http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–6 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.937699
ORIGINAL ARTICLE
The effect of narrative writing on maternal stress in neonatal intensive care settings
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Maliheh Kadivar1, Naiemeh Seyedfatemi2, Negarin Akbari3, and Hamid Haghani2 1
Division of Neonatology, Department of Pediatrics, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran, 2Center for Nursing Care Research, Iran University of Medical Sciences, Tehran, Iran, and 3Department of Neonatal Intensive Care Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Abstract
Keywords
Objective: This study was conducted to examine the effect of narrative writing on maternal stress in the Neonatal Intensive Care Units (NICUs) during infants’ hospitalization. Methods: A quasi-experimental study was conducted among 2 groups of mothers with preterm infants in the NICUs of two teaching hospitals of Tehran University of Medical Sciences. Pre- and post-tests were administered to a sample size of 70 during 6 months. The Parental Stressor Scale (PSS) was used. The data were analyzed using descriptive and analytical statistical methods. Results: The mean stress level in the control group was 73.9 ± 16.7 at the beginning of the study, and 82.5 ± 19.5 at the end of the study (on the 10th day). Paired t-test results in the control group showed that there was a statistically significant difference between the 3rd and the 10th day of the hospitalization (p50.001). In the intervention group, the mean stress level at the beginning of the study and on the 10th day of the hospitalization was 78.9 ± 16 and 48.8 ± 14.1, respectively (p50.001). The results revealed statistically significant difference between the 2 groups on the 10th day of the study (p50.001). Conclusion: According to the findings, the narrative writing may be considered as an efficient supportive intervention to reduce the maternal stress in the NICUs. However, more research is needed to justify its implementation.
Maternal stress, narrative writing, neonatal intensive care setting
Introduction It is estimated that 13 million preterm infants are born annually worldwide [1]. According to the WHO latest report, 31% of the neonatal mortality rate in Iran in 2006 was due to prematurity and low birth weight [2]. The birth of a preterm infant can cause different types of paternal feelings, so the families might not be prepared to withstand the shock of a preterm birth and sick infant. The mothers of preterm sick infants feel more disappointed [3]. The hospitalization of preterm infants in the NICUs are mostly unexpected, causing the families to experience some levels of stress, anxiety, and depression [4]. It takes a long time for parents to adopt to the complex and unfamiliar environment of NICU. The evidences show that witnessing a sick vulnerable infant and continuing grief for the loss of a normal child, change in the parental role, and their separation from the hospitalized
Address for correspondence: Negarin Akbari, Department of Neonatal Intensive Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq, Tehran, Iran. Tel: +98 21 61054404. E-mail: [email protected]
History Received 26 April 2014 Revised 31 May 2014 Accepted 19 June 2014 Published online 21 July 2014
infant exert a great deal of tension on the families [5]. Also, the light and sound, the neonatal appearance, stressful responses to invasive procedures, the health workers’ conversations, and their behaviors are among the main factors causing tension for the parents during hospitalization of their preterm infant [6,7]. In addition, the mothers in some NICUs are not initially, or indeed, in the later days of the hospitalization, permitted to hold, feed, and touch their infants or express their feelings. These parents are neither sufficiently supported nor receive appropriate information by the personnel. So, they undergo stress, fear, and isolation. The mothers, compared to the fathers, suffer more during their infant’s hospitalization [8]. The nurses play a significant role in facilitating the parents-infant relationship and in determining the parental needs [5]. There are various interventions to reduce maternal stress such as: parental education, familybased intervention, newborn individualized developmental care, creating opportunities for parental empowerment, mother-infant transactions programs, music therapy, parent support group, kangaroo care, parent consultation, NIDCAP1, and narrative writing [3,9–17]. Various studies 1
Newborn Individualized Developmental Care and Intervention Program
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have been conducted on the impact of narrative writing on the stress level, including the studies by Karen et al., Amanda et al., Neuner et al., and Stephen et al., [16,18–20]. In addition to reducing the stress level, narrative writing can be effective in improving health conditions, skill adaptation, more invlovement in the neonatal care, enhancing mother’s relationship with the nurses, improvement of the physical and mental health, increasing the problem solving ability, and personal development and evolution [21–24]. Narrative writing also can be used when the verbal expression of the problems is difficult [3]. Because nurses are considered as the key caregivers of patients and their families, being able to alleviate the mothers’ stress level during their infants’ hospitalization is very important. There are a few studies which accessed the effect of narrative writing on the reduction of stress level. However, no study has been conducted on NICUs in Iran. This study aimed at evaluating the effect of narrative writing on maternal stress in NICUs.
