Correlates of Anxiety, Hostility,

Depression, and Psychosocial

Adjustment in Parents of NICU Infants
Lynn V. Doering, RN, DNSc
Debra K. Moser, RN, DNSc
Kathleen Dracup, RN, DNSc

T HE BIRTH OF AN INFANT IS A DIFFICULT TIME FOR ALL

parents. When an infant is born with health problems
and requires placement in a neonatal intensive care unit
father), sociodemographic characteristics (age, marital status,
ethnicity, employment status, and education), and psychoso-
cial factors (social support, family functioning, and perceived
(NICU), parents experience intense emotions. Fears regard- control) (Figure 1).
ing the infant’s future and the
parents’ ability to care for him,1,2 BACKGROUND
ABSTRACT
feelings of grief surrounding the The bir th of a premature
loss of a fully healthy child,3 and Purpose: The birth of a premature or critically ill infant can and/or critically ill infant is a
result in debilitating parental responses. This study identi-
stress from unfamiliar sights and time of emotional difficulty for
4 fies correlates of parental anxiety, hostility, depression, and
sounds in the NICU have all psychosocial adjustment so that nurses can identify parents
parents.7,8 Anxiety and depres-
been documented. likely to need special attention or intervention. sion, particularly in mothers of
Neonatal clinicians consider Design: An explanatory, correlational design was used. premature infants, have been
both the infant and the infant’s Sample: The study involved 469 parents (mothers = 299, studied as manifestations of
parents as a family unit requiring 65 percent; mean age 29.1 ± 6.8 years) of infants hospital- parental emotional distress. Not
nursing care. Nurses need to ized in five Level III NICUs. surprisingly, mothers of prema-
understand the forces that con- Main Outcome Variable: The main outcomes were those ture low birth weight infants are
tribute to emotional distress variables which correlated with the independent variables more anxious and depressed
(anxiety, hostility, and depres- and included: parent status (mother or father), ethnicity, than mothers of term infants.9
sion) and poor psychosocial employment status, and education. These negative emotional states
Results: Parents experienced high levels of anxiety, hostili-
adjustment in parents whose appear to be heightened just
ty, and depression. Poorer family functioning, lower levels
infants require NICU care. of social support, and lower perceived control were associ-
prior to the infant’s hospital
Although parental distress has ated with higher levels of anxiety, hostility, and depression discharge.1
been reported, 1,4–6 factors associ- Little data have been report-
and with poorer adjustment. Parental status (mother or
ated with its presence or absence father), ethnicity, employment status, and education were ed regarding hostility and psy-
remain unclear. Clinicians caring significantly related to parental responses. chosocial adjustment in this
for infants and their parents in population. Regarding hostility,
the NICU may therefore fail to researchers using the Multiple
identify parents at risk. Affect Adjective Checklist have reported equivocal data. In a
The purpose of the current study was to identify correlates sample of mothers of low-weight preterm infants, Brooten
of anxiety, hostility, depression, and adjustment in parents of
infants in the NICU. We hypothesized that correlates in a This research was funded by National Institute of Nursing Research, National
multivariate model would be parental relationship (mother or Institutes of Health (R01 NR02434).

Accepted for publication January 1999. Revised September 1999.

N E O N ATA L N E T WO R K
VOL. 19, NO. 5, AUGUST 2000 15
FIGURE 1 ■ Hypothesized relationships among variables.
Parental Relationship
Mother/Father
Sociodemographics
Age Anxiety
Marital Status Hostility
Ethnicity Depression
Employment Status Adjustment
Education
Psychosocial Factors
Social Support
Family Functioning
Perceived Control
and colleagues found means for hostility that
were comparable to normative populations (e.g.,
adolescent mothers).1 Others have found levels
of hostility above normative data. Regarding
psychosocial adjustment, Doering and associates
reported poorer adjustment in mothers com-
pared to fathers. 10 Although little is known
about these variables in parents of high-risk
infants, research in related populations (e.g.,
families of high-risk cardiac patients) has shown
hostility and adjustment to be important vari-
ables of interest.11,12 Therefore, these variables
have been included in the current study.
