Empowering NICU

Parents
by Kathy Zimmerman MSN RN FNP-BC AHN-BC and Connie Bauersachs BSN RN

Abstract: With advances in technology, ment and unstable health status of their infant (Lawhon,
2002). Parents often feel stress over the sights and sounds in
infants are surviving at earlier ages.
the NICU and suffer from feelings of powerlessness in their
These small infants require life saving parental role.
equipment to thrive outside the womb as Parents of NICU infants also experience stress and
they adjust to an environment with which anxiety related to the unexpected delivery, loss of anticipated
they are not developmentally ready to normal infant, medical terms and equipment which are hard
to comprehend, and loss of caring for and bonding with
cope. While the NICU environment pro-
their infant (Reid & Bramwell, 2003). A study by Howland,
vides support for these fragile infants, it Pickler, McCain, Galser, and Lewis (2011) suggested a link
also poses many risks related to immature between high maternal stress levels with poor health out-
physiological systems and an interruption comes for mothers with an infant in the NICU. Fraley (1986)
in normal development. In addition, the studied Dr. Eakes’ theory of Chronic Sorrow in parents of
premature infants. The disparity created from the loss of the
family structure is affected by this prema-
‘perfect’ child was pervasive and cyclical in nature (Fraley,
ture delivery. There are many interven- 1986). Studies have also shown that women with chronic
tions, which will help provide holistic care illness and previous trauma were at higher risk of developing
and facilitate normal development for symptoms of PTSD, in addition to experiencing complica-
infant and family in a trajectory toward tions during childbirth (Theroux, 2009).

discharge.

Photo courtesy of Thinkstock

Keywords: NICU, preterm, NICU parents, culture

Some of the most stressful family hospital stays involve

the smallest of patients. A preterm delivery disrupts both
normal intrauterine growth and development and the psy-
chosocial adaptation of the family (Metford, 2004). Parents
have an adjustment into their new role with a healthy term
delivery and integrating the child into the family. A preterm
infant complicates this transition and families have to deal
with the potential illness of two family members, mother
and infant.
Given the advances in technology, infants are able to
survive outside the womb at younger gestational ages. Equip- Living in a complicated and stressful environment
ment often encircles the tiny patient, designated to help surrounding early delivery and admission to NICU, cultural
with hemodynamic monitoring and life saving techniques. differences are also an important aspect in caring for these
Normal parenting and bonding is interrupted due to equip-
continued on page 51

50 | International Journal of Childbirth Education | Volume 27 Number 1 January 2012

