Differences in parents', nurses' and physicians' views of NICU parent support

REGULAR ARTICLE

Differences in parents’, nurses’ and physicians’ views of NICU parentsupportLinda S Franck ([email protected])1, Anna Axelin1,2

1.Department of Family Health Care Nursing, University of California, San Francisco, CA, USA2.Department of Nursing Science, University of Turku, Turku, Finland

KeywordsNeonatal intensive care unit, Nurse, Parent,Physician, Support

CorrespondenceLinda S. Franck, RN, PhD, FRCPCH, FAAN, Professor& Chair, Department of Family Health Care Nursing,University of California, San Francisco, 2 Koret Way,N411F, Box 0606, San Francisco, CA 94143, USA.Tel: +415-476-4433 |Fax: 415-753-2161 |Email: [email protected]

Received23 November 2012; revised 28 February 2013;accepted 1 March 2013.

DOI:10.1111/apa.12227

ABSTRACTAim: To measure the perceptions of parent support by parents, nurses and physicians.

Methods: Perceptions were compared among parents (n = 227), nurses (n = 178) and

physicians (n = 43) in four neonatal intensive care units (NICU) using two versions of the

Nurse Parent Support Tool (NPST and NPSTpro).

Results: Overall, parents reported receiving support from nurses some or most of the time

and their perceptions were correlated with aspects of their NICU experience. Nurses

reported giving support to parents almost all of the time. The mean difference between

parent and nurse ratings was smallest for instrumental support (0.26, 0.16–0.36;

p < 0.001) and greatest for emotional support (0.82, 0.67–0.97; p < 0.001). Physicians

overall reported that they gave support to parents most of the time, significantly less

frequently than nurses (mean difference 0.58, 0.45–0.71; p < 0.001). They rated their

support as most frequent on answering parents’ questions satisfactorily and as least

frequent on teaching parents how to give care to their baby.

Conclusion: NICU nurses and physicians should be encouraged to critically reflect on

whether the type and consistency of support they provide to parents is in line with parents’

perceptions and needs. Further research is needed on effective methods for health

professionals to support parents of NICU infants.

INTRODUCTIONThe cognitive, emotional and physical distress experiencedby parents of infants cared for in neonatal intensive careunit (NICU) settings has been well described over severaldecades (1,2). The long-term consequences of NICU-related stress on parents’ physical, psychological and socialhealth and the parent–infant relationship are also welldescribed (3,4). More recently, research has focused onunderstanding the roles of health professionals in support-ing parents throughout the NICU experience. The constructof NICU parent support has primarily evolved from House’s(1981) model of social support and the Nurse ParentSupport Model (5), in which support is comprised of fourelements: emotional support, supportive communicationand information giving, parental role esteem support andinstrumental support. Recent research has highlighted theelements of supportive communication and informationgiving that enables parent involvement in decision-makingand participation in infant comfort care (6–8).

Studies of parent attitudes about support received fromnurses (5,8,9) and more generally from the healthcare team(10) have shown similarly positive views. Nevertheless,parents consistently express the desire for more informationand emotional support (7,8). Parents are particularly con-cerned that a lack of support from nurses can limit access totheir infant and make it harder for them to build arelationship with their newborn (11).

The role of physicians in supporting NICU parents hasbeen much less studied and primarily in the context of end-of-life decision-making (12). In infant daily care, bothphysicians and mothers view the physician’s role as one ofinforming parents of the infant’s medical care. Both groups

Abbreviations

FFC, family-centred care; GA, gestational age; NICU, neonatalintensive care unit; NIDCAP, newborn individual developmentcare and assessment program; NPST, Nurse Parent Support Tool;NPSTpro, Nurse Parent Support Tool Health professional.

Key notes� Parents of NICU infants desire and need a range of

support from health professionals.� Although generally parents feel supported some or

most of the time, we found differences in the type andfrequency of parent support given by nurses andphysicians and that perceived by parents.

� Further research is needed on effective methods forhealth professionals to support parents of NICU infants.

590 ª2013 Foundation Acta Pædiatrica. Published by Blackwell Publishing Ltd 2013 102, pp. 590–596

Acta Pædiatrica ISSN 0803-5253

view the nurse’s role as instructing parents in caregivingactivities (13).

With the current shift towards family-centred care (FCC),health professionals are expected to support parents bysharing more responsibility for infant care with parents andfacilitating parental involvement in all aspects of care,including decision-making, to achieve better outcomes forinfants and families (14). FCC initiatives with enhanced,multifaceted, support for parents can improve parentcompetence in infant care and strengthened the partnershipbetween healthcare professionals and parents (15,16).

The purpose of this research was to compare theperceptions of parental support among parents, nursesand physicians using the Nurse Parent Support Tool(NPST) in a sample of British parents whose infants wereadmitted to an NICU and in a sample of nurses andphysicians working in those same NICUs. The limitedresearch to date would suggest a tentative hypothesis thatparents and nurses would perceive nurse support across allfour elements, and physicians would perceive their supportas limited to supportive communication and informationgiving. Greater knowledge of the similarities and differencesin healthcare professionals’ and parents’ perceptions of thetype and frequency of support is needed for development ofsupport interventions that are well matched to parents’individual needs.