Parental Relationship to the Infant
When both parents have been studied, moth-
ers have been found to be more distressed than
fathers4,5,10,13,14 and to use different styles of
coping.15 Mothers sought more social support
and used escapist coping strategies more than
fathers did, although the two groups of parents
used overall efforts to cope with the situation
with the same frequency. Fathers tended to cope
by using minimization, an emotion-focused
strategy involving the avoidance of anxiety.15
Differing sources of anxiety in mothers and
fathers also have been reported.5 Mothers’ anxi-
ety was diffuse, while fathers were more anxious
about uncertain outcomes regarding the infant’s
health and about adopting the parental role.
Social Support
Social support has been identified as a media-
tor of anxiety, hostility, depression, and adjust-
ment in the normal transition to parenthood, as
N E O N ATA L N E T WO R K
16
well as in parents of low birth weight infants.16
For example, Prudhoe and Peters found that par-
ents and grandparents of infants in the NICU
used support networks, including social resources
and emotional support from others, to cope with
their infants’ illnesses.17 Increased emotional dis-
tress has been associated with decreased closeness
in important personal relationships, a reflection
of inadequate social support.18
Family Functioning
The effects of prior family functioning on
parental anxiety, hostility, depression, and adjust-
ment in response to the birth of a low birth
weight infant have rarely been studied.19,20 Many
investigators have reported on the effects of the
birth of a healthy infant on family functioning,
however—particularly on the quality of the mari-
tal relationship. These investigators have found
that marital satisfaction diminishes following the
birth of a healthy infant.21 The birth of a prema-
ture or critically ill infant affects the couple even
more negatively, particularly related to financial
burden, family and social disruption, and person-
al strain.22,23 For a couple with poor communica-
tion patterns or inadequate problem-solving
skills, such a birth may be a crushing burden.
Perceived Control
Perceived control as a moderator of parental
anxiety, hostility, depression, and adjustment in
the NICU has not been studied, but differences
in perceived control between mothers and
fathers have been documented. Mothers report-
ed having greater perceived control over the
infant’s recovery than fathers, although a moder-
ately high correlation between spouses’ percep-
tions of control was documented.15 One mother
of a critically ill infant described eloquently her
feelings of powerlessness while her infant was in
the NICU. This mother, who also happened to
be an NICU nurse, described lack of control as
intimidating and associated it strongly with feel-
ings of failure.3
Sociodemographic Characteristics
The relationship of sociodemographic charac-
teristics to parental anxiety, hostility, depression,
and adjustment is less clear. Sociodemographic
characteristics were included in the current study
because they are easily assessed by clinicians and
because previous work has indicated that factors
such as ethnicity, parental age, income, marital
AUGUST 2000, VOL. 19, NO. 5
status, and education may mediate the buffering effects of
social support, family functioning, or perceived control in
related populations. 18,23–27 Older parents may be more
mature and may have developed a greater repertoire of cop-
ing skills and/or material resources, for example. Of particu-
lar importance, little research has been done regarding the
relationship of ethnicity to parental anxiety, hostility, depres-
sion, and adjustment in the NICU setting. Most previous
work has been done in homogeneous, Anglo American sam-
ples. Although ethnic differences in parental adjustment have
not been evaluated, Koniak-Griffin and colleagues have
reported differences in social support across ethnic groups
among pregnant adolescents, with African American mothers
reporting significantly less total functional social support than
either Caucasian or Hispanic women.28 The diversity and size
of the sample in the current study made it possible to consid-
er the role of ethnicity as a factor potentially influencing
parental anxiety, hostility, depression, and adjustment in the
NICU.
METHODS
The current research was conducted as part of a prospec-
tive, multisite study designed to compare four types of car-
diopulmonary resuscitation training for parents of high-risk
infants in the NICU.29 Institutional review board approval
was obtained at participating hospitals. Parents from five
NICUs in two university-affiliated and three community hos-
pitals volunteered and were enrolled when they responded to
signs posted in each unit inviting participation. All parents
signed consent forms prior to the study.
