الفهرس 
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Abstract
Preterm infant is an infant born before the end of the thirty-seventh week of pregnancy. During pregnancy most of women and their partners don’t give serious consideration to the possibility of the preterm delivery or illness in their newborn infant. In most cases admission of newborn to the Neonatal Intensive Care Units (NICUs) is un expected and stressful for the parents as they are unfamiliar with the potentially complex problems their infant is facing now and in the future. Preterm infants may have health problems because their organs did not have enough time to develop and they need special medical care in NICU. They may develop anemia, intraventricular hemorrhage, bronchopulmonary dysplasia, neonatal sepsis, neonatal jaundice, respiratory distress syndrome, necrotizing enterocolitis and neonatal hypoglycaemia.
Coping is a strategy that refers to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events. Some of the coping patterns utilized by the preterm infant’s parents include trying to gain a deeper understanding of the problem, establishing a degree of control of the situation, seeking social support from other people and escaping from or minimizing the apparent severity of the situation. Mothers tend to look for support from others and to search for an explanation for what has happened, whereas fathers are more likely to try to minimize the situation by concentrating on supporting their partners.
The nurse role in dealing with preterm infants is important and vital. The nurse must develop a plan of care based on assessment findings to ensure consistent and comprehensive care for the preterm infants and their families. Intervention program for reducing maternal stress during hospitalization of their preterm infant should be designed and implemented. Additionally, while the preterm infant is in the hospital and before the infant goes home, the mother should be instructed about her responsibilities when the infant discharged.
AIM OF THE STUDY
This study aiming to study the effect of nursing intervention on stressors and coping patterns of mothers having preterm infants. This aim will be attained through the following objectives:
• Assess the stressors and coping patterns of mothers having preterm infants.
• Design, implement and evaluate the effectiveness of the nursing intervention.
Research setting
This study was conducted at Neonatal Intensive Care Unit (NICU) at Maternity and Gynecological Hospital affiliated to Ain Shams University Hospitals and El-Monira Hospital affiliated to Cairo University Hospitals.
Research subjects
The study sample composed of one hundred and twenty mothers and their preterm infants regardless their gender were chosen from the previously mentioned settings. In each setting sixty preterm infants and their mothers.
Inclusion criteria for the studied preterm infants:
- Preterm infants regardless their gender and birth weight.
- Preterm infants with gestational age < 37 weeks.
- Expected duration of hospital stay not less than 21 days.
Exclusion criteria for the studied preterm infants:
- Preterm infants with congenital anomalies and serious pathology e.g., necrotizing enterocolitis.
- Preterm infant with intraventricular haemorrhage.
- Infants of diabetic mothers.
Inclusion criteria for the studied mothers:
- Mothers of preterm infants in the previously mentioned settings regardless their age, level of education, parity, and employment.
- Mothers who were agreed and available to visit their infants at least 3 times / week to participate in infants’ care at NICU.
Exclusion criteria for the studied mothers:
- Mothers with post natal psychological disturbance.
Tools of data collection
- Data were collected through using the following tools pre/post nursing intervention and at follow up:
1. Pre-designed questionnaire format by interviewing.
- It was designed by the researcher after reviewing the related literature. It was written in simple Arabic language and consisted of the following parts:
Part I: Characteristics of the studied preterm infant as including: gender, birth weight, length, gestational age, chronological age, diagnosis, mode of delivery, and hospital stay. These data were checked with the preterm infants’ medical record.
Part II: Characteristics of the studied mothers, it included:
A- Personal data including name, age, level of education and employment.
B- Housing condition such as residence, type of home, water supply, sewage disposal, electricity and ventilation.
C- Maternal and obstetrical history such as previous pregnancy, delivery and abortion, antenatal care, mode of delivery, obstetrical history including previous premature birth or neonatal deaths, and previous disease or hospital admission.
Part III: Concerned with mothers’ awareness and knowledge regarding care of their PT infants. It included knowledge regarding concept, causes and problems of prematurity, how to prepare home to receive their PT infants after hospital discharge, PT infants methods of feeding, protection from infection, massaging PT infant, infant crying cues and complications of prematurity.
