Parents Responses to Stress in the Neonatal Intensive Care Unit

Parental stress resulting from experiences with infants hospitalized in the neonatalintensive care unit (NICU) is well documented.1-5 Stress emanating from the birth ofa premature or sick neonate has received considerable attention and is associated withconcurrent parental anxiety and depression.1,6-9 Less well studied is the relationship ofparental NICU stress to fatigue and sleep disruption. Lee and colleagues10,11 report high

Parents Responses toStress in the NeonatalIntensive Care UnitMORGAN BUSSE, RN, BSNKAYLEIGH STROMGREN, RN, BSNLAUREN THORNGATE, RN, CCRN, PhDKAREN A. THOMAS, RN, PhD

Neonatal Care

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 PatientReported Outcomes Measurement Information System (PROMIS) offers a valid and efficient means of assessingparents responses.OBJECTIVE To examine the relationship of stress to anxiety, depression, fatigue, and sleep disruption amongparents of infants hospitalized in the NICU.METHODS Thirty parents completed the Parental Stressor Scale (PSS:NICU) containing subscales for NICUSights 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 sleepdisturbance (r = 0.60). Scores for NICU Sights and Sounds were not significantly correlated with parents out-comes; however, scores for Alteration in Parenting Role were correlated with all 4 outcomes, and scores forInfant Appearance were correlated with all except fatigue.CONCLUSION Stress experienced by parents of NICU infants is associated with a concerning constellation ofphysical and emotional outcomes comprising anxiety, depression, fatigue, and sleep disruption. (Critical CareNurse. 2013;33[4]:52-60)

2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013715

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 stress2. Discuss the use of the PROMIS instruments 3. Describe interventions to reduce parental stress

CNE Continuing Nursing Education

52 CriticalCareNurse Vol 33, No. 4, AUGUST 2013 www.ccnonline.org

rates of sleep disturbance, including average sleepduration less than 7 hours per night, in mothers ofinfants hospitalized in the NICU, as well as elevatedfatigue and reduced well-being. The National SleepFoundation12 cites 7 to 8 hours per night as the basicsleep need in adults. Sleep is a particular concern giventhe prevalence of postpartum sleep problems (57.7%)and the complex relationship between postpartumsleep and depression.13

Parental stress emanating from the NICU experienceis important, potentially influencing parenting behavioras well as producing long-term emotional problems andhealth alteration. Early work by Miles and Holditch-Davis14

provides a model of pathways influencing parentalresponses and parenting of premature infants. Parentsstress, anxiety, depression, and fatigue alter parentingbehavior and perception of parental competence, parent-infant interaction, and ultimately infant outcomes suchas cognitive development, emotional regulation, andhealth.4,15-19 Miles et al7 identified increased odds of depres-sion related to parental role alteration and worry aboutchild health among NICU parents. In this same study,although depression declined over time after the infantsdischarge from the NICU, 13% of mothers remaineddepressed 27 months following birth and individualtrajectories were noted. In work by Holditch-Davis andcolleagues,1 individual patterns of maternal distress fol-lowing the birth of a premature infant did not consistentlydecline over time, and distinct groups of mothers haddiffering trajectories of distress and subsequent effects onparenting. Combined, these findings not only documentstress experienced by parents of NICU infants but alsohighlight emotional consequences and the individualnature of parents response to the NICU experience.

Notably the NICU experience is associated with long-term effects on parents emotions. Research suggestsparents responses are not limited to the period of hos-pitalization and that the NICU experience is associatedwith disorders such as acute stress disorder and post-traumatic stress disorder (PTSD).20,21 In 1 study,22 15% ofmothers and 8% of fathers demonstrated evidence ofPTSD when evaluated 30 days after their infants NICUadmission. Mothers of preterm infants demonstrate sig-nificant stress reactions 6 months after the infantsexpected due date,20 and in another study,1 mothers con-tinued to experience distress and evidenced alterationsin parenting 24 months after the infants due date.When compared with low-income mothers of healthyinfants, low-income NICU mothers demonstrated anincreased rate of acute stress disorder (3% vs 23%).23

Evidence suggests that emotional stress may notabate over time and that parents are at risk for delayedresponse.4,22-24 Further, the pattern of stress experiencedmay differ for mothers and fathers. In a study of PTSDoccurrence after a parental NICU experience, measuredusing theStanfordAcute StressReactionQuestionnaire, fathers had increased PTSD scores 4months after their childs birth. In this same study,24

33% of fathers, compared with 9% of mothers, met cri-teria for diagnosis of PTSD.