Parents were enrolled if they lived in the infant’s home,
they were literate in English or Spanish, and their infant was
identified as being at high risk for a cardiac or respiratory
arrest. High-risk infant criteria were prematurity (<38 weeks);
low birth weight (<2,500 gm); documented episodes of
apnea or bradycardia; congenital cardiac, neurologic, or gas-
trointestinal anomalies; respiratory distress syndrome; or
bronchopulmonary dysplasia.
Sample and Setting
Four hundred and sixty-one parents volunteered and pro-
vided baseline data prior to receiving any intervention. These
data constitute the subject of this article. They gave birth to
349 infants, including 296 single births, 19 sets of twins, and
5 sets of triplets. The most common diagnoses requiring
NICU admission were low birth weight (n = 280, 80 per-
cent) and prematurity (n = 249, 71 percent).
Most participants were mothers (n = 299, 65 percent) and
were married (n = 309, 67 percent). The sample included
136 mother-father pairs (n = 272) as well as 163 mothers and
26 fathers who participated without their spouse or partner.
Mean age was 29.1 (± 6.8) years, and mean years of educa-
tion was 12.7 (± 3.6). The average number of individuals liv-
N E O N ATA L N E T WO R K
VOL. 19, NO. 5, AUGUST 2000
ing in the household at the time of study enrollment was 4.1
(± 1.6). Participants constituted an ethnically diverse group.
One hundred ninety-nine (43 percent) identified themselves
as Hispanic-Latino, 155 (34 percent) as Caucasian, 45 (10
percent) as African American, 42 (9 percent) as Asian, and 20
(4 percent) as other. Many reported that they did not work
outside the home (n = 193, 42 percent). Forty-seven percent
had annual household incomes <$40,000. Fourteen percent
of participants reported incomes between $40,000 and
$59,999, and 16 percent reported incomes ≥$60,000.
Twenty-three percent of participants declined to report
income level.
Procedures
Prior to the infant’s discharge from the NICU, parents
completed questionnaire packets in a private conference room
adjacent to the NICU. They were instructed to complete
questionnaires without consulting anyone else, including
spouses. Parents were allowed to choose English or Spanish
language packets. Most parents spent approximately 45 min-
utes completing the questionnaires. Bilingual registered
nurses, serving as research assistants, were available to answer
questions during testing.
Instruments
To ensure equivalency between languages, study instru-
ments were translated from English to Spanish and back-
translated by a second interpreter. Two instruments were used
to measure parental emotional distress (anxiety, hostility, and
depression) and parental adjustment to the infant’s illness: the
Multiple Affect Adjective Checklist and the Psychosocial
Adjustment to Illness Scale. Hypothesized correlates of
parental anxiety, hostility, depression, and adjustment were
measured by three instruments. Social support was measured
by the Blumenthal Perceived Social Support Scale. Family
functioning was measured by the general functioning subscale
of the McMaster Family Assessment Device. Perceived con-
trol was measured by participants’ self-rating of their degree
of control regarding their infant’s health.
The Multiple Affect Adjective Checklist was used to
assess emotional or psychological distress. It has demonstrat-
ed validity in the measures of anxiety, depression, and hostility
associated with stressful or stress-alleviating conditions in a
wide range of populations.30,31 Higher scores correspond to
higher levels of distress. The highest possible scores for anxi-
ety, depression, and hostility are 21, 40, and 30, respectively.
Internal consistency scores using Cronbach’s alpha were 0.78
(anxiety), 0.87 (depression), and 0.76 (hostility).
The Psychosocial Adjustment to Illness Scale (family
version) is a forced-choice questionnaire of 46 items that
assesses seven areas with relevance for adjustment to medical
illness of a family member.32 Responses are rated on a four-
point scale from zero, indicating no distress, to three, indicat-
17
 ing extreme distress. Total scores range from 1
to 138; lower scores reflect improved adjust-
ment. This scale has been validated in a variety
of populations, including cardiac patients and
their families and parents of children with can-
cer.30,33 Cronbach’s alpha was used to test relia-
bility in the current study. Internal consistency
scores for the subscales were (1) health care ori-
entation, 0.53; (2) vocational environment,
0.67; (3) domestic environment, 0.63; (4) sexu-
al relationships, 0.76; (5) extended family rela-
tionships, 0.59; (6) social environment, 0.84;
and (7) psychological distress, 0.85. Cronbach’s
alpha for the total score was 0.89.
