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Documente Profesional
Documente Cultură
Parents Responses to
Stress in the Neonatal
Intensive Care Unit
MORGAN BUSSE, RN, BSN
KAYLEIGH STROMGREN, RN, BSN
LAUREN THORNGATE, RN, CCRN, PhD
KAREN A. THOMAS, RN, PhD
BACKGROUND Parents stress resulting from hospitalization of their infant in the neonatal intensive care unit
(NICU) produces emotional and behavioral responses. The National Institutes of Healthsponsored Patient
Reported Outcomes Measurement Information System (PROMIS) offers a valid and efficient means of assessing
parents responses.
OBJECTIVE To examine the relationship of stress to anxiety, depression, fatigue, and sleep disruption among
parents of infants hospitalized in the NICU.
METHODS Thirty parents completed the Parental Stressor Scale (PSS:NICU) containing subscales for NICU
Sights and Sounds, Infant Behavior and Appearance, and Parental Role Alteration, and the PROMIS anxiety,
depression, fatigue, and sleep disturbance short-form instruments.
RESULTS PSS total score was significantly correlated with anxiety (r = 0.61), depression (r = 0.36), and sleep
disturbance (r = 0.60). Scores for NICU Sights and Sounds were not significantly correlated with parents outcomes; however, scores for Alteration in Parenting Role were correlated with all 4 outcomes, and scores for
Infant Appearance were correlated with all except fatigue.
CONCLUSION Stress experienced by parents of NICU infants is associated with a concerning constellation of
physical and emotional outcomes comprising anxiety, depression, fatigue, and sleep disruption. (Critical Care
Nurse. 2013;33[4]:52-60)
arental stress resulting from experiences with infants hospitalized in the neonatal
intensive care unit (NICU) is well documented.1-5 Stress emanating from the birth of
a premature or sick neonate has received considerable attention and is associated with
concurrent parental anxiety and depression.1,6-9 Less well studied is the relationship of
parental NICU stress to fatigue and sleep disruption. Lee and colleagues10,11 report high
CNE
This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:
1. Examine effects of parental stress
2. Discuss the use of the PROMIS instruments
3. Describe interventions to reduce parental stress
2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013715
52
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Notably the NICU experience is associated with longterm effects on parents emotions. Research suggests
parents responses are not limited to the period of hospitalization and that the NICU experience is associated
with disorders such as acute stress disorder and posttraumatic stress disorder (PTSD).20,21 In 1 study,22 15% of
mothers and 8% of fathers demonstrated evidence of
PTSD when evaluated 30 days after their infants NICU
admission. Mothers of preterm infants demonstrate significant stress reactions 6 months after the infants
expected due date,20 and in another study,1 mothers continued to experience distress and evidenced alterations
in parenting 24 months after the infants due date.
When compared with low-income mothers of healthy
infants, low-income NICU mothers demonstrated an
increased rate of acute stress disorder (3% vs 23%).23
Evidence suggests that emotional stress may not
abate over time and that parents are at risk for delayed
response.4,22-24 Further, the pattern of stress experienced
may differ for mothers and fathers. In a study of PTSD
occurrence after a parental NICU experience, measured
using the
Stanford
The NICU experience is associated with
Acute Stress long-term effects on parents emotions.
Reaction
Questionnaire, fathers had increased PTSD scores 4
months after their childs birth. In this same study,24
33% of fathers, compared with 9% of mothers, met criteria for diagnosis of PTSD.
