Article Text

An educational-behavioural intervention for parents of preterm infants reduced parental stress in the NICU and infant length of stay
  1. Marilyn Ballantyne, RN, MHSc
  1. The Hospital for Sick Children, Toronto, Ontario, Canada

    Statistics from

 Q Does an educational-behavioural intervention for parents of premature infants improve parent-infant interactions and parental mental health and reduce infant length of stay in the neonatal intensive care unit (NICU)?


    Embedded ImageDesign:

    randomised controlled trial (Creating Opportunities for Parent Empowerment [COPE] NICU programme).

    Embedded ImageAllocation:


    Embedded ImageBlinding:

    blinded (primary care nurses and outcome assessors of parent-infant interactions).

    Embedded ImageFollow up period:

    2 months corrected infant age.

    Embedded ImageSetting:

    2 NICUs in Syracuse and Rochester, New York, USA.

    Embedded ImageParticipants:

    258 mothers (mean age 28 y) and 154 fathers/significant others (mean age 31 y) ⩾18 years of age (260 families) who could read and speak English, had not had another infant admitted to the NICU, and who had singleton infants (52% girls) born at the study sites with a gestational age of 26–34 weeks (mean 31 wks), birth weight <2500 g (mean 1650 g) and appropriate for gestational age, no severe disabling condition, and who were expected to survive.

    Embedded ImageIntervention:

    147 families were allocated to the COPE programme, which comprised audiotaped and written information on infant behaviour and parental roles and suggested activities to help parents implement the information. The programme was delivered in 4 phases: 2–4 days after NICU admission; 2–4 days after Phase I; 1–4 days before discharge; and 1 week after discharge (at home). 113 families were allocated to a comparison programme that comprised a series of audiotapes and written information delivered according to the 4 phases of the COPE programme (tapes 1 and 2 provided information about hospital services, tape 3 provided discharge information, and tape 4 provided information on immunisation).

    Embedded ImageOutcomes:

    included parental emotional coping (State-Trait Anxiety Inventory and Beck Depression Inventory, 2nd edition), parental stress in the NICU (Parental Stressor Scale—Neonatal Intensive Care), parental functional coping (Index of Parental Behavior in the NICU), parent involvement in infant care, and infant’s length of NICU stay and total hospital stay.

    Embedded ImagePatient follow up:

    247 families (95%) were included in the analyses (intention to treat).


    Mothers who received the COPE programme had less parental stress in the NICU than mothers who received usual care (1.78 v 1.98, effect size 0.27, p = 0.03); fathers in the 2 groups did not differ. Overall quality of interaction with infants in the NICU did not differ between groups for mothers or fathers, although both mothers and fathers in the COPE group scored higher on the subscale of positive interaction with a quiet alert infant (4.87 v 4.36, effect size 0.26, p = 0.04; and 4.63 v 3.48, effect size  =  0.55, p = 0.003, respectively), and fathers scored higher on involvement in physical care of the infant (79.04 v 69.13, effect size 0.42, p = 0.04). Length of NICU stay was 3.8 days shorter for infants in the COPE group compared with the usual care group (mean 31.86 v 35.63 d, p = 0.05), and overall hospital stay was 3.9 days shorter (mean 35.29 v 39.19 d, p = 0.02) (analyses controlled for gestational age, site, and maternal trait anxiety). At 2 months corrected infant age, mothers who received the COPE programme had less anxiety (28.72 v 30.83, effect size 0.24, p = 0.05) and depressive symptoms (5.56 v 7.21, effect size 0.30, p = 0.02) than mothers who received usual care. Fathers in the 2 groups did not differ for anxiety or depressive symptoms.


    An educational-behavioural intervention for parents of preterm infants reduced maternal stress in the neonatal intensive care unit (NICU) and length of NICU and overall hospital stay. At 2 months adjusted age, maternal anxiety and depression were also reduced. No differences were found in paternal stress or anxiety.


    Premature infants are at increased risk of developmental problems of a functional, cognitive, and behavioural nature.1,2 Dealing with this risk affects parenting and is stressful. The study by Melynk et al is the most recent in a series evaluating the efficacy of a parent focused educational-behavioural intervention (COPE) aimed at improving parent-infant interactions, parental mental health, and ultimately, the developmental outcomes of premature infants.

    Despite its strong theoretical and empirical foundations,3 the study has some important limitations. 45% of eligible families refused participation. Because attitudinal variables of non-responding families were not reported, it is unknown whether families who did not participate differed in important ways from those who participated.

    Numerous relevant outcomes were examined, and hence, numerous statistical comparisons were done. It is unclear whether analyses were corrected for multiple comparisons, and so the possibility that the results are due to chance cannot be ruled out. The lack of benefit in fathers and the relatively unclear clinical, as opposed to statistical, significance of the results should be important considerations of those thinking of introducing COPE style programmes.

    The reduced length of hospital and NICU stay, with potential reduced cost to the healthcare system, are of interest to health professionals caring for infants and parents in neonatal care settings. However, the longer term effects of the programme are unknown. Given the ongoing nature of the research, and the caveats already mentioned, clinicians may prefer to wait for the longer term clinical and economic picture to become clearer.


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    • For correspondence: Dr B M Melnyk, Arizona State University College of Nursing, Phoenix, AZ, USA. bernadette.melnyk{at}

    • Source of funding: National Institutes of Health/National Institute of Nursing Research.

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