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
Date received: December 17th, 2014
Date judged: May 29th, 2015
Date accepted: July 24th, 2015
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.
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.
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:
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.
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
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).
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).
|Table I. Socio-demographic characteristics of parents of critically ill newborns hospitalized in NICU (n = 45)|
|15 - 24||23||51|
|25 - 34||16||16|
|Teacher or technician||19||42|
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).
|Table II. Characteristics of critically ill newborns hospitalized in NICU (n = 45)|
|Type of birth|
|Number of children|
|Gestational age (weeks)|
|29 - 36||20||45|
|1500 - 2499||23||51|
|2500 - 3499||7||15|
|Day of hospital stay|
|Respiratory distress syndrome from HMD||10||22|
|Child of Rh-negative mother||6||14|
|Respiratory distress syndrome from other causes||15||34|
|Other (heart disease, pneumonia, jaundice, macrosomia/sepsis, neuroinfection)||9||18|
|HMD = hyaline membrane disease|
The most reported stress level perceived by parents in relation to the extrapersonal stressors was not very stressful with a minimum average of 1.60 (SD = 0.63) and a maximum of 3.66 (SD = 0.90) in Appearance and sounds of the unit and Appearance and behavior of the child, in the latter a maximum average of 3.66 was identified in the items appearance of wounds, cuts, or incisions and tubes and equipment in or near the baby, which was perceived by parents as moderately stressful (Table III).
|Table III. Scale of stress levels perceived by parents in relation to extrapersonal stressors (n = 45)|
|Extrapersonal stressors||Stress level||Average (SD)|
|Appearance and sounds of the unit||Having a machine breathing for my baby||x||2.37 (0.71)|
|The constant sound of monitors and equipment||x||2.22 (0.92)|
|The sudden sound of monitor alarms||x||1.82 (0.83)|
|The presence of monitors and equipment||x||1.70 (0.76)|
|Appearance and behavior of the child|
|Wounds, cuts, or incisions on my baby||x||3.66 (0.90)|
|Tubes and equipment on or near my baby||x||3.15 (1.10)|
|When my baby seems to be in pain||x||2.93 (1.10)|
|Seeing needles and tubes put into my baby||x||2.64 (0.77)|
|My baby being fed by an intravenous line or tube||x||2.40 (0.78)|
|My baby’s unusual breathing patterns||x||1.97 (0.69)|
|My baby’s weak and fleeting look||x||1.97 (0.69)|
|My baby’s unusual coloring||x||1.95 (0.60)|
|My baby cannot cry like other babies||x||1.62 (0.71)|
|When my baby looks sad||x||1.60 (0.53)|
|NS = not stressful; NVS = not very stressful; MoS = moderately stressful, VS = very stressful, ExS = extremely stressful|
Regarding the level of parental stress related to interpersonal stressors (relations and role of parents and communication with staff), the not very stressful level had averages between 2.0 (SD = 0.63) and 2.62 (SD = 0.68); the very stressful level had averages between 4.0 (SD = 0.82) and 4.17 (SD = 0.80) for the area of communication with staff regarding aspects of insufficient information on tests and treatments, insufficient time to communicate information, and difference in the information provided about their baby. Feelings reported as "feeling helpless about how to help their baby during hospitalization" and that "many different people talk to me," were motives generating moderate stress in parents (Table IV).
|Table IV. Scale of stress levels perceived by parents in relation to interpersonal stressors (n = 45)|
|Interpersonal stressors||Stress level||Average (SD)|
|Relationships and role of parents|
|Feeling useless to help my baby during this time||x||2.93 (0.71)|
|Being separated from my baby||x||2.53 (0.99)|
|Being unable to take care of them personally||x||2.48 (0.81)|
|Being unable to feed them personally||x||2.08 (0.87)|
|Feeling useless and unable to protect my baby||x||1.95 (0.67)|
|Communication with staff|
|They do not tell me enough about tests and treatments that they do to my baby||x||4.17 (0.80)|
|They do not talk to me long enough||x||4.02 (0.86)|
|They tell me different things about the condition of my baby||x||4.00 (0.82)|
|Staff explains things very fast||x||3.00 (0.67)|
|Staff uses words I don't understand||x||2.62 (0.68)|
|Difficulty obtaining information or assistance when I visit or call the unit||x||2.31 (0.87)|
|Staff acts like they do not understand my baby’s behavior and special needs||x||2.28 (0.66)|
|I do not feel sure that they will inform me about changes in my baby’s conditions||x||2.00 (0.63)|
|Many different people talk to me||x||2.73|
|NS = not stressful; NVS = not very stressful; MoS = moderately stressful, VS = very stressful, ExS = extremely stressful|
There was a satisfactory proposal to include at the end of the scale an item concerning additional stressors, with optional response to inquire if parents experienced other stressors that had not been included.
A total of 21 parents responded, of whom 13 were women and 8 men. The comments mainly concerned the request for further information in 38%, access being restricted only to parents in 28.5%, times during the night shift without access for visits in 19% and the short duration of visiting time in 14.5%.
The hypothesis of the environment in the neonatal intensive care unit is accepted, in which interpersonal stressors have greater influence than extrapersonal stressors on the stress level perceived by parents during hospitalization of the newborn in critical condition.
