Mother strategies-nursing

I

A STUDY TO ASSESS THE LEVEL OF STRESS AND COPING

STRATEGIES OF MOTHERS OF NEONATES ADMITTED

IN NICU AT SELECTED HOSPITALS,

BANGALORE, KARNATAKA.

BY

MADHU SUDHANA.K.P

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment

Of the requirements for the degree of

Master of Science in Nursing

In

Child Health Nursing

Under the guidance of

Associate Professor. Chithra.P

Sarvodaya College of Nursing

Rajiv Gandhi University of Health Sciences,

Karnataka, Bangalore

November -2005

II

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

DECLARATION BY THE CANDIDATE

I, Mr. Madhu Sudhana K.P. hereby declare that this dissertation entitled “A study

to assess the level of stress and coping strategies of mothers of neonates admitted in

NICU at selected hospitals, Bangalore, Karnataka” has been prepared by me under the

guidance and direct supervision of Mrs. Chithra.P, Associate professor, Department of

Child Health Nursing, Sarvodaya College of Nursing, Bangalore.

Date: Signature of the candidate

Place: MADHU SUDHANA.K.P

Sarvodaya College of Nursing

Bangalore-40

III

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A study to assess the level of

stress and coping strategies of mothers of neonates admitted in NICU at selected

hospitals, Bangalore, Karnataka” is a bonafide research work done by MADHU

SUDHANA.K.P in partial fulfillment of the requirement for the degree of Master of

Science in Nursing in Child Health Nursing.

Date: Signature of the Guide

Place: Mrs.Chithra.P. M.Sc. (N)

Associate Professor

Dept. of Child Health Nursing

IV

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that the dissertation/thesis entitled “A study to assess the level

of stress and coping strategies of mothers of neonates admitted in NICU at selected

hospitals, Bangalore, Karnataka” is a bonafide research work done by

MADHU SUDHANA.K.P under the guidance of Asst.Prof. Chithra.P (Department of

Child Health Nursing).

Seal & Signature of the HOD Seal & Signature of the Principal

Prof.Hemalatha. M.Sc. (N) Prof. T. Bheemappa M.Sc. (N)

Date: Date:

Place: Place:

V

COPY RIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

Date: Signature of the candidate

Place: MADHU SUDHANA.K.P

©Rajiv Gandhi University of Health Sciences, Karnataka.

VI

Acknowledgement

The satisfaction and pleasure that accompany the successful completion of any

task would be completed without mentioning the people who made it possible, whose

constant guidance, inspiration and encouragement rewards any effort with success.

My sincere and heartful gratitude to Almighty God for his support, guidance,

wisdom, courage, abundant grace, which strengthened me in each and every step

throughout endeavor.

I consider it a privilege to express my gratitude and respect to all those guided and

inspired me in the completion of this project.

I extend my indebted gratitude to Mr. Narayan Swamy, Chairman, Sarvodaya

College of Nursing, Bangalore, for his mobility and kindness towards me from the

beginning of the enrollment in M.Sc., Nursing in the institution and for his

encouragement at my every endeavor.

The present study could never have been successfully completed without the expert

guidance of research supervisors.

I express my deep sense of gratitude to Prof: T.Bheemappa, M.Sc., Nursing,

Principal, Sarvodaya College of Nursing, Bangalore, for his elegant direction and

valuable suggestions in completing the study. I sincerely acknowledge my gratitude to,

sir.

I am privileged to express my sincere thanks to Associate Professor.Chitra. P,

M.Sc (N)., department of Child Health Nursing, Sarvodaya College of Nursing,

VII

Bangalore for her intellectual enlightenment, valuable suggestions, for the elegant

direction and sustained patience for the successful completion of this study.

I express my deep sense of gratitude to my research advisor Prof. Hemalatha,

M.Sc (N)., Sarvodaya College of Nursing, Bangalore for her patience, valuable guidance,

direction, advice and for laying a strong foundation in molding this research project by

giving valuable suggestions.

I extend my indebted gratitude to Prof. Victorial., M.Sc (N). Coordinator of PG

studies, Sarvodaya College of Nursing, for her expert guidance and encouragement to

carry out this dissertation.

I express my sincere thanks to Prof.Chamnalkar, M.Sc (N). Former Principal of

Sarvodaya College of Nursing, for his valuable suggestions and sustained patience for the

successful completion of this study.

I express my deepest sense of gratitude to Dr. Adarsha, Associate professor of

Pediatrics, Kempegowda Institute of Medical Sciences Hospital and Research Center,

Bangalore, for his timely support and constructive suggestion as a co-guide to conduct the

study.

I am grateful to Mr. Amal Xavier M.Sc (N), Principal of Oriental College of

Nursing, Bangalore, for his valuable time in giving correction and suggestions in

completing the study.

My sincere thanks to Prof. Hilda Elizabeth, M.Sc (N). Psychiatric Nursing,

Sarvodaya College of Nursing, Bangalore, for her valuable suggestion and guidance.

VIII

I am forever indebted to Prof. Sugandhi meerabai, M.Sc (N). Community Health

Nursing, Sarvodaya College of Nursing, Bangalore, for her wonderful inspiration and

prayers for the success of this study.

My sincere thanks to the medical superintendent and chief administrators of

Kempgowda Institute of Medical sciences and Research Centre Hospital, and Bangalore

Children’s Hospital and Research Centre, Bangalore for their administrative permission

to conduct the study.

I acknowledge and thank all my teachers for their support, guidance and valuable

suggestions throughout the study.

My grateful acknowledgement to all the experts who validated the tool, for their

judgement and constructive criticism to make this piece of work beautiful.

My special thanks to all the participants who enthusiastically participated in the

study and for being very co-operative and also for adding light to my studies with their

heartfelt expressions.

I would like to thank Dr: Ramesh, M.Sc., Ph.d, Professor of Biostatistics, and

KIDWAI Memorial Institute of Oncology for his generous help and guidance in statistical

analysis of the study.

My sincere thanks to all the Mothers for their sincere efforts, for their interest, co-

operation and participation in the study.

I express my special thanks to all the faculty members, Sarvodaya College of

Nursing, Bangalore, for their support and generous co-operation in completing the study

successfully.

IX

I am thankful to the staff of our college library and other non-teaching

staffs, Sarvodaya College of Nursing, Bangalore, for their support and co-operation in

completing the study.

I am most grateful for the support, inspiration and encouragement of my grand

mother, mother and friends.

X

ABSTRACT

“A study to assess the level of stress and coping strategies of mothers of

neonates admitted in NICU at selected hospitals, Bangalore, Karnataka” was under taken

as a partial fulfillment of requirement for the Degree of Master of Science in Nursing at

Sarvodaya College of Nursing, Rajiv Gandhi University of Health Sciences, Bangalore

during the year 2005.

Objectives of the Study:

◊ To identify the level of stress among mothers when their neonates

are admitted in NICU.

◊ To identify the coping strategies used by the mothers in NICU.

◊ To correlate the stress with coping used by mothers in NICU.

◊ To determine the association of stress level and coping strategies

with the selected demographic variables.

Hypothesis:

Ho: There is no significant association between the stress levels and coping

strategies used by mothers of neonates admitted in NICU at selected hospitals.

Research Approach: A descriptive research approach was used.

Setting: The study was conducted in the NICU of Kempgowda Institute of Medical

sciences and Research Centre Hospital, and Bangalore Children’s Hospital and Research

Centre, Bangalore.

Sample: The sample of the study consisted of 60 mothers of neonates admitted in NICU

at selected hospitals.

XI

Tool: Structured interview schedule was used to collect the data. It consists of 3 sections.

Part I: Demographic variables which include age of the mother, educational status of

mother, occupation of the mother, income of their family, Religion, Area of living

number of children, Admission Condition, and number of days hospitalized.

Part II: Stress questionnaire consists of 40 items and

Part III: Coping questionnaire consists of 40 items. It is measured with the help of

modified three point Likert type scale.

Plan for Data Analysis:

� The data was planned to be analyzed on the basis of objective and hypothesis of

the study.

� The collected data was coded and transformed to master sheet for statistical

analysis.

� Demographic data was planned to represent in terms of frequency and percentage.

� Mean, median and standard deviation for total scores of the parents was

computed.

� Chi-square test was computed for finding out the association between level of

stress and demographic variables.

� Karl Pearson’s Coefficient of Correlation was calculated to find the relationship

between stress and coping.

XII

TABLE OF CONTENTS

Title Page No

1. INTRODUCTION

2. OBJECTIVES

3. REVIEW OF LITERATURE

4. METHODOLOGY

5.RESULTS

6.DISCUSSION

7.CONCLUSION

8.SUMMARY

9.BIBLIOGRAPHY

10.APPENDIX

1-9

10-15

16-29

30-38

39-58

59-62

63-69

70-75

76-81

82-99

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LIST OF TABLES

Sl. No Table Page No

1.

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Distribution of mother’s age.

Distribution of mothers educational status.

Distribution of mothers occupation.

Distribution of monthly family income.

Distribution of mothers area of living.

Distribution of mothers religion.

Distributions of mothers were having number of children.

Distribution of admission condition of neonates.

Distribution of mothers overall percentage according to

their stress level.

Area wise categorization of stress level of mothers.

Distribution of mothers according to their coping strategies.

Area wise categorization of coping strategies of mothers.

Relationship between stress level and coping strategies of

mothers admitted their neonates in NICU.

Association between stress level with selected demographic

variables of mothers admitted their neonates in NICU

Association between coping strategies with demographic

variables mothers admitted their neonates in NICU

41

42

43

44

45

46

47

48

49

50

52

53

54

55-56

57-58

XIV

LIST OF FIGURES

Sl. No Figures Page No

1

2

3

4

5

6

7

8

9

10

11

12

13

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Conceptual framework

Schematic representation of research design

Distribution of mothers age by using bar diagram.

Distribution of mothers educational status by using bar diagram.

Distribution of mothers occupation by using cone diagram.

Distribution of monthly family income by using bar diagram

Distribution of mothers area of living by using pie diagram.

Distribution of mothers religion by using pie diagram.

Distributions of mothers were having number of children by using

cylindrical bar diagram.

Distribution of admission condition of neonates by using bar

diagram.

Distribution of mothers overall percentage according to their stress

level using pie diagram.

Area wise categorization of stress level of mothers by using bar

diagram

Distribution of mothers according to their coping strategies using

pie diagram.

Area wise categorization of coping strategies of mothers by using

bar diagram

15

32

41

42

43

44

45

46

47

48

49

50

52

53

XV

1. INTRODUCTION

The birth of a child can represent a significant transition for most families and

requires establishment of new family roles and routines. The birth of a child with a

critical illness, however, creates unanticipated crises, alters family patterns in ways

that are stressful and makes coping demands for dealing with a critical child more

pronounced for the family system. How families respond to stress will depend on the

interaction of multiple factors such as economic and social stability of the family and

its internal support system, and the amount of external support to which the family

has access 1.

Meeting the needs of parents of children hospitalalised in neonatal intensive care unit

(NICU) is increasingly being recognized as important factor related to their future

parenting as well as child clinical out come. Having a child admitted to a NICU

creates stressful situation for parents. Parents of and infant admitted to NICU are

faced with high technology environment that inhibits normal parenting activities.

Parents of child admitted to the NICU typically responding to the crisis of sudden

illness of the child of the gravity planned major surgery. Parents of children in NICU

experience interruption of family normal activities and their parental responsibilities 2.

“If by saying that all men are born and equal, you mean that they are

all equally born, it is true, but true is in other sense; birth, talent,

labour, virtue, and providence, are forever making the differences.”

-Eugene Edwards

2

The arrival of a child prematurely or ill could be a disruption to the mother

mental coping process. Without question, early arrival of a child is a period of

difficulty for the fetus, which arrives without bodily and/or mental maturity; however,

it is also a time of emotional difficulty for the parents. While studies have been

conducted looking for the etiology and severity of parental problems, few have looked

at helping and supporting the parents jointly (most have looked exclusively at the

mother), and even fewer have looked at the problem through the lens of social

psychology 3.

The unexpected hospitalizations of mothers of sick babies are further removed

from friends and family. Sometimes they are moved to a hospital hours away with an

appropriate NICU, associating most frequently with unfamiliar and often rotating

hospital staff, and often having the means of self-initiated outside contact limited

because of cost, phones, or Internet access 4.

The field of neonatal intensive care has changed dramatically in the past 40

years. Technological and scientific advances have progressively decreased neonatal

morbidity and mortality. However, the NICU environment is one of high stress, crises,

and turbulent emotions for the families of premature and ill neonates in human life

stress is often equated with tension, anxiety, worry and pressure. In day-to-day life all

have stress especially women have more and being a mother in routine life is a

stressful one. When child is admitted in hospital the effects of stress will be more 5.

Less attention has been focused on finding

the best ways to meet the

psychosocial needs of the infant and family than on meeting the infant’s physical

needs. Parents play the central role in providing for most children’s

emotional,

3

physical, social, and developmental needs, yet historically they have been limited in

participating in their child’s care in the NICU. There is growing recognition that

environments designed to make delivery of technological care efficient for staff may

not be optimal for nurturing the growth and development of sick neonates or for their

families 6.

Family-centered care places the needs of the individual infant in the context of the

family and redefines the relationship between parents and caregivers. Information

sharing and collaboration are cornerstones of family-centered care, and they shape a

unit’s

culture, policies, programs, and facility design as well as the day-to-day

interactions between mothers, caregivers and families. The potential benefits of

family-centered care include improved satisfaction with care, decreased parental

stress, increased parental comfort and competence with postdischarge care, improved

success with breastfeeding, shortened hospital lengths of stay, decreased readmissions

postdischarge, and increased staff satisfaction 7.

In human life stress is often equated with tension, anxiety, worry and pressure. It is an

accepted fact that stress is necessary for life and it can cause either beneficial or

detrimental effects. In day-to-day life all have stress especially woman have more and

being a mother in routine life is a stressful one. That too child is admitted in hospital

the effects of stress will be more 8

.