Empowering NICU Parents

Photo courtesy of Thinkstock

continued from page 50

fragile infants. Most NICU’s in the US are in large cities com-

prised of ethnically diverse populations. Caring for cultur-
ally diverse families has become more common in not only
North America but across the world (Purnell, 2009). Health
practices and issues around childbirth, and childrearing are
concepts relative to a specific culture. The childbirth educa-
tor also plays a significant role in alleviating stress, facilitating
bonding, promoting coping skills, and offering support for
parents in preparing to take care of their infant.
To survive outside the womb, preterm infants confront
countless challenges. The goal is to provide care, which
is holistic and supports the infant and family to maintain
the integrity of a healthy family (Mefford, 2004). Mefford
describes Levine’s conservation model to explain a theory of
health promotion for preterm infants and support whole-
ness through adaptation. Premature delivery necessitated the
infants adjust to extrauterine environment before they are
physiologically ready. According to Levine’s model there is a
disruption of wholeness in the infant’s physiological, struc-
tural, and neurological immaturity in addition to disruption
in family structure (Mefford, 2004). Not only does the infant
have to make the adjustment from full support of the intra-
uterine environment, but also the families must learn to deal
with a critical care environment. Developmental and family must be taken to position and handle them carefully to pre-
centered care is structured to support physiologic stability, vent bleeding in the brain. The myriad of stimulation from
neurobehavioral organization, and reduce stress for infant sound, light, handling, all have potential to disrupt normal
and family (Bowden, Greenberg, & Donaldson, 2000). development in the infant. Clustering care and careful han-
The infant’s intrauterine environment provided com- dling all allow for minimal disruptions and overstimulation
plete support, nourishment, and comfort. In the extrauterine for the infant.
environment, the premature infant must deal with immature In addition to these measures above, bonding is vital to
lungs requiring oxygen supplementation and exposure to both infant and parents. While the challenge is to combine
mechanical ventilation putting them at risk for Bronchopul- technology to support life for these fragile infants with indi-
monary dysplasia and Retinopathy of prematurity. The infant vidualized care for the families, there are many interventions,
is also at risk for musculoskeletal complications as a result of which will support bonding and promote normal develop-
lack of muscle tone and inability to stay in a flexed posture ment (Mefford & Alligood, 2011). A study by Van Riper
from increased gravity and lack of confined uterine environ- (2001) reported that the nature of the relationship which de-
ment. Positioning the infant in a developmentally appropri- veloped between health care workers and parents influenced
ate flexed position similar to the fetal position and placing the parents overall experience of being in the NICU. Health
them in a blanket ‘nest’, provides feelings of security and care providers who incorporated family centered care had a
boundaries to push up against. positive influence on the overall well-being of families in the
Measures need to be taken to prevent infection as a NICU. Family centered care includes incorporating families
result of immature immune system and repeated exposure to into the plan of care and are supported to participate in
procedures. In addition, the infant’s vascular bed is immature decision making for their infant.
placing them at risk for hemorrhage within the brain. Care continued on page 51

Volume 27 Number 1 January 2012 | International Journal of Childbirth Education | 51

Empowering NICU Parents aware of and sensitive to various cultures, it also includes
continued from page 51 issues related to race, gender, sexual orientation, social class,
and economic situations.
Health care decision-making varies in different cultures.
Family centered care includes allowing the parents to
For instance, in the Arabic and Mexican cultures, the women
participate in the care of their infant. This also facilitates
provide all the care for their children, however the male
bonding between infant and parents. Parents are often afraid
makes all the decisions for the family. Communication to the
to even touch their infant and frequently need encourage-
family will be directed toward the father and male members
ment and acceptance to participate in care. The younger the
of the family. Mexican women will often wait until they are
gestational age of the infant, the more sensitive to touch and
home to breastfeed, so they may need some encouragement
repositioning they might be. In the beginning, having parents
to pump milk, explaining the benefits for their infant. In
just lay hands on their infant is enough to develop a bond and
Asian cultures, privacy and modesty are very important. A
connection with their infant. Basic hygiene, from wiping their
new baby is the central focus of the family and breastfeeding
infant’s mouth to helping change their diaper, all facilitate the
is preferred over bottle-feeding.
parents’ participation in care. Explaining to the parents that
While Amish families usually have their children at
something as simple as a pacifier lets their infant experience
home with a midwife, they welcome lifesaving medical
non-nutritive sucking needed for normal development and
treatments. The family will remain as much as possible at the
comfort helps keep involved in interacting with the baby.
bedside in the hospital and are respectful of communication.
While skin touch is a basic human need, stroking can
Their primary language may be Dutch or German, but they
actually be irritating to the premature infant. Their neuro-
speak English fluently.
logical system is not organized yet and light stroking is too
Somali families value large families. Women practice a
much stimulation. A technique that involves placing the
custom, “afartanbah”, for a period of 40 days after child-
hands lightly over the infant gives both infant and par-
birth where they stay home, eat well, and are assisted by
ent a comforting touch that promotes bonding. Another
family members. Some seek traditional healers first but also
technique, which has gained popularity over the years, is
integrate with allopathic treatments and practices. They
kangaroo care. The parents place their infant on their chest
will breastfeed their infant for up to 2 years and may need
for up to an hour at a time. Parents need to be informed that
encouragement to pump milk.
they will place their baby on their chest, skin to skin and a
Indian families primarily practice Hinduism and the
blanket will be placed to ensure privacy and modesty. Ensur-
family structure is traditionally patriarchal. Women often do
ing that the infant is stable enough to tolerate kangaroo care
not breastfeed for several days, so education on the impor-
for about an hour offers a better-quality experience for both
tance of breast milk for her infant is important. Traditional
parent and infant (Anderson et al., 2010).
healing practices are common in India, but most embrace
Parents also report that they experience increase anxiety
allopathic therapies.
from lack of knowledge regarding the plan for their infant.
These are just some of the examples of cultural dif-
A study by Ward (2010) demonstrated results of a parent
ferences that we have seen in our NICU. The main focus
survey identifying assurance and information, as high priority
is on assessing individual families social and cultural and
needs. Regular updates and participating in rounds empow-
needs. Asking open-ended questions, providing therapeutic
ers parents to stay connected and demonstrates a family
communication, and developing a trusting relationship will
centered approach to care.
facilitate in developing culturally competent and family
Given the vast cultural diversity in the health care field,
centered education and support for parents of premature
nurses and educators can offer specific culturally appropriate
infants. Helping to foster a positive relationship between
care. The nursing profession’s aim is to provide care to indi-
the families and health care providers in the NICU can have
viduals, which is meaningful and respectful of their cultural
a profound influence over the experience they have during
values and way of life through cultural competence (Ayaz,
their infants stay. Incorporating a family centered approach
Biligli, & Akin, 2010). Nurse educators can promote and
provides positive effects on the overall well-being for families
support multiculturalism by respecting individual differences
and their preterm infant.
and diversity of ethno cultural and religious beliefs (Purnell,
2009). Culturally competent care includes not only being continued on page 53