Based on current knowledge, evaluation of parentsduring infant NICU hospitalization is needed to assesscurrent responses to stress associated with the NICUexperience and to identify parents at risk for extendedphysical and emotional consequences. Such clinicalevaluation requires instrumentation that is not onlypsychometrically solid but also offers straightforwardadministration and scoring and provides populationnorms for comparison. An instrument that meets psy-chometric measurement requirements must be valid andreliable. Instruments available from the Patient ReportedOutcomes 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 relation-ship between stress associated with hospitalization of aninfant in the NICU and parents responses. Parentsresponses studied were anxiety, depression, fatigue, and

AuthorsMorgan Busse is a staff nurse in a maternal-infant unit at Group HealthCooperative in Seattle, Washington.

Kayleigh Stromgren is a staff nurse in neonatal intensive care at Univer-sity of Washington Medical Center in Seattle.

Lauren Thorngate is a postdoctoral fellow in Biomedical and HealthInformatics at the University of Washington School of Medicine, Seattle.

Karen Thomas is a professor in the Department of Family and ChildNursing at the University of Washington.Corresponding author: Karen A. Thomas, Professor, Department of Family and ChildNursing, Box 357262, University of Washington, Seattle, WA (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia,Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

www.ccnonline.org CriticalCareNurse Vol 33, No. 4, AUGUST 2013 53

The NICU experience is associated withlong-term effects on parents emotions.

sleep disruption as measured by using PROMIS instru-ments. Research questions included (1) What are therelationships among parental sources of stress (infantbehavior and appearance, NICU sights and sounds, andalteration of parental role)? (2) What are the relation-ships among parental responses to NICU stress (sleepdisturbance, fatigue, anxiety, and depression)? and (3) What is the relationship of NICU parent stress(infant behavior and appearance, NICU sights andsounds, and alteration of parental role) to anxiety,depression, fatigue, and sleep disruption?

Materials and MethodsDesign and Subjects

Data were collected in a 32-bed, level III NICU usingan exploratory design. The study was approved by theUniversity of Washingtons institutional review board.Parents who were at least 18 years old, literate in Eng-lish or Spanish, and whose infant was hospitalized inthe unit were invited to participate. Parents of infantsconsidered in medical crisis (ie, life-threatening circum-stance) per determination of the charge nurse were notapproached for participation. These parents were excludedto avoid unnecessary burden during a particularly chal-lenging time.

InstrumentsParental Stressor Scale. Sources of parents

stress were measured by using the Parental StressorScale: Neonatal Intensive Care Unit (PSS:NICU, 2002), awell-established self-report survey in which parents ratedsources of stress by using a Likert scale (1 = not at allstressful, 5 = extremely stressful) within 3 domains: InfantBehavior and Appearance (17 items), Sights and Sounds

(6 items),andParentalRole Alter-ations (11

items).28 Parents were asked to mark only those eventsthey had experienced or that were relevant to theirNICU stay per standard administration protocol. Con-struct validity of the PSS:NICU has been demonstratedthrough correlation with measures of state anxiety (r =0.46-0.61, P < .001).5 Internal consistency of thePSS:NICU is reported as greater than 0.70 for all

domain scales and equal to 0.89 to 0.90 for the entireinstrument.28 Mean scores were calculated within domains.

PROMIS. The PROMIS was developed by a consor-tium of investigators working at 12 primary researchsites across the country to provide unified, efficient, reli-able, and valid measures of self-reported health for useby clinicians and researchers.26 PROMIS instrumentsassess self-reported health in 3 primary areas and 7 sub-domains: Physical Healthsymptoms, function; MentalHealthaffect, behavior, cognition; and Social Healthrelationship, function.26 PROMIS instruments are avail-able for online use or as printed hard copy and includeshort-form or computerized adaptive tests. Althoughmost current PROMIS instruments are designed foradults, a number are available for pediatric applicationsand a number of instruments have been translated fornonEnglish-speaking respondents. The PROMIS short-form instruments range from 4 to 10 items and cover awide range of outcomes such as cognition, pain, emo-tional distress, physical function, sexual function, socialrole participation, and illness impact. The followingPROMIS short forms were used to quantify health out-comes: Sleep-Disturbance (8 items), Fatigue (7 items),Anxiety (7 items), and Depression (8 items). Develop-ment of the PROMIS instruments, along with validityand reliability testing, has been reported.25,27,29-31