The Blumenthal Perceived Social Support
Scale was used to measure subjectively assessed
social support from three sources: family, friends,
and significant others.34 It consists of 12 items
rated on a seven-point scale, with higher scores
indicating greater support. Possible scores range
from 12 to 84. Internal consistency and con-
struct validity have been established.35 Internal
consistency using Cronbach’s alpha in the cur-
rent study was 0.92.
The McMaster Family Assessment Device
was used to evaluate six dimensions of family
functioning: (1) problem solving, (2) communi-
cation, (3) roles, (4) affective involvement, (5)
affective responsiveness, and (6) behavior con-
trol.36 In addition to these subscales, a general
functioning scale assesses the overall
health/pathology of the family. Respondents
indicate degree of agreement on a four-point
scale to 60 statements about families. Total
scores range from one (healthy) to four
(unhealthy). Reliability and validity of the sub-
scales, as well as the general functioning scale,
have been established.37 For the general func-
tioning scale, used in this study, internal consis-
tency using Cronbach’s alpha was 0.86.
Perceived control was measured by asking
each parent to rate agreement with the following
statement: “In regard to my infant’s health
problem, I feel in control.” A five-point scale
was used, so that feelings of being “totally in
control” received a value of one and feelings of
being “not in control at all” were weighted with
a value of five. Responses to this single question
have been shown to be related to feelings of per-
ceived control regarding health in adult cardiac
patients and their spouses.30 This approach was
selected because the question posed is directly
related to the specific health circumstance under
N E O N ATA L N E T WO R K
18
study. In contrast, locus of control instruments
perform poorly in measuring control related to
specific health circumstances, probably because
of their general nature.38
Analysis
The demographic and psychosocial character-
istics of the sample were evaluated using statis-
tics of central tendency. Significance was set at
.05 for all analyses.
To assess relationships among all the variables
of interest, we constructed a correlation matrix
to test the relationship of each of the three
potential correlates (social support, family func-
tioning, and perceived control) with each of the
four outcome measures of emotional and psy-
chosocial adjustment (anxiety, depression, hostil-
ity, and adjustment to the infant’s illness). For
each outcome measure, a model of criterion
variables was tested using stepwise multiple
regression. Each model included parental rela-
tionship to the infant (mother or father), psy-
chosocial correlates, and sociodemographic vari-
ables (age, marital status, ethnicity, employment
outside the home, and years of education).
Variables were entered into each model equa-
tion in a hierarchical fashion, with parental rela-
tionship and sociodemographic variables entered
as a block first, followed by psychosocial vari-
ables. Parental relationship and sociodemo-
graphic variables were entered first because they
are not amenable to intervention and their early
entry into the model controls for their effect.
Customary criteria for entry into and removal
from the model (.05 and .10, respectively) were
used.39 Each model was assessed for collinearity
using a variance inflation factor (VIF) and condi-
tion index. The VIF values for each model were
well below the critical value of 10. Likewise, the
content index values were below the critical
value of 30, which indicates that collinearity was
not a significant threat to the four models
tested.40 Finally, the use of a stepwise procedure
guards against collinearity because variables
already in the model are tested for removal at
each step.