Methods A quasi-experimental study was conducted among 2 groups of mothers with preterm infants in the Children’s Medical Center and Arash Hospital affiliated with the Tehran University of Medical Sciences (TUMS) in Tehran. The data collection took place between April and August 2013. The study sample consisted of 74 mothers, of which, 37 were in the control group and 37 in the intervention group. Four mothers of the intervention group were excluded from the study due to their lack of cooperation, and finally 70 mothers (37 in the control group and 33 in the intervention group) participated in the study. The inclusion criteria were: having an infant less than 37 gestational age with at least three days of hospitalization in NICU, being 18–45 years old, having at least pre-high school education, not having another child with the history of hospitalization in the NICU, not having sick children at home, not having a severe stressful problem in the last 2 months, being present in NICU at least three times a week, not having a history of psychedelic and drug use, and for the infant not suffering from genetic disorders or syndromes. Mothers’ exclusion criteria included: lack of interest in participation in the research, presence of less than three times a week, narrative writing less than three times a week, infant’s death, infant’s surgery, and less than 10 days of infant’s hospitalization. The research started from the 3rd day of the infants’ hospitalization in NICU, and continued until the end of the 10th day. Firstly, the control group took part in the study, and the mothers in the control group completed the Parental Stressor Scale on the 3rd day of the infant’s hospitalization. Then, the mothers in the control group followed only the routine procedures of the NICU, and they were asked to complete the PSS questionnaire again at the end of the 10th day. After collecting the control groups’ questionnaires, in the intervention group, the mothers completed the PSS on the 3rd day of the infants’ hospitalization and then were asked to perform narrative writing at least three times until the end of the 10th day of the hospitalization, when they were asked again to complete the PSS questionnaire.
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Instrument Data were collected as demographic information consisted of two sections. The first part was completed by the mothers (sex, education status, occupation, infertility history, etc.), and the second part was completed according to the infants’ demographic data (weight, APGAR score, Reasons for hospitalization, etc.). The other instrument was the PSS2 for neonatal intensive care units. PSS was developed by Miles, Funk and Carlson [25] and is adjusted for Iranian NICUs. The instrument has also been used in domestic studies [26,27]. The Cronbach’s alpha for the questionnaire was 0.87 in the study by Mozafarinia [27]. Generally, the questionnaire is an instrument for measuring the parents’ perception of the stresses produced by the physical, psychological, and social environments of NICUs. The questionnaire is designed in the Likert scale, includes 22 items with answers from 0 (no stress), to 5 (extremely stressful). The questionnaire has three dimensions including: (1) Sights and sounds of the NICU, which include 6 items, such that scores 6–14, 15–22, and 23–30 denoting low, average, and high stress levels, respectively. (2) Infant behavior and appearance, which include 8 items, such that scores 8–18, 19–29, and 30–40 denoting low, average, and high stress levels, respectively. (3) Parental role and the parents’ relationship with the infants and the unit’s personnel, which include 8 items, such that scores 8–18, 19–29, and 30–40 denoting low, average, and high stress levels, respectively. The overall score of the instrument is the sum of the results of the three dimensions. If the mothers’ stress level is less than the 50% of the instrument’s overall score (22–54), the stress level is low; if it is 50–70% of the overall score (55–77), the stress level is average; and if it is more than the 70% of the overall score (78–110), the stress level is high. Data analysis and ethical issues After obtaining the permission from the ethics committee of the university, the aim of the study was explained to all the mothers and they were persuaded to cooperate. Then, they were informed that they can take part in the study if they are interested and they can withdraw from the study at any time they wished without any changes happening to the infant’s care. After sample selection, a written informed consent letter was obtained. Before starting the study, all the mothers reviewed and completed the informed consent questionnaire. The questionnaires were coded and anonymously completed by the participants. Data were analyzed in the SPSS software version 21 (Chicago, IL). Frequency, percentage, mean, standard deviation, paired and independent t-test, Mann– Whitney and Chi-square tests were used for data analysis.