PROMIS measures have been tested extensively inlarge diverse samples drawn from the general populationand clinical groups, and validity has been demonstratedby correlation with well-standardized measures.25,32

Results of such testing follow: PROMIS depression testbank items correlation with the Center for Epidemiologi-cal Studies-Depression, r=0.83 (n=782); PROMIS anxi-ety test bank items correlation with the Mood andAnxiety Symptom Questionnaire, r=0.80 (n=788);PROMIS sleep disturbance test bank items correlationwith the Pittsburgh Sleep Quality Index, r=0.85 (n=2252); short form PROMIS fatigue scale correlation withthe FACIT-Fatigue Scale, r=0.91 (n=9047). Responsesfor each PROMIS measure were summed to form a rawscore and converted to a T score (standardized score)using tables available through the PROMIS website. Forall PROMIS instrument T scores, the population meanwas 50 and standard deviation was 10. Thus a T score of60 indicates a score 1 standard deviation about the pop-ulation mean.


Stress experienced by parents whose infantis hospitalized in the NICU is strongly correlated with anxiety, fatigue, depression,and sleep disruption.

Demographic Survey. Respon-dents provided information abouttheir infants birth and health status,age, marital status, ethnicity and race,education, occupation, residence dis-tance from the NICU, time spent withthe infant, and family members. Fur-ther, parents added comments in anopen-ended portion of the demo-graphic survey.

ProcedureInvestigators made biweekly rounds

and approached eligible parents, usingan approved script, to elicit possibleinterest in the study. Parents were thenprovided with a packet containing aninformation sheet describing the study,study instruments, and an envelope tobe used in returning responses anony-mously to a drop box at the units frontdesk. The packet also contained a $5gift card for the hospital coffee shop.Spanish-speaking parents were offeredinstruments in Spanish; approach andconsent discussions occurred in Span-ish provided by a Spanish-speakinginvestigator. Official Spanish versionsof the PSS:NICU and PROMIS instru-ments, available from the PROMISwebsite, were used26; other study mate-rials were translated into Spanish bya Spanish-speaking member of theresearch team and back translated foraccuracy. For back translation, theSpanish versions of the instrumentswere translated into English and this English version wasthen compared with the original English text.

ResultsDemographic characteristics describing the 30 par-

ents who participated in the project are provided inTable 1. Four respondents chose to complete the surveyin Spanish. The sample was predominantly married orpartnered (n = 26, 87%), white, and educated (n = 27,76% high school or higher level of education). A third ofthe sample lived more than 50 miles from the medical

center. Most parent respondents (n = 24, 80%) reportedcoming to the NICU more than 5 times per week andspending more than 30 hours per week (n = 19, 63%)with their infant. Thirteen respondents (43%) had 1 ormore children at home (range, 1-6 other children). Themajority of infants were 28 to 36 weeks gestation atbirth (n = 20, 67%; mean 30.2 weeks), hospitalized from4 to 110 days (mean [SD], 24.7 [17]), and born bycesarean birth (n = 20, 67%).

Instrument reliability, determined by using Cron-bach , was as follows for the PROMIS scales: SleepDisturbance, 0.90; Fatigue, 0.88; Anxiety, 0.89; and

Table 1 Demographic characteristics of the 30 parents who participated in the study

Variable

Parents age, y

Time in unit, days

ParentMotherFather

Race, ethnicityWhiteHispanicAsianNative American

Married/partnered

EducationHigh school

Distance from hospital, miles0-1011-2021-3031-40>50

Visits per week to neonatalintensive care unit0-23-5>5

Visits, hours per week0-56-1011-2021-3031-40>40

Gestational age, weeks

Depression, 0.89. PSS:NICU subscale reliability wasSights and Sounds, 0.74; Infant Behavior and Appear-ance, 0.86; Parental Role Alterations, 0.85. Note thatreliability for the PSS was calculated by using codingmetric 2 (not applicable coded as 1; represents theoverall stress level related to the NICU environment) asdescribed by the tools author.28

