This study was supported by KonKuk University in 2018.
This study was conducted to evaluate the efficacy of a community-based follow-up program on parenting stress, parenting efficacy, and coping among parents with premature infants.
A non-equivalent control group pre-post quasi-experimental design was used. This program consisted of structured home visits and self-help group meetings for 6 months. The experimental group (n=29) received visits by an experienced neonatal intensive care unit (NICU) nurse and the control group (n=27) was visited by a visiting nurse. Data were analyzed using the
Parents' coping behavior significantly differed in the experimental group compared to the control group (t=3.14,
The findings of this study suggest that home visits by an experienced NICU nurse provided through a community-based follow-up program were an effective intervention to improve coping behavior among parents with premature infants.
Follow-up programs after discharge for premature infants play an important role in promoting premature babies' health and effective parenting [
Prematurity is a risk factor for the development of motor, psychiatric, behavioral, and emotional disorders in comparison with normal babies; consequently, mothers of premature infants are subject to a substantial amount of stress in the process of parenting and monitoring their children's health following discharge [
Parents are generally more likely to take better care of their children when they are capable of managing their feelings and responding to a crisis [
Previous studies have presented the importance of social support and linkage with community services for premature infants, demonstrating improvements of health in premature infants, parenting stress, and family coping after providing a systematic follow-up program for mothers of premature infants [
Upon discharge from the neonatal intensive care unit (NICU), an emergency event or ongoing therapies such as oxygen administration, tube feeding, medication administration, and apnea monitoring evoke fright as the parents assume responsibility for their premature infant [
The goal of this study was to examine whether mothers with premature infants who received a follow-up program providing tailored parenting support, including home visits by an experienced NICU nurse, had improved parenting stress, parenting efficacy, and coping compared to those who received traditional home visits.
• Parenting stress would differ between the experimental group, which received home visits by an experienced NICU nurse, and the control group, which received traditional home visits.
• Parenting efficacy would differ between the experimental group, which received home visits by an experienced NICU nurse, and the control group, which received traditional home visits.
• Coping would differ between the experimental group, which received home visits by an experienced NICU nurse, and the control group, which received traditional home visits.
This quasi-experimental study used a nonequivalent control group pretest-posttest design to investigate the effects of home visits by an experienced NICU nurse for parents with premature infants on parenting stress, parenting efficacy, and coping.
This study used convenience sampling to enroll mothers of premature infants who joined the infant service in S county, Seoul, South Korea. The participants in the experimental group were recruited in 2013, while the control participants were recruited in 2016. The following inclusion criteria were applied to the infants: 1) gestational age of less than 37 weeks, 2) no congenital anomalies or serious complications, and 3) corrected age of less than 6 months. Mothers were required to meet the additional following criteria: 4) having no postpartum complications, 5) being the primary caregiver of the child, and 6) understanding the purpose of the study and providing consent to participate in the study.
The sample size was calculated using the G*Power 3.1.2 program [
Parenting stress was assessed using the Parenting Stress Index (PSI), which was developed by Abidin [
Parenting efficacy among mothers of premature infants was assessed using the Parenting Sense of Competence (PSOC) scale, which was developed by Gibaud-Wallston [
Coping was assessed using the Coping Health Inventory for Parents (CHIP), which was developed by McCubbin et al. [
A community-based follow-up program for parents with premature infants was developed based on the results of previous studies and a needs assessment by the parenting support center of K University Hospital [
The home visit program assessed the physical, psychosocial, health behaviors, and home environment domains. For the physical domain, measurements were made of the infant's height, weight, and head circumference, and growth was checked using a growth chart. For the psychosocial domain, the home visit team evaluated the mother's parenting attitude, affection, stress, interpersonal relationships, and external contact, and the health behaviors domain included an assessment of the mother's knowledge associated with nutrition, bathing, activity level, vaccinations, and sleep in children. Additionally, the home environment domain was investigated by assessing the economic status, safety management, hygiene, and degree of parenting support; when any relevant problems were identified, education or solutions were provided.