The fact that 272 of the 461 participants
were part of a pair in which both partners
participated in the study raised concern that this
subsample would violate the assumption of inde-
pendence among subjects. A test of the correla-
tion between paired scores on the four outcome
variables (e.g., maternal and paternal anxiety) for
AUGUST 2000, VOL. 19, NO. 5
TABLE 1 ■ Description of Variables 10.50 (± 4.11) were well above the normal range of 7 or less,
Variable Mean Standard Deviation Range with higher scores indicating worse anxiety and hostility.31
Anxiety 9.74 4.30 0.00–21.00 Mean depression scores of 15.87 (± 6.62) reflected moderate
Hostility 10.50 4.11 0.00–26.00 to severe clinical depression.41 Anxiety, hostility, and depres-
Depression 15.87 6.62 1.00–34.00 sion were more pervasive in these parents than in families of
Adjustment 32.64 16.00 0.00–81.00 high-risk cardiac patients42 or in earlier reports of mothers of
Social support 68.63 13.93 12.00–84.00 preterm infants.1 The measure of psychosocial adjustment
Family functioning 1.87 0.49 1.00–3.67 used in this study was designed so that lower scores reflect
Perceived control 2.62 1.10 1.00–5.00 better adjustment. Adjustment to the infant’s illness averaged
32.64 (± 16.00), with a possible range of 0 (best) to 138
(worst). These adjustment scores were better than those doc-
these 136 couples, however, demonstrated weak correlations umented in adult cardiac patients.42
(i.e., <.30) not powerful enough to justify use of a nested The relationships between the identified independent and
analysis. To further assure that the inclusion of parental pairs dependent variables were assessed using Pearson Product
did not violate the assumption of independence, we conduct- Moment Correlations (Table 2). The correlations were mod-
ed multivariate analyses for the paired and nonpaired partici- erate at best. Nonetheless, because of the complexity of the
pants separately. In these separate analyses, the independent relationships and because partial correlations in regression
correlates were identical to those of the whole sample, with may be different from first-order correlations, a conservative
one exception. In the nonpaired subsample, the parental rela- approach of including even modestly correlated variables in
tionship to infant (mother or father) was not correlated inde- the multivariate analysis was applied.39 This approach was
pendently with anxiety and adjustment, as it was for the used so that as many significant relationships as possible could
whole sample. This was probably because the whole sample be identified.
included more fathers (35 percent) than the nonpaired only The degree of correlation between social support and fam-
sample did (14 percent). The amounts of variance explained ily functioning (–0.458) reflected possible conceptual overlap
by the models for the nonpaired and paired subsamples were between the two measures. In fact, one of the three subscales
similar (i.e., <5 percent difference) to those for the whole of the social support scale measures support from family (in
sample. Therefore, only results for the whole sample are contrast to friends and significant others). In an attempt to
reported here. reduce overlap, the family subscale was eliminated from the
Because previous work suggests that factors influencing total score, and the two variables (social support and family
responses to the NICU hospitalization of an infant may differ functioning) were compared again using Pearson Product
between mothers and fathers,4,5,10,13,14 the interaction of the Moment Correlations. The result was similar to the first anal-
mother/father relationship with ethnicity and levels of social ysis using the total social support instrument (–0.425); there-
support, family functioning, and perceived control were also fore, the entire questionnaire was used in the multivariate
examined. The General Linear Model was used, and parents analyses.
were divided into high or low groups via media splits for The multivariate relationships of criterion variables to anxi-
social support, family functioning, and perceived control. Age ety, hostility, depression, and adjustment were modeled
and educational level were used as covariates. through stepwise multiple regression (Table 3). Variables
explained 17 to 29 percent of the total variance. Parental rela-
RESULTS tionship to the infant (mother or father) had no significant
Key variables of interest are summarized in Table 1. Mean interaction effects with social support, family functioning,
anxiety scores of 9.74 (± 4.30) and mean hostility scores of perceived control, or ethnicity.