The relationships among sample characteristics,PROMIS scores, and the PSS:NICU scores were assessedby using correlation. The convenience sample of 30 pro-vided power of 90% to detect a large effect size (r =0.50)at a .05 significance level. The analysis was focused on

large effect size andresultant ability toexplain a large pro-portion of variance,which increases the

clinical significance of findings. Before addressing theresearch questions, the correlations between samplecharacteristics, PROMIS scores, and PSS:NICU scoreswere evaluated. Correlations of responding parents age,education, language, length of hospitalization, andinfant gestational age did not correlate significantly withPSS:NICU or PROMIS scores. Fatigue was correlated withsample characteristics as follows: increased fatigue wasassociated with shorter distance from the medical center(r=-0.42, P=.02), increased number of trips to the unit(r=0.41, P=.02), and increased hours spent in the unit

(r=0.42, P=.02). Having other children in the family wascorrelated with anxiety (r = 0.44, P = .02) but not withany other outcome variable. A total of 22 mothers (73%)and 8 fathers (27%) completed the instruments.

Descriptive information for study variables and thecorrelation structure among scores on the Anxiety, Depres-sion, Fatigue, Sleep Disturbance, and Parent Stress are pro-vided in Table 2. The relationships among parental sourcesof stress (research question 1) are shown in the correla-tions among the scores on the PSS:NICU subscales. Alter-ation in parenting role was the largest source of parentalstress (mean score, 3.25; SD, 0.99; Table 2) whereas sightsand sounds of the NICU ranked lowest as a source of stress(mean score, 2.37; SD, 0.81). Scores for all of the PSS:NICUsubscales (Infant Behavior and Appearance, NICU Sightsand Sounds, and Parental Role Alterations) are signifi-cantly correlated (r=0.72-0.94). The second research ques-tion focuses on the relationships among parents responsesto NICU stress. Parents reported experiences of anxiety,depression, fatigue, and sleep disturbance (Table 2, seeFigure). Significant correlation was found among scores onall of the PROMIS scales (Sleep Disturbance, Depres-sion, Anxiety, Fatigue; r=0.42-0.74).

The correlations between the PSS:NICU and PROMISscales were examined to answer the third research ques-tion, the relationship between parents stress and parentsresponses. Although scores for NICU Sights and Soundswere not significantly correlated with parents outcomes,


Descriptive statistics PROMIS subscale correlation (r)

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)

a n = 27, all other scales n = 30.b P < .01.c P .05.

PROMIS (raw scores)

Anxietya

Depression

Fatigue

Sleep Disturbance

PSS: NICU

Sights and Sounds

Infant Appearance

Role

Total Stress

Mean (SD)

21.96 (4.97)

17.77 (6.92)

20.80 (6.18)

27.17 (6.26)

2.37 (0.81)

3.09 (0.88)

3.25 (0.99)

3.01 (0.83)

Min, max

12, 32

8, 33

10, 34

16, 40

1.00, 3.83

1.5, 4.5

1.13, 5.0

1.29, 4.29

Depression

0.74b

Fatigue

0.43c

0.42c

Sleep disturbance

0.51b

0.45c

0.44c

Parents anxiety is clearly evident,with the entire sample above thepopulation mean.

scores on Infant Behavior and Appearance, Parental RoleAlterations, and total score were significantly correlatedwith anxiety, depression, and sleep disturbance, and

score on Parental Role Alterationswas significantly related to fatigue(Table 2).