Based on current knowledge, evaluation of parents
during infant NICU hospitalization is needed to assess
current responses to stress associated with the NICU
experience and to identify parents at risk for extended
physical and emotional consequences. Such clinical
evaluation requires instrumentation that is not only
psychometrically solid but also offers straightforward
administration and scoring and provides population
norms for comparison. An instrument that meets psychometric measurement requirements must be valid and
reliable. Instruments available from the Patient Reported
Outcomes Measurement Information System (PROMIS)
funded by the National Institutes of Health are valid,
reliable, and efficient and meet these requirements.25-27
The purpose of this study was to test the relationship between stress associated with hospitalization of an
infant in the NICU and parents responses. Parents
responses studied were anxiety, depression, fatigue, and
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sleep disruption as measured by using PROMIS instruments. Research questions included (1) What are the
relationships among parental sources of stress (infant
behavior and appearance, NICU sights and sounds, and
alteration of parental role)? (2) What are the relationships among parental responses to NICU stress (sleep
disturbance, fatigue, anxiety, and depression)? and
(3) What is the relationship of NICU parent stress
(infant behavior and appearance, NICU sights and
sounds, and alteration of parental role) to anxiety,
depression, fatigue, and sleep disruption?
54
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Table 1
Variable
Mean (SD)
Min, Max
Parents age, y
30
32.17 (7.49)
18, 44
29
24.66 (17.0)
4, 110
Parent
Mother
Father
22
8
73
27
Race, ethnicity
White
Hispanic
Asian
Native American
20
6
2
1
67
21
7
3
Procedure
87
Married/partnered
26
Investigators made biweekly rounds
Education
and approached eligible parents, using
7
<High school
2
an approved script, to elicit possible
34
High school
10
interest in the study. Parents were then
41
>High school
17
provided with a packet containing an
Distance from hospital, miles
13
0-10
4
information sheet describing the study,
27
8
11-20
study instruments, and an envelope to
10
3
21-30
17
31-40
5
be used in returning responses anony33
10
>50
mously to a drop box at the units front
Visits per week to neonatal
desk. The packet also contained a $5
intensive care unit
gift card for the hospital coffee shop.
3
1
0-2
17
5
3-5
Spanish-speaking parents were offered
80
24
>5
instruments in Spanish; approach and
Visits, hours per week
consent discussions occurred in Span3
1
0-5
ish provided by a Spanish-speaking
10
3
6-10
13
4
11-20
investigator. Official Spanish versions
10
3
21-30
of the PSS:NICU and PROMIS instru27
8
31-40
37
11
>40
ments, available from the PROMIS
website, were used26; other study mateGestational age, weeks
27
8
<28
rials were translated into Spanish by
67
20
28-36
a Spanish-speaking member of the
7
2
37-42
research team and back translated for
accuracy. For back translation, the
Spanish versions of the instruments
center. Most parent respondents (n = 24, 80%) reported
were translated into English and this English version was
coming to the NICU more than 5 times per week and
then compared with the original English text.
spending more than 30 hours per week (n = 19, 63%)
with their infant. Thirteen respondents (43%) had 1 or
Results
more children at home (range, 1-6 other children). The
Demographic characteristics describing the 30 parmajority of infants were 28 to 36 weeks gestation at
ents who participated in the project are provided in
birth (n = 20, 67%; mean 30.2 weeks), hospitalized from
Table 1. Four respondents chose to complete the survey
4 to 110 days (mean [SD], 24.7 [17]), and born by
in Spanish. The sample was predominantly married or
cesarean birth (n = 20, 67%).
partnered (n = 26, 87%), white, and educated (n = 27,
Instrument reliability, determined by using Cron76% high school or higher level of education). A third of
bach , was as follows for the PROMIS scales: Sleep
the sample lived more than 50 miles from the medical
Disturbance, 0.90; Fatigue, 0.88; Anxiety, 0.89; and
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Table 2
Descriptive data and correlation of Patient-Reported Outcomes Measurement Information System (PROMIS)
and Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU; N = 30)
Descriptive statistics
PROMIS (raw scores)
Min, max
Depression
Fatigue
Sleep disturbance
21.96 (4.97)
12, 32
0.74b
0.43c
0.51b
Depression
17.77 (6.92)
8, 33
0.42c
0.45c
Fatigue
20.80 (6.18)
10, 34
0.44c
Sleep Disturbance
27.17 (6.26)
16, 40
2.37 (0.81)
1.00, 3.83
Infant Appearance
3.09 (0.88)
1.5, 4.5
Role
3.25 (0.99)
1.13, 5.0
Total Stress
3.01 (0.83)
1.29, 4.29
Anxietya
Mean (SD)
PSS: NICU
an
bP
cP
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Infant appearance
Parent role
0.38
0.62b
0.60b
0.16
0.37c
0.39c
0.14
0.26
0.37c
0.30
0.60b
0.60b
0.72b
0.72b
0.82b
80
70
T score
60
50
40
Discussion
30
Anxiety
Fatigue
Depression
Sleep
Disturbance
Figure Boxplot of parents Patient-Reported Outcomes Measurement Information System (PROMIS) T scores evaluated
against general populations scores. Median = line within box,
interquartile range = shaded box, vertical lines = minimum
and maximum. Population horizontal lines, mean = 50 (solid
horizontal line) and mean plus 1 SD (60, dotted line) and
mean plus 2 SDs (70, dashed line).
