for parents, since stress factors converge such as the change in family dynamics after birth and the presence of disease in the newborn, a painful condition representing an unexpected situation. 

According to the Holmes scale,^3,4 the sum of these events and others of a financial nature (if we consider the monetary costs involved in specialized care), changes in recreation (wholesale dedication to the child), social activities, and sleep habits, nutrition, hygiene or grooming, it generates a degree of stress that increases the likelihood of psychosomatic illness.

When looking for a response to a stressful situation, changes occur in the body because it prepares for action; the difficulty is in diagnosing these changes, and it is harder still to determine their level. In an attempt to objectify the existence and intensity of stress, the situations that cause tensions have been explored, as well as the intensity corresponding to each one, through a scale useable at any social level and throughout the world. It is divided into three parts: the first is a biographical record, the second assesses the stress level in the field of social relations, and the third evaluates the tensions generated by personal habits. It is pertinent to note that measuring stress at a low or very low level is not indicative of health or wellness.⁵

The version of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) addresses two diagnostic criteria for acute stress disorder and posttraumatic stress. Based on these criteria, the assessment of the influence of environmental stress on people’s behavior requires clinical investigation of their adaptive strengths as a socio-psychophysiological response to environmental stressors. These can be seen as psychophysiological disruption of homeostasis, and they arise when there is an actual or perceived imbalance in the demands and capabilities between the individual and their social environment.⁶

Betty Neuman’s Systems Model, based on general systems theory, reflects the nature of organisms as open systems, also incorporating elements of Gestalt theory describing homeostasis as a process in which a body is kept in balance. She also bases the theory on Selye’s definition of stress, so stress is synthesized as the non-specific demand for activity; the constituents thereof, recognized as stressors, are both positive and negative incentives, and are derived from stress that produces subsequent tension.⁷

Neuman's primary interest is the phenomenon of stress and the reaction to it, which arises from the interaction of the person’s system with the external and internal environment.^8,9 Systems and phenomena are a set of elements that interact with each other within a border capable of filtering the inputs and outputs to the system, and based on this, the systems are hierarchically ordered and possess subsystems and supersystems. If they are open, they can import products (input), rearrange them (processes), and throw them out (output). When the output information is monitored back to the system as input it is known as "feedback", which produces a change in its overall pattern of performance and as a dynamic equilibrium with its environment.¹⁰

The main assumptions of the Neuman model are: Nursing as the belief that one should care for the whole person; the Person as a customer, conceptualized as an open system in reciprocal interaction with the environment, the customer system is a dynamic set of interrelationships among physiological, psychological, sociocultural, developmental, and spiritual factors; Health, as a continuous movement of a dynamic nature that changes constantly; the Environment, which is all the internal and external factors surrounding and influencing the client system, stressors (intrapersonal, interpersonal, and extrapersonal) are described as environmental forces that interact with the stability of the system and can alter it.¹¹

One of the first projects on the care of family needs of critically ill patients was in 1979, with the creation of the questionnaire Critical Care Family Needs Inventory (CCFNI). This questionnaire is an inventory of needs with 45 items on the Likert scale, evaluating five aspects concerning information, comfort, support from professionals, proximity to the patient, and certainty that their family member is being well cared for.^12,13

In particular, the birth of a premature or sick newborn is an unexpected and overwhelming fact that by its very nature requires psychological and/or emotional preparation for parents and families to face it; experience shows that the hospitalization of a newborn born in the Neonatal Unit Intensive Care (NICU) causes different reactions in parents, generally intense and disturbing.^14,15

Physical symptoms of stress and depression are two common disorders in parents of infants hospitalized in the NICU, which can interfere with their interaction with the child and communication with professionals caring for the newborn. It is therefore important to consider that some of the factors related to parental stress can be the health condition of the newborn, the environmental characteristics of the place, and the separation of the parents-child dyad.^16,17

The first assumption of Neuman’s model that Nursing must care for the whole person, is based on the fact that this is a unique profession that deals with all the variables affecting the person's response to stress. The nurse’s perception influences the care provided, and the great possibility of interacting with the newborn and their parents allows them to identify their needs and feelings about the health of their child.¹⁸

Therefore, the nurse, through an effective therapeutic relationship, may be the professional that promotes a force of maturation in parents to build a creative, constructive, productive, personal, and community-based life.¹⁹ Encouraging parents to be part of caring for the baby during visits in order to strengthen the bonds for life, and the mother-child bond by promoting breastfeeding and making sure to lessen the intensity of parents’ anguish and despair by keeping them informed about the development and health of their child, are the human and essential tasks that a nurse should aspire to.^20,21

The purpose of this study is to describe the level of stress perceived by the parents of a newborn in critical condition during hospitalization in a Neonatal Intensive Care Unit (NICU).

