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Stress in the NICU: Impact on Families and Infants. Susan Blackburn RN, PhD, FAAN Department of Family and Child Nursing University of Washington Seattle, Washington. Challenges to Parenting in the NICU. Separation and distance Stress, anxiety, loss, fatigue

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stress in the nicu impact on families and infants

Stress in the NICU: Impact on Families and Infants

Susan Blackburn RN, PhD, FAAN

Department of Family and Child Nursing

University of Washington

Seattle, Washington

challenges to parenting in the nicu
Challenges to Parenting in the NICU
  • Separation and distance
  • Stress, anxiety, loss, fatigue
  • Infant appearance and behavior
  • Nursery appearance and policies
  • Lack of privacy and control
  • Staff-parent interactions
  • Financial concerns
  • Family issues
parental feelings after preterm birth




Helplessness, impotence

Thinking about baby continually

Loss of control

Loss of role as decision maker and caregiver

Unsure how to parent in NICU









Stress disorders

Parental Feelings After Preterm Birth
difficult times in the nicu
Difficult Times in the NICU
  • During Antepartum Care
  • Still on L&D, unable to see baby
  • First visit to the NICU
  • Being discharged without baby
  • Difficult news
  • Transitions
  • Death of baby on unit
  • Discharge home with baby

(March of Dimes NICU Family Support)

parent needs in the nicu cleveland 2008 hurst 2001
Parent Needs in the NICU (Cleveland, 2008; Hurst, 2001)
  • Accurate information and inclusion in the infant's care
  • Vigilant watching over and protection of the infant
  • Contact with the infant
  • Being positively perceived by the nursery staff
  • Individualized care
  • Therapeutic relationship with staff
psychological stress in nicu parents
Psychological Stress in NICU Parents
  • Parents of infants in the NICU are at increased risk of depression and stress disorders both during the infant’s hospitalization and in the postdischarge period
    • Acute stress and distress
    • Posttraumatic stress disorder
    • Anxiety
    • Depression/postpartum mood disorders
  • (Beck, 2003; Groer et al, 2002; Howland et al, 2011; Padovani et al, 2009; Poehlmann et al, 2009; Shaw et al, 2009)
stress and distress
Stress and Distress
  • Stress: “...a physical, chemical, or emotional factor that causes bodily or mental tension and may be recognized as a factor in disease causation.” (Merriam Webster's Collegiate Dictionary)
  • Distress: adverse effects seen when a stress causing event has exceeded the organisms limits of stress tolerance
consequences of stress
Consequences of Stress
  • During pregnancy = increase risk of preterm labor and birth
  • Postpartum: early stressful experiences can subsequently affect parental attitudes, behaviors and care giving relationship
  • Long term health risks for parents and infants
acute stress disorder
Acute Stress Disorder
  • Significant stressor
  • Initial "daze“ and disorientation, followed by symptoms such as depression, anxiety, anger, despair, over activity, withdrawal
  • Usually diminishes after 24–48 hours
critical features of postpartum mood disorders siegel gardner dickey 2011
Critical Features of Postpartum Mood Disorders (Siegel, Gardner & Dickey, 2011)
  • Over concern for the baby or excessive anxiety over the infant’s health
  • Feelings of guilt , inadequacy, worthlessness, failure at mother hood
  • Fear of losing control or “going crazy”
  • Lack of interest in the baby
  • Fear of harming the baby
  • Obsession
post traumatic stress disorder dsm iv tr
Post-traumatic Stress Disorder (DSM-IV-TR)
  • Exposure to traumatic event
  • Re-experiencing the event through intrusive thoughts
  • Avoidance of stimuli that represent the event
  • Increased arousal after the event that was not present before
  • Duration of >1 month
  • Significant impairment in social or other functioning
  • Reported among parents of VLBW
post traumatic stress and nicu families
Post Traumatic Stress and NICU Families
  • Wereszczak et al. (1997)
    • Qualitative study of vividness of memories primary caregivers recall 3 years post preterm birth (n = 44)
    • Vivid memories related to infant appearance and behavior, pain, procedures, illness severity, and uncertainty of outcomes
  • Holditch-Davis et al (2003)
    • PTSD questionnaire and interview of 30 PT mothers at 6 mo corrected age
    • All had at least 1 PTSD symptom, 12 had 2, 16 had 3
    • PTSD symptoms associated with infant illness severity
post traumatic stress and nicu families1
Post Traumatic Stress and NICU Families
  • Pierrhumbert et al. (2003)
    • PTSD questionnaire to parents (50 PT, 25 FT) at 6 mo
    • 67% of mothers of preemies vs. 6% controls exhibited clinical post-traumatic reactions
    • Intensity correlated with eating/sleeping problems of infants
  • Kersting et al. (2004)
    • PTS responses (scale) in 50 PT vs 30 FT mothers at 5 times from birth to 14 months
    • Higher rates and similar intensity of traumatic symptoms in PT mothers at all time points to 14 months
post traumatic stress and nicu families2
Post Traumatic Stress and NICU Families
  • Shaw et al. (2009)
    • Prevalence of ASD (birth) and PTSD 4 months after the birth of PT or sick NB (n = 18)
    • 33% of fathers, 9% of mothers met criteria for PTSD
    • ASD symptoms correlated with PTSD and depression
    • Fathers: PTSD more delayed onset, greater risk by 4 mo
  • Vanderbilt (2009)
    • Assessment of postpartum acute PTS and depression in 59 NICU & 60 well NB mothers in first week after birth
    • NICU mothers show increased symptoms of acute PTS stress and depression. 23% NICU and 3% well NB reached severity criteria for acute stress disorder
post traumatic stress and nicu families3
Post Traumatic Stress and NICU Families
  • Feeley et al (2011)
    • Maternal PTSD symptoms, characteristics of mother and her infant, and effect on mother-infant interaction (n = 21)
    • 23% scored in the clinical range on PTSD measure
    • Infant illness related to mothers' PTSD symptoms
    • Greater the PTSD symptoms . The less sensitive and effective at structuring interaction with their infant
enhancing parenting and reducing stress
Enhancing Parenting and Reducing Stress
  • Emotional support
  • Supportive environment
  • Understanding infant behavior and characteristics
  • Involvement in caregiving and decision making
  • Knowledge, sensitivity, skills
  • Skin to skin holding (kangaroo care)
parent emotional support
Parent Emotional Support
  • Build trust and emotional safety
  • Validate feelings/reassure emotions are normal response
  • Help feel respected, valued, successful
  • Communication
  • Assist with problem solving techniques
  • Review experiences
  • Assist in identifying and using support
  • Recognize and support coping strategies
parent emotional support o donnell 1986
Parent Emotional Support (O’Donnell, 1986)
  • Help parents understand their responses and their partner’s responses
  • Provide information and empathy
  • Assist in interpreting information
  • Respond to all questions fully and openly
  • Support family from within their perspective
  • Respect responses
  • Repeat explanations
  • Flexibility and availability to talk with family when they are ready
supportive environment
Supportive Environment
  • Family centered care
  • Continuity of care
  • Parent to parent support
  • Partnering with parents
  • Transition to home
family centered care
Family-Centered Care
  • Supports development of parental competence
  • Focuses on:
      • Identifying and building on individual and family strengths
      • Partnering and collaborating with parents
      • Empowering families so they can care for their infant in the NICU and at home