TABLE 2 ■ Intercorrelation of Variables

Anxiety Hostility Depression Adjustment Social Support Family Functioning Perceived Control
Anxiety 1.0
Hostility 0.668* 1.0
Depression 0.807* 0.749* 1.0
Adjustment 0.538* 0.501* 0.606* 1.0
Social support –0.187* –0.276* –0.195* –0.343* 1.0
Family functioning 0.223* 0.307* 0.219* 0.297* 0.458* 1.0
Perceived control 0.289* 0.220* 0.281* 0.298* –0.072 0.25 1.0

* p <.01

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VOL. 19, NO. 5, AUGUST 2000 19
TABLE 3 ■ Multiple Regression of Anxiety, Hostility, Depression, and Adjustment of Several sociodemographic correlates of
Parents with Infants in the NICU*
parental response were identified, and they were
(Step) Variable Change in R2 F Change Final beta somewhat different for the four outcome vari-
Anxietya ables studied. (1) Ethnicity was important in
(1) Mother vs father .023 10.6e .15e anxiety, hostility, depression, and psychosocial
(2) Hispanic vs all others .017 8.2e –.13e adjustment. Hispanic parents were less likely to
(3) African American vs all others .012 6.0f –.12f report high levels of anxiety, hostility, and
(4) Perceived control .062 32.1g .26g depression and poor psychosocial adjustment;
(5) Family functioning .053 28.8g .23g African Americans were less likely to report feel-
(6) Social support .010 5.4f –.11f ing anxious or depressed. Caucasian parents
Hostilityb were less likely to report feeling hostile. (2)
(1) Not employed vs employed .022 10.4e .15e Parents who were not working outside the
(2) Hispanic vs all others .013 6.0f –.11f home were more likely to report feeling hostile
(3) Caucasian vs all others .011 5.3f –.14f than parents who were employed. (3) Parents
(4) Family functioning .087 45.8g .30g with higher levels of education were more likely
(5) Perceived control .040 22.2g .21g to describe poorer psychosocial adjustment. Age
(6) Social support .019 10.9e –.16e did not enter into any of the multivariate equa-
Depressionc tions as a correlate of parental distress.
(1) Mother vs father .063 30.6g .25g
(2) Hispanic vs all others .037 18.7g –.29g DISCUSSION
(3) African American vs all others .008 4.1f –.09f Although our models included influences
(4) Family functioning .059 32.4g .25g commonly hypothesized to contribute to
(5) Perceived control .044 25.6g .22g parental anxiety, hostility, depression, and adjust-
(6) Social support .014 8.4e –.14e ment, the amount of variance explained by each
Adjustmentd model was relatively small (i.e., <30 percent).
(1) Mother vs father .046 21.9g .21g No single variable accounted for a large propor-
(2) Hispanic vs all others .034 16.7g –.18g tion of the variance. These results indicate the
(3) Years of education .012 6.0f .12f complexity of the emotional and psychosocial
(4) Social support .142 84.5g –.38g states for parents with an infant in the NICU
(5) Perceived control .038 23.9g .21g and support the need for further research.
(6) Family functioning .029 18.9g .20g
Parental Relationship to the Infant
* Degrees of freedom for analyses ranged from 1, 454 to 1, 459. Compared to fathers, mothers were more
a Total R2 = .166, F(6, 454) = 16.30, p <.001. likely to report higher levels of anxiety and
b Total R2 = .182, F(6, 454) = 18.09, p <.001. depression, along with poor adjustment, a find-
c Total R2 = .215, F(6, 454) = 22.02, p <.001. ing noted by other investigators.10,14 Miles and
d Total R2 = .291, F(6, 454) = 32.5, p <.001.
colleagues reported that, although both parents
e p <.005.
had significant anxiety, the source of anxiety was
f p <.05.
different for fathers and mothers, and mothers
g p <.001.
found the entire NICU experience and its after-
Parental relationship to the infant (mother or math more stressful than fathers. 5 Similarly,
father) was associated with anxiety, depression, Shields-Poe and Pinelli used the Parental
and adjustment. Specifically, mothers were likely Stressor Scale: NICU, to identify associations
to demonstrate higher anxiety, more depression, between situational, parental, and infant vari-
and poorer psychosocial adjustment than fathers. ables and sources of parental stress in the NICU.
All the hypothesized psychosocial factors of A mother’s stress regarding her interactions with
parental response across the four outcome vari- her infant was correlated with her age and with
ables were significant, although their individual the location where she first saw her infant, while
contribution to the explained variance was small. her stress regarding the infant’s appearance was
Lower levels of social support and perceived correlated with her marital status. For fathers,
control and poor family functioning were associ- unique correlates of stress related to interactions
ated with anxiety, hostility, depression, and poor with the infant were the gap between perceived
psychosocial adjustment in parents. and measured morbidity and frequency of atten-

N E O N ATA L N E T WO R K
20 AUGUST 2000, VOL. 19, NO. 5
dance at religious services. Paternal stress related to sights and
sounds of the NICU were correlated with timing of the first
visit and discussion with a social worker.14 These differences
in the reasons for parental stress may account for the differ-
ences in parental anxiety, depression, and adjustment found in
the current study.