Results The sample comprised of 70 mothers, 37 in the control group and 33 in the intervention group. The demographic variables of the mothers and their infants are presented in Table 1. The results showed no significant difference between the control group and the intervention group. 2
Parental Stressor Scale
Narrative writing and maternal stress
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Table 1. Demographic characteristics of mothers and their newborn infants. Control group (n ¼ 37)
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Groups Variables
N (%)
Age of mothers 18–24 25–30 31–35 36–40 Number of children (Total) 1 child 2 children 3 children Maternal job House wife Clerk Employee Gestational age (weeks) 25–31 32–37 Sex of Infant Female Male Birth weight (gr) 700–999 1000–1999 42000 APGAR score at 5 minutes 5–7 8–10 Mechanical ventilation Yes No
37 14 15 5 3 37 1 28 8 37 30 5 2 37 18 19 37 19 18 37 2 26 9 37 10 27 37 16 21
Mean ± SD
(52.8) (37.8) (40.5) (13.5) (8.1) (52.8) (2.7) (75.7) (21.6) (52.8) (81) (13.5) (5.5) (52.8) (48.6) (51.3) (52.8) (51.4) (48.6) (52.8) (5.4) (70.3) (24.3) (52.8) (27) (73) (52.8) (43.2) (56.8)
10th day Hospitalization
Stress level
n
n
Low Average High Total Minimum–maximum Mean ± SD Test Result
5 18 14 37
13.5 48.6 37.9 100 31–107 73.9 ± 17.6 p ¼ 0.005
33 8 18 6 1 33 0 29 4 33 27 6 0 33 8 25 33 20 13 33 1 13 19 33 8 25 33 25 8
– – – 1650 ± 570.3 – – – 8.24 (1.38) – – 2.46 (1.361) – –
3rd day Hospitalization (%)
N (%)
26.7 ± 5.2 – – – – 1.2 ± 0.46 – – – – – – – 31.6 ± 2.4
Table 2. The frequency distribution of the stress levels of the mothers in the control group. Control group
Intervention group (n ¼ 33)
(%)
4 10 23 37
10.8 27 62.2 100 26–108 82.5 ± 19.5 t ¼ 3.08
The results of the paired t-test (p ¼ 0.005) in Table 2 shows that a significant difference exists between the mean score of stress on the 3rd and the 10th day in the control group. Furthermore, the total stress mean average level was 48.6 on the 3rd day which was higher than the 10th day of hospitalization (62.2). The difference shows that maternal stress significantly increased during the hospitalization. The results of the paired t-test (50.001) in Table 3 shows that a significant difference exists between the mean score of stress on the 3rd and the 10th day in the intervention group. The difference shows that narrative writing can decrease maternal stress significantly decrease during the hospitalization. The results of independent t-test presented in Table 4 shows that there is a significant statistical difference between the average stress scores of the control and intervention groups on the 10th day of the infant’s hospitalization (p50.001). The mothers’ overall stress level on the 10th day of the
(47.2) (24.25) (54.55) (18.2) (3) (47.2) (0) (87.9) (12.1) (47.2) (81.8) (18.2) (0) (47.2) (24.2) (75.7) (47.2) (60.6) (39.4) (47.2) (3) (39.4) (57.6) (47.2) (24.2) (75.8) (47.2) (75.8) (24.2)
Mean ± SD
Test results
26.9 ± 4.9 – – – – 1.12 ± 0.33 – – – – – – – 32.9 ± 3.1 – – – – – 1959.4 ± 630.8 – – – 8.6 (1.2) – – 1.8 (1.55) – –
t test p ¼ 0.88 t ¼ 0.15 Mann–Whitney p ¼ 0.45 t ¼ 0.7 Chi square p ¼ 0.363 x2 ¼ 2/02 Chi square p ¼ 0.035 x2 ¼ 2/7 Chi square p ¼ 0.44 x2 ¼ 0.60 t test p ¼ 0.007 t ¼ 2.15 Chi square p ¼ 0.79 x2 ¼ 0.07 Chi square p ¼ 0.006 x2 ¼ 7.59
Table 3. Distribution of mothers’ stress levels in the intervention group. 3rd day hospitalization
10th day hospitalization
Stress
n
n
Low Average High Total Minimum–maximum Mean ± SD Test Result
4 8 21 33
Intervention group
(%) 12.1 24.2 63.7 100 45–104 78.9 ± 16 p50.001
(%)
22 10 1 33
66.7 30.3 3 100 24–108 48.8 ± 14.1 t ¼ 9.7
Table 4. Frequency distribution of mothers’ stress levels in the control and intervention groups on the 10th day of infant’s hospitalization. Groups
Control group (n ¼ 37)
Stress
n
Low Average High Total Minimum–maximum Mean ± SD Test Result (independent t-test)
4 10 23 37
(%)
12.1 24.2 63.7 100 26–108 82.5 ± 19.5 p50.001
Intervention group (n ¼ 33) n
(%)
22 10 1 33
66.7 30.3 3 100 24–108 48.8 ± 14.1 t ¼ 8.2
infant’s hospitalization in the control group was lower than the intervention group (62.6% compared to 66.7%). The mean stress level in the intervention group (narrative writing) declined significantly. In this study, a multivariate linear
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Table 5. Relationship between the intervening confounding factors and the stress variable levels of the 10th day, a multiple linear regression model. Co-linearity statistics (tolerance)
p value
B
SE
0.842 0.898 0.910 – 0.917 0.957 0.864
0.451 50.001 50.001 50.001 – 0.030 0.182 0.091
6.398 34.001 .481 38.917
8.431 3.474 0.103 10.015
10.125 13.164 5.970
4.567 9.763 3.475
regression model was employed to determine the relationship between the independent variables and the stress levels on the 10th day of the hospitalization. To this end, the variables which had a relationship with the 10th day stress variable, significant at less than 0.2, were entered into the initial regression model (Table 5). Therefore, the intervening variables were entered into the initial regression model to identify the predictors of the 10th day stress level and included: the 3rd day stress level, the number of the children, the number of the days the infant is connected to the ventilator, the gestational age, the history of giving birth to preterm infants, the mother’s occupation, health insurance coverage, the weight at birth (categorical), and connection to the ventilator. Table 5 illustrates the remaining final variables in the regression model. The five variables of intervention, the 3rd day stress level, occupation, the history of giving birth to preterm infants, and ventilator-dependent respiration remained in the final regression model. The mean stress level difference between the control and intervention groups on the 10th day was higher than 34 (p50.001); while the mean stress level on the 10th day in the mothers with a history of giving birth to preterm infants was, on average, 38.9 units higher than this figure in the mothers without such a history (p50.001). Regarding the occupation variable, the mean stress level in the office worker mothers on the 10th day was 10 units higher than the housekeeper mothers, considering the other remaining variables in the final model (p ¼ 0.03). Thus, it can be inferred that despite the effect of intervening factors, narrative writing can affect the maternal stress.