Parents PROMIS raw scores wereconverted into T scores by using thetable of published values32 and plot-ted to illustrate anxiety, depression,fatigue, and sleep disturbance com-pared with national values (see Figure).Population T scores are centered witha mean of 50 and standard deviation(SD) of 10 (ie, mean + 1 SD = 60;mean + 2 SDs = 70). Sample medianscores for the Anxiety, Depression,Fatigue, and Sleep Disturbance scalesall exceeded the population mean.Parents anxiety is clearly evident,with the entire sample above thepopulation mean. The frequency

(and percentage) of subjects with PROMIS T scoresgreater than 1 and 2 SDs above the population are pro-vided in Table 3. The distribution of parents responseswas further explored by using cluster analysis, a type ofexploratory analysis that identifies groups within asample that show similar characteristics. When clusteranalysis was used, the parents fell into 2 groups differen-tiated by high (n = 16) and low (n = 14) T scores fordepression, anxiety, fatigue, and sleep disturbance. Incluster analysis, the metric distance measures the dis-similarity between groups. The distance between theabove 2 clusters of parents was 19.52.

DiscussionThe philosophy of family-centered care in the NICU

hinges on parents involvement in care and support forparents.33 Identification of parents at risk for severeresponses is essential to direct nursing actions that mayreduce parental stress, decrease untoward responses, andimprove both parental health and parenting behavior.

The magnitude of parents sources of stress in thecurrent study, assessed by the PSS:NICU, was similar tothat reported in previous publications, with alteration inparenting role a leading source of stress also detected inthese studies.3,5,28,34 Simply stated, parents find it difficultto carry out parenting activities in the critical care setting.The occurrence of anxiety, depression, fatigue, and sleepdisturbance among parents of NICU infants, demonstrated


PSS: NICU x PROMIS correlation (r)

Sights and sounds

0.38

0.16

0.14

0.30

Infant appearance

0.62b

0.37c

0.26

0.60b

0.72b

Parent role

0.60b

0.39c

0.37c

0.60b

0.72b

0.82b

Total stress

0.61b

0.36c

0.33

0.60b

0.84b

0.94b

0.94b

Figure Boxplot of parents Patient-Reported Outcomes Meas-urement Information System (PROMIS) T scores evaluatedagainst general populations scores. Median = line within box,interquartile range = shaded box, vertical lines = minimumand maximum. Population horizontal lines, mean = 50 (solidhorizontal line) and mean plus 1 SD (60, dotted line) andmean plus 2 SDs (70, dashed line).

T sc

ore

80

70

60

50

40

Anxiety Fatigue Depression Sleep Disturbance

30

in prior studies,1,6-11 was also revealed in the PROMISmeasures used in the current study. Parents of NICUpatients experience a combination of related emotionalresponses and alteration in sleep. The current study isunique in using the clinically relevant PROMIS measuresto document these responses and in providing evidenceof the constellation of anxiety, depression fatigue, andsleep disruption experienced by parents in the NICU. Ourdata from the PROMIS measures show that parents expe-rience a combination of responses, and PROMIS T scoresillustrate that these responses exceed national values.

The PROMIS instruments are publically available,easily administered and scored, and interpretable. ThePROMIS instruments provide clinicians with outcomemeasures that may be used to evaluate care as well asprovide benchmarks for quality improvement. In addi-tion to research applications, findings illustrate how thePROMIS instruments and T scores could be used clini-

cally to identify par-ents experiencingheightenedresponses and to

provide intervention and referral for services, particu-larly for treatment for anxiety and depression. Fatigueand sleep disturbance scores could guide parents sup-port measures delivered by critical care nurses as well ascounseling parents on self-care. Although clinical cut-offscores have not been developed for the PROMIS instru-ments, use of the T scores and comparison with nationalstatistics allows identification of scores 1 or 2 standarddeviations above the mean.

Nurses may assist parents in developing a visitingpattern that promotes attachment with the infant whileensuring adequate rest for parents. Assurance that thenurse will phone parents if the infants condition deteri-orates may increase parents comfort when unable to be

at the infants bedside, particularly at night. As possible,providing parents with in-unit napping opportunitiesmay reduce fatigue. Provision of competent care in a calmand reassuring manner as well as clear communicationand careful explanations geared to parental comprehen-sion capability may reduce parental anxiety. Interventionsaddressing NICU parent stress, depression, and anxietynot only improve parents outcomes but infants out-comes as well.15,35

LimitationsThese exploratory findings are taken from a study

within a single NICU and involved a limited sample size.Given the small sample size and the fact that only 1 par-ent per infant provided data, differences between theresponses of fathers and mothers and differences withincouples could not be determined. Because prior researchhas shown discrepancies between the magnitude andpattern of mothers and fathers responses,24 future researchshould evaluate the constellation of responses experi-enced by both parents. Further study should include abroader range of units. Parents of infants experiencinglife-threatening conditions were not included. This at-risk group requires additional consideration.