2. An observation checklist.
It was used to assess the actual mothers’ practice related to care of their preterm infants pre and post implementation of nursing intervention and at follow up. It was adopted form Ministry of Health and Population (2004), Davis (2006), Bown and Greenberg (2008), and Children & Youth and Women’s Health Services (2009). It included maternal practices in infant’s hygiene, expression of breast milk, breast feeding, formula feeding, massage therapy, measuring axillary temperature and oral medication administration.
3. Psychometric measurements:
A) Parental Stressors Scale: NICU (related to Infant Hospitalization):
• It was adopted from Miles and Brunsser (1998). It was used to measure the mothers’ perception of stressors arising from the physical and psychosocial environment of the neonatal intensive care unit.
B) Hamilton Rating Scale for Depression.
It was adopted from Hamilton (1997), to assess the degree of depression experienced by mothers during hospitalization of their preterm infants.
C) Coping Health Inventory for Parents (CHIP).
It was adopted from McCubbin et al., (2003), to measure mothers’ response to management of family life when they have an infant who is seriously ill.
D) Maternal Confidence Questionnaire.
It was adopted from Russel (2005), to assess the mothers’ confident behavior toward care of their preterm infants.
E) Mothers’ Bonding Behavioral scale.
• It was adopted from (Bhakoo et al., 1994), to assess the mothers’ emotional and behavioral interaction (bonding) with their preterm infants pre and post nursing intervention.
4) Stressors Scale for Mothers of Preterm Infants:
It was designed by the researcher after reviewing the related literature; it was including four dimensions which are financial, psychological, social stressors and physical signs and symptoms of stress. It used to determine types and degrees of stressors experienced by mothers of preterm infants and physical signs and symptoms of stress.
5) Coping Scale for Mothers of Preterm Infants:
It was adopted from Rosalind, (2001), to assess coping patterns of mothers of preterm infants. It included 2 dimensions which are positive and negative coping patterns. Time consumed to fill in this questionnaire by each mother was 5 minutes.
6) Infant’s Follow up Monitoring Sheet:
It was designed by the researcher to gather information about preterm infant during follow up.
7) Maturational Assessment of Gestational Age:
It was adopted from Hockenberry (2006), to assess appropriateness of the PT infants to their gestational age.
II – Operational design
1. Preparatory phase
Tools of data collection were designed, developed and adopted by the researcher and revised by experts in the field of neonatal care and pediatric nursing.
2. Exploratory phase
Pilot study
A pilot study was carried on 10% of the study population, involving 6 mothers and their preterm infants in the study and control groups in NICU to evaluate the content validity and feasibility of implementing the designed tools. The necessary modifications were carried out as revealed from the pilot.
Results:
The important findings of the current study can be summarized as the following:
• The mean gestational age of the studied preterm infants was 30.0±2.13 weeks for study group and 30.4± 1.8 for the control one. The mean birth weight was 1252±199 gms and 1400± 258 gms for study and control group respectively.
• Nearly less than three fourths of the studied preterm infants in both groups their age range from 5- <10 days. Meanwhile the mean hospital stay of them was 36.5± 12.3 days for study group and 38.7 ±1.3 days for the control one.
• Most of the studied preterm infants were appropriate for gestational age as found in 91.7% and 88.3% in both groups respectively.
• More than half of the studied preterm infants were male, as observed in 65.0% and 63.3 % in both study and control group.
• More than half of the studied preterm infants delivered by caesarean section as observed in 53.3% and 51.7% of both groups respectively.
• The most common diagnosis in the studied preterm infants was respiratory distress syndrome as found in 83.3% of the study group and 86.7% of the control one.
• Nearly two thirds of the studied preterm infants ranked in their families as the first infant.
• The mean age of the studied mothers in the study group was 29.4±5.8 years and 27.85 ± 5.99 years in control group. Also more than one third of them were secondary school as observed in both groups.
• Approximately less than three quarters of the studied mothers were house wives as found in 76.7% and 71.7 % of both study and control group respectively, and half of them have average housing condition as found in 50% of both groups.
• The common health problems of the studied mothers before pregnancy was hypertension as found in 71.4% and 56.7 % in the study and control group respectively.
• The most common diagnosis during pregnancy was hypertension as found in 63% of the study group and 44.2% of the control one. Meanwhile the minority (4.3% and 11.6%) in the study and control group respectively were suffering from diabetes mellitus.
• Only 16.7% and 18.3% of both groups had a history of previous preterm birth in both groups, more than half of them were due to hypertension as found in 60 % and 50 % in both study and control group respectively.