In short, the results obtained may be useful not only for the nurse who works every day in neonatal intensive care, they can also help administrators and managers making decisions to offer alternative work systems to promote or maintain equilibrium and wellness states for both providers and users of health services.

Methodology

A descriptive, correlational study was conducted in the NICU of the Unidad Médica de Alta Especialidad Hospital de Gineco-Pediatría 48 (UMAEHGP48), in the city of Leon, Guanajuato.

45 fathers or mothers of infants in critical condition with a hospital stay ≥ 24 hours were selected, who agreed to answer the interview. Sampling was by convenience according to their attendance at scheduled family visits to the NICU.

Parents exposed to interpersonal stressors for the following reasons were not included:

1. Infants who were in special critical situations due to serious or invasive procedures.
2. Infants admitted to the NICU a few days after birth, or those readmitted to the unit.
3. Infants transferred from other local or foreign hospital units.

Process

Prior to applying the "Parent Stressors Scale: Neonatal Intensive Care Unit" (PSS:NICU), it was verified that the parents met the inclusion criteria.

Informed consent was applied at the time of the family visit to the NICU.

Once the purpose of the study was explained and their agreement was declared, informed consent was signed.

During the implementation of the PSS NICU, the researcher participated directly, guiding parents with difficulties responding or in cases of illiteracy.

Data analysis was done with descriptive statistics using SPSS version 8.

Measuring instrument

Parent Stressors Scale: Neonatal Intensive Care22 was developed and validated in North Carolina, United States, by Dr. Margaret Miles; conceptual definitions of the following variables were built based on the description of stressful situations:^9,10,22-24 

• Stress, for this study was defined as the organism's socio-psychophysiological response to environmental stressors, characterized by a sense of anxiety, disorder, or stress experienced by parents during their child’s time in the NICU.
• Stressful experience is one that causes feelings of anxiety, disorder, or parental stress during their child’s time in the NICU.
• Stressful event is one in which environmental demands exceed the adaptive resources of an individual.
• Interpersonal factors are the stressors of the psychosocial environment of the NICU, in terms of parents' experiences in relations with NICU staff and their child.
• Extrapersonal factors are stressors of the physical environment of the NICU, which are potential sources of stress, such as sounds, the appearance of the unit, the newborn’s appearance and behavior.
• Environmental factors of the NICU are typical elements that exist in the unit, both physical and psychosocial, which can be recognized as inter- and extrapersonal factors, and which are potential sources of stress (when they cause stress they are called stressors).
• Interpersonal stressors are the forces of interaction of the external environment of the NICU that occur in a proximal range outside the boundaries of the parents.¹⁰
• Extrapersonal stressors are the forces of interaction of the external environment of the NICU that occur in a distal range outside the boundaries of the parents.
• Additional stressors are an item with optional response, to inquire if parents experienced other stressors that had not been considered.

Ethical considerations show that according to the general provisions of the Regulations of the Ley General de Salud in Health Research (1994), Title II, Chapter I: The criterion of respect for the human dignity of the study subject and the protection of their right to welfare prevail (Art. 13). The written informed consent of the research subject was obtained and the study proceeded when the authorization of the health institution was obtained (Art. 14 sections. V and VIII). The privacy of the individual research subject is protected, identifying them only when the results require it and this is authorized (Art. 16). 

It is considered a study with minimal risk, because although the survey the Parent Stressors Scale: Neonatal Intensive Care Unit was applied, the subject's behavior was not manipulated (Art 17, Section II.).

To this end, a clear and complete explanation was offered of the objectives, rationale, risks, and benefits to be gained, as well as verbal assurance of answering any questions and clarifying any doubts about them.

Subjects were verbally informed about their freedom to withdraw informed consent at any time and decline to participate in the study, with the guarantee that they will not be identified and the confidentiality of their information will be maintained (Art. 21, Section I, II, III, IV, VI, VII, and VIII). In addition, the final results of the study were reported to the authorities of the institution where the research was done (Art. 19).

Results

Of the total of 45 parents surveyed, 50% are in the range of 15 to 24 years of age, more than half are women (60%), marital status is married (69%), with secondary schooling (34 %), and they are teachers or technicians (42%), and half of them employed (51%) (Table I).

In the case of newborns hospitalized in the NICU, 64% were obtained by Caesarean section, 45% at gestational age of 29-36 weeks and 51% between 1,500 and 2,499 kg of weight, the hospital stay was ≤ 2 days for 40% and ≥ 5 days in 51% of cases. The main reason for NICU admission was respiratory distress syndrome, 34% due to other causes, and 22% hyaline membrane disease (Table II).