ConclusionIn conclusion, stress experienced by parents whose

infant is hospitalized in the NICU is strongly correlatedwith anxiety, fatigue, depression, and sleep disruption.Knowledge of these relationships can be used to guidefamily-focused nursing care in the NICU. CCN

AcknowledgmentThe authors appreciate support and guidance provided by the NICU nursinglocal practice council.

Financial DisclosuresThis work was supported by Pacific Northwest Association of Neonatal Nurses:P30 NR011400 (Thomas) and F31-NR011365 (Thorngate) awarded by theNational Institute for Nursing Research.


Alteration in parenting role was thelargest source of parental stress.

Table 3 Parents Patient-Reported Outcomes Measurement Information System (PROMIS) T scores larger than general population mean

Variable

Anxiety

Depression

Fatigue

Sleep Disturbance

>1 SD

15 (56)

8 (27)

12 (40)

11 (37)

>2 SD

3 (11)

2 (7)

3 (10)

1 (3)

No. (%) of parents

Now that youve read the article, create or contribute to an online discussionabout this topic using eLetters. Just visit www.ccnonline.org and select the articleyou want to comment on. In the full-text or PDF view of the article, clickResponses in the middle column and then Submit a response.

To learn more about caring for families in critical care, readIntensive Care Diaries and Relatives Symptoms of PosttraumaticStress Disorder After Critical Illness by Jones et al in the Ameri-can Journal of Critical Care, 2012;21:172-176. Available atwww.ajcconline.org.

References1. Holditch-Davis D, Miles MS, Weaver MA, et al. Patterns of distress in

African-American mothers of preterm infants. J Dev Behav Pediatr. 2009;30(3):193-205.

2. Trombini E, Surcinelli P, Piccioni A, Alessandroni R, Faldella G. Envi-ronmental factors associated with stress in mothers of preterm new-borns. Acta Paediatr. 2008;97(7):894-898.

3. Dudek-Shriber L. Parent stress in the neonatal intensive care unit andthe influence of parent and infant characteristics. Am J Occup Ther. 2004;58(5):509-520.

4. Olshtain-Mann O, Auslander GK. Parents of preterm infants two monthsafter discharge from the hospital: are they still at (parental) risk? HealthSoc Work. 2008;33(4):299-308.

5. Franck LS, Cox S, Allen A, Winter I. Measuring neonatal intensive careunit-related parental stress. J Adv Nurs. 2005;49(6):608-615.

6. Beck CT. Recognizing and screening for postpartum depression inmothers of NICU infants. Adv Neonatal Care. 2003;3(1):37-46.

7. Miles MS, Holditch-Davis D, Schwartz TA, Scher M. Depressive symp-toms in mothers of prematurely born infants. J Dev Behav Pediatr. 2007;28(1):36-44.

8. Paulson JF, Dauber S, Leiferman JA. Individual and combined effects ofpostpartum depression in mothers and fathers on parenting behavior.Pediatrics. 2006;118(2):659-668.

9. Mew AM, Holditch-Davis D, Belyea M, Miles MS, Fishel A. Correlatesof depressive symptoms in mothers of preterm infants. Neonatal Netw.2003;22(5):51-60.

10. Lee SY, Kimble LP. Impaired sleep and well-being in mothers with low-birth-weight infants. J Obstet Gynecol Neonatal Nurs. 2009;38(6):676-685.

11. Lee SY, Lee KA, Rankin SH, Weiss SJ, Alkon A. Sleep disturbance,fatigue, and stress among Chinese-American parents with ICU hospital-ized infants. Issues Mental Health Nurs. 2007;28(6):593-605.

12. National Sleep Foundation. How much sleep do we really need? 2011.http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need. Accessed July 3, 2012.

13. Dorheim SK, Bondevik GT, Eberhard-Gran M, Bjorvatn B. Sleep anddepression in postpartum women: a population-based study. Sleep.2009;32(7):847-855.

14. Miles MS, Holditch-Davis D. Parenting the prematurely born child:pathways of influence. Semin Perinatol. 1997;21(3):254-266.