The home visits in the experimental group were conducted by one visiting nurse and one specialized nurse with 10 years of work experience in the NICU. The experienced NICU nurse assessed the degree of developmental delay according to the child's health conditions and the corrected age by evaluating the child's vital signs, physical measurements, and physical assessment of whether any serious events were predicted. When a developmental delay or cerebral palsy was suspected, the experienced NICU nurse provided guidance on receiving the corresponding management by medical doctors and rehabilitation therapy. In contrast, the control group received home visits from two visiting nurses (community home visiting nurses), neither of whom was a specialist, and only made measurements of height, weight, and head circumference from the physical domain. The other evaluation items in the psychosocial, health behavior, and home environment domains were assessed in the same manner as the experimental group.
Both groups received home visits 1~2 times a month after a participant registered for the study, and the mean time taken in a single visit was 40 minutes. Parents for whom it was deemed necessary to conduct intensive management or who were suspected of neglect or abuse upon visiting the home were counseled in the second visit or in support group sessions. A second visits within a single month was conducted for six families; in two cases, the infant was suspected to have cerebral palsy, in two cases, the infant required oxygen therapy, and in two cases, there were concerns regarding child neglect.
Additionally, parents with premature infants in both groups participated in support group meetings that included professional education, parent counseling, and self-help sessions. In the professional education component, members of a multidisciplinary team (pediatricians, a pediatric nursing professor, physical therapists, nutritionists, psychotherapists, and special education teachers) rotated as guest speakers to provide expert knowledge. The topics of education in both the experimental and control group were the same, and all educators were the same except the nutritionists, as a nutritionist was replaced for personal reasons in the control group. At the self-help meetings, members asked questions each other about the changes experienced by the infant during the past month and communicated about possible solutions. The support group meetings were conducted monthly in the lecture room of the S district office for 2 hours each, and on average were attended by nine parents each month, with their children or alone.
The experimental group data were collected after obtaining permission from K hospital in 2013 (approval no. KUH1090018) and the control group data were collected after obtaining permission of K university in 2016 (approval no. 7001355-201609-HR-137), but remained unused. In 2018, research approval was approved from the Institutional Review Board of K University in Seoul (approval no. 7001355-201609-HR-137) to use the two datasets.
The data collection period of the experimental group was 6 months, beginning on April 1, 2013, when the home visit program for premature infants involving the participation of the experienced NICU nurse was initiated in S county of Seoul. Data collection for the control group began in April 1, 2016 and lasted for 6 months, while the community-based home visit program for premature infants was being operated in the same area.
After providing the subjects with an information sheet on research participation, data were collected by the researcher upon receiving voluntary written consent from the subjects, who were provided with information explaining that the data gathered would be used anonymously and would not be used for any purposes other than research, and that the subjects could withdraw consent to participation at any time during the study period.
A preliminary investigation of the experimental group was conducted using a questionnaire at the time of registration in the initial home visit program (in which the experienced NICU nurse participated) in 2013. The home visits were initiated within a month after program enrollment. Six months of monthly support group sessions followed. When the 6-month period was finished, a follow-up investigation was conducted by sending a questionnaire via email or postal mail. These procedures were conducted in an identical manner for the control group in 2016. The mean time consumed in completing the questionnaire was 15 minutes, and subjects were provided with a small gift for each of two questionnaire sessions (
The data were analyzed using SPSS for Windows version 20.0 (IBM Corp., Armonk, NY, USA). The participants' general characteristics, parenting stress, parenting efficacy, and coping behaviors were analyzed using descriptive statistics, and homogeneity testing was performed using the
There were 29 participants in the experimental group and 27 in the control group. In the homogeneity testing of the general characteristics of the experimental and control groups, the two groups had no significant differences in the mother's age (t=0.17,
The dependent variables-parenting stress (t=0.21,
Regarding hypothesis 1, the score of parenting stress was 77.27±24.24 points after home visits in the experimental group, and 80.81±24.11 points after home visits in the control group. The difference was not statistically significant (t=0.54,
For hypothesis 2, the score of parenting efficacy was 33.93 ±4.81 points after home visits in the experimental group, and 31.44±5.79 points after home visits in the control group. The difference was not statistically significant (t=1.75,
Hypothesis 3 was accepted, as the score of coping behaviors was 109.37±11.81 points in the experimental group, and 100.88 ±8.21 points in the control group, which was a statistically significant difference (t=3.14,
This interventional study was conducted to evaluate the effect of a community-based follow-up program including home visits by an experienced NICU nurse for parents of premature infants on their parenting stress, parenting efficacy and coping.