While looking at the various factors of neonatal illness and care of the mother

with meticulous stress on mother internal and external environmental condition, we

have often overlooked many other major factors influencing newborn care and

survival. In a country plagued by differences of caste, creed, social and educational

bias, we have often forgotten to link adverse social and cultural events to neonatal

4

morbidity and mortality. Many contributory factors like poverty, illiteracy, poor

maternal health, barriers to exclusive breastfeeding, harmful traditional practices and

inadequate health care facilities and lack of psychological, emotional, social support

to be studied in great deal and deficiencies adequately addressed before we expect to

see a substantial dent in the indices of newborn as well as mother health 9.

If mothers are the primary care givers and they may not able to meet the

demands of their family needs while devoting themselves to the care of an ill child.

Emotional and financial problems may increase because of the family disruption and

the cost of caring an ill child. The birth of a premature baby, or critically sick,

whether it is expected or not, is a traumatic experience for mothers and family. To

speak about initial feelings of shock and anxiety as they find themselves in an

environment and set of circumstances which are entirely unfamiliar and a

significantly faced with the possibility of losing their baby parents describe the

experience of having to cope with these circumstances as a daily struggle, which can

fluctuate from one moment to the next according to their baby’s changing health

circumstances. Many mothers who describe a spiral of difficulties, these difficulties

relate to parents in emotional turmoil, which in turn leads to a lack of clear

communication and information exchange, leaving mothers feeling inadequate and

lost. Mothers describe being worried that they may harm their baby if they try to get

involved in aspects of their care, which results in a lack of confidence and inadequacy

in looking after their baby once they leave the hospital 10

.

5

NEED FOR THE STUDY:

The global burden of neonatal deaths is estimated to be 5 million of which 3.2

million deaths occur during the first week of life. Almost a quarter of the burden of

neonatal mortality is shared by India with three babies dying every minute, and every

fourth baby born being low birth weight. The problems faced by newborn infants vary

significantly in different parts of the globe; even among developing nations there is

much heterogeneity in the causes of neonatal morbidity and mortality. While planning

and providing health care services to newborn infants, we have primarily looked at the

information originating in specialized neonatal units rather than at the grass root

level11

.

While looking at the various causes of neonatal illness and death, we have often

overlooked many other major factors influencing newborn care and survival. In a

country plagued by differences of caste, creed, social and educational bias, we have

often forgotten to link adverse social and cultural events to neonatal morbidity and

mortality. Many contributory factors like poverty, illiteracy, poor maternal health,

barriers to exclusive breastfeeding, harmful traditional practices and inadequate health

care facilities and transport need to be studied in great detail and deficiencies

adequately addressed before we expect to see a substantial dent in the indices of

newborn health 12

.

Mother with high–risk pregnancy is having increased risk for

subsequent parenting problems. If the need for NICU is anticipated before birth,

maternal transport to proper facility should be planned. Repeated studies have been

confirmed that better survival rate of high risk infants whose mother transported to

prenatal centers for delivery compared to infants transported after birth to NICU. It is

6

also very helpful to orient the parents to the units where their baby will occupy before

delivery which will help on decreasing the stress and increase the coping 13

.

Stress in human life includes tension, anxiety, worry and pressure. It is an

accepted fact that stress is necessary for life and it can be either beneficial or

detrimental. These effects can be physical, emotional, intellectual, spiritual and

social. Illness is an added stressful event for a person and a quick resolution of such

stressful situations is sometimes needed to test the possibility of an escalating stress

that could overwhelm a person experiencing it. Understanding the concept of stress is

therefore necessary as it provides a way of understanding a person as a unified being

who responds in totality to a variety of chaos that takes place in daily life 14

.

When a child is admitted to the NICU the parent’s role is altered.

Assuming the role of parents can be very difficult for the parents whose child is in

NICU. Holding, touching and eye contact, talking to the child is important for the

child and the parents. Before parents visit the NICU for the first time the need to

prepare them for the unfamiliar environment is necessary before they enter. The

flashing lights and buzzers on the monitors and all the equipment attached to the child

can be very frightening 15

.

According to Selye defines stress as the non-specific response of the body to any

demand regardless of its nature. This response included a series of physiologic

reactions that he labeled as general adaptation syndrome, which as 3 stages Alarm,

Resistance and exhaustion. During the alarm stage, physiological mechanisms in the

body are mobilized so that the person can deal with whatever is threatening

homeostasis. During the resistance stage, the person is adapting to the stressor and is

trying to return to a stage of equilibrium. The stage of exhaustion occurs when the

7

body stressor is overwhelming in intensity or duration and the person no longer has

the resources to handle the situation16

.

According to Lazarus and Folkman defines coping as constantly changing cognitive

and behavioral efforts to manage specific external and internal demands that are

appraised as taxing or exceeding the resources of the person. Emotion focused coping

is aimed at reducing emotional distress and maintaining a satisfactory internal state

for processing information and action. They identified 2 types of coping responses as

problem focused and emotion focused. Problem focused coping involves efforts to

deal with the sources of stress whether by changing one’s own problem maintaining

behaviour by changing environmental conditions 17

.

Gorski had said that the early birth of a baby or unplanned admission to a

NICU presents a crisis for the parents. McGovern had described that unplanned

admission of a child to NICU will produce negative feelings of aggression, anxiety,

guilt, shock; fear confusion to the mothers may surround the situation. Hospitalization

involves that parents are in an unfamiliar environment and their parental role changes.

Parents of children with critical conditions often face agonizing situation about NICU.

Nurses and physicians can best support families in this situation, showing sensitivity

to the steps that parents use to cope up 18

.

Melnyk B.M, Small L, Carno MA, Studied the effects of family resources,

coping, and strains on family adjustment 18 to 24 months after the NICU experience.

The purpose is to examine the relationship of family coping, resources and strains on

family adjustment over time following the NICU experience. Using Longitudinal,

correlational study based on Resiliency Model of Family Stress, Adjustment and

Adaptation. The main outcome variables in the study were family adjustment,

8

measured by the McMaster Family Assessment Device. The independent

Management, family coping, as measured by the Family crisis Oriented evaluation

Scales: Family strain, as measured by the family inventory of life events and Changes;

and parent gender, family system (first-time parent or not), and the child’s health, as

measured by the Demographic Information Questionnaire. The result of this study is

improved family adjustment over time for mothers and fathers. Fathers of infants with

ongoing health problems reported significantly poorer family adjustment. Family

resources were related to family adjustment and decrease over time for both parents.

Families used more coping mechanisms and different coping patterns over time 19

.

Any illness severe enough to necessitate admission to a critical care unit is life

threatening and can precipitate severe anxiety within a family system. Mother

perceives fear of death, uncertain outcome, emotional turmoil, financial concerns, role

changes, disruptions of routines and unfamiliar hospital environments are a few

sources of anxiety for the family members.

Where problems arise, whether anticipated or unexpected, parents should be

aware that in the interests of the mother or newborn baby, transfer to a specialist unit

might be needed. During the admission period families must deal with many stressors

including parental role alteration, financial inadequacies, uncertain prognosis,

isolation from other family members, dramatic disruption in daily routines and

unknown intensive care unit environments. Stress is a big problem in our society. In

recent years stress and its possible effect on mental health have become increasingly

important in nursing. Moreover public has become more aware of the potential effects

of stress on their lives.

9

The investigators had observed during his experience and while conducting

study in that mother were under extreme stress when their babies were admitted in

NICU. It is a good professional role to let a mother involve at her own level,

supporting her in her coping skills, boosting her confidence and understanding

herself, supplementing her effort instead of giving detailed directions cautions which

may increase her confidence. This study is to identify and compare the stress and

coping methods of the mothers of neonates are admitted in neonatal intensive care

unit (NICU). Identifying the experiences perceived as most stressful and coping

methods used by mothers can help the nurse in anticipating mother’s needs and

formulation of policies and interventions. Much effort has been expended in recent

times by pediatric nurses, social scientists, psychologists included in coming to terms

with the ubiquitous presence of technology in our lives. Of particular significance is

the use of proper information communication focused on coping is aimed at reducing

emotional distress and maintaining a satisfactory internal state for processing

information and action.

Statement of the Problem:

“A Study To Assess The Level Of Stress And Coping Strategies Of

Mothers Of Neonates Admitted In Neonatal Intensive Care Unit (NICU) At

Selected Hospitals, Bangalore, Karnataka”.

10

2. OBJECTIVES OF THE STUDY

It deals with the statement of the problem, objectives of the study, operational

definitions, assumptions of the study and conceptual framework.

Statement of the Problem:

“A Study To Assess The Level Of Stress And Coping Strategies Of

Mothers Of Neonates Admitted In Neonatal Intensive Care Unit (NICU) At

Selected Hospitals, Bangalore, Karnataka”.

Objectives of the Study:

1. To identify the level of stress among mothers when their neonates are admitted in

Neonatal Intensive Care Unit (NICU).

2. To identify the coping strategies used by the mothers in NICU.

3. To correlate the stress with coping used by mothers in NICU.

4. To determine the association of stress level and coping strategies with the selected

demographic variables.

Hypothesis:

Ho: There is no significant association between the stress level and coping strategies

used by mothers admitted their neonates in NICU.

Operational Definitions:

Neonanate:

Referred to the first month of life or the interval from the birth to 28 days of

age who are admitted in NICU.

11

Stress:

It is defined as the factors which are commonly experienced by mothers of

whose neonates have admitted in NICU.

Stress in human life includes tension, anxiety, worry and pressure. It is an

accepted fact that stress is necessary for life and it can be either beneficial or

detrimental. Stress is the tension producing factors that have the potential of

weakening the normal lines of defense, which is divided into physical, physiological,

emotional, cognitive, psychological and parental, economical domains.

Coping strategies:

Coping is the cognitive and behavioural efforts used to manage external and internal

stressful demands that are appraised to be exceeding the resources of the persons. It

means the extent which mother experience and try to adjust to the situation and ability

to deal with the stress successfully and realistically and willing to choose different

coping strategies by mothers towards problem solving.

Assumptions:

� The mothers of neonates in neonatal intensive care unit may undergo high

levels of stress and a crisis when their neonates in NICU.

� The mothers of neonates admitted in neonatal intensive care unit may go

through a crisis when their neonates critically ill or hospitalized and they try to

adapt the situation by using various coping methods.

� Expectation and perceive needs of mothers are identified by staff of the

hospital when they spend time to interact with the mothers.

� Mother’s perception of stress may differ according to their age, Educational

qualification, Occupation of the mother, Monthly family Income, Religion,

12

Area of living, Number of Children, Nature of treatment and Number of days

hospitalized.

Delimitations:

The study could be generalized only to mothers who were with the critically ill

and sick neonates during their admission to the Neonatal Intensive Care Unit of

Kempgowda Institute of Medical sciences and Research Centre Hospital, and

Bangalore Children’s Hospital and Research Centre, Bangalore.

Projected Outcome:

This study attempted to identify and analyse the stressful factors and coping

methods of mothers with neonates admitted in NICU. The stressful events and coping

methods will be identified to help nurses to modify the care provided for the mothers

and neonates in such a way to reduce stress to mothers. By identifying the stressful

factors of the mothers when the child is hospitalized and their coping strategies, the

nurse can use their knowledge to enhancing the coping strategy and reduce the stress.

This helped investigator to identify various areas of stressful situation and different

coping strategies used by mothers during their neonates admitted in NICU

Conceptual Framework of the Study:

The conceptual framework serves as a springboard for theory development

and scientific advancements. The theoretical context enhances the importance of the

study, where a model symbolically represents a phenomenon. . It is a device that helps

to stimulate research and the extension of knowledge by providing direction, impetus

as well as application of this process in clinical area.

13

Roy’s adaptation model serves as the conceptual framework for this study which

was designed by Sister Callista Roy in 1970. The focus of Roy’s adaptation model is

the set of process by which a person adapts to environmental stressors. When the

demands of environmental stimuli are too great or the person’s adaptive mechanisms

are too low, the person’s behavioural responses are ineffective for coping. A group of

concepts and a set of propositions that spells out the relationships between them. The

overall purpose of this conceptual framework is to make scientific findings

meaningful and generalizable.

In this study mothers are considered as an adaptive system and she functions

as a whole through interdependence of its parts. The system consists of input, control

process, output and feedback.

The inputs are stimuli from the external environment and the internal self.

Here it is the stress from the hospital environment and from her internal self. This is

the range of stimuli to which a person adaptively responds with ordinary effort. The

range of responses is unique to the individual. Each person’s adaptation level is

constantly changing aspect, which is modulated by coping mechanisms of that person.

In this study control process includes both biological and psychological

coping of the mother. Roy’s Adaptation model views a person as an adaptive system

in constant interaction with an internal and external environment. The environment is

the source of a variety of stimuli that either threaten or promote the person’s unique

wholeness. A stimulus is any entity that provokes a response. The person’s major task

is to maintain integrity in face of these environmental stimuli and coping mechanisms

which were primarily aimed at solving a problem in handling a stressful situation and

strategies used to manage emotions in stressful situations20

.

14

Output is the adaptive and non adaptive behaviour responses of the mother.

Output includes adaptive or ineffective responses. Adaptive responses promote

integrity of the person where as ineffective responses to stimuli leads to disruption of

the integrity of the person.

Output behaviors demonstrated in this study are inferred by use of positive

coping mechanisms such engaging in activities, involve in spiritual and divertional

activity, talks with the family, seeks comfort and help from others. And negative

coping mechanisms such as not interested in social gathering, blaming herself, sitting

alone, etc

Feedbacks of information regarding the behavioural responses are conveyed as

an input in the system. Each person is affected by various stressors called stimuli. The

focal stimuli or a change may immediately confront the person. Here mothers have to

adapt to the intensive care environment and stress relate to hospitalization of their

neonate require an adaptive system.