15. Melnyk BM, Crean HF, Feinstein NF, Fairbanks E. Maternal anxiety anddepression after a premature infants discharge from the neonatal inten-sive care unit: explanatory effects of the creating opportunities for par-ent empowerment program. Nurs Res. 2008;57(6):383-394.

16. Feldman R, Eidelman AI. Maternal postpartum behavior and the emer-gence of infant-mother and infant-father synchrony in preterm and full-term infants: the role of neonatal vagal tone. Dev Psychobiol. 2007;49(3):290-302.

17. Righetti-Veltema M, Conne-Perreard E, Bousquet A, Manzano J. Post-partum depression and mother-infant relationship at 3 months old. J Affect Disord. 2002;70(3):291-306.

18. Dunkel Schetter C, Tanner L. Anxiety, depression and stress in preg-nancy: implications for mothers, children, research, and practice. CurrOpin Psychiatry. 2012;25(2):141-148.

19. Field T. Postpartum depression effects on early interactions, parenting,and safety practices: a review. Infant Behav Dev. 2010;33(1):1-6.

20. Holditch-Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumaticstress symptoms in mothers of premature infants. J Obstet GynecolNeonatal Nurs. 2003;32(2):161-171.

21. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acutestress disorder among parents of infants in the neonatal intensive carenursery. Psychosomatics. 2006;47(3):206-212.

22. Lefkowitz DS, Baxt C, Evans JR. Prevalence and correlates of posttraumaticstress and postpartum depression in parents of infants in the neonatalintensive care unit (NICU). J Clin Psychol Med Settings. 2010;17(3):230-237.

23. Vanderbilt D, Bushley T, Young R, Frank DA. Acute posttraumatic stresssymptoms among urban mothers with newborns in the neonatal inten-sive care unit: a preliminary study. J Dev Behav Pediatr. 2009;30(1):50-56.

24. Shaw RJ, Bernard RS, Deblois T, Ikuta LM, Ginzburg K, Koopman C.The relationship between acute stress disorder and posttraumatic stressdisorder in the neonatal intensive care unit. Psychosomatics. 2009;50(2):131-137.

25. Cella D, Riley W, Stone A, et al. The Patient-Reported Outcomes Meas-urement Information System (PROMIS) developed and tested its firstwave of adult self-reported health outcome item banks: 2005-2008.J Clin Epidemiol. 2010;63(11):1179-1194.

26. PROMIS: Dynamic Tools to Measure Health Outcomes from the PatientPerspective. http://www.nihpromis.org/Measures/DomainFramework.Accessed April 25, 2013.

27. Pilkonis PA, Choi SW, Reise SP, Stover AM, Riley WT, Cella D. Itembanks for measuring emotional distress from the Patient-Reported Out-comes Measurement Information System (PROMIS(R)): depression,anxiety, and anger. Assessment. 2011;18(3):263-283.

28. Miles MS, Funk SG, Carlson J. Parental Stressor Scale: neonatal intensivecare unit. Nurs Res. 1993;42(3):148-152.

29. Buysse DJ, Yu L, Moul DE, et al. Development and validation of patient-reported outcome measures for sleep disturbance and sleep-relatedimpairments. Sleep. 2010;33(6):781-792.

30. Riley WT, Rothrock N, Bruce B, et al. Patient-Reported Outcomes Meas-urement Information System (PROMIS) domain names and definitionsrevisions: further evaluation of content validity in IRT-derived itembanks. Qual Life Res. 2010;19(9):1311-1321.

31. Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. The use ofPROMIS and assessment center to deliver patient-reported outcomemeasures in clinical research. J Appl Meas. 2010;11(3):304-314.

32. PROMIS Scoring Manuals. http://www.assessmentcenter.net/Manuals.aspx. Accessed April 25, 2013.

33. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Fam-ily support and family-centered care in the neonatal intensive care unit:origins, advances, impact. Semin Perinatol. 2011;35(1):20-28.

34. Schenk LK, Kelley JH. Mothering an extremely low birth-weight infant:a phenomenological study. Adv Neonatal Care. 2010;10(2):88-97.

35. Turan T, Basbakkal Z, Ozbek S. Effect of nursing interventions on stres-sors of parents of premature infants in neonatal intensive care unit. J Clin Nurs. 2008;17(21):2856-2866.