Discussion Critical and stressful conditions create disequilibrium. When roles, activities, and resources of a family are in a state of disequilibrium as a result of some events or situations, the family is under stress and experience varying degrees of threat. Normative changes in a family such as the birth of a child results in a certain degree of disequilibrium as family members assume new roles and responsibilities attempting to incorporate the infant structure. The birth of a preterm infant can be expected to throw the family into a considerable disequilibrium, particularly, if the infant requires NICU and prolonged hospitalization before discharge home [9]. The studies in the past 20 years have shown that narrative writing about traumatic or stressful events can reduce the stress levels and improve the physical and psychological health. The approach helps individuals to know themselves
Basic level By Intervention – – House keeper
(Constant) Intervention 3rd day stress history of preterm infant job Clerk Self-employer connected to ventilator
and their experiences as well. Narrative writing allows one to organize and remember the events in a coherent fashion while integrating thoughts and feelings. In essence, this gives individuals a sense of predictability and control over their lives. Once an experience has a structure and meaning, it would follow and the emotional effects of that experience are more manageable. Constructing stories facilitates a sense of resolution, which results in less rumination and eventually allows disturbing experiences to subside gradually from conscious. Painful thoughts that are not structured into a narrative format may contribute to the continued experience of negative thoughts and feelings [28]. The expression of feelings is used as a psychological therapy [29]. The study results indicate that narrative writing can reduce mothers’ stress level. The mean stress level of the mothers in the control group on the 3rd and 10th days of the infant’s hospitalization was 73.9 ± 16.7 and 82.5 ± 19.5, respectively. This showed a significant difference in the mothers’ stress level on the 3rd and the 10th day of the infants’ hospitalization in NICU, when the stress level increased during the infants’ hospitalization. A study conducted by Borimnejad et al. in Iran showed that the parents, and in particular the mothers of preterm infants, experienced higher stress level and more disappointment [30]. Franck reported that the physical environment of neonatal intensive care units is a source of tension for the parents. The physical environment including bright lights, noisy life support and monitoring equipments is a major stress source for parents, particularly mothers. The sight of their ill infant connected to mechanical ventilator can be very disturbing [31]. Nystro¨m and Axelsson and Davis et al. in their studies showed that the mothers had a lot of concern over the infant’s death and their appearance, behavior, lethargy, sickness, and weakness [5,32]. The mean stress level in the intervention group on the 3rd and 10th days of the infant’s hospitalization was 78.9 ± 16 and 48.8 ± 14.1, respectively (p50.001), showing a significant difference between the mothers’ stress level on the 3rd and the 10th day of the infants’ hospitalization in NICU. This revealed that maternal stress level significantly declined as a result of narrative writing for at least three times during the infant’s hospitalization period. Another study by Karen et al. in Australia about the effect of narrative writing on patients with psychological disorders showed that narrative writing reduces the participants’ stress level [18]. A study by Pizzaro in California about the efficacy of art and narrative therapy after exposure to traumatic experience among undergraduate students indicated that art and narrative therapy
DOI: 10.3109/14767058.2014.937699
about traumatic events reduce the students’ stress level [21]. A study by Andrew et al. in Colombia showed that narrative writing by the mothers of preterm infants during their infants’ hospitalization in NICU alleviates the maternal stress; a result which is consistent with our results [3]. According to the findings of this study, the medical team, particularly the nurses, could consider the narrative writing to reduce the parental stress during infants’ hospitalization in NICUs.
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Limitations Iranian people are not used to writing and the participants were not feeling comfortable when given the narrative writing worksheets. In addition, no content analysis was performed in this study, Since the study was conducted in two hospitals with different levels of NICU, maternal stress may also be influenced by the NICU levels.
Recommendation for future research The effects of narrative writing on the patients and the caregivers might be examined in further studies. According to the impact of narrative writing on the maternal stress level of preterm infants, the effect on fathers and other infants also could be investigated in further studies. in addition, the content analysis of the narratives may be conducted in future to identify and meet the parental needs.
Conclusion This study showed that the mothers of preterm infants in NICUs experience a lot of stress, which could affect the parent–infant interactions. In this situation, supporting systems for the mothers during their infants’ hospitalization in NICU are needed. Therefore, narrative writing is suggested as an effective approach for reducing maternal stress, due to its low cost, emotional expression advantages and its ease of application.
