Measuring neonatal intensive care unit-related parental stress

AIMS: This paper reports a study: (1) to determine the validity and reliability of the Parent Stressor Scale:Neonatal Intensive Care Unit (PSS:NICU) for use with United Kingdom (UK) parents; (2) compare UK scores with those from a contemporary reference sample from the United States (US), (3) to identify the sources of greatest NICU-related stressors for parents and (4) to identify demographic or situational factors influencing NICU-related parental stress. BACKGROUND: Evaluation of the adequacy of nursing care and psychosocial support services for parents of ill infants in the NICU requires valid and reliable measures of parental stress. The PSS:NICU is a well-validated scale developed in the US to measure NICU-related parental stress. However, it has not been tested in the UK. METHODS: Consecutive samples of parents (n = 257) of infants in nine UK NICUs and two reference US units completed the PSS:NICU and the Spielberger State-Trait Anxiety Scale approximately 1 week after admission. Psychometric properties of the PSS:NICU, including internal consistency reliability and construct, concurrent and predictive validity, were evaluated. RESULTS: PSS:NICU scores were similar in the UK and US samples and high internal consistency reliability was found for all metrics (e.g. Overall Stress: 0.94 for both samples). A three-factor principal components solution accounted for 66% of the variance in the scores, with the items grouped into the three a priori scales specified in the PSS:NICU (Infant Behaviour and Appearance, Parental Role Alterations, and Sights and Sounds). Stress Occurrence and Overall Stress were moderately correlated with State Anxiety in both samples (r = 0.46-0.61, P < 0.001). Thirty-one per cent of the variance in Stress Occurrence in the UK sample was explained by State Anxiety, infant severity of illness score, parent gender, and less frequent visitation. CONCLUSIONS: The PSS:NICU demonstrated appropriate psychometrics in a large sample of parents from diverse NICUs in the UK. These findings support its wider use in research and clinical practice to identify parental distress and evaluate the effectiveness of nursing care and psychosocial support services for parents.     

The neonatal intensive care unit environment: sources of stress for parents

Many aspects of neonatal intensive care units (NICUs) are stressful to parents, including prolonged hospitalization, alterations in parenting, exposure to a technical environment, and the appearance of their small, fragile infant. To identify potential NICU stressors for parents, levels of stress these experiences engender, and their relationship to anxiety, parents of infants hospitalized in three NICUs were interviewed using the Parental Stressor Scale: NICU and the State-Trait Anxiety Inventory. Alterations in parental role caused by the infant's illness generated the greatest stress. The second highest areas of stress were the infant's appearance and behavior. State anxiety levels were higher than normative means and significantly related to stress scores.     

Parental perspectives on technology use to enhance communication and closeness during the COVID-19 parental presence restrictions

ObjectiveTo explore parental perspectives on the use of technology in neonatal intensive care units (NICU), and its impact during COVID-19 parental presence restrictions.MethodsCo-designed online survey targeting parents of infants admitted to a Canadian NICU from March 1st, 2020 until March 5th, 2021.ResultsParents (n = 117) completed the survey from 38 NICUs. Large variation in policies regarding parental permission to use technology across sites was reported. Restrictive use of technology was reported as a source of parental stress. While families felt that technology helped them feel close to their infant when they could not be in the NICU, it did not replace being in-person.ConclusionLarge variation in policies were reported. Despite concerns about devices in NICUs, evidence on how to mitigate these concerns exists. Benefits of using technology to enhance parental experiences appear substantial. Future study is needed to inform recommendations on technology use in the NICU.     

