This quasi-experimental study was done from October 2019 to May 2020.The sample included parents of premature infants hospitalized in one of the NICUs of the Hazrat Zeinab Hospital (due to having five sections of NICU) in Shiraz, Iran. The sample size was calculated for each group as 25mothers and 25 fathers) at 95% confidence level and statistical power of 90% using the following equation . S1 and S2 were unknown and were estimated from a pilot study with size of 5. In each group, 24 parents were estimated, and in terms of 5% probability of falling sample, 25 parents were selected in each group.
d = 2.5
S1 = 2.3
S2 = 2.8
α = 0.05
β = 0.02
In this way, the researcher referred to the NICU daily and if the parents were eligible, they were included in our study. Parents were randomly assigned to intervention and control groups. The cards with the words C and M written on them were prepared and each participant was asked to choose a card at random. Then parents with a card with the letter C in the control group and parents with a card with the letter M were located in the intervention group.
The inclusion criteria were the willingness to participate in the study, ability to care for the baby, having literacy, having Iranian nationality, being fluent in Persian, availability of both parents, fetal age of the baby being 30–36 weeks because infant mortality is significantly higher in infants born before 30 weeks of gestation, the baby’s hospitalization for at least 14 days in the ward, the parents’ non-attendance in educational-supportive courses related to the premature infant, and the parents’ non-use of psychiatric drugs. The exclusion criteria were the infant’s death, the parents’ death, and having an infant with another disorder that could be diagnosed and cause maternal anxiety and frustration. Besides, the participants who were absent at two sessions of the training course and those who had a history of premature birth or hospitalization in the NICU were excluded from the study.
The instruments were a demographic questionnaire and Distress Tolerance Scale (DTS). It was built by Simons and Gaher in 2005 and have 15 items and four subscales called tolerance (3 items), absorption (3 items), regulation (3 items) and appraisal (6 items). Items were rated on a 5-point scale: (5) Strongly disagree, (4) Mildly disagree (3) Agree and disagree equally, (2) Mildly agree, (1) Strongly agree. High scores represent high distress tolerance. The minimum score is 15 and the maximum is 75. Test–retest reliability was good (intra-class r = .61) . The reliability of the scale was assessed by Azizi and co-workers (2010). They reported that Cronbach's alpha and the test-retest reliability of the scale were 0.67 and 0.79, respectively .
After the admission of the premature infant the questionnaires were given to the parents. To prevent parental stress, each parent separately completed the questionnaires (mothers in the restroom next to the ward and fathers in the conference room). The control group did not receive any intervention except for routine ward care, breastfeeding training and kangaroo care. The intervention was conducted in two educational and supportive stages. In the educational stage, five 45-minute training sessions in 3 times a week were held face to face, both individually and in the groups. The same training sessions were held through WhatsApp groups due to lack of full presence and availability to parents. The training sessions included an introductory session, a baby care session, two sessions on stress reduction and tolerance, and question and answer session by the researcher and a psychologist using PowerPoint, Voice messages, and WhatsApp groups. At the end of the sessions, the parents were given an educational booklet. Besides, one day after the training stage, the support stage was implemented in the presence of the parents. To exchange their ideas and share information, the parents attended a room next to the ward for three days in five groups at the appointed time upon prior arrangements made with the manager and the head of the ward and talked for half an hour. Then, they spent half an hour together by the baby's bed, watching and caring for the baby. One month after the end of the supportive stage in the clinic, when the parents came to visit the pediatrician, the distress tolerance scale was completed again by the participants in both groups. The questionnaire was distributed by the researcher.
Our education was based on a comprehensive approach in the domain of family education that evaluates seven domains including communication, problem solving, emotional responses, roles, emotional involvement, general function, and behavioral control. This can be used to help couples who have some problems and families with a physically disabled member [17, 18].
To comply with ethical principles, the participants in the control group were given an educational package. Finally, the collected data were encoded and analyzed by SPSS 24 using paired t-test, independent t-test, and chi-square test at the significance level of 0.05.
The research proposal was approved by the Ethics Committee of Yazd Shahid Sadoughi University of Medical Sciences (IR.SSU.REC.1398.207). The research goals, anonymity of the information provided and voluntary participation were first explained and the participants then read and signed the written informed consent form; then, they completed the questionnaires.