Acknowledgements This article is a part of a 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 to the participating mothers.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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ORIGINAL ARTICLE
The effect of narrative writing on maternal stress in neonatal intensive care settings
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
Maliheh Kadivar1, Naiemeh Seyedfatemi2, Negarin Akbari3, and Hamid Haghani2 1
Division of Neonatology, Department of Pediatrics, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran, 2Center for Nursing Care Research, Iran University of Medical Sciences, Tehran, Iran, and 3Department of Neonatal Intensive Care Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Abstract
Keywords
Objective: This study was conducted to examine the effect of narrative writing on maternal stress in the Neonatal Intensive Care Units (NICUs) during infants’ hospitalization. Methods: A quasi-experimental study was conducted among 2 groups of mothers with preterm infants in the NICUs of two teaching hospitals of Tehran University of Medical Sciences. Pre- and post-tests were administered to a sample size of 70 during 6 months. The Parental Stressor Scale (PSS) was used. The data were analyzed using descriptive and analytical statistical methods. Results: The mean stress level in the control group was 73.9 ± 16.7 at the beginning of the study, and 82.5 ± 19.5 at the end of the study (on the 10th day). Paired t-test results in the control group showed that there was a statistically significant difference between the 3rd and the 10th day of the hospitalization (p50.001). In the intervention group, the mean stress level at the beginning of the study and on the 10th day of the hospitalization was 78.9 ± 16 and 48.8 ± 14.1, respectively (p50.001). The results revealed statistically significant difference between the 2 groups on the 10th day of the study (p50.001). Conclusion: According to the findings, the narrative writing may be considered as an efficient supportive intervention to reduce the maternal stress in the NICUs. However, more research is needed to justify its implementation.
Maternal stress, narrative writing, neonatal intensive care setting
Introduction It is estimated that 13 million preterm infants are born annually worldwide [1]. According to the WHO latest report, 31% of the neonatal mortality rate in Iran in 2006 was due to prematurity and low birth weight [2]. The birth of a preterm infant can cause different types of paternal feelings, so the families might not be prepared to withstand the shock of a preterm birth and sick infant. The mothers of preterm sick infants feel more disappointed [3]. The hospitalization of preterm infants in the NICUs are mostly unexpected, causing the families to experience some levels of stress, anxiety, and depression [4]. It takes a long time for parents to adopt to the complex and unfamiliar environment of NICU. The evidences show that witnessing a sick vulnerable infant and continuing grief for the loss of a normal child, change in the parental role, and their separation from the hospitalized
Address for correspondence: Negarin Akbari, Department of Neonatal Intensive Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq, Tehran, Iran. Tel: +98 21 61054404. E-mail: [email protected]
History Received 26 April 2014 Revised 31 May 2014 Accepted 19 June 2014 Published online 21 July 2014
infant exert a great deal of tension on the families [5]. Also, the light and sound, the neonatal appearance, stressful responses to invasive procedures, the health workers’ conversations, and their behaviors are among the main factors causing tension for the parents during hospitalization of their preterm infant [6,7]. In addition, the mothers in some NICUs are not initially, or indeed, in the later days of the hospitalization, permitted to hold, feed, and touch their infants or express their feelings. These parents are neither sufficiently supported nor receive appropriate information by the personnel. So, they undergo stress, fear, and isolation. The mothers, compared to the fathers, suffer more during their infant’s hospitalization [8]. The nurses play a significant role in facilitating the parents-infant relationship and in determining the parental needs [5]. There are various interventions to reduce maternal stress such as: parental education, familybased intervention, newborn individualized developmental care, creating opportunities for parental empowerment, mother-infant transactions programs, music therapy, parent support group, kangaroo care, parent consultation, NIDCAP1, and narrative writing [3,9–17]. Various studies 1
Newborn Individualized Developmental Care and Intervention Program
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have been conducted on the impact of narrative writing on the stress level, including the studies by Karen et al., Amanda et al., Neuner et al., and Stephen et al., [16,18–20]. In addition to reducing the stress level, narrative writing can be effective in improving health conditions, skill adaptation, more invlovement in the neonatal care, enhancing mother’s relationship with the nurses, improvement of the physical and mental health, increasing the problem solving ability, and personal development and evolution [21–24]. Narrative writing also can be used when the verbal expression of the problems is difficult [3]. Because nurses are considered as the key caregivers of patients and their families, being able to alleviate the mothers’ stress level during their infants’ hospitalization is very important. There are a few studies which accessed the effect of narrative writing on the reduction of stress level. However, no study has been conducted on NICUs in Iran. This study aimed at evaluating the effect of narrative writing on maternal stress in NICUs.