The admission of a child to the NICU is a generator of stress for parents, mainly due to the continuous movement of lines of resistance to adapt to factors of a complex and different environment, and maintaining the normal line of defense.24
In environments such as the NICU, parental stress is of low intensity, which coincides with reports by Miles, with similar values in the measurement of interpersonal and extrapersonal stressors. This is the case of the subscale of appearance and sounds of the unit, which is perceived by parents as not stressful, slightly below the value reported. It is also reported that the issues covered in the subscale of appearance and behavior of the child are not stressful for parents, which relates to the hypothesis that lower gestational age of the newborn means higher stress level experienced by parents. It is also confirmed that the main extrapersonal stressors, such as wounds, cuts and/or incisions in my baby, are perceived by parents as moderately stressful.22
The imminent separation of parents from the time of the newborn’s admission to the NICU, forces parents to rely on the staff and give up the position of control, sometimes they are kept apart from the treatments and their opinion on them,2 as a result, the system of the father or the mother is threatened in its stability and a conflict may arise in their role,13 feeling not very or not useful to help their baby during hospitalization, and separation of the newborn is reported by parents as a moderately stressful experience.22 Board4 confirms this, reporting that separation is stressful for anyone who has anticipated a happy and enjoyable time. Another of the extrapersonal stressors are those determined by communication with staff, this subscale has the highest average stress values.
In this regard, the references in the literature are variable, on the one hand they report them to be moderately stressful, on the other they find them less stressful or not stressful.25 The basis of good communication requires adequate interpersonal relations by health professionals, considering the emotional and information needs of parents and relatives.
According to Rivera Vazquez,26 the essence of comprehensive nursing care in the NICU is that it is focused on the newborn, with functions connected multidisciplinarily, and promoting parental involvement in caring for their baby. Although in this study the actions of staff communication with parents were perceived between not very stressful and very stressful, change is needed in the quality time dedicated to parents to meet their information needs. Otherwise the actions of nurses can create an interpersonal communication barrier.
Motler12 found that the need identified as the most important by relatives of ICU patients is hope, but it is also of great importance for them to receive adequate and honest information, and to feel that members of the ICU team are concerned about the patient. In this line, Kirchoff18 states that family member satisfaction is related to communication with the physician and decision making, so adequate and honest information would be vital for the psychosocial health and satisfaction of the family. Hughes meanwhile published a study involving eight relatives of patients admitted to the ICU for at least 48 hours whose admission had been unscheduled, and five nursing professionals in the unit, with the aim of exploring the overall experience of the family member with the ICU environment, to identify any evidence that might arise as a traumatic experience and to examine the perceptions of the care team. These reactions were more intense during the first 24 to 48 hours of admission, at which time the family’s ability to process information was lower. Even when they received information about the health status of the patient, and visiting hours and facilities at their disposal; according to the authors, it appears that the communication between the ICU and the family was not adequate. The authors conclude that the information should be provided in small episodes, with subsequent verification of whether the family understood it correctly.19
Another study found that information is one of the most important needs expressed by relatives of patients in an ICU, from their perspective it must be provided as precisely as possible. In addition it is stated that family members need to maintain a closeness with the patient and to see them regularly. However, restricted visiting hours and lack of adequate infrastructure often interfere with attempts to meet this need for family members.13
Alternatives have been proposed to provide information to relatives of critically ill patients, Atkinson20 states that a meeting with the family can reduce their agitation and help minimize the potential conflict between the ICU care team and the family. In order to assess the impact of an informational leaflet for relatives of patients admitted to the ICU, Azoulay et al.21 conducted a multicenter study in 34 intensive care units (ICU) with 175 relatives of patients admitted for at least 48 hours. The family received standard information from the ICU care team, plus a leaflet containing general information about the ICU and hospital, the name of doctor of the unit caring for the patient, a diagram of a typical room at the ICU with the names of the devices, and a glossary of 12 terms commonly used in these units. This information was provided during the family’ first visit to the ICU, and they were evaluated at 3 to 5 days using the Critical Care Family Needs Inventory (CCFNI)12 and the Hospital Anxiety and Depression Scale (HADS).27 The results showed that the leaflet improved the family’s understanding in the experimental group, concluding that since the leaflet significantly improves the family’s understanding, ICU team members should provide it during their first visit to the unit.
The results of this study show that in the environment of the neonatal intensive care unit, interpersonal factors have more influence on the stress level that parents manifest during their child’s hospital stay.
For most (60%) of parents interviewed in this study, the experience of having their child hospitalized in the NICU was not very stressful or not stressful, while for 25% of them it was only moderately stressful. However, for a total of 35% of parents, having their newborn child admitted to the NICU was reported as an extremely or very stressful event (Figure 1).
Figure 1. Stress level of parents of critically ill newborns hospitalized in the NICU (n = 45). NICU = neonatal intensive care unit
The Parent Stressors Scale: Unit Neonatal Intensive Care (PSS: NICU) is consistent. Using the concepts of extra- and interpersonal stressors from Neuman’s systems model in the PSS: NICU scale for the study of parental stress, can address and understand this problem in third level institutions.
One of the additional stressors that parents reported refers to the strict schedule of visits and the need for more information.