A Cotextual stimulus is all other stimuli present in the environment and

person. That is, the technical equipment and other instruments in NICU, alter family

process and financial crisis etc.

Residual stimulus is the beliefs, attitudes or traits that affect the present

situation. Mother’s belief and attitudes of past experience with some one will produce

stress in present situation20

.

15

Fig 01

16

3. REVIEW OF LITERATURE

Review of literature refers to an extensive, exhaustive and systematic

examination of publications relevant to the study. It is an essential part of every

research, which helps to support the hypothesis under the study and to critically

analyze the structure and content of the research report 21

.

Review of literature makes the researcher familiar with the existing studies

and provides information, which helps to focus on a particular problem and lays a

foundation upon which the new knowledge can be based.

A literature review is one of the major components of the research process. The

review literature relevant to the present study was not documented on large scale.

However and attempt is made in this chapter to bring out the available literature

related to the study.

The scope of review of literature includes obtaining different types of

information available on a particular topic. The literature was reviewed from

published journals, textbooks and website lines to widen the understanding of

research problem and methodology for the study. The reviewed literature is classified

under the following headings 21

.

The review of literature relevant to this study which has been arranged in the

following categories:

1) Overall view of stress and coping of mothers.

2) Studies related to Stress factors of mothers

3) Studies related to Coping strategies of mothers

17

1) Overall view of stress and coping of mothers:-

Children are usually admitted in an intensive care unit when they require

intensive therapy to maintain their physiological homeostatic equilibrium. The

intensive care unit is often a perplexing and frightening environment for critically ill

children and mothers. The child is often bombarded with a massive array of sensory

stimuli, the focus of which is primarily to maintain the physiological equilibrium.

Emphasis is on tasks rather than on the person who is critically ill. In such an

environment it is sometimes difficult for staff to provide intensive care and also, to

maintain mother-child relationships.

Shellabarger SG, Thompson TL.did a study on the parental stresses caused

by a premature birth and the NICU experience may create problems in the parent-

child relationship. These problems may lead to subsequent difficulty in bonding or

parenting, and may even be related to child neglect and abuse. The NICU staff is in a

unique position to help minimize parental stress by providing information, support,

and understanding to facilitate coping with fear and uncertainty. Parents need help in

adjusting their expectations to reality, especially during the early days in the NICU.

While the mother is still hospitalized, the father is in an especially vulnerable

position, as he may be unprepared to be a primary caregiver, threatened by the female

staff, and expected to assume a focal role while he may need comfort himself.

Information that is most helpful to parents is that which helps return some control to

them. Involving parents in the child's care giving and in decision making also helps

increase parental feelings of control and decrease feelings of stress. Attention should

be paid to the questions and nonverbal communication of the parents to ascertain

when communication is especially important. Key times during which communication

is typically crucial are identified 22

.

18

Shields L reviewed from developed countries aim of this review was to critically

examine publication relating to the effect of hospitalization on children and their

parents. ‘Parents”. In this context, were considered as the child’s natural or adoptive

parents, step-parents or any other context of parent-child. Most of the work was

sourced from the nursing literature, while in developing countries; the available

literature was largely from medicine. Conclusion from developed countries indicated

hat parents should be allowed to stay in hospital with their child, and that care must be

development stage appropriate. Further more, staff needs to be educated about special

needs of children; children should be prepared for hospital a

mission (if possible) and Parents needs met. In developing countries, the meager

literature available Suggested that recognition of the important role parents play in a

child’s hospitalization is starting to become recognized 23

.

Field had conducted a study about potentially stressful features of the intensive care

unit environment and found that factors such as continuous high intensity noise and

bright light have generated concern over the environment of the neonatal intensive

care unit. 24

Young Seideman R, Watson MA, Corff KE, Odle P, Haase J. did a this study to

identify and compare parental perceptions of their stress and coping experiences with

children in neonatal intensive care units (NICU) and the pediatric intensive care units

(PICU). The sample consisted of 31 NICU and 20 PICU parents. Parents in both units

experienced the most stress from alteration in their parenting role and in their infants'

behavior and appearance. Parents of children in PICU found assistance with parenting

role more helpful than parents of children in NICU. Parents with children in the PICU

perceived problems-focused coping more helpful than parents with children in the

19

NICU; parents of children in NICU found emotion-focused coping more helpful than

parents of children in PICU. Parents in both units considered problem-focused coping

more helpful than appraisal- or emotion-focused coping 25

.

Stota MC explained that the sight and sound of an equipment attached to sick babies

causes anxiety and fear. Parents often cannot distinguish between alarms that signal

life-threating conditions or those that may indicate some times as simply as a

complicated medicine. The presence of other sick injured of crying children and their

apprehensive parents cause additional stress and alteration in parent role 26

.

Holditch-Davis D, Miles MS. The purpose of this article is to let mothers tell the

stories of their neonatal intensive care unit (NICU) experiences and to determine how

well these experiences fit the Preterm Parental Distress Model. Interviews were

conducted with 31 mothers when their infants were six months of age corrected for

Prematurity and were analyzed using the conceptual model as a framework. The

analysis verified the presence in the data of the six major sources of stress indicated in

the Preterm Parental Distress Model: (1) pre-existing and concurrent personal and

family factors, (2) prenatal and perinatal experiences, (3) infant illness, treatments,

and appearance in the NICU, (4) concerns about the infant's outcomes, (5) loss of the

parental role, and (6) health care providers. The study indicates that health care

providers, and especially nurses, can have a major role in reducing parental distress

by maintaining ongoing communication with parents and providing competent care

for their infants 27

.

Miles MS, Funk SG, Kasper MA. Many aspects of neonatal intensive care units

(NICUs) are stressful to parents, including prolonged hospitalization, alterations in

20

parenting, exposure to a technical environment, and the appearance of their small,

fragile infant. To identify potential NICU stressors for parents, levels of stress these

experiences engender, and their relationships to anxiety, parents of infants

hospitalized in three NICU were interviewed using the Parental Stressor Scale: NICU

and the State-Trait Anxiety Inventory. Alterations in parental role caused by the

infant's illness generated the greatest stress. The second highest areas of stress were

the infant's appearance and behavior. State anxiety levels were higher than normative

means and significantly related to stress scores 28

.

Carter JD, et; al compared the psychosocial functioning of the parents (mother and

father) of infants admitted to a neonatal intensive care unit (NICU) with the parents of

infants born at term and not admitted to the NICU. Data collected randomly from 447

parents (242 mothers; 205 fathers) with an infant admitted to a regional NICU during

a 12 month period; 189 parents (100 mothers; 89 fathers) with infants born at term

and not requiring NICU admission. It is noticed that Overall, levels of anxiety and

depression were low in both parent groups. Compared with control parents, a higher

percentage of NICU parents had clinically relevant anxiety and were more likely to

have had a previous NICU admission and be in a lower family income bracket. Infant

prematurity was associated with higher levels of symptomatology in both NICU

others and fathers. The results indicated that Infant prematurity impacts negatively on

the father as well as the mother. Consequently these parents may benefit from

increased clinical attention 29

.

Meyer Ellaine had conducted a study about pediatric intensive care. The

parents experience, and found the factors from the parents perspective, intensive care

units are busy and intimidating places, dominated by sick children, worried staff and

21

family members, advanced medical technology, bright lights and shrill monitors. The

technical languages used by the staffs are confusing to the parents 30

.

The Government of India has set a target of reducing the infant mortality rate

from 64 to 30 per 1000 live births by the year 2010, which can only be possible if

neonatal mortality is reduced from 44 to 20 in this period(3). However, there has been

only a 15% decline in neonatal mortality during the 1990s that plateau in recent

years(4). In a country as vast and varied as ours there is also much geographical

variation in the rates of neonatal mortality; more than half of the burden of neonatal

deaths is shared among three large states (Uttar Pradesh - 26%, Madhya Pradesh-13%,

Bihar-12%)(5). Sepsis, asphyxia and prematurity are the primary causes of neonatal

deaths in rural India. Hence plans and programs have to necessarily be tailor-made to

meet the local requirements. The pioneering work from Gadchiroli among tribal

population with none or minimal neonatal care services has shown that community

interventions aimed to provide essential newborn care and treat sepsis effectively by

dedicated community health workers could bring down neonatal mortality to a large

extent 31

.

In the recent past there has been a mushrooming of ‘neonatal intensive care

units’ especially in the urban areas and metropolis. A large number of medical

personnel have received training in new and advanced treatment modalities. In these

units, management is directed towards salvaging the tiniest of babies with

sophisticated and expensive techniques such as new modes of ventilation,

administration of surfactant and total parenteral nutrition. Sadly enough, the support

systems needed for further growth and development of these particularly vulnerable

babies has not been adequately developed and thus these NICU graduates often

22

struggle to have an optimum long-term outcome and often with an increased risk for

future psychomotor retardation. Hence, the Academy in association with the National

Neonatology Forum proposes to organize neuro-developmental follow up programs

and promote developmental friendly well-baby clinics at all pediatric facilities 32

.

2) Studies related to stress factors of mothers:-

Several research articles have described parental stress and needs of family

members or parents of children hospitalized in intensive care unit. The potential

sources of stress that affect parents of children in intensive care unit as found by

Miles MS, Carlson J, Funk SG. Over the past two decades, awareness of the

importance of social support for individuals faced with a major life transition or a

stressful event has increased. The purpose of this study was to identify the perceptions

of mothers and fathers of critically ill infants about the helpfulness of support

provided to them by family, health care professionals, and other when their infants

were in a neonatal intensive care unit (NICU). Social support in this study is

conceptualized as the interpersonal transactions that parents of preterm infants

perceive as helpful in reducing their stress and coping with their child's illness. Data

were collected using the Illness Support Scale, on which subjects rated the helpfulness

of support from individuals across their network. Findings indicate that these parents

experienced a moderately high level of support and perceived NICU nurses as very

helpful. Nurses need to continue to develop their role in helping families by

identifying specific supportive interventions 33

.

Seideman. Et al., conducted a study on parents stress and coping in NICU and PICU.

The purpose of the study was to identify and compare parental perception of their

stress and coping experience with children in pediatric intensive care unit and

23

neonatal intensive care units. The sample consisted of 31 NICU and 20 PICU parents.

Parents in both units experience the most stress from alternation in their parenting role

and in their infant’s behaviour and appearance. Parents in both units considered

problem focused coping was more helpful than appraisal or emotion focused coping34

.

Bell studied the adolescent mothers perception of the NICU environment. Forty six

mothers found that the most stressful aspects of the NICU were parental role

alternation and the infant’s appearance and behaviours. Less stressful were the sights

and sounds of the NICU and communication with staff members 36

.

Marcia S which have done survey study on parents coping with infants requiring

home cardio respiratory monitoring in Mankato state University, Mankato, MN. The

sample consisted of 20 families whose children had been released from hospital to

home for not less than 1 month. A 19-item semi structured interview schedule was

conducted and the interviews were tape-recorded. The findings of the study is the

greatest percentage (85%) of the parents reported the persistent gravity of the situation

was the most stressful part of caring for their infant at home, (85%) indicated that it

was stressful to try to relax while their infant was in the care of incompetent and non

nurturing home care nurses, 70% said that their own feelings of inadequacy and lack

of confidence were a source of stress for them, 55% described social isolation as

stressful and inadequate financial assistance for the infant’s care was reported by

(20%) 36

.

Haines, Perger and Nagy in their study on 71 parents of children in a technologically

intense pediatric intensive care unit identified the major sources of stress for parents.

They also compared the sources of stress for parents whose children were intubated

with those whose children were not intubated. The findings showed that parents were

24

most distressed by a) the painful procedures with their children were subjected to b)

by the sights and sounds of the pediatric intensive care unit and c) by their children

reactions to intensive care. Parents of intubated children were compared with

parents of non-intubated children. It showed that painful procedures were a source

of greater stress to parents of intubated children whereas the behaviors of staff and the

children’s reactions to the intensive care experiences caused greater stress to the

parents of non-intubated children. Health professionals need to help parents to adjust

to the pediatric intensive care environment by ensuring that continual discussions and

explanations take place throughout the child’s stay 37

.

Kratochvil MS, Robertson CM, Kyle JM. Length of stay in neonatal intensive care

and outcome were among the not significant variables. Parents of 597 survivors

indicated whether the initial illness and separation had had a long-term effect on their

parent-child relationships. Forty percent felt there was an effect on the parent-child

relationship, sixty percent did not. Neonatal, medical and social conditions, and the

child's outcome (i.e., disabled or not) were variables analyzed to determine

differences between the two groups of parents. Parents who felt an effect from the

initial illness and separation had children who required supplemental oxygen

significantly longer and were from significantly higher socioeconomic and education

levels38

.

3) Studies related to coping strategies:

Majority of mothers reported the following coping strategies, trying to keep

feelings about the problem from interfering with other things, letting feelings out

some how, trying to analyze the problem to understand it better, concentrating on

what to do next and talking to someone about feelings. Important coping strategies

25

were grouped as seeking social support, problem solving and positive reappraisal.

Problem solving coping strategies were associated with the educational level and age

of mothers.

Doering LV and Moser DK had done correlational study to identify relation between

parental anxiety, hostility, depression, and psychosocial adjustment in 469 parents

(mothers & parents) whose infants are hospitalized in NICU. It is noticed that Parents

experienced high levels of anxiety, hostility, and depression. Poorer family

functioning, lower levels of social support, and lower perceived control were

associated with higher levels of anxiety, hostility, and depression and with poorer

adjustment. Parental status (mother or father), ethnicity, employment status, and

education were significantly related to parental responses 39

.

Pinelli J has done a study to investigate relationship between family coping and

resources and family adjustment and parental stress in the acute phase of the NICU

experience. Data collected from 124 mothers using the family Crisis Oriented

Personal Evaluation Scales, and the General Functioning subscale of the McMaster

Family Assessment Device. The results indicated that adequate resources were more

strongly related to positive adjustment and decreased stress than were either coping or

being a first-time parent. The relationships among the variables were generally the

same for both parents. Mothers utilized more coping strategies than did father and it

recommended that families with limited resources should be identified early to

facilitate their adjustment to the NICU 40

.

