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
 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
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Grief
Fear
Hope
Anger
Helplessness, impotence
Thinking about baby
continually
Loss of control
Loss of role as decision
maker and caregiver
Unsure how to parent in NICU
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Anxiety
Happiness
Shock
Restlessness
Emptiness
Depression
Frustration
Distress
Stress disorders
Difficult Times in the NICU
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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)
 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
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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: “...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
 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
 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)
 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)
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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
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Wereszczak et al. (1997)
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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)
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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
Families
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Pierrhumbert et al. (2003)
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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)
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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
Families
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Shaw et al. (2009)
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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)
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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
Families
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Feeley et al (2011)
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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
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Emotional support
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Supportive environment
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Understanding infant behavior and characteristics
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Involvement in caregiving and decision making
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Knowledge, sensitivity, skills
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Skin to skin holding (kangaroo care)
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)
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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
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Family centered care
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Continuity of care
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Parent to parent support
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Partnering with parents
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Transition to home
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
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(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)
Key Components of Parent Support
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Parents are respected and valued members of
the health care team
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Parents and health professionals form effective
partnerships
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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 Support
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All parents can give and receive; teach and
learn; care and be cared for
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Parents are viewed in the context of their
families, neighborhoods or communities
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Parent support services are accessible
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Information shared by parents is confidential
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(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)
Promoting Parenting in the NICU
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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.
Empowerment
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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
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Partnership between NICU care provider and
parent/family = interdependency and
collaboration (Gibbins et al, 2008; Lawhon, 1997)
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“Unique and vital contribution of both the family
and the care provider to the infant’s health and
well being” (Gibbins et al, 2008)
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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)
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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
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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, 1998
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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
Goal
“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
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Goals for promoting parenting and reducing stress in the
NICU
 Collaboration
 Advocacy
 Role promotion
 Empowerment
 Support
March of Dimes
Resources for Parents
NICU Family Support
http://www.marchofdimes.com/baby/inthenicu_
program.html
Share Your Story online community
www.shareyourstory.org
Understanding Your Premature Infant
http://www.marchofdimes.com/modpreemie/pr
eemie.html
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:
1.
PrematurityPrevention.org 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: prematurityprevention.org or purchase:
marchofdimes.com/catalog
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. prematurityprevention.org
Preterm Labor Assessment Toolkit – Provides standardized protocols for
assessing patients in preterm labor. prematurityprevention.org
Preterm Labor: Prevention and Nursing Management Nursing Module –
Discusses nursing management of women presenting in preterm labor. 3.9
Contact Hours available for RNs. marchofdimes.com/nursing
2.
3.
4.
5.
Selected References
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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 References
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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, 141148.
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, 2028.
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
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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, 230237.
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 Resources
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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, 131137.
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 familycentered rounds (FCRs) in a neonatal intensive care unit
(NICU). J Matern Fetal Neonatal Med, 24, 1-4.