A nurse practitioner model of practice in the neonatal intensive care unit

PURPOSE: The purpose of this study was to describe the practice of the nurse practitioner (NP) in the neonatal intensive care unit (NICU) in an attempt to define an advanced practice nursing model that is unique to NP practice in the NICU. DESIGN: This qualitative research used an ethnographic case study design to answer the research question: 'What is the practice model of nurse practitioners working in the NICU?' METHODS: Seven nurse practitioners working in five level II/III NICUs in Massachusetts and Rhode Island were interviewed and observed in practice. Audiotaped interviews using open-ended questions and field notes from participant observations were analyzed for patterns of behavior. RESULTS: These nurse practitioners practiced within a model of advanced practice nursing that emphasized health, holism, and caring within the highly technological and medical NICU environment. CLINICAL IMPLICATIONS: A model of NP practice in the NICU is emerging and needs further development and testing. Nurse educators and administrators must find ways to support the nursing model in the advanced practice nursing role in the NICU. Nurse practitioners need to be more active in promoting a clearer understanding of their practice and contributions to the NICU care delivery team.     

Content Validation of Parental Role Conflict in the Neonatal Intensive Care Unit

PURPOSE. To validate the content of the nursing diagnosis parental role conflict made by neonatal intensive care (NICU) nurses and researchers in the field and to identify the related major and minor defining characteristics.METHOD. Fehring's Diagnostic Content Validation model using 59 neonatal specialists.FINDINGS. Nineteen defining characteristics were validated for use in NICUs: four were considered major and 15 as minor. There was no correlation between nurse profiles and defining characteristic scores.CONCLUSIONS. In this study, parental role conflict was validated for use in neonatal units but defining characteristics must be described in a clearer and more objective manner.NURSING IMPLICATIONS. Validation studies in different healthcare settings are required so that the specificities of each clientele are met. NANDA diagnoses must be tested and validated at neonatal units, because this setting has developed few studies and their use in practice is a potential way to improve nursing care.     

Nurses' beliefs and values about doing cue-based care in an NICU in Taiwan

Although advances in medical technology have increased the survival rate of preterm infants, science is no cure-all for these high-risk patients. A growing number of studies report that caregiving interventions cause physiological and behavioral distress in such infants. The results have prompted changes in caregiving practices, attempting to reduce stress and strengthen protection for the infants, in order to promote their stability and development in the neonatal intensive care unit (NICU) . This study uses qualitative research methods to grasp the richness and diversity of nurses' beliefs and experience in the taking care of preterm infants. Ten groups of questions explore how NICU nurses take care of premature infants, nurses' perspectives on cue-based care, and the extent to which NICU nurses practice cue-based care. The results generated three themes: (1) timely and skillful management of the preterm infants; (2) compassionate and holistic care for the infants and their highly stressed families; and (3) the relationship between good nursing care and meeting the needs of preterm infants, families, physicians, units, and the environment. It is apparent that the approach to care delivery in NICU practice is still clinical-based, and that there are some obstacles to the delivery of cue-based care. The reasons for this include lack of knowledge, incomplete collaboration with team members, and insufficient support from the administrative systems. To improve the quality of nursing care and preterm infant outcomes, it will be necessary to educate NICU nurses on cue-based care, to enhance collaboration among all team members, to reduce their non-nursing workload, and to re-design NICUs for optimal cue-based care.     

Parents' perceptions of their infant's pain experience in the NICU

Despite numerous advances in the recognition, assessment, and management of pain in neonates over the past two decades, there has been limited improvement in the knowledge base regarding parental responses to their infant's pain. This study examined parents' views of their experiences observing and coping with their infant's pain in the neonatal intensive care unit (NICU). Twelve participants were recruited using purposive sampling from two groups: (a) parents who had infants currently receiving care in the NICU (n=6); and (b) parents whose infants had been discharged from the NICU and were enrolled in the outpatient follow-up clinic at each hospital (n=6). An exploratory, semi-structured format was used to interview parents individually (n=5) or in focus groups (n=7) regarding their infant's clinical course, infant pain experiences, and the parenting experience during and after the NICU stay. Thematic content analysis was used to develop conceptual categories. Two broad themes were identified: (a) infant pain as a source of parental distress and (b) relief of parental distress due to infant's pain.     