Social Support
Lack of social support was associated with anxiety, hostility,
depression, and poor adjustment. This finding corresponds to
other reports that higher stress is associated with decreased
closeness in personal relationships.43 The finding is particular-
ly important for mothers. Women count on close personal
support from sources outside the marriage.43 When the hos-
pitalization of a critically ill infant disrupts those sources of
support or when mothers lack extramarital support, these
mothers may be at greater risk for negative responses to their
infant’s NICU hospitalization.
Family Functioning
Family functioning also explained a percentage of the vari-
ance in anxiety, hostility, depression, and adjustment.
Although this finding is consistent with reports of diminished
marital satisfaction during the transition to parenthood,21 it
also highlights the need to consider other dimensions of fami-
ly functioning when assessing parents’ risk for negative emo-
tional or psychosocial responses. In addition to marital satis-
faction, the family’s problem-solving abilities, communication
patterns, and role or behavior expectations may influence
parental distress in the NICU.
Perceived Control
An important contribution of the current study is the eval-
uation of perceived control as an aspect of the parental experi-
ence in the NICU. The evaluation of perceived control is
important because it has received little attention from clini-
cians and researchers to date and because, unlike locus of con-
trol, which is personality driven, perceived control is
amenable to nursing intervention.30 In the current study, low
perceived control was associated with higher anxiety, hostility,
and depression and poorer adjustment. These findings high-
light the need for nurses to assess manifestations of low per-
ceived control in parents and seek opportunities to minimize
it. Future research needs to focus on design and testing of
interventions, such as parental involvement in decision mak-
ing, to enhance parents’ sense of control while their infants
are in the NICU.
Sociodemographics
Several sociodemographic variables accounted for a por-
tion of the explained variance in parental anxiety, hostility,
depression, and adjustment. Ethnicity was related to anxiety
and depression. Both ethnicity and employment status were
N E O N ATA L N E T WO R K
VOL. 19, NO. 5, AUGUST 2000
related to hostility; ethnicity and educational attainment were
related to parental adjustment. These findings reinforce the
need to identify sociodemographic factors that characterize a
group of parents at high risk for negative emotional response
and poor adjustment after the birth of a premature or critical-
ly ill infant.
Ethnicity was associated with anxiety, hostility, depression,
and adjustment, but the relationships varied by ethnic group.
Hispanic ethnicity was associated with more positive parental
responses, specifically lower levels of anxiety, hostility, and
depression and with higher levels of parental psychosocial
adjustment. This finding differs from other reports in clinical
populations outside the NICU,28,43 in which non-Caucasian
ethnicity was associated with more negative parental respons-
es. However, this is the first large study of Hispanic parents,
many of whom did not speak English. The results of previous
investigators who have studied English-speaking Hispanics
may have been influenced by the acculturation that occurs as
immigrants adapt to a new country and face the challenges of
integrating two different cultures. Fluency in the dominant
language, in this case English, is a well-accepted surrogate for
acculturation.44 The role of social support, family function-
ing, and perceived control in unacculturated, non-English-
speaking Hispanics requires further study.
Although there were no correlations between any of the
outcomes measures (anxiety, hostility, depression, or adjust-
ment) and age or marital status in the current study, other
investigators have reported that age and marital status may be
associated with maternal stress. In particular, age and marital
status have been reported as correlates of maternal stress
related to infant-mother interactions and infant’s appearance,
respectively.14 Differences in the samples of the two studies
may explain the difference in findings. The sample of the ear-
lier study was homogeneous, including only English speakers,
and greater percentages were married and college educated.
The difference in findings may also arise from the difference
in outcome measures. Shields-Poe and Pinelli measured
parental stress.14 The current study measured emotional states
often considered to be responses to stress.