Miles MS et; al. in this study identified the perceptions of mothers and fathers of

critically ill infants about the helpfulness of support provided to them by family,

health care professionals, and other when their infants were in a neonatal intensive

26

care unit (NICU). Over the past two decades, awareness of the importance of social

support for individuals faced with a major life transition or a stressful event has

increased. Social support in this study is conceptualized as the interpersonal

transactions that parents of preterm infants perceive as helpful in reducing their stress

and coping with their child's illness. Data were collected using the Illness Support

Scale, on which subjects rated the helpfulness of support from individuals across their

network. Findings indicate that these parents experienced a moderately high level of

support and perceived NICU nurses as very helpful. Nurses need to continue to

develop their role in helping families by identifying specific supportive

interventions41

.

Doucette J and Pinelli J examined relationship of family coping, resources, and

strains on family adjustment over time following the NICU experience. Data were

collected based on the Resiliency Model of Family Stress, Adjustment and Adaptation

model from 71 couples, 18 to 24 months following the birth of their infant. The

results showed that Family adjustment improved over time for mothers but decreased

for fathers. Fathers of infants with ongoing health problems reported significantly

poorer family adjustment. Family resources were related to family adjustment and

decreased over time for both parents 42

.

Ward K did a study to identify the perceived needs of parents of infants in a neonatal

intensive care unit (NICU). A convenience sample of 52 parents of NICU infants

completed the NICU Family Needs Inventory that was modified from the Critical

Care Family Needs Inventory (CCFNI). Data were analyzed using descriptive

statistics. The differences between mother and father responses were analyzed by

ANOVA. The ten most important and least important need statements were

27

identified. The participants reported assurance and information-related routine needs

as the most important, while support needs were ranked as least important. Out come

revealed a significant difference between mother and father responses. Fathers ranked

support, information, and assurance needs more significantly less important than

mothers did. The findings suggest the need to inform parents of the infants treatment

plan and procedures, answer parents' questions honestly, actively listen to parents'

fears and expectations, assist parents in understanding infant responses to

hospitalization, and other effective nursing interventions to help meet the needs of

parents of NICU infants 43

.

Lydia B Olley conducted a survey on perceived stress factors and coping mechanisms

among mothers of children with sickle cell disease in Western Nigeria. They have

selected 200 mothers by non-probability sampling. Acceptance (80%) was the pre

dominant mode of coping, (38%) tried to avoid the problem, 19.5% would complain

and 10% confront it 44

.

Miles and Carter identified five coping strategies perceived as most helpful to

parents of critically ill children. These 5 categories included 1) seeking help or

comfort from others, 2) behaving that the child is getting the best possible care 3)

seeking as much information as possible 4) having hope, 5) being near the child as

much as possible. The use of prayers, asking questions to the staff and talking with

other parents was also mentioned as helpful 45

.

Lynda L et;al conducted a study on optimism, anxiety and coping in parents of

children hospitalized for spinal surgery in Vanderbilt university school of nursing,

Nashville, USA. They have selected 60 parents and administered the Life Orientation

Test to assess Optimism and the Ways of coping questionnaire. The findings of the

28

study revealed that the positive reappraisal was the most often used emotion focused

coping strategy and seeking social support was the most often used problem focused

coping strategy 46

.

Swallow and Jacoby did a qualitative study to assess the mother’s coping in chronic

childhood illness, the effect of presymptomatic diagnosis of vesico ureteric reflux.

They have selected mothers of 15 children with vesico ureteric reflux diagnosed pre

symptomatically and post symptomatically and did a semi structured in depth

interviews. Findings for both groups fall into 3 discrete phases: the prediagnostic

diagnostic and post diagnostic. The mothers in the post symptomatic diagnosis group

experienced most problems in coping and mothers in the pre symptomatic group

coped well apart from those who themselves had vesico ureteric reflux. Both the

group required improved information provision and support to assist coping with the

sustained uncertainty of the condition 47

.

Gale G, Franck L., and Eund C. did a study and reported that Skin to skin holding

of the intubated premature infant. In that, it has been reported that it was a useful

technique for helping mothers feel close to their intubated infants hospitalized in the

NICU 48

.

Waston. M in an article mentioned that the needs of the mother while her infant is in

the NICU are many and varied, as each individual responds differently to the demands

and stresses of her infants hospitalisation. Only by adopting a synchronized approach

to the care of the mother and infant an effective system of care is created 49

.

29

Jarret, M.H. did a study on Parent partners: a parent support program in the NICU. It

is specified that a well organized parent-to-parent support program can provide both

support and resources to help parents deal with the stress of having a baby in the

NICU50

.

Raines. D.A. Conducted a study on Parent values: a missing link in the neonatal

intensive care equation. This study reviews the existing literature related to parents

opinions and perceptions of care in the NICU and proposes a framework for the

exploration of the valve systems of parents of infants requiring neonatal intensive

care51

.

30

4. RESEARCH METHODOLOGY

The research methodology includes research design, research approach, study

setting and sampling technique, data collection method, development of the tool,

description of the tool and data analysis. The present study aims to assess the level of

stress and coping strategies of mothers of neonates who are admitted in NICU at

selected hospitals, Bangalore, Karnataka. The research methodology organizes all the

component of the study, providing the overall framework for availing valid answer to

the sub problems that have been stated.

Research Approach:

A descriptive approach is used to accomplish the objectives of the study, and

intended to gather data concerning level of stress and coping strategies. It describes

the situations as they exist in the world and provides an accurate account of

characteristics of particular sample, individuals, and situations. The outcome of

descriptive research provides a basis for future quantitative research.

Research Design:

The research design is the plan for the study, connected with an investigators

overall framework of conducting the study and obtaining answers to the research

questions, it is stated that the research design incorporates the most important

methodological decisions that a researcher makes in conducting research study 52

.

The research design helps the researcher in the selection of subjects for

interviewing the mothers, and determines the type of analyses to be used to interpret

the data. The selection of research design depends on the purpose of the study.

31

The research design used for this study was descriptive. The descriptive design was

selected since it aided in attaining first hand information and enhanced obtaining

accurate and meaningful information data.

32

Fig: 02

33

Setting of the Study:

The setting refers to the area where the study is conducted. The setting of this

study was in NICU of Kempegowda Institute of Medical Sciences and Research

Centre Hospital, Bangalore, Karnataka. It is a 950 bedded hospital in Bangalore

which consists of all the specialties and superspecialities. It is an educational and

research institute as well as referral center. It has a separate neonatal Intensive Care

Unit (NICU) .and Bangalore Children’s Hospital and Research Centre, Bangalore,

Karnataka .It is a 250 bedded pediatric specialty hospital as well as research center for

higher studies. The above settings were selected because availability of the sample,

feasibility of conducting study and ethical clearance.

Population: In this present study the population consisted of mothers admitted their

neonates in NICU at selected hospitals, Bangalore from 27-08-2005 to 27-09-2005.

The population referred to as the entire aggregation of cases that met designed set of

criteria 53

.

Sample: A sample is a small proportion of a population selected for observation and

analysis. The process of sampling makes it possible to draw valid inferences and

generalization. In this study sample consisted of 60 mothers who had admitted their

neonates in NICU, and who met the inclusion criteria.

Sampling Technique: In this study purposive sampling technique was adopted and it

is referred to as judgemental sampling, which involves the conscious selection by the

investigator on the basis accessibility. Data was collected from the mother admitted

their neonates in NICU. From each mother 45 minutes to one hour was spent towards

the structured interview. Sampling defines the process of selecting a group of people

or other elements with which to conduct a study.

34

Sampling Criteria:

a) Inclusion Criteria:

•••• Mothers of neonates who are admitted in NICU in selected hospital,

Bangalore.

•••• Mothers who can communicate in English and Kannada.

•••• Mothers who were willing to co-operate.

Selection and Development of Tool: The instrument was developed based on related

studies, informal discussion with opinion of experts, based on review of literature and

it is based on research problem and objectives of the study the following steps were

undertaken.

Development of Tool: A structured interview schedule was prepared to assess the

level of stress and coping strategies of mothers of neonates who are admitted in NICU

(3 point likert scale).

The tool was developed:

◊ After reviewing the related literature

◊ Based on the experience of the investigator and

◊ Based on the contact and consultation of the subject experts.

Description of the tool: The researcher developed a structured interview schedule,

which contains items on the following aspects.

Part I: Demographic data of mothers admitted their neonates in NICU.

Part II: Three point likert scale for assessing the level of stress of mothers admitted

their neonates in NICU and

35

Part II: Three point likert scales for assessing coping strategies of mothers admitted

their neonates in NICU.

Stress questionnaire consists of 40 items. It is measured with the help of

modified likert scale. Each item has 3 alternatives agree, can’t say, disagree. It

includes physical stress, physiological, psychological, emotional, cognitive,

communication with staff, parental role alteration and socioeconomic domains.

Coping questionnaire consists of 40 items. It is measured with the help of

modified likert scale. Each item has 3 alternatives agree, can’t say, disagree. It

includes following domains such as physical, cognitive, emotional, spiritual, social

and divertional activities.

Content Validity: Content validity refers to the degree to which an instrument

measures what it is intended to measure 53

.

The prepared instrument along with the objectives and criteria checklist was

submitted to eight experts in the field of Child Health Nursing and Mental Health

Nursing for establishing content validity. The first draft of the tool consisted of 46

questionnaire on stress levels and 42 questionnaire on coping methods and then based

on the suggestions given by the experts, modifications, deletion, and added some

questions and rearrangements were made. Thus the second draft of the tool consisted

on 40 questions on stress levels and 40 questions on coping methods.

Translation of the Tool: The tool was translated by the language expert into

Kannada and English.

Pilot Study:

36

Pilot study is a small-scale version or trial run of the major study. To assess the

feasibility in conducting main study and to obtain information for improving the

project, pilot study was under taken.

After obtaining a formal permission from the Chief Administrative officer of

Bangalore Children’s Hospital and research centre, Bangalore. Study was conducted

on 6 mothers on 2/08/2005 to 8/08/2005. A purposive sampling and the inclusion

criteria was taken into consideration during sample selection. The consent was taken

by explaining the purpose of the study. Structured interview schedule consisting of 9

items on demographic variables, 40 questions on stress and 40 items on coping.

Data collected for 45-60 minutes. The subjects found the language of the tool simple

and understandable.

Reliability of the Tool:

The reliability of the measuring instrument is a major criterion for assessing

the quality and adequacy. According to Polit and Hungler the reliability of

instruments is the degree of consistency with which it measures the attribute it is

supposed to be measuring52

.

The reliability of the tool is computed by using split half technique with raw

score method - Spearman Brown Prophecy Formula

Spearman Brown Prophecy Formula for reliability

2 r

r1 = Where

1 + r

r1 = is the estimated reliability of the item

r = is the correlation co-efficient computed on split halves.

For computing coefficient the formula used is

37

Deviation method

Σxy

r=

[ Σx2

X Σy2 ]

The reliability obtained by using Spearman Brown Prophecy formula

is 0.96 so the questionnaire found to be reliable.

Data Collection Method:

A formal written permission was obtained from the medical superintendent of

Kempgowda Institute of Medical sciences and Research Centre Hospital, Bangalore.

The data collected from 27/08/2005 to 26/09/2005, from mothers admitted their

neonates in NICU, who fulfilled sample inclusion criteria. The structured interview

schedule was conducted for 45-60 minutes. Before conducting the study, consent was

taken from them by explaining the purpose of the study.

Plan for Data Analysis: The data was planned to be analyzed on the basis of

objective and hypothesis of the study.

• The collected data was coded and transformed to master sheet for statistical

analysis.

• Demographic data was planned to represent in terms of frequency and

percentage.

• Mean, median and standard deviation for total scores of the parents was

computed.

• Chi-square test was computed for finding out the association between level of

stress and demographic variables.

38

• Karl Pearson’s Coefficient of Correlation was calculated to find the relationship

between stress and coping.

SUMMARY:

This chapter on methodology has dealt with research approach and design, the

setting, population, sample and sampling technique, development of the tool and its

description, the pilot study, procedure for data collection and the plan for data

analysis.

39

5. RESULTS

This chapter deals with the statistical analysis, which is a method of rendering

quantitative information in a meaningful and intelligible manner. Statistical procedure

of the data gathered to assess the stress level and coping strategies of mothers

admitted their neonates in NICU enables the researcher to organize, interpret, and

communicate information meaningfully.

The data collected were grouped and analyzed using descriptive and

inferential statistics were used to assess the level of stress level and coping methods

of stress among mothers when their neonates are admitted in NICU. Tables and

figures are used to explain the result. Analysis is a process of organizing and

synthesizing the data in such a way that research questions may be answered and

hypothesis tested.

The analysis and interpretation of the data of this study are based on the data

collected through structured interview schedule on the stress levels and coping

strategies of stress among mothers when their neonates were admitted in NICU.

Objectives of the Study:

1. To identify the level of stress among mothers when their neonates are

admitted in NICU.

2. To identify the coping strategies used by the mothers in NICU.

3. To correlate the stress with coping used by mothers in NICU.

4. To determine the association of stress level and coping strategies with the

selected demographic variables.

40

Organization and presentation of the obtained data were entered in to the

master sheet for tabulation and statistical processing that is results were computed

using descriptive and inferential statistics. The analysis of data was organized and

presented under the following section.

This chapter is divided in to five sections.

Section – I: Describes the distribution of demographic variables of mothers

admitted their neonates in NICU.

Section – II: Describes the stress of mothers admitted their neonates in NICU.

Section – III: Describes the coping strategies of mothers admitted their neonates

in NICU.

Section – IV: Describes the relationship between stress and coping strategies

of mothers their neonates admitted in NICU.