(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)

key components of parent support
Key Components of Parent Support
  • Parents are respected and valued members of the health care team
  • Parents and health professionals form effective partnerships
  • The focus is on parental strengths; parents define their own needs and priorities

(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

key components of parent support1
Key Components of Parent Support
  • All parents can give and receive; teach and learn; care and be cared for
  • Parents are viewed in the context of their families, neighborhoods or communities
  • Parent support services are accessible
  • Information shared by parents is confidential

(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

promoting parenting in the nicu
Promoting Parenting in the NICU
  • Provide support to parents
  • Help parents identify and use support systems
  • Collaborate with families in planning and providing care
  • Enhance the role of parents as advocates for their infant
  • Empower parents to care for their infant, participate in rounds, ask questions, meet with the care team, etc.
  • To equip or supply with an ability; enable
  • Helping process
  • Caring presence building on parents strengths
  • Active participation with increasing control
  • Sharing of knowledge and skills
  • Partnership with mutual decisions, choices and responsibility
  • Enabling or transferring power to the other
family support and empowerment
Family Support and Empowerment
  • Partnership between NICU care provider and parent/family = interdependency and collaboration (Gibbins et al, 2008; Lawhon, 1997)
  • “Unique and vital contribution of both the family and the care provider to the infant’s health and well being” (Gibbins et al, 2008)
  • Creating Opportunities for Parent Empowerment (COPE) (Melynk et al, 2006)
Kangaroo Care Parenting Effects (Dodd, 2004; Feldman, 2004; Feldman & Eidelman, 2003; Ludington-Hoe et al, 2008)
  • Skin-to-skin contact between infant and parent provides high levels of comfort to parents (Cooper et al, 2007)
  • Benefits to attachment
    • Contingent stimulation
    • Sensory environment of breast
  • Parental
    • Reduced anxiety, stress
    • Increased parental bonding and satisfaction
    • Parent comfort
attachment behaviors of parents of nicu infants gale franck 1998
Attachment Behaviors of Parents of NICU Infants (Gale & Franck, 1998)
  • Eagerly performs caregiving activities
  • Expresses pleasure in meeting infant needs
  • Able to comfort infant when distressed
  • Brings toys, other items to personalize infant’s space
  • Makes personalized observations about infant
attachment behaviors of parents of nicu infants gale franck 19981
Attachment Behaviors of Parents of NICU Infants (Gale & Franck, 1998
  • Offers suggestions and makes demands for personalized care
  • Demonstrates advocacy behaviors
  • Feels knows and can care for infant better than anyone else
  • Demonstrates consistent visiting and/or calling patterns
  • Questions focus on total infants, not only physiological parameters