The study results showed that parenting stress decreased in both groups after home visits; however, the difference was not statistically significant. Having a greater number of home visits is more effective for reducing parenting stress [
Second, although there was no statistically significant difference between the two groups in parenting efficacy, the score increased to a greater extent in the experimental group. The quality of care of the program provided in this study was insufficient to meet the needs of the participants. Parents reported feeling more comfortable interacting with an experienced NICU nurse during home visits because the experienced nurse was a source of useful information on how to provide optimal care and cope with emergency situations in premature infants [
Third, the significantly greater increase in coping behaviors in the experimental group in comparison with the control group demonstrates the positive effects of home visits by the experienced NICU nurse on mothers' coping behaviors. These results can be interpreted as evidence that the mothers in the experimental group were capable of overcoming stressful situations and taking effective countermeasures. Brisch, Bechinger, Betzler and Heinemann [
Among the results of the three coping behavior subscales, significant differences were found between the experimental group and the control group in the scores of subscale I (family integration) and subscale III (medical consultation). This result indicates that subjects frequently utilized coping behaviors for direct resolution of problems through integrated family support and professional counseling. In other words, mothers who participated in home visits by the experienced NICU nurse were able to integrate positive cooperation by the family when checking their premature infant's health conditions and monitoring any warning signs of developmental delays. Of course, it appears that support group provided for both groups allowed the subjects to devise approaches to crisis management and to learn strategies for coping with stress from counseling specialists such as pediatricians, a pediatric nursing professor, physical therapists, nutritionists, psychotherapists, and special education teachers. The self-help meetings provided a network with other parents who were experiencing similar challenges and an environment to freely communicate thoughts and feelings. Discussion between parents allowed an exchange of valuable information and served as a place for learning.
As parents tend to use social support and avoidance as coping behaviors when their infants' health conditions are poor, establishment of self-identity through stable interpersonal relationships and social support, which alleviate stress among mothers of premature infants, facilitates successful coping responses [
The findings of this study show the importance of the participation of an experienced NICU nurse in a community-based follow-up program for parents of premature infants. These home visits enabled effective cooperation and partnership with the mothers of premature infants through the establishment of appropriate solution plans. Participation in community-visit nursing is also useful as a way to reemploy nurses with NICU experience who are no longer active in this field. Since reemployment can be difficult for inactive nurses in this position due to their job satisfaction and career history, community visits by experienced NICU nurses should be encouraged as a way to enhance nursing professionalism and clinical self-efficacy [
Because this study analyzed a small number of participants in S county, the results need to be interpreted carefully. Moreover, data were collected separately in 2013 and 2016; therefore, the exogenous variables that may have affected participants' characteristics were not controlled. The reliability score of the measurements used in this study was low; therefore, in subsequent research it will be necessary to identify and exclude the items that reduced reliability.
In accordance with the increase in the number of premature infants in Korea, specialized healthcare, information dissemination, and communication with the parents of premature infants are necessary to promote optimal growth and development among these infants upon returning home after discharge. This study was conducted to evaluate a community-based follow-up program with home visits by an experienced NICU nurse designed to decrease parenting stress and to increase parenting efficacy and coping behaviors among mothers of premature infants. Monthly home visits and support group meetings provided professional education and counseling, as well as a framework for maintaining interactions among the members. The community-based follow-up program with home visits by an experienced NICU nurse was effective in increasing coping behaviors against stress among mothers of premature infants. In order to improve parenting stress, parenting efficacy, and coping among parents of premature infants, it is necessary to develop guidelines and provide educational programs to improve the quality of care provided by visiting nurses with responsibility for premature infants. Consequently, this study provides evidence for the need to develop and implement a community-based parenting follow-up program based on a social support system involving home visiting by specialists within the community and support group sessions for the future establishment of public healthcare support policies regarding post-discharge management of premature infants.
No existing or potential conflict of interest relevant to this article was reported.
Flow diagram of the home visit program study.