Section – V: a) Association between stress level with selected demographic variables.

b) Association between coping strategies with selected demographic

variables.

Section – I Describes the distribution of sample variables of mothers admitted

their neonates in NICU.

The data on sample characteristics were analyzed using descriptive statistics and

presented in terms of frequency, percentage and diagrams. The data obtained from

sample are presented in terms related to the mothers age, Educational qualification,

Occupation of the mother, Monthly family Income, Religion, Area of living, Number

of Children, Nature of treatment and Number of days hospitalized.

41

Section I : Description of baseline Variables of mothers admitted their

neonates in NICU.

Table: 1.1 shows the distribution of mothers by age group.

N=60

DISTRIBUTION OF SUBJECTS BY AGE GROUP OF THE MOTHER

AGE ( in yrs) Frequency Percent

Below 20 10 16.7

21 - 25 29 48.3

26 - 30 20 33.3

>30 1 1.7

Total 60 100

Fig: 3 AGE OF THE MOTHER

The data presented in the table 1: 1 and fig: 3 reveals that a majority of mothers

29(48.3%) were in age group of 21-25yrs, 20(33.3%) mothers were between 26-30yrs

age group and 10(16.6%) mothers were belonging to below20yrs and followed by

only one(1.7%) mother is above 30years age group.

10

29

20

1

0

10

20

30

40

50

NO.OF SUBJECTS

Below 20 21 - 25 26 - 30 >30

SUBJECTS BY AGE OF MOTHER

42

Table 1.2 shows the distribution of mothers educational qualification.

N=60

EDUCATION Frequency Percent

Not literate 6 10

Primary 14 23.3

High School 29 48.3

Graduate 11 18.3

Total 60 100

Fig: 4 EDUCATION OF MOTHERS

The above table and figure represented the educational status of the mother. It is

evident that majority 29(48.3%) of mothers were educational back ground was high

school, 14(23%) were educated upto primary school, and 11(18.3%) were degree

educational qualification, and 6(10%) were not literates.

SUBJECTS BY EDUCATION OF MOTHER

6

14

29

11

0

5

10

15

20

25

30

35

Illiterate Primary High

School

Graduate

NO.OF

SUBJECTS

43

Table 1.3 shows the distribution of mothers occupation.

N = 60

DISTRIBUTION OF SUBJECTS BY OCCUPATION OF MOTHER

OCCUPATION Frequency Percent

House Wife 37 61.7

Govt. Employee 6 10.0

Pvt. Employee 17 28.3

Total 60 100.0

Fig: 5 OCCUPATION OF MOTHER.

The above table and figure explains that the occupation of mothers it is observed that

majority 37(61.7%) of the mothers were housewives; while17 (28.3%) of mothers

were private employees and 6(10%) were government officials.

37

6

17

0

5

10

15

20

25

30

35

40

NO.OF SUBJECTS

HouseWife Govt.

Employee Pvt.

Employee

OCCUPATION

SUBJECTS BY OCCUPATION OF MOTHER

44

Table 1.4 shows the distribution of subjects monthly family income.

N = 60

DISTRIBUTION OF SUBJECTS BY MONTHLY FAMILY INCOME

INCOME IN RUPEES Frequency Percent

<1000 2 3.3

1001 - 2000 20 33.3

2001 - 3000 15 25

>3000 23 38.3

Total 60 100

Fig: 6 FAMILY MONTHLY INCOME.

The monthly family incomes of the mothers of neonates were admitted in NICU. It is

observed that a majority 23(38.3%) of parents belonged to the income group of above

3000, 20(33.3%) of family income were between 1001-2000, 15(25%) of the family

income were between 2001-3000, and only 2(3.3%) of the family income was below

1000.

SUBJECTS BY INCOME

23

15

20

2

0

10

20

30

40

50

60

70

80

<1000 1001 - 2000 2001 - 3000 >3000

NO.OF

SUBJEC

TS

45

Table 1.5 shows the distribution of subjects by area of living.

N = 60

DISTRIBUTION OF SUBJECTS BY AREA OF LIVING

Area of living Frequency Percent

Urban 34 56.7

Rural 26 43.3

Total 60 100

Fig: 7 AREA OF LIVING.

The above table and figure reveals that 34(56.7%) of mothers are hailed from urban

area and 26(43.3%) of mothers are living in rural area.

SUBJECTS BY AREA OF LIVING

Urban, 56.7

Rural, 43.3

Urban Rural

46

Table 1.6 shows the distribution of subjects by religion.

N = 60

DISTRIBUTION OF SUBJECTS BY RELIGION

RELIGION Frequency Percent

Hindu 41 68.3

Christian 9 15

Muslim 10 16.7

Total 60 100

DISTRIBUTION OF SUBJECTS BY

RELIGION

Hindu, 41,

68%

Muslim,

10,

17%

Christian,

9,

15%

Fig: 8 RELIGION OF MOTHER.

The data presented in the table 1.6 and figure 8 show that a vast majority of mothers

hailed from Hindu religion that is 41(68.3%), Muslims were 10(16.7%) and followed

by Christians they were 9(15%).

47

Table 1.7 shows the distribution of subjects by number of children.

N = 60

DISTRIBUTION OF SUBJECTS BY NUMBER OF CHILDREN

NUMBER OF CHILDREN Frequency Percent

One 26 43.3

Two 26 43.3

Three and above 8 13.3

Total 60 100.0

Fig: 9 NUMBER OF CHILDREN.

The above table explained the number of children that mothers were having. As per

present day norm the number of children in the family is one or two. It can be seen

that majority of the parents had one two child 26(43%) and 26(43%) each and

minimum of children 8(13.3%) were having more than three.

26 26

8

0

5

10

15

20

25

30

NO.OF SUBJECTS

One Two Three

SUBJECTS BY NO.OF CHILDREN

48

Table: 1.8 DISTRIBUTION OF SUBJECTS BY ADMISSION CONDITION.

N = 60

DISTRIBUTION OF SUBJECTS BY ADMISSION CONDITION

ADMISSION CONDITION Frequency Percent

Medical 49 81.7

Surgical 5 8.3

Others 6 10

Total 60 100

Fig: 10 ADMISSION CONDITION.

The above table and figure represents the admission condition status of the neonate to

the NICU. It is evident that majority 81% of neonates are admitted with medical

problem, 10% were admitted with other diagnostic purpose and constant observation

and 8.3% had admitted for surgical treatment and for constant observation.

Medical Surgical

Others

49

5 60

10

20

30

40

50

60

NO.OF SUBJECTS

SUBJECTS BY ADMISSION CONDITION

49

SECTION – II Distribution of mothers according to their Stress level.

This section deals with the analysis and interpretation of data with regard to

the stress level of mothers of neonates admitted in NICU obtained through the stress

rating scale. The scores obtained by each sample were tabulated in a master data

sheet. Data regarding the stress scores was analyzed using descriptive and inferential

statistics. The data were presented in the form of tables & diagram.

Table: 2 Distribution of mothers according to their Stress level

N= 60

Sl. No Stress scores No % Category

1

2

3

83 and less

84 – 94

>94

36

17

7

60%

28.3%

11.6%

Mild stress

Moderate stress

Severe stress

Fig: 11.Stress level of mothers.

The data depicted in table – 2 and fig: 11 in the present study it was show that

7(12%) mothers had severe stress and 17(28.3%) of mothers had moderate stress and

remaining 36(60%) of mothers are with mild stress.

60%

28%

12%

83 and less 84-94 >94

50

Table: 3 Area wise Categorization of Stress level of mothers admitted their

neonates in NICU at selected hospitals

N=60

Number Min Max Mean Median

Mean

% SD

Sl. No STRESS SCALE 40 63 106 83.15 81 100% 10.32

1. Physical 6 8 18 12.55 12 15% 2.76

2. Physiological 8 10 37 17.28 18 20.78% 4.52

3. Emotional 5 8 17 12.42 12 14.93% 2.02

4. Cognitive 6 9 18 13.05 13 15.69% 2.92

5.

Communication

with staff 6 6 18 11.12 11 13.37% 3

6.

Parental Role

Alternation 4 5 12 8.78 9 10.55% 1.76

7. Socio Economic 5 5 12 7.95 8 9.56% 2.02

AREAWISE MEAN SCORES OF STRESS

17.313.1 12.6 12.4 11.1

8.8 8.0

83.2

0

10

20

30

40

50

60

70

80

90

TOTA

L

Physiological

Cognitive

Physical

Emotional

Communication with staff

Parental Role Alternation

Socio Econom

ic

MEAN SCORES

Fig: 12 Area wise Categorization of Stress level of Mother

51

The data depicted in table 3 and fig: 12 shows that the mothers admitted their

neonates in NICU had more stress in physiological domain (mean score 20.78 %),

cognitive domain (mean score15.69%) stress and physical and emotional domain

stress (mean score 15%), and it is followed by communication with staff that is (mean

score 13.37%)

52

SECTION – III Distribution of mothers According to their Coping strategies.

This section deals with the analysis and interpretation of data obtained through

a coping scale with regard to coping methods adopted by the mothers of neonates

admitted in NICU. Data regarding the coping methods was analyzed using

descriptive and inferential statistics. This data is also represented in the form of tables

and diagrams.

Table: 4 Distribution of Mothers According to their Coping strategies

N - 60

Sl. No Coping scores No % Category

1

2

3

83 and less

84 – 102

>102

13

35

12

21.6%

58.3%

20%

Poor coping

Moderate coping

Good coping

Fig: 13 Coping scores of mothers

The data presented in the Table-4 and Fig: 13 shows that 12(20%) of mothers

had good coping, 35(58.3%) of mothers had moderate coping and remaining

13(21.6%) of mothers had poor coping.

22%

58%

20%

83 and less 84-102 102 and above

53

Table: 5 Area wise Categorization of coping strategies of mothers admitted their

neonates in NICU at selected hospitals

N=60

Number Min Max. Mean Median

Mean

% SD

Sl.No

COPING

TOTAL 40 73 115 92.32 92.5 100% 9.44

1. Physical 6 10 18 13.63 13 14.76% 2.02

2. Cognitive 8 14 24 20.02 20.5 21.68% 2.78

3. Emotional 7 12 21 15.77 16 17.33% 2.37

4. Spiritual 6 9 18 15.07 15 16.24% 1.95

5. Social 7 9 21 15.83 16 17.33% 3.23

6.

Diversional

activity 6 6 18 12 12.5 13.53% 3

AREAWISE MEAN SCORES OF COPING

2016 16 15 14 12

92

0

10

20

30

40

50

60

70

80

90

100

TOTAL

Cognitive

Social

Emotional

Spiritual

Physical

Diversional

activity

MEAN SCORES

Fig: 14 Area wise Categorization of Coping strategies of Mother

The data depicted in table 5 and fig: 14 shows that the mothers admitted their

neonates in NICU had Cognitive domain as good coping strategies (mean score

21.68%), Emotional and Social coping domain are (mean score 17.33 %) respectively,

Spiritual coping domain of (mean score 16.24%), and it is followed by Physical

domain (mean score 14.76 %), and divertional activity domain was (mean score13.53

%).

54

SECTION: IV Relationship between Stress Level and Coping strategies of

mothers admitted their neonates in NICU at selected hospitals.

This section presents the relationship between stress level and coping

strategies of mothers admitted their neonates in neonatal intensive care unit. In order

to test the relationship, a null hypothesis has been formulated.

Ho : There is no significant relationship between the stress and coping strategies of

mothers admitted their neonates in neonatal intensive care unit.

The hypothesis was tested by using Karl Pearson‘s Coefficient of correlation.

Table: 6 Relationship between Stress level and Coping strategies of mothers

admitted their neonates in NICU at selected hospitals

Variable Mean + SD Correlation Coefficient Inference

Stress 83.15 + 10.32

Coping strategies 92.32 + 9.44

r = 0.06

Not

Significant

(P = 0.67)

Data in the table-6 show that there is no significant relationship between

coping and stress scores (r = 0.06, P = 0.67). Hence the null hypothesis is accepted.

55

SECTION – V

This section deals with the analysis and interpretation of the association between the

stress of mothers admitted their neonates in neonatal intensive care unit with selected

demographic variables such as age of the mothers, Educational Status, Monthly

family Income, Religion, Area of living, Number of Children, and Nature of

treatment. While there is a significance between these two variables number of days

hospitalized and Occupation of the mother.

This was tested by using Chi-square (x2) test by preparing contingency table.

The stress scores were put in the master data sheet. The scores above the mean and

below mean were identified and grouped according to the demographic variables.

a) Association between Stress levels with selected demographic variables of

mothers admitted their neonates in NICU at selected hospitals.

Table: 7

Median= 81

Variables Stress scores

Median & below

Median

Stress scores

above median χχχχ2

p

Age

25 and less

>25

19

12

20

9

0.39**

0.53

NS

Educational

Status

Illiterate/Primary

High School

Graduate

10

14

7

10

15

4

0.79**

0.67

NS

Occupation of

mothers

House Wife

Govt. Employee

Pvt. Employee

13

5

13

24

1

4

10.65*

<0.01

Significant

Income

2000 or Less

>2000

8

23

14

15

3.26**

0.07

NS

56

Area of living

Urban

Rural

19

12

15

14

0.56**

0.45

NS

RELIGION

Hindu

Christian

Muslim

19

5

7

22

4

3

1.87**

0.39

NS

No. of children

One

Two/Three

11

20

15

4

1.61**

p = 0.21

NS

Admission

condition

Medical

Surgical

other

23

5

3

26

1

2

2.99**

0.22

NS

Number of days

Hospitalized

Less than 2 days

2-4 days

>4days

15

9

7

4

15

10

8.34*

< 0.22

Significant

* = Significant

** = Non-significant

The obtained chi-square value is less than the table value indicating that there

is no significant association between the stress level of mothers with selected

demographic variables such as age of the mothers, Educational Status, Monthly

family Income, Religion, Area of living, Number of Children, and Nature of treatment

While there is a significance between these two variables number of days

hospitalized(χ2 =8.34, p<0.22) and Occupation of the mother(χ2

=10.65, p<0.01).