52 | International Journal of Childbirth Education | Volume 27 Number 1 January 2012

Empowering NICU Parents Mefford, L. (2004). A theory of health promotion for preterm infants based
on Levine’s conservation model of nursing. Nursing Science Quarterly, 17(3),
continued from page 52 260-266.
Mefford, L., & Alligood, M. (2011). Testing a theory of health promotion
for preterm infants based on Levine’s conservation model of nursing. The
Figure 1 Journal of Theory Construction & Testing, 15(2), 41-47.
Howland, L., Pickler, R., McCain, N., Glaser, D., & Lewis, M. (2011). Explor-
ing biobehavioral outcomes in mothers of preterm infants. Maternal Child
Nursing, 36(2), 91-97.
Parker, L. (2011). Mothers’ experience of receiving counseling psychotherapy
on a neonatal intensive care unit (NICU). Journal of Neonatal Nursing, 17,
182-189.
Peng, N., Bachman, J., Jenkins, R., Chen, C., Chang, Y. C., & Chang, Y. S.
(2009). Relationships between environmental stressors and stress biobehav-
ioral responses of preterm infants in NICU. Journal of Perinatal and Neonatal
Nurses, 23(4), 363-371.
Purnell, L. (2009) Guide to culturally competent health care (2nd ed). Phila-
delphia, PA: F.A. Davis Company.
Reed, T., & Bramwell, R. (2003) Using the parental stressor scale: NICU
with a British sample of mothers of moderate risk preterm infants. Journal of
Reproductive and Infant Psychology, 21(4), 279-291.
Theroux, R. (2009). PTSD in the postpartum period. Nursing for Women’s
Health, 13(5), 437-440.
Van Riper, M. (2001). Family-provider relationships and well being in fami-
lies with preterm infants in the NICU. Heart and Lung, 30(1), 74-84.
Ward, K. (2001). Perceived needs of parents of critically ill infants in a
neonatal intensive care unit. Pediatric Nursing, 27(3), 281-285.
White, R. (2011). The newborn intensive care unit environment of care:
How we got here, where we’re headed, and why. Seminars in Perinatology:
Holistic Family Centered Care of the NICU Family, Journal of Perinatology, 29, 623–629; doi:10.1053/j.semperi.2010.10.002
Zimmerman 2011

Kathy Zimmerman is an assistant professor APSU School of

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