“Support for ongoing development of parental competence is the goal of neonatal nursing care, which in essence displaces the role of the professional and encourages parents, through mutual interactive communication, to support the infant in developing increasing differentiation and functioning.” (Lawhon, 1997, p.51)

family support
Family Support
  • Goals for promoting parenting and reducing stress in the NICU
    • Collaboration
    • Advocacy
    • Role promotion
    • Empowerment
    • Support
march of dimes resources for parents
March of DimesResources for Parents

NICU Family Support

Share Your Story online community

Understanding Your Premature Infant

This Continuing Professional Education Program is generously supported by a March of Dimes Grant from an Anonymous Donor
  • For additional online resources on preterm birth, please visit:
  • Online source of information on prematurity. The PPRC is primarily for professional use and includes current information on interventions, research, advocacy, professional education, global initiatives, teaching tools and resources to use with patients.
  • Elimination of Non-medically Indicated Elective Deliveries Before 39 Weeks Gestational Age. Outlines successful initiatives and sample implementation plan to reduce elective deliveries before 39 weeks at hospital, health system and statewide levels. Free download: or purchase:
  • Toward Improving the Outcome of Pregnancy III. Explores the elements that are essential to improving quality, safety and performance across the continuum of perinatal care.
  • Preterm Labor Assessment Toolkit – Provides standardized protocols for assessing patients in preterm labor.
  • Preterm Labor: Prevention and Nursing Management Nursing Module – Discusses nursing management of women presenting in preterm labor. 3.9 Contact Hours available for RNs.
selected references
Selected References
  • Ashton, M, Meagher-Stewart, D, et al. (2006). Family health nursing and empowering relationships. Pediatr Nurs, 32, 61-67
  • Cooper, L.G., Gooding, J.S., et al. (2007). Impact of a Family-Centered Care Initiative on NICU Care, Staff and Families. Journal of Perinatology, 27, S32-S37.
  • Feeley, N., Zelkowitz, P. et al. (2011). Posttraumatic stress among mothers of very low birthweight infants at 6 months after discharge from the neonatal intensive care unit. Appl Nurs Res, 24, 114-117.
  • Feldman, R, Eidelman, A, et al. (2002). A comparison of skin-to-skin (kangaroo) and traditional care, parenting outcomes and preterm infant development. Pediatrics,, 110-16-26.
selected references1
Selected References
  • Gibbins, S., et al. (2008). The universe of developmental care, a new conceptual model for application in the neonatal intensive care unit. Adv Neonat Care, 8, 141-148.
  • Gooding, J.S., Cooper, L.G., et al. (2011). Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol, 35, 20-28.
  • Howland, L.C., Pickler, R.H., et al. (2011). Exploring biobehavioral outcomes in mothers of preterm infants. Am J Matern Child Nurs, 36, 91-97
  • Lawhon, g. (1997). Proving developmentally supportive care in the newborn intensive care unit: An evolving challenge. J Perinat Neonat Nurs, 10 (4), 48-61.
selected resources
Selected Resources
  • Lefkowitz, D.S., Baxt, C. & Evans, J.R. (2010). Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive Care Unit (NICU). J Clin Psychol Med Settings, 17, 230-237.
  • Ludington-hoe, S., Morgan, K. & Abouelfettoh, A. (2008). A clinical guideline for implementation of kangaroo care with premature infants of 30 or more weeks post-menstrual age. Adv Neonat Care, 8(Supplement),S3-S23.
  • Melnyk, B.M., et al. (2006). Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics, 118, e1414-e1427.
selected resources1
Selected Resources
  • Moore, K.A., et al. (2003). Implementing potentially better practices for improving family-centered care in neonatal intensive care units: successes and challenges. Pediatrics, 111(4 Pt 2), e450-460.
  • Shaw, R.J., et al. (2009). The relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics, 50, 131-137.
  • Sweeney, M.M. (1997). The value of a family-centered approach in the NICU and PICU: one family's perspective. Pediatric Nursing, 23, 64-66.
  • Voos, K.C., et al. (2011). Effects of implementing family-centered rounds (FCRs) in a neonatal intensive care unit (NICU). J Matern Fetal Neonatal Med, 24, 1-4.