Methods A quasi-experimental study was conducted among 2 groups of mothers with preterm infants in the Children’s Medical Center and Arash Hospital affiliated with the Tehran University of Medical Sciences (TUMS) in Tehran. The data collection took place between April and August 2013. The study sample consisted of 74 mothers, of which, 37 were in the control group and 37 in the intervention group. Four mothers of the intervention group were excluded from the study due to their lack of cooperation, and finally 70 mothers (37 in the control group and 33 in the intervention group) participated in the study. The inclusion criteria were: having an infant less than 37 gestational age with at least three days of hospitalization in NICU, being 18–45 years old, having at least pre-high school education, not having another child with the history of hospitalization in the NICU, not having sick children at home, not having a severe stressful problem in the last 2 months, being present in NICU at least three times a week, not having a history of psychedelic and drug use, and for the infant not suffering from genetic disorders or syndromes. Mothers’ exclusion criteria included: lack of interest in participation in the research, presence of less than three times a week, narrative writing less than three times a week, infant’s death, infant’s surgery, and less than 10 days of infant’s hospitalization. The research started from the 3rd day of the infants’ hospitalization in NICU, and continued until the end of the 10th day. Firstly, the control group took part in the study, and the mothers in the control group completed the Parental Stressor Scale on the 3rd day of the infant’s hospitalization. Then, the mothers in the control group followed only the routine procedures of the NICU, and they were asked to complete the PSS questionnaire again at the end of the 10th day. After collecting the control groups’ questionnaires, in the intervention group, the mothers completed the PSS on the 3rd day of the infants’ hospitalization and then were asked to perform narrative writing at least three times until the end of the 10th day of the hospitalization, when they were asked again to complete the PSS questionnaire.
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Instrument Data were collected as demographic information consisted of two sections. The first part was completed by the mothers (sex, education status, occupation, infertility history, etc.), and the second part was completed according to the infants’ demographic data (weight, APGAR score, Reasons for hospitalization, etc.). The other instrument was the PSS2 for neonatal intensive care units. PSS was developed by Miles, Funk and Carlson [25] and is adjusted for Iranian NICUs. The instrument has also been used in domestic studies [26,27]. The Cronbach’s alpha for the questionnaire was 0.87 in the study by Mozafarinia [27]. Generally, the questionnaire is an instrument for measuring the parents’ perception of the stresses produced by the physical, psychological, and social environments of NICUs. The questionnaire is designed in the Likert scale, includes 22 items with answers from 0 (no stress), to 5 (extremely stressful). The questionnaire has three dimensions including: (1) Sights and sounds of the NICU, which include 6 items, such that scores 6–14, 15–22, and 23–30 denoting low, average, and high stress levels, respectively. (2) Infant behavior and appearance, which include 8 items, such that scores 8–18, 19–29, and 30–40 denoting low, average, and high stress levels, respectively. (3) Parental role and the parents’ relationship with the infants and the unit’s personnel, which include 8 items, such that scores 8–18, 19–29, and 30–40 denoting low, average, and high stress levels, respectively. The overall score of the instrument is the sum of the results of the three dimensions. If the mothers’ stress level is less than the 50% of the instrument’s overall score (22–54), the stress level is low; if it is 50–70% of the overall score (55–77), the stress level is average; and if it is more than the 70% of the overall score (78–110), the stress level is high. Data analysis and ethical issues After obtaining the permission from the ethics committee of the university, the aim of the study was explained to all the mothers and they were persuaded to cooperate. Then, they were informed that they can take part in the study if they are interested and they can withdraw from the study at any time they wished without any changes happening to the infant’s care. After sample selection, a written informed consent letter was obtained. Before starting the study, all the mothers reviewed and completed the informed consent questionnaire. The questionnaires were coded and anonymously completed by the participants. Data were analyzed in the SPSS software version 21 (Chicago, IL). Frequency, percentage, mean, standard deviation, paired and independent t-test, Mann– Whitney and Chi-square tests were used for data analysis.