Comparison of the Intervention Procedures of the Two Group
Contents | Experimental group | Control group | |
---|---|---|---|
Home visiting | Visiting members | - One experienced NICU nurse and one visiting nurse | - Two community visiting nurses |
Number of visits | - 1~2 times per month for 6 months | - Equal to the experimental group | |
Role of visitors | - Physical domain: physical measurements, vital signs, physical examinations | - Physical domain: physical measurements | |
- Psychosocial domain: parenting attitude, affection, stress, interpersonal relationships, external contact | - Psychosocial domain: same as the experimental group | ||
- Health behavior domain: nutrition, bathing, activity level, vaccinations, and sleep | - Health behavior domain: same as the experimental group | ||
- Home environment domain: economic status, safety management, hygiene, and degree of parenting support | - Home environment domain: same as the experimental group | ||
Support group meetings | Number of meetings | - Once a month for 6 months | |
Activities | - Professional education and counseling: pediatricians, pediatric nursing professor, physical therapists, nutritionists, psychotherapists, and special education teachers had special lectures by one person each month | ||
- Self-help group meeting: Q&A between members |
NICU=Neonatal intensive care unit; Q&A=Question and answer.
Homogeneity of General Characteristics and Dependent Variables of Participants (
Variables | Characteristics | Categories | Range | Exp. (n=29) |
Cont. (n=27) |
||
---|---|---|---|---|---|---|---|
n (%) or M±SD | n (%) or M±SD | ||||||
Mothers' characteristics | Age (year) | 35.4±3.8 | 35.2±4.4 | 0.17 | .861 | ||
Education level | ≥College | 4 (14.8) | 2 (7.4) | 1.13 | .568 | ||
≤High school | 25 (86.2) | 25 (92.6) | |||||
Employment | Employed | 16 (55.2) | 9 (33.3) | 2.69 | .100 | ||
Unemployed | 13 (44.8) | 18 (66.7) | |||||
Religion | Religious affiliation | 12 (41.4) | 10 (37.0) | 0.11 | .740 | ||
No religious affiliation | 17 (58.6) | 17 (63.0) | |||||
Marital satisfaction | Satisfied | 26 (89.7) | 21 (77.7) | 4.27 | .233 | ||
Dissatisfied | 3 (10.3) | 6 (22.3) | |||||
Health problems | Has a disease | 11 (38.0) | 10 (37.0) | 4.42 | .352 | ||
Has no disease | 28 (62.0) | 17 (63.0) | |||||
Artificial insemination | No attempt | 25 (86.2) | 19 (70.4) | 2.56 | .277 | ||
Attempt | 4 (13.8) | 9 (29.6) | |||||
Infants' characteristics | Birth weight (gm) | 1,651.8±282.8 | 1,714.3±546.6 | 0.23 | .816 | ||
506.0~2,798.0 |
490.0~2,700.0 |
||||||
Gestational age (week) | 29.4±2.0 | 31.2±2.2 | 0.65 | .519 | |||
24.2~35.8 | 25.9~36.1 | ||||||
Length of hospital stay (day) | 37.1±5.1 | 36.9±4.0 | 0.08 | .936 | |||
32.0~44.3 |
33.2~45.0 |
||||||
Dependent variables | Parenting stress | 0~140 | 86.20±17.52 | 87.29±20.43 | 0.21 | .831 | |
Parenting efficacy | 0~45 | 30.68±5.07 | 30.22±6.24 | 0.30 | .759 | ||
Coping | 0~180 | 88.41±15.93 | 84.25±21.34 | 0.82 | .411 | ||
Coping subscale I (family) | 0~76 | 39.27±6.75 | 38.59±8.71 | 0.32 | .743 | ||
Coping subscale II (social) | 0~72 | 34.34±7.46 | 32.40±9.93 | 0.82 | .411 | ||
Coping subscale III (medical) | 0~32 | 14.79±3.75 | 13.25±3.86 | 1.50 | .138 |
Min~Max;
Cont.=Control group; Exp.=Experimental group.
Post-differences in the Dependent Variables between the Two Groups (
Variables | Exp. (n=29) |
Cont. (n=27) |
t | |
---|---|---|---|---|
M±SD | M±SD | |||
Parenting stress | 77.27±24.24 | 80.81±24.11 | 0.54 | .586 |
Parenting efficacy | 33.93±4.81 | 31.44±5.79 | 1.75 | .086 |
Coping total | 109.37±11.81 | 100.88±8.21 | 3.14 | .003 |
Coping subscale I (family) | 46.51±4.47 | 43.59±3.81 | 2.63 | .011 |
Coping subscale II (social) | 42.93±5.96 | 40.66±3.23 | 1.78 | .082 |
Coping subscale III (medical) | 19.93±2.40 | 16.62±3.29 | 4.30 | <.001 |
Cont.=Control group; Exp.=Experimental group.