57

b) Association between coping strategies with selected demographic variables of

mothers admitted their neonates in NICU at selected hospitals

Table: 8

Median: 92

Variables Coping scores

Median &

below Median

Coping scores

above median χχχχ2

p

Age

25 and less

>25

18

12

21

9

0.66**

0.42

NS

Educational

Status

Illiterate/Primary

High School

Graduate

14

10

6

6

19

5

6.08*

<0.05

Signific

ant

Occupation of

mothers

House Wife

Govt. Employee

Pvt. Employee

18

2

10

19

4

7

1.22**

0.54

NS

Monthly family

Income

2000 or Less

>2000

9

21

13

17

1.15**

0.28

NS

Area of living

Urban

Rural

16

14

18

12

0.27**

0.60

NS

RELIGION

Hindu

Christian

Muslim

18

5

7

23

4

3

2.32**

0.31

NS

No. of children

One

Two/Three

12

18

14

16

0.27**

0.60

NS

Admission

condition

Medical

Surgical

other

22

4

4

27

1

2

2.98**

0.23

NS

58

Number of days

Hospitalized

Less than 2 days

2-4 days

>4days

12

18

8

7

14

9

2.04**

0.36

NS

* = Significant

** = Non-significant

The obtained chi-square value is less than the table value indicating that there is no

significant association between the coping strategies such as age of the mothers,

Occupation, Monthly family Income, Religion, Area of living, Number of Children,

Nature of treatment and Number of days hospitalized. Number of days hospitalized.

While there is a significant association with educational status of the mother (χχχχ2 -6.08,

p<0.05).

59

6. DISCUSSION

The present study was conducted to explore the level of stress and coping

strategies of mothers admitted their neonates in neonatal intensive care unit at selected

hospitals, Bangalore. The findings of the study have been discussed based on the

objectives of the study and findings of other similar studies. For a better clarity and

thorough understanding, this chapter is divided into the following sections:

1. Stress level of mothers admitted their neonates in NICU at selected hospitals

In this present study it was shows that (12%) mothers had severe stress and

(28.3%) of mothers had moderate stress and remaining (60%) of mothers are with

mild stress.

The area wise categorization of stress scores among the mothers showed, show that

the mothers admitted their neonates NICU had stress in physiological domain (mean

score 20.78 % ), cognitive domain (mean score15.69%) stress and physical and

emotional domain stress (mean score 15%), and it is followed by communication with

staff that is (mean score 13.37%)

While the findings were consistent with the findings of Doering LV, Dracup

K, Moser D. mothers were more poorly adjusted and were more anxious, hostile, and

depressed than fathers, but mother significantly experienced more level of distress 38

.

Shields PD, Pinelli J. did a descriptive study on how parents perceived the severity of

their infant's illness was the most powerful variable associated with their stress scores.

Trait anxiety, desire for the pregnancy, and where and when parents first saw the baby

were other variables significantly correlated with stress scores 23

.

Holditch DD, Miles MS. The study indicates that health care providers, and especially

nurses, can have a major role in reducing parental distress by maintaining ongoing

communication with parents and providing competent care for their infants27

.

60

2. Coping strategies of mothers admitted their neonates in NICU at selected

hospitals.

In this study it was found that more than half of mothers 35(58.3%) were had

moderate coping strategies to counter the stress, and remaining mothers 12(20%) with

good coping and remaining mothers 13(21.6%) had poor coping methods.

The findings also revealed the area wise categorization of coping scores

among mothers admitted their neonates in NICU had Cognitive domain as good

coping strategies (mean score 21.68%), Emotional and Social coping domain are

(mean score 17.33 %) respectively, Spiritual coping domain of (mean score 16.24%),

and it is followed by Physical domain (mean score 14.76 %), and divertional activity

domain was (mean score 13.53 %).

The finding was consistent with the report of Ward K. found in his data were

analysed that participants reported assurance and, information related treatment plan,

procedures were required most important perceived need of parents of NICU

infants43

.

3. Relationship between stress level and coping strategies of mothers

Present study found that there is no correlation between stress and coping ((r =

0.06, P = 0.67). Christopher SE, Bauman KE, Veness-Meehan K. written an article in

that they state all hypotheses were rejected. Neither social supports nor perceived

stress were related to affectionate behaviors, and no statistical interactions among the

3 variables were identified 55

.

61

4. Association between stress levels with selected demographic variables.

The present study found that there is no significant association between the

stress level of mothers with selected demographic variables such as age of the

mothers, Educational Status, Monthly family Income, Religion, Area of living,

Number of Children, and Nature of treatment. While there is a significance between

these two variables number of days hospitalized (χ2=8.34, p<0.22) and Occupation of

the mother(χ2=10.65, p<0.01).

This was supported by the study conducted by Doering LV, Moser DK, Dracup K.

stated that parents experienced high level of anxiety, hostility, depression, poorer

family functioning, lower level of social adjustment. Parental status (mother or

father), ethnicity, employment status, and education were significantly related to

parental responses 39

.

This was consistent with the findings of Carter JD, Mujder RT, Bartram AF.

Compared and stated that parents of control group, a higher percentage of NICU

parents had clinically relevant anxiety and more stress than they likely to have had a

previous admission 29

.

Docherty SL, Miles MS, Holditch-Davis D. This study examined child health worry

among mothers of medically fragile infants with differing health problems and

identified factors associated with maternal worry. Medically fragile infants were term

(38%) and preterm (62%) infants who had a life-threatening health problem that

necessitated a long hospitalization and dependence on technology for survival. The 78

mothers were recruited during their infants' hospitalization. Their mean age was 26

years. Most had a high school education, were married, and were from diverse

ethnic/racial backgrounds 56

.

62

The chi-square test did not establish any significant relationship between

income and stress. With regard to number of children, there is no association between

number of children and stress.

4. Association between coping strategies with demographic variables.

The present study findings showed that there is no significant association

between the coping strategies such as age of the mothers, Occupation, Monthly family

Income, Religion, Area of living, Number of Children, Nature of treatment and

Number of days hospitalized. While there is a significant association with educational

status of the mother (χ2 =6.08, p<0.05).

While it is supported by the study of Kratochvil MS, Robertson CM, Kyle JM. Shows

that length of stay in neonatal intensive care and outcome were among the not

significant variables 57

.

This is supported by the study done by Shyamala Kumari who found in her study that

the mothers of children with leukemia used the coping behaviour pray to God and

reported as being the most helpful coping behaviour. The findings of the present study

indicate that one of the most frequently used coping behaviour is pray more than usual

(72%). Also another coping behaviour used in this context by the mothers is making

special offering (62.7%). This shows that mothers had belief in the spiritual systems

as it would give peace and reduce their stress level and better coping 54

.

The study did not establish any significant association between the stress and previous

hospitalization. This was supported by the study done by Goldberg S, Simonons RT,

Newman J, Campbell K, Fowler RS. Who found that previous hospitalization does

not have any association with stress 57

.

63

7. CONCLUSION

The aim of the study was to assess the level of stress and coping strategies of

mothers of neonates admitted in NICU at selected hospitals, Bangalore, Karnataka

was under taken as a partial fulfillment of requirement for the Degree of Master of

Science in Nursing at Sarvodaya College of Nursing, Rajiv Gandhi University of

Health Sciences, Bangalore during the year 2005.

The sample of the study consisted of 60 mothers of neonates admitted in NICU at

Kempgowda Institute of Medical sciences and Research Centre Hospital, and

Bangalore Children’s Hospital and Research Centre, Bangalore.

Structured interview schedule was used to collect the data. It consists of 3 sections.

Part I: Demographic variables which include age of the mother, educational status of

mother, occupation of the mother, income of their family, Religion, Area of living

number of children, Admission Condition, and number of days hospitalized.

Part II: Stress questionnaire consists of 40 items and

Part III: Coping questionnaire consists of 40 items. It is measured with the help of

modified three point Likert scale.

The organization and presentation of the obtained data were entered in to the master

sheet for tabulation and statistical processing that is results were computed using

descriptive statistics in terms of frequencies and percentage and inferential statistics

like chi square test, standard deviation, and pearson’s correlation coefficient were

computed.

The following conclusions were based on the findings. The results were described by

using descriptive and inferential statistics.

64

Major findings of the study:

• In the present study it was show that 7(12%) mothers had severe stress and

17(28.3%) of mothers had moderate stress and remaining 36(60%) of mothers

are with mild stress.

• Area wise distribution of stress scores show that the mothers admitted their

neonates in NICU had more stress in physiological domain (mean score 20.78

% ), cognitive domain (mean score15.69%) stress and physical and emotional

domain stress (mean score 15%), and it is followed by communication with

staff that is (mean score 13.37%)

• The data presented in the present study shows that 12(20%) of mothers had

good coping, 35(58.3%) of mothers had moderate coping and remaining

13(21.6%) of mothers had poor coping.

• Area wise distribution of coping scores shows that the mothers admitted their

neonates in NICU had Cognitive domain as good coping strategies (mean

score 21.68%), Emotional and Social coping domain are (mean score 17.33 %)

respectively, Spiritual coping domain of (mean score 16.24%), and it is

followed by Physical domain (mean score 14.76 %), and divertional activity

domain was (mean score 13.53 %).

• Relationship between Stress level and Coping strategies of mothers admitted

their neonates in NICU at selected hospitals, shows that there is no significant

relationship between coping and stress scores (r = 0.06, P = 0.67). Hence the

null hypothesis is accepted.

• The present study findings showed that there is no significant association

between the stress level of mothers with selected demographic variables such

as age of the mothers, Educational Status, Monthly family Income, Religion,

65

Area of living, Number of Children, and Nature of treatment. While there is a

significance between these two variables number of days hospitalized (χ2

=8.34, p<0.22) and Occupation of the mother(χ2=10.65, p<0.01).

• The present study findings showed that there is no significant association

between the coping strategies such as age of the mothers, Occupation,

Monthly family Income, Religion, Area of living, Number of Children, Nature

of treatment and Number of days hospitalized. While there is a significant

association with educational status of the mother (χ2 =6.08, p<0.05).

Nursing Implications:

Nurses have a vital role in helping the mother to cope with stressful situation.

They can do much help the mothers to cope with crisis during admission and

separation, from the child. Nurses can explain to the mothers according to the level of

understanding and mental status of mothers regarding the condition and treatment.

They can give continues reassurance to the mothers admitted their neonates in NICU

by giving report of their children on time to time.

Enough time should be spent with the mothers during the admission of their children

and to reduce stress. It also helps to identify the stressor along with the initial

assessment. It helps in planning individualized and family centered care. Those who

are willing to work or posted in NICU have to be given regular in service education

programme to gain adequate Knowledge and development positive attitude A “Nurse

Educator” can be posted as a “Nurse counselor” in NICU.

Nurses should be able to recognize coping strategies used by the mothers to provide

adequate counseling and guidance to them and to promote their coping strategies. The

66

guide prepared by the investigation will be used for the Nurses working in NICU, to

enhance their knowledge and there by in providing quality care.

Nursing Service:

Nurses have a unique role in providing comprehensive holistic care to

critically ill or sick children, their mothers and families. Understanding the level of

stress and coping strategies, can act as reference for nurses in planning appropriate

interventions to minimize the stress level. Nurses need to help mothers get adjust to

NICU environment by giving information and proper explanations through out the

child’s stay. Such information should include orientation of mothers about the

condition of their child in the NICU. To provide this information, nursing staffs need

to be educated on concept of stress and coping of mothers admitted their neonates in

NICU and on the factors to be considered while providing information and

explanation.

The present study revealed that cognitive domain and physiological domain

are the most important cause stress in the mothers; therefore nurses have the

opportunity to provide a large percentage of the information on these domains. Nurses

must be very active and anticipate the psychological burden on mothers, by

recognizing and attempting to meet these information needs and help to perceive their

needs in more realistic way. This would provide useful information for planning

individualized and family care and counseling aimed at enhancing better health out

comes of mothers.

Nursing Education

Nurses are the ones who are with the patient for a longer time than any other health

personnel. When the mothers are stressed, they can not verbalize their feelings of

anxiety, tension, and frustration. As a nurse educator, we need to contribute to the

67

existing body of nursing knowledge about the needs of psychological and emotional

support to mothers of neonates admitted in NICU to facilitate a more holistic

approach to meet both the needs of neonates and mothers. Concepts such as

comprehensive nursing and mother participation should be taught and more emphasis

should be given on the NICU environment and routines. But babies with life-

threatening disorders need intensive care from specialist nurses and doctors, using

highly specialised techniques and equipment, delivered in a family and child-focused

environment.

In order to reach modern standards of care for the sick newborn babies,

intensive care is most effectively concentrated in neonatal intensive care units in

which skilled attention to their needs can be achieved more readily and urgently. So

they need to be educated and competent knowledge about neonatal intensive care unit.

Hence more emphasis should be given to conduct in service education programme to

upgrade the knowledge of the nurses about factors causing stress and its relationship

with coping, which may help to plan effective care. Nurse educators must be update

the concepts of the NICU in the nursing curriculum, to make the nursing students

more versatile in dealing with these precarious situations in the NICU.

Nursing Research:

Nursing research can be done in the area of stress and coping to identify

stressors of mothers during their neonates stay in the neonatal intensive care unit. The

child with a critical illness, however, creates unanticipated crises, alters family

patterns in ways that are stressful and makes coping demands for dealing with a

critical child more pronounced for the family system.

68

Research can help the nurses to develop confidence as well as faith in mothers

whose neonates are admitted in NICU and also to develop constructive coping

methods among them. Increasing capability of technology and development of health

care expertise has led to greater numbers of very small babies being born alive and

surviving. In the past many such babies died before or just after birth. Now very

premature or very low birth weight babies require very prolonged periods of intensive

supportive care, often over several weeks. Capacity needs to develop to meet this

demand and make mother to understand about advancement in saving babies life. So

the nurses need to make the mother aware of recent advances and how to handle

stressful situation in neonatal intensive care unit.