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Table 3
>1 SD
Anxiety
15 (56)
3 (11)
8 (27)
2 (7)
Fatigue
12 (40)
3 (10)
Sleep Disturbance
11 (37)
1 (3)
Depression
>2 SD
Limitations
1,6-11
58
CriticalCareNurse
Conclusion
In conclusion, stress experienced by parents whose
infant is hospitalized in the NICU is strongly correlated
with anxiety, fatigue, depression, and sleep disruption.
Knowledge of these relationships can be used to guide
family-focused nursing care in the NICU. CCN
Acknowledgment
The authors appreciate support and guidance provided by the NICU nursing
local practice council.
Financial Disclosures
This work was supported by Pacific Northwest Association of Neonatal Nurses:
P30 NR011400 (Thomas) and F31-NR011365 (Thorngate) awarded by the
National Institute for Nursing Research.
Now that youve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article
you want to comment on. In the full-text or PDF view of the article, click
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CNE Test Test ID C1343: Parents Responses to Stress in the Neonatal Intensive Care Unit
Learning objectives: 1. Examine effects of parental stress 2. Discuss the use of the PROMIS instruments 3. Describe interventions to reduce parental stress
1. Which of the following is a disadvantage of using the Patient Reported Outcomes Measurement Information System (PROMIS) to assess parents responses?
a. Complicated scoring procedures that lead to difficulty in interpreting the data
b. High licensure fees that are required for use of the instrument
c. Lack of clinical cut-off scores to determine when interventions are needed
d. Complex administration procedures that require lengthy training
3. Limitations of the study include a limited sample size and which of the
following?
a. Only one parent per infant provided data
b. The study setting included several different types of units
c. Only one cultural background was represented in the study
d. The majority of the participants were parents of infants experiencing
life-threatening conditions
9. According to the study, having other children in the family was correlated
with which of the following?
a. Anxiety
b. Sleep disturbance
c. Depression
d. Fatigue
10. The authors suggest that the PROMIS instruments could be used
clinically to do which of the following?
a. Identify infants who may benefit from limitation of visitors
b. Evaluate the infants response to the sights and sounds of the neonatal
intensive care unit environment
c. Determine which infants should have private rooms
d. Identify parents who should receive referrals for interventions
11. Which of the following are suggested interventions to decrease
parental anxiety?
a. Allowing unlimited visiting hours for parents and siblings
b. Providing explanations that are geared toward parental comprehension
c. Encouraging parents to stay at the infants bedside throughout the night
d. Focusing on positive information and limiting discussion of negative outcomes
6. According to the study, increased fatigue was associated with which of the
following?
a. Having other children in the family
b. Shorter distance from the medical center
c. Infant gestational age
d. Length of hospital stay
12. Which of the following groups has the highest incidence of acute stress
disorder after having an infant hospitalized in a neonatal intensive care unit?
a. White mothers
b. Low-income mothers
c. Hispanic fathers
d. Unmarried parents
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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Synergy CERP Category B Test writer: Jodi Berndt, MSN, RN, CCRN, PCCN, CNE
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