Overlapping Nature of Dependent Variables
As reflected by the correlation matrix (see Table 2),
parental anxiety, hostility, depression, and adjustment are
related concepts. It is not surprising, therefore, that factors
related to one variable are also related to others. Because each
variable was considered as the dependent variable in separate
analyses, however, separate sociodemographic and psychoso-
cial influences have been identified. Such information may be
helpful for clinicians, who must identify parents who need
special support or intervention while their infant is in the
NICU. Given the relatively modest nature of our findings,
however, clinicians must remember that individuals vary
greatly and that the prognostic value of specific correlates
21
must be considered in the context of each individual family or
parental situation.
Limitations
The study is limited by the use of a volunteer, convenience
sample. Parents were enrolled when they came to a meeting
in response to signs posted in the NICU. Although no par-
ents who volunteered decided not to participate after coming
to the posted meeting, we cannot verify the representativeness
of the sample. Parents who volunteered may have had differ-
ent responses to their infants’ NICU hospitalization or had a
different set of resources than parents who did not volunteer.
Given the nature of the study and the requirements of the
institutional review boards, however, it was not possible to
recruit parents more purposefully or to obtain data on parents
who elected not to volunteer.
CONCLUSION
Further research is needed to distinguish among ethnic
groups (especially Hispanic) characteristics that influence
parental anxiety, hostility, depression, and adjustment. Within
large ethnic groups, the role of acculturation in promoting or
hindering parental adjustment has not been explored and may
explain apparently conflicting findings to date. Also, further
research is required to understand the role of perceived con-
trol as it influences parental adjustment in the NICU setting.
Perceived control may be an important variable mediating the
psychosocial response of parents with a critically ill infant in
the NICU, but it is not clear if such perceived control is a
personality characteristic or if it can be enhanced by interven-
tions employed by NICU staff.
These findings suggest an initial set of variables that clini-
cians may find useful in assessing parents in the NICU.
Nurses should consider both sociodemographic characteristics
and psychosocial resources in assessing parents’ vulnerability
to anxiety, hostility, depression, and poor adjustment.
Psychosocial resources and sociodemographic characteristics
may prove useful in identifying individuals or subgroups that
need more intensive follow-up and in developing interven-
tions to facilitate adjustment. Parents may need assistance in
identifying and using supportive relationships and in finding
ways in which they can feel more in control during the period
when their infant is hospitalized in the NICU. Finally, clini-
cians should be aware that there are great differences in indi-
vidual responses to the NICU experience and should conduct
well-rounded individualized assessments of parental needs.
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About the Author
Lynn Doering holds an MN and DNSc from UCLA, where she is
currently an assistant professor in acute care. Her research program
focuses on physiologic and psychosocial adaptation of high-risk patients
with cardiac disease. As both a clinician and a researcher, she has worked
extensively with patients at high risk for cardiac events and their families,
including both adults and infants. Her current work involves the study
of depression in women recovering from cardiac events and the role of
family members in treatment-seeking behavior for cardiac symptoms.
Debra Moser holds an MN and DNSc from UCLA and is an associ-
ate professor at the College of Nursing, Ohio State University. Her
research program includes biobehavioral study of cardiac patients, espe-
cially those with acute myocardial infarction and those with heart fail-
ure. Her current work focuses on testing nurse-managed community care
in heart failure patients.
Kathleen Dracup holds an MN from UCLA and a DNSc from
UCSF, where she is currently professor and dean of the School of Nursing.
Dr. Dracup is internationally known for her work in psychosocial adjust-
ment in cardiac patients. Her current research includes a multidisci-
plinary study of psychosocial, immunologic, autonomic, costs and quality
of life outcomes of exercise in heart failure patients, and an international
study of a nurse-directed intervention to decrease delay in treatment-seek-
ing behavior in patients with symptoms of acute myocardial infarction.
The authors wish to thank Mary Lynn Brecht, PhD, for her sugges-
tions related to statistical analysis.
For further information, please contact:
Lynn V. Doering, RN, DNSc
Assistant Professor
UCLA School of Nursing
PO Box 956918
Los Angeles, CA 90095-6918
(310) 825-4890
FAX (310) 206-7433
E-mail: ldoering@sonnet.ucla.edu
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