Future research studies can build on this database and involve comparisons of

these variables in families at various stages of development with other chronic

childhood conditions. The purpose of subsequent research will be to develop family

Health Nursing Intervention Strategies.

Limitations:

The limitations of the present study were: -

1. The study was conducted using purposive sample, which restricted the

generalization that could be made.

2. The study is limited to specific dimensions of stress and coping of mothers

admitted their neonates in NICU.

3. The tools used were not standardized tools.

69

Recommendations:

In the view of the findings reported, the following recommendations are made

for further research.

1. A similar study could be conducted with larger sample size to confirm the

result of the study.

2. A comparative study regarding the parents (father & mother) stress and coping

can be done.

3. An evaluative study can be done to determine the effectiveness of relaxation

therapy in reducing stress.

4. A comparative study on NICU parents and PICU parents stress and coping can

be carried out.

5. A comparative study can be done on literate mothers stress and coping with

non-literate mothers.

6. An evaluative study on the effectiveness of the stress management techniques

among mothers admitted their neonates in NICU.

7. Developmental studies are recommended for constructing standardized tool on

stress and coping in Indian setting context.

8. Organization of stress management programs for mothers admitted their

neonates in NICU.

70

8. SUMMARY

The focus of this was to assess the stress levels and coping strategies of

mothers admitted their neonates in NICU. The birth of a premature baby, whether it is

expected or not, is a traumatic experience for mothers and family. Over half the

mothers who speak about initial feelings of shock and anxiety as they find themselves

in an environment and set of circumstances which are entirely unfamiliar and a

significant number are faced with the possibility of losing their baby. Mothers

describe the experience of having to cope with these circumstances as a daily struggle,

which can fluctuate from one moment to the next according to their baby’s changing

health circumstances.

Many mothers who describe a spiral of difficulties. These difficulties relate to

mothers in emotional turmoil, not wanting to be demanding by asking too many

questions from staff, which in turn leads to a lack of clear communication and

information exchange, leaving parents feeling inadequate and lost. Mothers describe

being worried that they may harm their baby if they try to get involved in aspects of

their care, which results in a lack of confidence and inadequacy in looking after their

baby once they leave the hospital.

It is important that the philosophy and practice of family centered care be

maintained and extended throughout the service, with particular emphasis placed on

improving and increasing communication between all staff and mothers. In these

situations, mothers find they are frequently overlooked but they have a have a

powerful need to be supported, reassured and guided.

71

Objectives of the Study were:

1. To identify the level of stress among mothers when their neonates are

admitted in Neonatal Intensive Care Unit (NICU).

2. To identify the coping strategies used by the mothers in NICU.

3. To correlate the stress with coping used by mothers in NICU.

4. To determine the association of stress level and coping strategies with the

selected demographic variables.

Assumptions of the study:

� The mothers of neonates in neonatal intensive care unit may undergo high

levels of stress and a crisis when their neonates in NICU.

� The mothers of neonates admitted in neonatal intensive care unit may go

through a crisis when their neonates critically ill or hospitalized and they try to

adapt the situation by using various coping methods.

� Expectation and perceive needs of mothers are identified by staff of the

hospital when they spend time to interact with the mothers.

� Mother’s perception of stress may differ according to their age, educational

status, occupation, monthly family income, area of living, religion, number of

children, admission condition, and number of days hospitalized.

The study attempted to examine the following Hypothesis:

Ho: 1. There is no significant relationship between the stress and coping strategies

used by mothers admitted their neonates in NICU.

2. There is no significant association between the stress and coping strategies and

selected demographic variables.

The conceptual framework of the study was based on Roy’s Adaptation Model. The

study was conducted in the Neonatal intensive Care Unit, Kempegowda Institute of

72

Medical Sciences Hospital and Research Center, Bangalore, and Bangalore Children’s

Hospital and Research Centre, Bangalore.

The research approach used in this study was descriptive approach. Population

consisted of mothers admitted their neonates in NICU of the selected hospital with the

help of structured questionnaire which consisted of 80 items. This study was

conducted from 27/08/2005 to 26/09/2005 in selected hospitals, Bangalore. The

sample in this study comprised of 60 mothers who were selected by purposive

sampling technique.

The tools used in the study were:

I. Demographic variables which include age of the mother, educational status of

mother, occupation of the mother, income of their family, Religion, Area of living

number of children, Admission Condition, and number of days hospitalized.

II. Stress questionnaire consists of 40 items. It is measured with the help of

modified likert scale. Each item has 3 alternatives agree, can’t say, disagree. It

includes physical stress, physiological, psychological, emotional, cognitive,

communication with staff, parental role alteration and socioeconomic domains.

III. Coping questionnaire consists of 40 items. It is measured with the help of

modified likert scale. Each item has 3 alternatives agree, can’t say, disagree. It

includes following domains such as physical, cognitive, emotional, spiritual, social

and divertional activities.

Discussion with experts and reviewing the literature guided to the construction of the

tools. Content validity of the tool was established by eight experts, by submitting the

prepared instrument along with the objectives and criteria checklist. The experts

comprised of Nurse Educators, Pediatric Specialist, Psychiatrist and psychologist. The

73

reliability obtained by using Spearman Brown Prophecy formula. So the questionnaire

found to be reliable.

The pilot study was conducted in Bangalore Children’s Hospital and Research

Centre, Bangalore of 6 mothers admitted their neonates in NICU on 2/08/2005 to

8/08/2005. The investigator obtained from the Chief Administrative Officer of

Bangalore Children’s Hospital and Research Centre, Bangalore. Six mothers were

selected whose neonates are admitted in NICU who met the inclusion criteria.

Data obtained was analyzed by descriptive and inferential statistics.

Frequency and percentage were used to analyze the demographic characteristics.

Frequency, Percentage, Mean, standard deviation, mean percentage score, range and

coefficient of co-relation of stress and coping scores were calculated. The relationship

between coping strategies and stress levels were found by Karl Pearson’s Correlation

coefficient formula. Association between the stress and selected demographic

variables were calculated by using Chi-square test.

Findings of the Study:

Description of the sample characteristics.

� Majority of the mothers 29(48.3%) were in age group of 21-25yrs, 20(33.3%)

mothers were between 26-30yrs age group and 10(16.6%) mothers were

belonging to below20yrs and followed by only one(1.7%) mother is above

30years age group.

� It is evident that majority 29(48.3%) of mothers were educational back ground

was high school, 14(23%) were educated upto primary school, and 11(18.3%)

were degree educational qualification, and 6(10%) were not literates.

74

� Occupation of mothers it is observed that majority 37(61.7%) of the mothers

were housewives; while17 (28.3%) of mothers were private employees and

6(10%) were government officials.

� It is observed that a majority 23(38.3%) of parents belonged to the income

group of above 3000, 20(33.3%) of family income were between 1001-2000,

15(25%) of the family income were between 2001-3000, and only 2(3.3%) of

the family income was below 1000.

� Reveals that 34(56.7%) of mothers are hailed from urban area and 26(43.3%)

of mothers are living in rural area.

� vast majority of mothers hailed from Hindu religion that is 41(68.3%),

Muslims were 10(16.7%) and followed by Christians they were 9(15%).

� As per present day norm the number of children in the family is one or two. It

can be seen that majority of the parents had one two child 26(43%) and

26(43%) each and minimum of children 8(13.3%) were having more than

three.

Major findings of the study:

• In the present study it was show that 7(12%) mothers had severe stress and

17(28.3%) of mothers had moderate stress and remaining 36(60%) of mothers

are with mild stress.

• Area wise distribution of stress scores show that the mothers admitted their

neonates in NICU had more stress in physiological domain (mean score 20.78

% ), cognitive domain (mean score15.69%) stress and physical and emotional

domain stress (mean score 15%), and it is followed by communication with

staff that is (mean score 13.37%)

75

• The data presented in the present study shows that 12(20%) of mothers had

good coping, 35(58.3%) of mothers had moderate coping and remaining

13(21.6%) of mothers had poor coping.

• Area wise distribution of coping scores shows that the mothers admitted their

neonates in NICU had Cognitive domain as good coping strategies (mean

score 21.68%), Emotional and Social coping domain are (mean score 17.33 %)

respectively, Spiritual coping domain of (mean score 16.24%), and it is

followed by Physical domain (mean score 14.76 %), and divertional activity

domain was (mean score 13.53 %).

• Relationship between Stress level and Coping strategies of mothers admitted

their neonates in NICU at selected hospitals, shows that there is no significant

relationship between coping and stress scores (r = 0.06, P = 0.67). Hence the

null hypothesis is accepted.

• The present study findings showed that there is no significant association

between the stress level of mothers with selected demographic variables such

as age of the mothers, Educational Status, Monthly family Income, Religion,

Area of living, Number of Children, and Nature of treatment. While there is a

significance between these two variables number of days hospitalized and

Occupation of the mother.

• The present study findings showed that there is no significant association

between the coping strategies such as age of the mothers, Occupation,

Monthly family Income, Religion, Area of living, Number of Children, Nature

of treatment and Number of days hospitalized. While there is a significant

association with educational status of the mother variable

76

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82

TABLE OF APPENDICES

Sl. No Title Page No

1

2

3

4

5

6

7

8

Letter requesting permission to conduct study

Letter seeking permission for validation of tool

Criteria rating scale for validating the questionnaire of stress

scale and coping strategies

Content validity certificate

Letter requesting conducting pilot study

Questionnaire on stress level and coping strategies (English).

Questionnaire on stress level and coping strategies (kannada).

List of content validators

83

84-85

86-89

90

91

92-98

100-106

99

83

APPENDIX - I

LETTER REQUESTING PERMISSION TO CONDUCT STUDY

From

Mr. Madhu Sudhana.K.P

2nd

Year M.Sc. Nursing

Sarvodaya College of Nursing

Bangalore – 40.

To

The Medical Superintendent

Kempegowda Institute of Medical Sciences

and Research Centre Hospital

Bangalore.

Through:

The Principal

Sarvodaya College of Nursing

Bangalore – 40.

Respected Sir,

Sub: Request for permission to conduct study in the Hospital

I Mr. Madhu Sudhana.K.P a Post Graduate Nursing student (Child Health

Nursing) of Sarvodaya College of Nursing, have selected the below mentioned topic

for Dissertation to be submitted to Rajiv Gandhi University of Health Sciences,

Bangalore, as a partial fulfillment of Master Degree in Nursing.

Title of the study:

“A study to assess the level of stress and coping strategies of mothers of

neonates admitted in NICU at selected hospitals, Bangalore, Karnataka”.

Regarding this, I am in need of your help and co-operation to conduct study in

your hospital in the month of September 2005. Kindly consider and do the needful.

Thanking you in anticipation

Prof. T. Bheemappa Yours faithfully

(Madhu Sudhana.K.P)

(Principal)

84

APPENDIX - 2

LETTER SEEKING PERMISSION FOR VALIDATION

To

Through

The Principal

Sarvodaya College of Nursing

Vijay Nagar,

Bangalore – 560 040.

Sub: Seeking permission for validation of the Research Tool

Respected Madam/Sir,

I Mr. Madhu Sudhana.K.P a Post Graduate Nursing student (Child Health

Nursing) of Sarvodaya College of Nursing, request your good self, if you would

kindly accept to validate my research tool on the topic.

“A study to assess the level of stress and coping strategies of mothers of neonates

admitted in NICU at selected hospitals, Bangalore, Karnataka”.

I would be obliged if you would kindly affirm your acceptance to endorse

your valuable suggestions on this topic. I shall send the details of my study along

with the research tool.

Thanking you in anticipation

Yours Sincerely

(Madhu Sudhana.K.P)

From

Mr. Madhu Sudhana.K.P

2nd

Year M.Sc. Nursing

Sarvodaya College of Nursing

Bangalore – 40.

85

REPLY LETTER

Topic: “A study to assess the level of stress and coping strategies of mothers of

neonates admitted in NICU at selected hospitals, Bangalore, Karnataka”.

I, …………………………………………………………………………………

Agree / disagree to validate the research tool.

Name:

Designation:

Signature:

Date:

86

APPENDIX - 3

CRITERIA RATING SCALE FOR VALIDATING THE STRESS SCALE AND

COPING QUESTIONNAIRE

Respected Madam/Sir.

Kindly go through the content and place right mark ( ) against questionnaire

in the following columns. When found to be not relevant and needs modification

kindly give your opinion, in the remarks column.

Part: 1 Demographic data

Includes all the relevant variables of the parent and child.

Part: 2 Questionnaire on stress level and coping method

PART II

STRESS PERCEIVED BY MOTHERS WHOSE CHILDRENS WHO ARE

ADMITTED IN NICU

3 2 1

Sl.No

Statements/Events Agree

Can’t

Say

Disagree

I

1. PHYSICAL DOMAIN:

I am concerned about seeing large number of health

professionals in NICU

2. Seeing other sick children around

3. Restriction of activities

4. Lack of facilities for food and drinking water in the

waiting area

5. Lack of place to sleep near NICU

6. Lack of calm and quiet environment in the waiting

area

II

7. PHYSIOLOGICAL DOMAIN:

Feels difficulty on breathing

8. My heart beats quickly palpitation

9. Feels restless and frigidity

87

10. Easily gets tired

11. I get headache due to constant waiting

12. I am unable to eat (Loss of appetite)

13. I feel like Nausea and Vomiting

14. I experience disturbed sleep

III

15.

EMOTIONAL DOMAIN:

I always feel mentally exhausted and frustrated

16. I am constantly fear of my child recovery

17. Feeling irritable and aggressive

18. I always feel lonely and helpless

20. Craving for sympathy and affection

IV

21. COGNITIVE DOMAIN:

I am unable to take initiative in any activity

22. I feel that I have inadequate knowledge about

routine of the NICU

23. Unfamiliar procedure in the NICU

24. I am worried about the recovery of the child

25. I am imaginative and introspective about the child’s

expected outcome

26. I do not get adequate explanation of child’s condition

V

27.