• Regarding previous preterm death, nearly two thirds (66.7%) of mothers reported that respiratory distress syndrome was the primary leading cause of their previous preterm deaths in study group, while 71.4% of them in the control group reported that neonatal sepsis was the common causes of their previous neonatal death.
• Total mean score of mothers’ knowledge in study group was 160.8±17.5 post nursing intervention and 157.8±17.3 during follow up compared to 69.8±24.3 and 81.1±34.9 for the control group with highly statistical significant difference (p<0.001) between the two groups post intervention and during follow up .
• There was no statistical significant difference between study and control groups regarding bottle feeding post intervention (p> 0.05) while there was highly statistical significant difference between the two groups regarding all items of practical skills during follow up.
• The highest mean score of mothers’ practical skills was among the study group post intervention (377.0±14.1) and during follow up (430.6±21.6) with highly statistical significant difference (P< 0.0001) between both groups.
• The total mean score of maternal stressors for study group was 78.2±10.7 post intervention and 62.5±6.6 during follow up compared to 148.0±13.8 and 139±12.7 for control group.
• There was highly statistical significant difference (P> 0.0001) between study and control groups as regards all items of maternal stressors post intervention and during follow up.
• The total mean score of mother’s depression in study group was 13.1±3.5 and 9.4±3.2 post intervention and during follow up respectively compared to 22.1±3.9 and 19.2±3.3 for the control group with highly statistical significance difference between both groups.
• The highest total mean score of mothers coping was among mothers in study group [87.0±7.2 and 85.4±4.7] post intervention and during follow up respectively. Meanwhile, there was highly statistical significant difference between the two groups (P< 0.0001).
• Mothers in the study group had a highly confident behaviors toward care of their preterm infant post nursing intervention and at follow up compared to mothers in the control group with highly statistical significant difference (P< 0.0001).
• As regards total mean score of maternal-infant bonding, the highest mean scores were observed among study group post intervention (38±6.12) and during follow up (40.4±7.1) with highly statistical significant difference (P< 0.0001) between the study group and the control one.
• The highest mean scores of financial, psychological and social stressors were among control group with highly statistical significant difference between both groups post intervention and during follow up.
• The highest mean score of physical signs and symptoms of stress was observed among control group post intervention (31.4±2.9) and during follow up (30.5±3.1) with highly statistical significant difference between the study and control groups.
CONCLUSION
B
ased on results of the current study; it was concluded that, mothers had incorrect knowledge and unsatisfactory practice regarding care of their preterm infants. Additionally, mothers had poor confidence and poor bonding behaviour with high level of stress and depression. Mothers in the study group were found to have lower stress scores, positive coping behaviour and improved knowledge and practice regarding care of preterm infants. Furthermore, mothers in the study group were developed high maternal confidence with strong mother’s bonding behaviour associated with lower depression scores and lower physical signs and symptoms of stress.
RECOMMENDATIONS
In the light of the findings of the current study it was recommended that:
1. Special attention should be given to the females during period of childhood to promote their health and increase their health awareness as future mothers.
2. Special care should be provided for all pregnant mothers to promote their health and their pregnancy outcomes.
3. Mothers expecting twins should offered a specialized antenatal class and discussion with staff from the neonatal unit to be acquainted about what would happen to their babies immediately after birth.
4. Written simple documents should be prepared to provide information for parents when their infants are admitted to the NICU about the unit and how their infant’s needs will be met and satisfied.
5. Enhance Kangaroo care and infant’s massage to reduce maternal anxiety and increase mother’s sense of competence and sensitivity towards her infants.
6. Improvement of communication and involvement of parents in care of their preterm infants to reduce the length of stay, need for re-hospitalization and long term morbidity for preterm infants.
7. Mother’s stressors should be assessed and their coping patterns should be identified during period of hospitalization of their preterm infants to provide suitable nursing intervention during this period.
8. Consistent information about how to care for preterm infants and encouragement for expressing breast milk and breast feeding should be provided during hospitalization of preterm infants.
9. Providing story boards and photo albums of preterm infants who had previously been at the neonatal unit.
10. Mothers should receive written discharge information with verbal clarification at discharge.
11. Emphasize the importance of regular medical follow-up care after infants’ discharge in the neonatal follow-up clinics to assess the infants’ growth and development and to help mothers to overcome any problem.