Evaluation of the effect of narrative writing on the stress sources of the parents of preterm neonates admitted to the NICU

Abstract

Objective: Identification of the nurses’ and families’ understanding of the stresses in the facilitates nursing interventions and increases parental satisfaction.

Material and methods: The quasiexperimental study with pretest and posttest was administered to a sample size of 70 mothers with preterm neonates hospitalized in the NICUs of two teaching hospitals of Tehran University of Medical during 6 months. The Parental Stressor Scale (PSS) was used. The data were analyzed using descriptive and analytical statistical methods.

Results: Evaluation of the differences in the domains of the questionnaire between the 3rd and 10th day of admission using a multivariate analysis showed that narrative writing had significant effects on all three domains (Roys' largest root = 2.141, F = 47.11, p values < 0.001). The results showed that the highest stress reduction was observed in Infant Behavior and Appearance (−11.847) followed by Sights and Sounds of the Unit (−11.352) while the lowest stress reduction was observed in the Parental Role Alterations (−6.149) in the intervention group, while the control mothers experienced a stress increase in all domains.

Conclusion: According to the findings, narrative writing may be considered an efficient supportive intervention to reduce the maternal stress Infant behavior and appearance in the NICUs. However, more research is needed to justify its implementation.

Keywords:

• Narrative writing
• neonatal intensive care unit
• preterm neonate
• stress

Introduction

Along with a birth incidence of 9%, it is estimated that about 15 million preterm neonates are born every year [1,2]. In the US, preterm births comprised 8.6% of all live births in 2010 [1,3]. Prematurity leads to the death of 60–80% of the neonates without congenital anomalies [1,4]. According to the latest report of the WHO, 13% of the mortality of Iranian neonates in 2010 was due to prematurity [1,2,4]. In most cases, NICU admission is unexpected and makes the families experience stress, anxiety, and depression [4,5]. Moreover, the birth of a preterm neonate not only has many consequences for the baby, such as physical, mental, and behavioral problems, but also results in great financial and emotional burdens for the family, as well [4,6]. Research has shown that mothers experience much more stress than fathers during NICU admission [4]. Many mothers feel stressed, anxious, and even depressed following the admission of their neonates in the NICU. With the birth of a preterm neonate and NICU admission, the parents experience a situational crisis and a great deal of stress, and feel desperate. The most important source of stress in the NICU is the change in the parental role. In addition, a feeling of guilt, concerns about the baby’s survival and health, doubts about the their ability to take care of the new family member, and issues related to the baby’s development and physical and psycho-social environment are other stress sources. Furthermore, all the many devices and apparatuses, noise, heat, crowd, numerous visiting doctors and nurses, and the procedures, and hesitations whether they are allowed to touch and caress the neonate are other sources of stress [4,7,8]. The mothers of preterm babies with health problems feel more frustrated than the mothers of healthy term babies [4,9]. On the other hand, because the mothers are not allowed to hug, feed, and touch their babies and show their emotions and are not well supported and informed by the NICU staff in the early days of NICU admission, they feel stressed, frightened, and isolated. Mothers experience much more stress than fathers during NICU admission [4,6]. In the meantime, the role of the nurses has received more attention than other members of the health team due to their daily contacts with the families of the admitted neonates. Therefore, the nurses may play an important role in facilitating the relationship between the babies and their parents, determining the needs of the parents, and decreasing their stress [4,7]. There are many medical and non-medical interventions to decrease maternal stress, including parental educational programs, family-centered interventions, newborn individualized developmental care, parental empowerment programs, mother–child interaction programs, music therapy, family support groups, kangroo mother care, parental counseling, and narrative writing. Narrative writing is one of the strategies than can reduce stress. Some studies have shown that narrative writing can be effective in recovery from stressful conditions and reducing stress, improving the health status, enhancing coping skills, increasing satisfaction, problem solving, improving interaction, and critical thinking [1,4,9,10]. Moreover, narrative writing forms an experimental basis for nursing care which helps to vent the feelings of the patient and create a better relationship between the patient and the nurse [4,9,11–15].

Considering the unique situation of the nurses and their duties in the NICU, identification of the nurses’ and families’ understanding of the stresses in the NICU facilitates nursing interventions and increases parental satisfaction. However, most studies in this regard in Iran have focused on the treatment problems of these newborns or providing nursing care for the preterm newborn, and no study has yet evaluated parental stress sources. Therefore, the aim of the present study was to determine this status and to use the results for future planning.