新生儿重症监护室中家庭参与式护理实践及建议的质性研究

目的 深入了解家庭参与式护理在新生儿重症监护室的实践情况,探讨目前家庭参与式护理实践的挑战及建议,为扩大其开展范围提供参考。方法 于2021年5—6月采用半结构式电话访谈,选取我国9个省市已开展家庭参与式护理的医院中9名新生儿重症监护室护理管理者进行访谈,运用主题框架分析法对所得资料进行分析。结果 提炼出3个一级主题,9个二级主题：新生儿重症监护室家庭参与式护理的实践重点（医护人员资质与认知、家长参与积极性与舒适性、项目安全性与实践效果）;实践挑战（实践与收费标准缺位、硬件设施与人力资源有限、家长认知差异大且参与度不足）;实践建议（规范服务过程与服务内容、设置收费项目并改善病房环境、组建多学科团队并设专人岗位）。结论 家庭参与式护理目前存在政策、环境、人力等方面的诸多挑战,实践仍有提升空间。应在相对充足的资源支持下积极完善各实施环节,制定实践规范以促进家庭参与式护理的推广。     

Measuring nursing workload in neonatal intensive care

AIM: To determine if a suitable method of measuring nursing workload could be developed in neonatal intensive care units (NICUs). BACKGROUND: Nursing is a multifunctioning activity and previous methods measuring the demand for nurses do not put enough emphasis on the individual capabilities. The reporting of NICU activity has traditionally been related to bed occupancy and the number of infants requiring ventilator support. A classification system based on activity, hours of care and nursing staff ratios has been used; however, it does not consider the clinical ability of the individual nurses. METHODS: A 5-month prospective study was undertaken in which nurses in two NICUs scored their patients' level of dependency and professional assessment of the level of intensity of care required by the infants in each shift. In addition, serial measures of severity of illness scores for each patient were collected. KEY ISSUES: The study identified methods of measuring workload that consider the individual nurse's ability and contributing organizational factors. We found that the estimates of nursing hours using the two traditional dependency measures did not match the current practice or take into account the skill of the nurses. A method in which the nurses indicated the intensity of nursing care required by their patients was suitable one for capturing their individual capabilities. System factors were also found to contribute to the nursing workload. CONCLUSIONS: It is not sufficient to use patient acuity or severity of illness alone. Other factors such as the nurse's assessment of the intensity of care required and the organizational factors are important components of workload estimates.     

Addressing the Needs of Mothers with Infants in the Neonatal Intensive Care Unit: A Qualitative Secondary Analysis

PurposeMothers of infants hospitalized in neonatal intensive care units (NICUs) need to be recognized as essential partners of the care team as their presence and involvement are key to infants' health and developmental outcomes. Addressing mothers' perceived needs is beneficial for the improvement of supportive nursing care; however, little qualitative research on their unmet needs has been conducted in South Korea. This study assessed mothers' perspectives on their NICU experiences and their unmet needs within the South Korean cultural context.MethodA cross-sectional, multicentered, secondary analysis study was conducted using the written responses to an open-ended questionnaire. Of the 344 NICU-experienced mothers, 232 throughout South Korea (seven cities and five provinces) voluntarily completed the questionnaire via smartphone-based or web-based surveys. Their narrative responses were analyzed using thematic content analysis guided by the critical incident technique.ResultsFour themes emerged. NICU-experienced mothers of preterm infants referred to the “family-friendly environment” (16.4%) as a positive experience. The greatest unmet need was “relationship-based support” (58.2%), followed by “information and education-based support” (20.0%) and “system-level challenges” (5.4%).ConclusionThe importance of creating a family-friendly NICU environment should be emphasized by ensuring 24-hour unrestricted access and encouraging active parental involvement in infant care, as well as actively supporting NICU families through supportive words and actions. The assurance of antiinfection management and better staffing levels should be fundamentally guaranteed to NICU staff.     