Results The sample comprised of 70 mothers, 37 in the control group and 33 in the intervention group. The demographic variables of the mothers and their infants are presented in Table 1. The results showed no significant difference between the control group and the intervention group. 2
Parental Stressor Scale
Narrative writing and maternal stress
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Table 1. Demographic characteristics of mothers and their newborn infants. Control group (n ¼ 37)
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Groups Variables
N (%)
Age of mothers 18–24 25–30 31–35 36–40 Number of children (Total) 1 child 2 children 3 children Maternal job House wife Clerk Employee Gestational age (weeks) 25–31 32–37 Sex of Infant Female Male Birth weight (gr) 700–999 1000–1999 42000 APGAR score at 5 minutes 5–7 8–10 Mechanical ventilation Yes No
37 14 15 5 3 37 1 28 8 37 30 5 2 37 18 19 37 19 18 37 2 26 9 37 10 27 37 16 21
Mean ± SD
(52.8) (37.8) (40.5) (13.5) (8.1) (52.8) (2.7) (75.7) (21.6) (52.8) (81) (13.5) (5.5) (52.8) (48.6) (51.3) (52.8) (51.4) (48.6) (52.8) (5.4) (70.3) (24.3) (52.8) (27) (73) (52.8) (43.2) (56.8)
10th day Hospitalization
Stress level
n
n
Low Average High Total Minimum–maximum Mean ± SD Test Result
5 18 14 37
13.5 48.6 37.9 100 31–107 73.9 ± 17.6 p ¼ 0.005
33 8 18 6 1 33 0 29 4 33 27 6 0 33 8 25 33 20 13 33 1 13 19 33 8 25 33 25 8
– – – 1650 ± 570.3 – – – 8.24 (1.38) – – 2.46 (1.361) – –
3rd day Hospitalization (%)
N (%)
26.7 ± 5.2 – – – – 1.2 ± 0.46 – – – – – – – 31.6 ± 2.4
Table 2. The frequency distribution of the stress levels of the mothers in the control group. Control group
Intervention group (n ¼ 33)
(%)
4 10 23 37
10.8 27 62.2 100 26–108 82.5 ± 19.5 t ¼ 3.08
The results of the paired t-test (p ¼ 0.005) in Table 2 shows that a significant difference exists between the mean score of stress on the 3rd and the 10th day in the control group. Furthermore, the total stress mean average level was 48.6 on the 3rd day which was higher than the 10th day of hospitalization (62.2). The difference shows that maternal stress significantly increased during the hospitalization. The results of the paired t-test (50.001) in Table 3 shows that a significant difference exists between the mean score of stress on the 3rd and the 10th day in the intervention group. The difference shows that narrative writing can decrease maternal stress significantly decrease during the hospitalization. The results of independent t-test presented in Table 4 shows that there is a significant statistical difference between the average stress scores of the control and intervention groups on the 10th day of the infant’s hospitalization (p50.001). The mothers’ overall stress level on the 10th day of the
(47.2) (24.25) (54.55) (18.2) (3) (47.2) (0) (87.9) (12.1) (47.2) (81.8) (18.2) (0) (47.2) (24.2) (75.7) (47.2) (60.6) (39.4) (47.2) (3) (39.4) (57.6) (47.2) (24.2) (75.8) (47.2) (75.8) (24.2)
Mean ± SD
Test results
26.9 ± 4.9 – – – – 1.12 ± 0.33 – – – – – – – 32.9 ± 3.1 – – – – – 1959.4 ± 630.8 – – – 8.6 (1.2) – – 1.8 (1.55) – –
t test p ¼ 0.88 t ¼ 0.15 Mann–Whitney p ¼ 0.45 t ¼ 0.7 Chi square p ¼ 0.363 x2 ¼ 2/02 Chi square p ¼ 0.035 x2 ¼ 2/7 Chi square p ¼ 0.44 x2 ¼ 0.60 t test p ¼ 0.007 t ¼ 2.15 Chi square p ¼ 0.79 x2 ¼ 0.07 Chi square p ¼ 0.006 x2 ¼ 7.59
Table 3. Distribution of mothers’ stress levels in the intervention group. 3rd day hospitalization
10th day hospitalization
Stress
n
n
Low Average High Total Minimum–maximum Mean ± SD Test Result
4 8 21 33
Intervention group
(%) 12.1 24.2 63.7 100 45–104 78.9 ± 16 p50.001
(%)
22 10 1 33
66.7 30.3 3 100 24–108 48.8 ± 14.1 t ¼ 9.7
Table 4. Frequency distribution of mothers’ stress levels in the control and intervention groups on the 10th day of infant’s hospitalization. Groups
Control group (n ¼ 37)
Stress
n
Low Average High Total Minimum–maximum Mean ± SD Test Result (independent t-test)
4 10 23 37
(%)
12.1 24.2 63.7 100 26–108 82.5 ± 19.5 p50.001
Intervention group (n ¼ 33) n
(%)
22 10 1 33
66.7 30.3 3 100 24–108 48.8 ± 14.1 t ¼ 8.2
infant’s hospitalization in the control group was lower than the intervention group (62.6% compared to 66.7%). The mean stress level in the intervention group (narrative writing) declined significantly. In this study, a multivariate linear
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Table 5. Relationship between the intervening confounding factors and the stress variable levels of the 10th day, a multiple linear regression model. Co-linearity statistics (tolerance)
p value
B
SE
0.842 0.898 0.910 – 0.917 0.957 0.864
0.451 50.001 50.001 50.001 – 0.030 0.182 0.091
6.398 34.001 .481 38.917
8.431 3.474 0.103 10.015
10.125 13.164 5.970
4.567 9.763 3.475
regression model was employed to determine the relationship between the independent variables and the stress levels on the 10th day of the hospitalization. To this end, the variables which had a relationship with the 10th day stress variable, significant at less than 0.2, were entered into the initial regression model (Table 5). Therefore, the intervening variables were entered into the initial regression model to identify the predictors of the 10th day stress level and included: the 3rd day stress level, the number of the children, the number of the days the infant is connected to the ventilator, the gestational age, the history of giving birth to preterm infants, the mother’s occupation, health insurance coverage, the weight at birth (categorical), and connection to the ventilator. Table 5 illustrates the remaining final variables in the regression model. The five variables of intervention, the 3rd day stress level, occupation, the history of giving birth to preterm infants, and ventilator-dependent respiration remained in the final regression model. The mean stress level difference between the control and intervention groups on the 10th day was higher than 34 (p50.001); while the mean stress level on the 10th day in the mothers with a history of giving birth to preterm infants was, on average, 38.9 units higher than this figure in the mothers without such a history (p50.001). Regarding the occupation variable, the mean stress level in the office worker mothers on the 10th day was 10 units higher than the housekeeper mothers, considering the other remaining variables in the final model (p ¼ 0.03). Thus, it can be inferred that despite the effect of intervening factors, narrative writing can affect the maternal stress.