Materials and Methods

This quasiexperimental study with pretest and posttest was performed in 2 teaching hospitals affiliated with Tehran University of Medical Sciences, Arash Hospital and Children’s Medical Center. The study population was 74 mothers, 37 in the intervention group and 37 in the control group. Four mothers in the intervention group were excluded from the study. Finally, 70 mothers participated in the study (37 in the control group and 33 in the intervention group). The inclusion criteria of the mothers were having newborns less than 37 weeks gestation, singleton pregnancy, a minimum of 3 days admission in the NICU, age between 18 and 45 years, a minimum of junior high school education, having no other children with a history of NICU admission, having no sick children at home, lack of recent stressful events in the past 2 months, presence in the NICU at least 3 times a week, no history of using psychedelics or drugs, and lack of genetic or syndromic diseases in the neonate.

Exclusion criteria of the mothers were unwillingness to participate, presence in the NICU less than 3 times a week, and narrative writing less than 3 times a week. Exclusion criteria of the newborn babies were death, surgery, and admission less than 10 days. In this study, 70 eligible mothers were evaluated. The study started from the third day of NICU admission through the 10th day of admission. First, the control mothers entered the study and completed the stress questionnaire on the third day of admission. They received the routine treatment in the NICU and completed the questionnaire once more on the 10th day of admission. On the following day, sampling for the intervention group started. Similarly, the mothers in the intervention group were requested to complete the stress questionnaire on the third day of NICU admission. Then, they wrote their narratives at least three times until the end of the 10th day of admission, when they were requested to complete the questionnaire again.

Instrument

Data were collected through two instruments. The first instrument was a questionnaire for demographic data that included 2 parts; the first part was completed by mothers (sex, educational status, occupation, history of infertility, etc.) and the second part was completed by the researcher using the hospital files of the babies (weight, APGAR score, reason for admission, etc.) The second tool was the Parental Stressor Scale for Neonatal Intensive Care Units, developed by Miles, Funk, and Carlson [4,16,17].

Modifications have been made in the questionnaire with regards to the conditions of Iranian NICUs [4]. This questionnaire has been already used in domestic studies with a Cronbach’s alpha of 0.87 [4,18]. In general, this questionnaire is used to measure the parents’ perception of the stresses caused by the physical and psycho-social environment of the NICU. This questionnaire contains 22 questions in a Likert scale with scores ranging from 0 (I had no experience) to 5 (extremely stressful). This questionnaire has 3 domains: infant behavior and appearance (8 questions, a score of 8–18, 19–29, and 30–40 indicates low stress, moderate stress, and extreme stress, respectively of t), sights and sounds of the unit (6 questions, a score of 6–14, 15–22, and 23–30 indicates low stress, moderate stress, and extreme stress, respectively), and parental role and the parents’ relationship with the infants and the unit’s personnel (8 questions, a score of 8–18, 19–29, and 30–40 indicates low stress, moderate stress, and extreme stress, respectively). The sum of the scores of the three domains comprises the stress score. A stress score below 50% (22–54), between 50 and 70% (55–77), and more than 70% of the maximum score (78–110) indicates a low, moderate, and high level of stress, respectively [4].

Analysis and ethical issues

After obtaining the approval of the Ethics Committee of Tehran University of Medical Sciences, the researcher presented her introduction letter to Arash Hospital and Children’s Medical Center, and explained the objectives of the study to the related authorities in the hospitals. Then, the mothers were informed that they could participate in the study if they were willing to. They were also informed that they could withdraw from the study anytime during the study without any consequences regarding the care their neonates received in the NICU. After sampling, informed consent was obtained from the neonates’ parents. Moreover, all eligible mothers completed and signed the consent form prior to joining the study. The questionnaires were coded for each mother without mentioning the mother’s name.

Data were analyzed using SPSS version 21 (Chicago, IL). Descriptive statistics like frequency, frequency percentage, mean, and standard deviation, paired and independent t-test, Mann–Whitney test, and Chi square were used for data analysis.

Results

The study samples included 70 mothers, 37 in the control group and 33 in the intervention group. Tables 1 and 2 present some demographic characteristics of the mothers and their neonates hospitalized in the NICUs of Arash Hospital and Children’s Medical Center.

Table 1. Demographic characteristics of mothers.