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

Program evaluationYes No

Objective 1 was met q qObjective 2 was met q qObjective 3 was met q qContent was relevant to my

nursing practice q qMy expectations were met q qThis method of CNE is effective

for this content q qThe level of difficulty of this test was:

q easy q medium q difficultTo complete this program,

it took me hours/minutes.

1. Which of the following is a disadvantage of using the Patient Reported Out-comes Measurement Information System (PROMIS) to assess parents responses?a. Complicated scoring procedures that lead to difficulty in interpreting the datab. High licensure fees that are required for use of the instrumentc. Lack of clinical cut-off scores to determine when interventions are neededd. Complex administration procedures that require lengthy training

2. According to The National Sleep Foundation, which of the following is thebasic sleep need for adults?a. 4-5 hours per nightb. 5-6 hours per nightc. 6-7 hours per nightd. 7-8 hours per night

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 studyd. The majority of the participants were parents of infants experiencing life-threatening conditions

4. Which of the following is an advantage of using the PROMIS instruments?a. They are valid and reliable for self-reported health informationb. They can be used to measure contributing factors to infant behaviorc. They can predict the likelihood of posttraumatic stress disorder in parentsd. They are specific to one cultural group and socioeconomic status

5. Which of the following interventions is recommended for nurses to incorporate into practice in order to reduce parental stress?a. Limit visiting times between 8 PM and 6 AMb. Promote rest and a visiting pattern that promotes attachment with the infantc. Allow only one family member to sit at the infants bedsided. Limit visitors to only the mother and father of the infant

6. According to the study, increased fatigue was associated with which of thefollowing?a. Having other children in the familyb. Shorter distance from the medical centerc. Infant gestational aged. Length of hospital stay

7. Which of the following describes the prevalence of postpartum sleepproblems? a. 24%b. 82%c. 36%d. 57%

8. Which of the following was an exclusion criterion for participants in thestudy? a. Parents who were over 40 years oldb. Parents whose primary language was Spanishc. Parents of infants considered in medical crisisd. Parents of more than 2 children

9. According to the study, having other children in the family was correlatedwith which of the following?a. Anxietyb. Sleep disturbancec. Depressiond. 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 visitorsb. Evaluate the infants response to the sights and sounds of the neonatal intensive care unit environmentc. Determine which infants should have private roomsd. Identify parents who should receive referrals for interventions

11. Which of the following are suggested interventions to decreaseparental anxiety?a. Allowing unlimited visiting hours for parents and siblingsb. Providing explanations that are geared toward parental comprehension c. Encouraging parents to stay at the infants bedside throughout the nightd. Focusing on positive information and limiting discussion of negative outcomes

12. Which of the following groups has the highest incidence of acute stressdisorder after having an infant hospitalized in a neonatal intensive care unit?a. White mothersb. Low-income mothersc. Hispanic fathersd. Unmarried parents

For faster processing, takethis CNE test online at

www.ccnonline.org or mail this entire page to:

AACN, 101 Columbia Aliso Viejo, CA 92656.

Test ID: C1343 Form expires: August 1, 2016 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP Category B Test writer: Jodi Berndt, MSN, RN, CCRN, PCCN, CNE

Name Member #

Address

City State ZIP

Country Phone

E-mail

RN Lic. 1/St RN Lic. 2/St

Payment by: q Visa q M/C q AMEX q Discover q Check

Card # Expiration Date

SignatureThe American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.

AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

1. qa qb qc qd

10. qa qb qc qd

12. qa qb qc qd

11. qa qb qc qd

9. qa qb qc qd

8. qa qb qc qd

7. qa qb qc qd

6. qa qb qc qd

5. qa qb qc qd

4. qa qb qc qd

3. qa qb qc qd

2. qa qb qc qd

Copyright of Critical Care Nurse is the property of American Association of Critical-CareNurses and its content may not be copied or emailed to multiple sites or posted to a listservwithout the copyright holder's express written permission. However, users may print,download, or email articles for individual use.

Parents Responses to Stress in the Neonatal Intensive Care Unit

Documents

Transcript of Parents Responses to Stress in the Neonatal Intensive Care Unit