Discussion Critical and stressful conditions create disequilibrium. When roles, activities, and resources of a family are in a state of disequilibrium as a result of some events or situations, the family is under stress and experience varying degrees of threat. Normative changes in a family such as the birth of a child results in a certain degree of disequilibrium as family members assume new roles and responsibilities attempting to incorporate the infant structure. The birth of a preterm infant can be expected to throw the family into a considerable disequilibrium, particularly, if the infant requires NICU and prolonged hospitalization before discharge home [9]. The studies in the past 20 years have shown that narrative writing about traumatic or stressful events can reduce the stress levels and improve the physical and psychological health. The approach helps individuals to know themselves
Basic level By Intervention – – House keeper
(Constant) Intervention 3rd day stress history of preterm infant job Clerk Self-employer connected to ventilator
and their experiences as well. Narrative writing allows one to organize and remember the events in a coherent fashion while integrating thoughts and feelings. In essence, this gives individuals a sense of predictability and control over their lives. Once an experience has a structure and meaning, it would follow and the emotional effects of that experience are more manageable. Constructing stories facilitates a sense of resolution, which results in less rumination and eventually allows disturbing experiences to subside gradually from conscious. Painful thoughts that are not structured into a narrative format may contribute to the continued experience of negative thoughts and feelings [28]. The expression of feelings is used as a psychological therapy [29]. The study results indicate that narrative writing can reduce mothers’ stress level. The mean stress level of the mothers in the control group on the 3rd and 10th days of the infant’s hospitalization was 73.9 ± 16.7 and 82.5 ± 19.5, respectively. This showed a significant difference in the mothers’ stress level on the 3rd and the 10th day of the infants’ hospitalization in NICU, when the stress level increased during the infants’ hospitalization. A study conducted by Borimnejad et al. in Iran showed that the parents, and in particular the mothers of preterm infants, experienced higher stress level and more disappointment [30]. Franck reported that the physical environment of neonatal intensive care units is a source of tension for the parents. The physical environment including bright lights, noisy life support and monitoring equipments is a major stress source for parents, particularly mothers. The sight of their ill infant connected to mechanical ventilator can be very disturbing [31]. Nystro¨m and Axelsson and Davis et al. in their studies showed that the mothers had a lot of concern over the infant’s death and their appearance, behavior, lethargy, sickness, and weakness [5,32]. The mean stress level in the intervention group on the 3rd and 10th days of the infant’s hospitalization was 78.9 ± 16 and 48.8 ± 14.1, respectively (p50.001), showing a significant difference between the mothers’ stress level on the 3rd and the 10th day of the infants’ hospitalization in NICU. This revealed that maternal stress level significantly declined as a result of narrative writing for at least three times during the infant’s hospitalization period. Another study by Karen et al. in Australia about the effect of narrative writing on patients with psychological disorders showed that narrative writing reduces the participants’ stress level [18]. A study by Pizzaro in California about the efficacy of art and narrative therapy after exposure to traumatic experience among undergraduate students indicated that art and narrative therapy
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about traumatic events reduce the students’ stress level [21]. A study by Andrew et al. in Colombia showed that narrative writing by the mothers of preterm infants during their infants’ hospitalization in NICU alleviates the maternal stress; a result which is consistent with our results [3]. According to the findings of this study, the medical team, particularly the nurses, could consider the narrative writing to reduce the parental stress during infants’ hospitalization in NICUs.
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Limitations Iranian people are not used to writing and the participants were not feeling comfortable when given the narrative writing worksheets. In addition, no content analysis was performed in this study, Since the study was conducted in two hospitals with different levels of NICU, maternal stress may also be influenced by the NICU levels.
Recommendation for future research The effects of narrative writing on the patients and the caregivers might be examined in further studies. According to the impact of narrative writing on the maternal stress level of preterm infants, the effect on fathers and other infants also could be investigated in further studies. in addition, the content analysis of the narratives may be conducted in future to identify and meet the parental needs.
Conclusion This study showed that the mothers of preterm infants in NICUs experience a lot of stress, which could affect the parent–infant interactions. In this situation, supporting systems for the mothers during their infants’ hospitalization in NICU are needed. Therefore, narrative writing is suggested as an effective approach for reducing maternal stress, due to its low cost, emotional expression advantages and its ease of application.
Acknowledgements This article is a part of a 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 to the participating mothers.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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