Groups	Control group (n = 37)		Intervention group (n = 33)
Variables	N (%)	Mean ± SD	N (%)	Mean ± SD	Test results
Age of mothers	37 (52.8)	26.7 ± 5.2	33 (47.2)	26.9 ± 4.9	t-testp = 0.88t = 0.15
18–24	14 (37.8)	–	8 (24.25)	–
25–30	15 (40.5)	–	18 (54.55)	–
31–35	5 (13.5)	–	6 (18.2)	–
36–40	3 (8.1)	–	1 (3)	–
Number of children (total)	37 (52.8)	1.2 ± 0.46	33 (47.2)	1.12 ± 0.33	Mann–whitney p = 0.45t = 0.7
1	1 (2.7)	–	0 (0)	–
2	28 (75.7)	–	29 (87.9)	–
3	8 (21.6)	–	4 (12.1)	–
Maternal job	37 (52.8)	–	33 (47.2)	–	Chi squarep = 0.363χ²=2/02
House wife	30 (81)	–	27 (81.8)	–
Clerk	5 (13.5)	–	6 (18.2)	–
Employee	2 (5.5)	–	0 (0)	–

Table 2. Demographic characteristics of neonates.

Gestational age (weeks)	37 (52.8)	31.6 ± 2.4	33 (47.2)	32.9 ± 3.1	Chi squarep = 0.035χ² = 2/7
25–31	18 (48.6)		8 (24.2)	–
32–37	19 (51.3)		25 (75.7)	–
Sex of infant	37 (52.8)	–	33 (47.2)	–	Chi squarep = 0.44χ² = 0.60
Female	19 (51.4)	–	20 (60.6)	–
Male	18 (48.6)	–	13 (39.4)	–
Birth weight (g)	37 (52.8)	1650 ± 570.3	33 (47.2)	1959.4 ± 630.8	t testp = 0.007t = 2.15
700–999	2 (5.4)	–	1 (3)	–
1000–1999	26 (70.3)	–	13 (39.4)	–
>2000	9 (24.3)	–	19 (57.6)	–
APGAR score at 5 minutes	37 (52.8)	8.24(1.38)	33 (47.2)	8.6 (1.2)	Chi squarep = 0.79χ² = 0.07
5–7	10 (27)	–	8 (24.2)	–
8–10	27 (73)	–	25 (75.8)	–
Mechanical ventilation	37 (52.8)	2.46 (1.361)	33 (47.2)	1.8 (1.55)	Chi squarep = 0.006χ² = 7.59
Yes	16 (43.2)	–	25 (75.8)	–
No	21 (56.8)	–	8 (24.2)	–

The results (Tables 1 and 2) showed no significant difference between the control group and intervention group.

According to Table 3, there was no significant difference between case and control groups on the third day of admission.

Table 3. The mean and standard deviation of the domains of PSS: NICU in intervention and control groups on the third day of admission.

	Control		Intervention
Group domains of PSS	Mean	Standard deviation	Mean	Standard deviation	Test results
Infant behavior and appearance	31.540	7.467	34.182	7.108	0.922
Sights and Sounds	17.649	6.969	22.061	5.350	0.153
Parental role and the parents’ relationship	24.973	7.697	22.667	7.896	0.999

Moreover, evaluation of the differences in the domains of the questionnaire between the 3rd and 10th day of admission using multivariate analysis showed that the intervention (narrative writing) had significant effects on all three domains (Roys' largest root = 2.141, F = 47.11, p values < 0.001).

Moreover, univariate analysis on the difference of each domain between the two groups between the 3rd and 10th day of admission showed that narrative writing was effective in all domains (Table 4).

Table 4. Univariate analysis of the differences of the questionnaire domains between intervention and control groups between the third and 10th day of admission.

Source	Dependent variable	Sum of squares	df	Mean square	F	p values
Group	Diff_ sights and sounds	3032.007	1	3032.007	115.994	0.000
	Diff_infant behavior and appearance	3987.896	1	3987.896	68.575	0.000
	Diff_parental role	2345.255	1	2345.255	36.385	0.000

Table 5 shows the difference in the questionnaire domains between the 3rd and 10th day of admission in case and control groups. The results showed that the highest stress reduction was observed in the domain of infant behavior and appearance (−11.847) followed by sights and sounds of the unit (−11.352), while the lowest stress reduction was observed in the parental role alterations (−6.149) in the case group. However, the control mothers experienced a stress increase in all domains.