COMMUNICATION WITH STAFF:

Not introducing themselves

28. Using words that are not understood

29. Not saying what is wrong

30. Explaining too fast

31. No response to the phone at any time

32. No proper Information about their child’s progress

VI

33.

PARENTAL ROLE ALTERNATION :

Not allowed to see the child

34. Not able to attend on child needs

35. Not knowing how to help the child

36. Thoughts about needs of other children at home

88

VII

37.

SOCIO-ECONOMIC DOMAIN:

Inappropriate interaction with family members

38. Lack of interaction with friends and relatives

39. Loss of income due to absence from work

40. Not able to manage the new economic crisis in the

family

COPING MECHANISM ADOPTED BY MOTHERS WHOSE CHILDRENS

WHO ARE ADMITTED IN NICU 3 2 1

Sl.No

Statements/Events Agree

Can’t

Say

Disagree

I

1

PHYSICAL COPING:

Good facilities for food and drinking water.

2 Waiting room near the child.

3 Place to sleep near NICU

4 Telephone facilities in the waiting area.

5 locker for your personal belongings

6 calm and quiet environment in the waiting area

7 Engaging in physical activity / exercises

8 Reading materials within the ward/waiting room

(books, newspapers) in local languages.

II

9

COGNITIVE COPING:

Explanations about of the NICU before going in.

10 Orientation of the staff/doctors of NICU

11 Aware of child’s condition everyday.

12 Knowing the doctor & nurse, caring for your child

13 Knowledge about the diagnostic tests done for your

child.

14 Aware about the treatment plan for your child and cost

of it.

15 Being aware of the expected outcome/prognosis of

your child

16 Services in the hospital like-Pharmacy, Canteen,

Chapel, Telephone, Place to stay for relatives etc...

III

17

EMOTIONAL COPING:

Having someone to listen to you

18 Seek help from family/ friends

19 Being with spouse / family members in the hospital

20 Having hope for your child

21 Having doctors & nurses on whom you can depend

upon the needs of your child

22 Able to clarify your doubts without

89

inhibitions/hesitation

23 Getting involved with discussion regarding your

child’s treatment plan.

IV

24

SPIRITUAL COPING

Able to have time for prayer

25 Having a place to pray in the hospital campus.

26 Visiting places of worship.

27 Making special offerings / prayers

28 Reading religious and philosophical books

V

29

SOCIAL COPING

Talking with someone who have gone through a

similar situation.

30 Having family support all the time

31 Feeling accepted by the hospital staff

32 Being with friends / relatives

33 Encouraged to be involved in the care of your child

34 Getting along with family/friends during social

gatherings

VI

35

DIVERSIONAL ACTIVITY

Spending time with friends/ relatives

36 Listening to music

37 Watching television / movies

38 Reading books

39 Engaging in physical activity / exercises

40 Taking break for a while from the hospital

90

APPENDIX - 4

CONTENT VALIDITY CERTIFICATE

I hereby certify that I have validated the tool of Mr. Madhu Sudhana.K.P,

M.Sc. Nursing Student, who is undertaking a study.

“A study to assess the level of stress and coping strategies of mothers of

neonates admitted in NICU at selected hospitals, Bangalore, Karnataka”.

Place: Signature of the expert

Date: Name and Designation

91

APPENDIX - 5

LETTER REQUESTING PERMISSION TO CONDUCT A PILOT

STUDY

From

The Principal

Sarvodaya College of Nursing

Bangalore – 40.

To

The Chief Administrator,

Bangalore Children’s Hospital and Research Centre,

Rajarajeshwarinagar,

Bangalore-98.

Respected Sir,

Sub: Letter requesting permission for conducting pilot study

Mr. Madhu Sudhana.K.P is a post graduate nursing student of our institution.

He has selected the below mentioned topic for his research project to be submitted to

Rajiv Gandhi University of Health Sciences as a partial fulfillment of Master Nursing

Degree.

Title of the Topic:

“A study to assess the level of stress and coping strategies of mothers of

neonates admitted in NICU at selected hospitals, Bangalore, Karnataka”.

Regarding this project, he is in need of your esteemed help and co-operation as

he is interested in conducting a study of his project, in your institution. I request you

to kindly permit him to conduct the proposed study and provide him the necessary

facilities.

The student will furnish further details of the study, if required personally.

Please do the needful and oblige.

Thanking you,

Yours faithfully,

(Prof. T. BHEEMAPPA)

PRIINCIPAL

Place:

Date:

92

APPENDIX – 6

QUESTIONNAIRE ON STRESS LEVEL AND COPING METHODS

ENGLISH VERSION

Consent Form

Dear respondent,

I am a post graduate nursing student (Child health Nursing) from the

Sarvodaya College of Nursing, Bangalore. Conducting A study to assess the level of

stress and coping strategies of mothers of neonates admitted in NICU at selected

hospitals, Bangalore, Karnataka.

Hope you will cooperate with me for the same.

I request you all to answer the given stress and coping Scale with the most

appropriate responses. Kindly do not leave any question unattended. The information

given by you will be kept confidential and used only for the study purpose. Kindly

sign the consent form given below.

Thanking you,

Yours Faithfully,

(Madhu Sudhana.K.P )

CONSENT FORM

I ---------------------------------------------- here with consent for the above said

study knowing that all the information provided by me will be treated with utmost

confidentiality by the investigator.

Date : Signature of the Participant

Place: Name and Address

93

INSTRUCTION TO THE RESPONDENT

Dear Mothers,

I am interested in knowing the level of stress and their coping strategies of the

mothers of neonates who are admitted in NICU. Since you are with the child name

coded _____________________ I will be reading a few statements which represents

the stress experienced and your ability to cope up with it, I would appreciate if you

could tell me which of these factors you have. In addition I would also want you to

tell me how important the need is in the form of number ranging from 1 to 3.

This would help me to know what your needs are, as well as help me to plan for ways

in which we can meet your needs. The numbers mean,

Kindly go through each statement in the following scale and please

place a tic ( √ ) mark in the appropriate column, which express your opinion. The five

responses given are as follows for assessing the level of stress;

Agree – Indicates------ 3

Can’t say –Indicates-------2

Disagree – Indicates----- 1

All information given by you will be kept confidential and used only

for the study purpose.

Questionnaire contains items on the following aspects.

Part : I – It deals with Demographic data of the mother.

Part : II – Questionnaire on Stress Scale and

Part : III- Questionnaire on Coping Methods.

94

PART I: DEMOGPAPHIC DATA OF MOTHERS OF NEONATES

ADMITTED IN NICU

Sl.

No.

Demographic Variables of Mother Answers

1. Code of the mother

2. Age of the Mothers in years a. Below 20

b. 21-25

c. 26-30

c. >30

3. Educational Status of the Mother a. No formal education

b. Primary School

c. High School

d. Graduate & above

4. Occupation of the Mother a. Housewife

b. Government Employee

c. Private Employee

d. Others (Specify if any )

5. Monthly Family Income in Rs. a. Rs. < 1000

b. Rs. 1001-2000

c. Rs. 2001-3000

d. Rs. >3000

6. Residence(Place of Living) a. Urban

b. Rural

7. Religion a. Hindu

b. Christian

c. Muslim

d. Others

8. Number of Children a. One

b. Two

c. Above Three

9. Admission condition a. Medical

b. Surgical

c. Others (Investigations)

10. Number of days hospitalized a. <2 days

b. 2-4 days

c. 5-7 days

d. >7 days

95

PART II

STRESS PERCEIVED BY MOTHERS WHOSE NEONATES WHO ARE

ADMITTED IN NICU

3 2 1

Sl.No

Statements/Events Agree

Can’t

Say

Disagree

I

1. PHYSICAL DOMAIN:

I am concerned about seeing large number of health

professionals in NICU

2. Seeing other sick children around

3. Restriction of activities

4. Lack of facilities for food and drinking water in the

waiting area

5. Lack of place to sleep near NICU

6. Lack of calm and quiet environment in the waiting

area

II

7. PHYSIOLOGICAL DOMAIN:

Feels difficulty on breathing

8. My heart beats quickly palpitation

9. Feels restless and frigidity

10. Easily gets tired

11. I get headache due to constant waiting

12. I am unable to eat (Loss of appetite)

13. I feel like Nausea and Vomiting

14. I experience disturbed sleep

III

15.

EMOTIONAL DOMAIN:

I always feel mentally exhausted and frustrated

16. I am constantly fear of my child recovery

17. Feeling irritable and aggressive

18. I always feel lonely and helpless

20. Craving for sympathy and affection

IV

21. COGNITIVE DOMAIN:

I am unable to take initiative in any activity

22. I feel that I have inadequate knowledge about

routine of the NICU

23. Unfamiliar procedure in the NICU

96

24. I am worried about the recovery of the child

25. I am imaginative and introspective about the child’s

expected outcome

26. I do not get adequate explanation of child’s condition

V

27.

COMMUNICATION WITH STAFF:

Not introducing themselves

28. Using words that are not understood

29. Not saying what is wrong

30. Explaining too fast

31. No response to the phone at any time

32. No proper Information about their child’s progress

VI

33.

PARENTAL ROLE ALTERNATION :

Not allowed to see the child

34. Not able to attend on child needs

35. Not knowing how to help the child

36. Thoughts about needs of other children at home

VII

37.

SOCIO-ECONOMIC DOMAIN:

Inappropriate interaction with family members

38. Lack of interaction with friends and relatives

39. Loss of income due to absence from work

40. Not able to manage the new economic crisis in the

family

97

PART -II

COPING MECHANISM ADOPTED BY MOTHERS WHOSE NEONATES

ADMITTED IN NICU

3 2 1

Sl.No

Statements/Events Agree

Can’t

Say

Disagree

I

1

PHYSICAL COPING:

I engage in physical activity/ exercise

2 I read books, newspapers & magazines

3 I take additional action to try to get rid of the

problem

4 I ask directly to the Health Professionals recovery of

my child

5 I try out different ways of solving the problem.

6 I do what has to be done, one step at a time.

II

7

COGNITIVE COPING:

I need explanation about the routine of the NICU

8 I am aware of child condition.

9 I make a plan of action.

10 I try to come up with a strategy about what to do.

11 I think about how I might best handle the problem.

12 I think hard about what steps to take care of my

child.

13 I look for something good and recovery of the child

14 I tell to myself not to worry because everything

would workout fine.

III

15

EMOTIONAL COPING:

I get upset and let my emotions out

16 I let my feeling out with my family members

17 I feel a lot of emotional distress

18 I find myself expressing those feelings a lot

98

19 I have been getting comfort and understanding from

someone

20 I try to forget about the stressful situation

21 I have been getting emotional support from others

IV

22

SPIRITUAL COPING

I put my trust in God

23 I seek God’s help

24 I visit places of worship.

25 I try to find comfort in doing prayer

26 I pray more than usual

27 I meet religious leaders

V

28

SOCIAL COPING

I talk with someone who have gone through a

similar situation.

29 I learn to live with it

30 I try to get advice from someone about what to do

31 I talk to someone to find out more about the situation

32 I talk to health professionals who could do

something about the problem

33 To be involved in the care of my child

34 Getting along with family/friends during social

gatherings

VI

35

DIVERSIONAL ACTIVITY

I turn to work of others activities to take my mind

off things

36 I listen to music

37 I Watch television / movies

38 I read books, newspapers & magazines

39 I sleep more than usual

40 I take break for a while from the hospital

99

APPENDIX - 8

LIST OF EXPERTS

1. Dr. G. Kasthuri,

Principal, Professor,

The Oxford College of Nursing,

Bangalore.

2. Mrs. Prabhavathi,

Associate Professor,

M.S. Ramaiah College of Nursing

Bangalore.

3. Ms. Jayalakshmi,

Principal, Professor,

Chinai College of Nursing,

Bangalore.

4. Mrs. Kulkarni. B.G,

Principal, Professor,

Infant Jesus College of Nursing

Bangalore.

5. Dr. Nagarajaiah,

Asst. Professor,

NIMHANS,

Bangalore.

6. Mr. Nandeesh. J,

Principal, Professor,

Gangothri College of Nursing

Bangalore.

32

Sample Subjects Variables Tool of Data Plan of analysis

Collection

Mothers of

neonates

admitted in

Neonatal

Intensive

Care Unit

(NICU)

� STRESS LEVEL

� COPING

STRATEGIES

• Mothers age

• Educational

qualification

• Occupation of the

mother

• Monthly family

Income

• Religion

• Area of living

• Number of

Children

• Nature of

treatment and

• Number of days

hospitalized.

Coping Scale

Stress Scale

Demographic

Data

Distribution of

Selected

Dmographic

Variables

STRESS LEVEL

Low stress

Moderate stress

Severe stress

COPING LEVEL

Poor coping

Moderate coping

Good coping

15

CONCEPTUAL FRAMEWORK BASED ON ROY’S ADAPTATION MODEL

INPUT PROCESSES EFFECTORS OUTPUT

FEED BACK

MOTHERS

Age of the

mother

Education

Occupation

Family income

Residence

Religion

Number of

children

Admission

Condition

Number of days

hospitalized

CONTROL PROCESS

Coping Strategies

I make a plan of

action.

I think hard about

what steps to take

care of my child.

I feel a lot of

emotional distress

I put my trust on God

I meet religious

leaders

I try to handle things

I Hope things will get

better.

Use of negative

coping mechanisms

1. PHYSICAL

DOMAIN

2.PHYSIOLOGICAL

DOMAIN

3.EMOTIONAL

DOMAIN

4.COGNITIVE

DOMAIN:

5.COMMUNICATION

WITH STAFF

6.PARENTAL ROLE

ALTERNATION

7.SOCIO-ECONOMIC

DOMAIN

ADAPTIVE

MODES

Use of positive

coping mechanisms