Impact of NICU design on environmental noise

For neonates requiring intensive care, the optimal sound environment is uncertain. Minimal disruptions from medical staff create quieter environments for sleep, but limit language exposure necessary for proper language development. There are two models of neonatal intensive care units (NICUs): open-bay, in which 6-to-10 infants are cared for in a single large room; and single-room, in which neonates are housed in private, individual hospital rooms. We compared the acoustic environments in the two NICU models. We extracted the audio tracks from video-electroencephalography (EEG) monitoring studies from neonates in an open-bay NICU and compared the acoustic environment to that recorded from neonates in a new single-room NICU. From each NICU, 18 term infants were studied (total N = 36; mean gestational age 39.3 ± 1.9 weeks). Neither z-scores of the sound level variance (0.088 ± 0.03 vs. 0.083 ± 0.03, p = 0.7), nor percent time with peak sound variance (above 2 standard deviations; 3.6% vs. 3.8%, p = 0.6) were different. However, time below 0.05 standard deviations was higher in the single-room NICU (76% vs. 70%, p = 0.02). We provide objective evidence that single-room NICUs have equal sound peaks and overall noise level variability compared with open-bay units, but the former may offer significantly more time at lower noise levels.     

Noise and sleep disturbance factors before and after implementation of a behavioural modification programme.

The purpose of this study was to examine sleep disturbance factors documented by the personnel and recorded noise level during two weeks before (measurement one M1) and after (measurement two M2) the implementation of a behavioural modification programme. The behavioural modification programme included non-disturbance periods on a neurointensive care unit (NICU) in a University hospital. Sleep disturbance factors were identified as general and specific nursing care, and medical treatment documented over fourteen 24-h periods. Minimum, maximum and peak mean noise levels in dBA were recorded continuously during fourteen 24-h periods by a decibel meter. The behavioural modified programme included changing nursing and medical routines and the introduction of afternoon and night non-disturbance periods. The most disturbing documented factors at both M1 and M2 were general nursing care activities. Noise levels showed great variation at both M1 and M2. At M2 minimum and maximum noise levels varied when compared to M1. Implementation of a behavioural modification programme and non-disturbance periods co-ordinated routines resulted in reduced sleep disturbance factors and partly reduced noise levels on the NICU. Changes of the physical care/working environment, preparations before non-disturbance periods, regular evaluations of routines and education are needed to improve sleep on NICUs.     

Transition to home from the newborn intensive care unit: applying the principles of family-centered care to the discharge process

Increasingly newborn intensive care units (NICUs) are embracing family-centered care principles. Family-centered newborn intensive care requires that families are welcomed as partners in caregiving and decision making. Traditionally, discharge planning has been done without significant family involvement. In fact, parent participation in caregiving may still be limited until discharge is imminent. By increasing parental involvement in caregiving throughout hospitalization and working with families to facilitate the discharge process, parents may emerge from the NICU experience with increased competence and confidence in infant caregiving. This article reviews common discharge practices and processes in the NICU and offers strategies to assist nurses in integrating a family-centered approach into discharge planning.     

Effect of nursing interventions on stressors of parents of premature infants in neonatal intensive care unit

Aim. This study was planned for the purpose of determining the effect of stress‐reducing nursing interventions on the stress levels of mothers and fathers of premature infants in a Neonatal Intensive Care Unit (NICU). Design. Randomised intervention. Background. The physical and psychosocial environment of the NICU is a major factor in the stress experienced by the family. Method. Interviews were conducted with the parents of premature infants who agreed to participate in the research. An approximately 30‐minute educational programme about their infant and the intensive care unit was held for the mothers and fathers in the intervention group within the first week after their infant was admitted to the intensive care unit. Then they were introduced to the unit and personnel. They were given the information they requested and their questions were responded to. The parents in the control group received nothing in addition to the routine unit procedures. The mothers and fathers’ stress scores were measured for both groups after their infants’ 10th day in the NICU with the Parental Stress Scale: NICU (PSS:NICU). Results. The difference between the intervention group and the control group mothers’ mean stress score was found to be statistically significant (t = 4·05, p < 0·05). It was determined that the stress scores for the fathers in the treatment group in this research were lower, but the difference between the two groups was not found to be statistically significant (p > 0·05). Conclusion. It has been determined that parents experience very high stress levels when their infants are admitted to an NICU and that there are nursing interventions which can be implemented to decrease their levels of stress. Relevance to clinical practice. Determining the sources of stress experienced by parents can help NICU nurses use appropriate interventions in cooperation with other members of the team to decrease the stress that parents experience.