Table 5. Descriptive statistics of the difference of the questionnaire domains between the third and 10th day of admission in intervention and control groups.

	Intervention group (n = 33)			Control group (n = 37)
	Diff_sights and sounds	Diff_infant behavior and appearance	Diff_parental role	Diff_sights and sounds	Diff_infant behavior and appearance	Diff_parental role
Mean	−11.4545	−13.3636	−6.7576	1.7297	1.7568	4.8378
Std. deviation	5.79920	6.47986	6.31482	4.41367	8.51602	9.29012
Std. error of mean	1.00951	1.12800	1.09927	.72560	1.40002	1.52729
Standardized mean	−11.352	−11.847	−6.149	2.386	1.255	3.168

Discussion

The most stressful domain according to mothers in the case group on the third day of NICU admission was the infant behavior and appearance, and narrative writing could decrease the stress level in this domain more than other domains. In other words, narrative writing had the greatest effect on the infant behavior and appearance, and the lowest effect on parental role and the parents’ relationship with the infants and the unit’s personnel, while the most stressful domain according to control mothers was parental role and the parents’ relationship with the infants and the unit’s personnel, with routine care in the ward.

Since the behavior and appearance of a preterm neonate may be stressful, it is important to explain the characteristics of the preterm neonate, including the weight, size, lack of epidermal fat, respiration, and weak cries to the parents [19].

Educational programs on communicative and behavioral activities regarding the behavioral and physical characteristics of the preterm baby through video clips and pamphlets decrease the parental stress in the NICU, enhance the relationship with the neonates, and improve the beliefs about the parental role [20].

Conducting family support programs for the fathers of preterm neonates admitted to the NICU caused a decrease in their stress in two domains of infant behavior and appearance, and parental relationship and parental role [21].

Nystrom et al. and Davis et al. reported that mothers had a lot of concerns and stress about the appearance and behavior of the baby, and their weakness and disease, and also reported fear of death as a source of stress [7,22].

Frank reported that the physical environment of the NICU was a stress source for the parents. Moreover, the sight of their baby connected to devices, tubes, and wires surrounded by physicians and nurses can be very concerning [23].

In a study conducted by Akbarbegloo et al., the findings showed differences in the effectiveness of three domains of parental stress sources in the NICU from the viewpoint of the nurses, and the mean stress score of the domains of infant appearance and behavior and parental relationship and parental role was high. Therefore, according to nurses, the lowest stress was related to the NICU environment [24]. A study by Akbarbegloo et al. in Iran showed that the greatest source of stress according to mothers was parental relationship and parental role [24].

Kadivar et al. conducted a study entitled “The effect of narrative writing on maternal stress in neonatal intensive care settings” and concluded that narrative writing by mothers reduced the stress in the intervention group during their neonates’ hospitalization (p < 0.001) [4].

Miles et al. reported the lack of satisfaction with the parental role as the greatest source of parental stress. The parents felt hopeless because they could not fulfill their parental duties and protect their children from harms as they expected [17].

A study by Seidman et al. showed that parents experienced high levels of stress regarding the change in the parental role and normal activities that should be continued at home [25].

Studies by Axelsson & Nyström, and Davis et al, identified changes in the parental role and separation from the baby due to long hospitalization as stress sources for the parents. These mothers also experienced feelings like strangerhood with frustration, lack of power, confusion, and extreme psychological pressure [7,22].

Recommendations for future studies

Considering the effect of narrative writing on the stress levels of the mothers of NICU admitted preterm babies, it is recommended to conduct future studies on fathers and other neonates. Therefore, as for primary prevention, plans to decrease the birth rate of preterm babies and facilities to increase the knowledge of the parents about physical characteristics and behavior of preterm neonates as well as NICU conditions and environment should be considered. Moreover, it is suggested to use narrative writing as an effective tool to decrease maternal stress since it is not expensive and time-consuming. Also, in this study, the source of mothers’ stress was evaluated quantitatively. Meanwhile, doing quantitative study on the contents of writings in the future researches is also suggested.

Conclusion

Narrative writing decreased the stress of the mothers in all domains of the questionnaire in the intervention group on the 10th day of admission. The greatest stress reduction was seen in the domain of infant behavior and appearance.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgements

This article is part of an MSc nursing thesis in Tehran University of Medical Sciences. The researchers would like to express their gratitude to the personnel of the neonatal intensive care units of Children’s Medical Center and Arash Hospital, and also the participating mothers.