Background and significance

The neonatal intensive care unit (NICU) is designed to care for and provide appropriate support for the infant, and has been modified to provide comfort and engagement for the family.¹ The birth of a preterm infant (<37 weeks’ gestation) creates stress, alters the paternal role and causes feelings of separation that can delay paternal attachment.¹ If new fathers are feeling high levels of stress and anxiety, it is more difficult to bond with their infant. Fathers that find it harder to bond tend to shy away from participating in care of the infant and visit infrequently compared to mothers. Studies show that fathers want to get away from the NICU, often gravitating towards work and leisure-based activities to cope with the stress of the new situation.^2,3

Preterm births are common all over the world. In the United States, preterm birth affects one out of every 10 infants.⁴ Furthermore, according to the Centers for Disease Control and Prevention (CDC), preterm birth and low birth weight accounted for 17% of infant deaths in 2015.⁴ The World Health Organization (WHO) estimates that worldwide 15 million babies are born prematurely and the rate of preterm birth ranges from 5% to 18% of births.⁵

A review of current literature reveals a gap in knowledge regarding fathers of infants in the NICU. Little research has been devoted to the stress and anxiety levels of fathers of NICU babies. Mothers have been the primary focus of research on the experiences and needs of parents of critically ill infants because they are more likely to be the primary caregiver and are more readily available during the daytime.^6-10 Fathers have feelings of being a secondary parent as the primary focus remains on the mother and infant for care and decisions.¹¹ Fathers do show elevated stress levels and depressive symptoms along with mothers in these situations.¹ Factors of paternal stress stem from:

• the physical and emotional responsibility of concern for the hospitalised infant
• providing support for the mother
• communicating with concerned family and friends
• caring for other children
• returning to work.^1,12-14

Additionally, feelings of stress and loss of control are associated with not being involved in care and having to leave the infant at the NICU.¹⁵ It is important to identify what healthcare providers can do to help provide stress relief, educate regarding coping strategies, and enhance the bond between fathers and their preterm infant. In addition, depressive symptoms in both mothers and fathers are associated with less positive interactions with their infants and an interruption in the transition to parenthood.^1,16,17

Review of the literature

Studies have been conducted on parental stress and coping. The focus is on how mothers and fathers cope differently with stress, with the majority of participants being mothers. One study found that concerns about infant survival and development, parental stress, and insecurities about not being ‘legitimate’ parents make it difficult to have an infant in the NICU.¹⁸ This study determined coping strategies that some parents use when their infant is hospitalised. These strategies include participating in care, getting away from the NICU, gathering information, involvement of family and friends, and engagement with other NICU parents.¹⁸ The focus was on parents in general, with the majority of participants being the mothers of hospitalised infants. Participation in care of the infant was rated as the highest indicator of coping. Staff should support parents; however no strategies of how staff can be supportive were mentioned.

Another study found that mothers often want to participate in care, whereas fathers expressed confidence in delegating care to nurses.¹⁹ Communication between physicians, staff and parents was seen as key to confidence, and quality support from staff lessened parental stress. It was noted that interpersonal communication is a primary tool for exchanging information between health professionals and parents. Good communication and sharing of information is imperative for parents to feel confident in staff and reduce anxiety about the situation.

Few studies focus on the paternal role. Although fathers are acknowledged as being very important participants in the care of their infants, little is known about their experiences in the NICU.² Fathers may be in contact with the infant first, as the mother is in recovery, very ill or in another hospital, but the way fathers view and cope with the experience is not highly studied. Involvement of the father is important when decisions must be made, but is difficult if the father has not been closely involved. Arokiasamy et al found that fathers who felt a lack of control removed themselves from the care of the infant.² Through interviews with fathers of infants in a NICU, they found themes that included a sense of lack of control, their world view, information, communication, roles, and external activities. Lack of control over the situation and care of the infant was stressful for the fathers but information about their infant and communication with staff had an impact on how much control they felt. Additionally, the redefining of their roles in the family structure (father, caretaker, breadwinner and protector) was a large factor in paternal stress.²

Implications for practice

Support for parents is essential. Mothers like to be involved in the care of their infant. They want information and education to be able to participate in care and make decisions about the care of their infant. The focus of most studies is parents and mothers. Very few research studies single out the paternal experience and the needs, feelings and reactions of fathers. Helping the father cope and develop a bond with his baby is just as important and should be explored further to understand how to enhance that relationship. Knowing what fathers need and helping them cope will help develop a stronger bond between them and their infant.

Staff must engage in communication and provide adequate information to help fathers feel involved in care and decisions regarding their infant.²⁰ Teaching fathers how to care for and hold their infant will also enhance the bond between father and child. Neonatal nurses are in the unique position to provide care to the infant as well as support and care for both parents. Care plans should incorporate the support needs of fathers with appropriate persons identified to meet those needs.^19,20

TABLE 1 summarises fathers’ needs and proposed nursing interventions. For every identified need, there are at least two nursing/healthcare interventions. FIGURE 1 is a ‘job description’ for fathers. This job description can be provided for parents upon admittance of their baby to the NICU, hung at the bedside, or posted on the wall in the NICU. This helps to acknowledge the needs of the fathers to let them know that staff understand their feelings and want to help them through their journey in the NICU.²¹

TABLE 1 Fathers’ needs and targeted support to be provided by healthcare professionals.

FIGURE 1 The father’s job description to ensure inclusion in care.