PARTICIPANTS AND METHODSStudy designData were collected within the context of a larger random-ized clinical trial of an intervention aimed at increasingparental involvement in NICU infant pain management (6).The present analyses used only baseline data and wereperformed on the whole sample without regard tointervention or control group assignment.

Participants and settingsDetails of the study methods are reported elsewhere (6). Inbrief, all parents of infants admitted to one of four NICUstudy sites in Greater London who were older than 16 andwho could read and speak English were eligible forparticipation. Exclusion criteria included documented psy-chological or psychiatric condition among parents or anexpected length of stay <10 days for the infant. Nurses andphysicians working in the four NICU sites at the start of thestudy were eligible for participation.

MeasuresThe Nurse Parent Support Tool (NPST)The Nurse Parent Support Tool (NPST) (5) is a 21-item self-reported scale that measures parents’ perception of nursingsupport during their infant’s hospitalization in fourdomains: emotional support, supportive communicationand information giving, parental role esteem support andinstrumental support. Each item is scored on a numericalscale from one to five that corresponds to almost never (1),not very often (2), some of the time (3), most of the time (4)

and almost always (5). The mean total score or meansubscale scores are reported, and higher scores indicateperceptions of more frequent support from nurses (5).

Initial psychometric testing was carried out with 108parents of medically fragile infants with a mean age of12 weeks (range 3�51). Factor analysis provided supportfor the underlying one-dimension construct. Concurrentvalidity was demonstrated with significant correlations withthe different dimensions of Stress Support Scale(r = 0.48–0.76). Internal consistency was high (Cronbach’salpha = 0.89�0.95) and the NPST showed adequate sensi-tivity for discriminating among parents who perceiveddifferent levels of support (5,9). The NPST has been usedwith parents of NICU infants in several countries (5,7–10).

Two modifications to the NPST were made for thepurposes of this study. The wording of the NPST wasmodified to be appropriate for use with nursing and medicalprofessionals (NPSTpro) by replacing the word ‘nurses’with ‘I’ and the words ‘me/my’ with ‘parents’. In addition,the question ‘Nurses show they like my child’ was omittedfrom both the parent (NPST) and health professional(NPSTpro) versions of the questionnaire because it wasfound in pilot testing that nurses felt the question couldimply an unprofessional caring relationship or that nursesfavoured certain patients over others.

Demographic informationSelected items from the parent baseline questionnaire wereused in this analysis, including selected demographics(parent age, ethnicity, education, employment status) andhow soon they were able to see and hold the infant afterbirth (hours). Parent ratings of other aspects of their NICUexperience that might be relevant to their perceptions ofsupport were also included. For all items, parents wereasked to use a 1 to 5 rating scale to describe their visitingpattern (stay all the time to visit once a week), satisfactionwith infant care (very satisfied to very unsatisfied), stress-fulness of the NICU stay (never stressful to extremelystressful) and perception of infant illness severity (not sickto very sick). Infant gender, gestational age (GA), birth-weight and the length of hospital stay were obtained fromthe medical charts. Nurse and physician baseline demo-graphic questions included profession, job title, age, gender,education, years of experience in the NICU setting andyears of experience in the current unit.

PROCEDURESWithin 3–7 days of their infant’s admission, parentsreceived the baseline questionnaire set that included basicdemographics and perceptions of nurse-to-parent support.Parents were not asked to rate perceptions of physiciansupport because of the lack of previous research specific toparents’ views of physician support, the potential forconflating responses regarding the two health professionalgroups and concern for questionnaire fatigue. Prior tocommencement of parent enrolment, nurses and physicianscompleted a questionnaire that included basic demographics

ª2013 Foundation Acta Pædiatrica. Published by Blackwell Publishing Ltd 2013 102, pp. 590–596 591

Franck and Axelin Views about NICU parent support

and questions about their provision of parental support(Figure 1).

AnalysisData were analysed using SPSS Statistics Release 18.0(SPSS, Chicago, IL, USA). NPST and NPSTpro mean total,and mean subscale scores were calculated for all partici-pants with <20% missing data. Descriptive statisticsincluded mean and standard deviations for continuousvariables and frequencies and percent for categoricalvariables. NPST and NPSTpro scores differed by rater(parent, nurse, or physician) and by hospital site. To ensurethat rater differences were not confounded by site differ-ences, a two-way analysis of variance was conducted toevaluate the effects of both variables. The rater effectremained significant, but the hospital site and interactioneffects were not. Therefore, hospital site was excluded fromsubsequent analyses. The differences in NPST and NPSTproscores between groups were tested with two sample t-tests.The reliability of the NPST and NPSTpro total and subscalescores was evaluated with Cronbach’s alpha internal con-sistency coefficient. Associations between continuous vari-ables were evaluated with Pearson correlation coefficientsand between ordinal variables with Spearman correlationcoefficients.

Ethical considerationsThe study was approved by an authorized committee of theUnited Kingdom National Research Ethics Service, andwritten informed consent was obtained from all parents,nurses and physicians who participated in the study.

RESULTSParent and health professional characteristics at baselineOf the 256 eligible parents who were approached andagreed to participate, 232 completed the baseline NPST, ofwhich five were subsequently excluded because of missingdata. A majority of the final sample of 227 parents weremothers (n = 192). Parent and infant characteristics areshown in Table 1.

A total of 224 health professionals returned the NPSTpro,representing 80–95% of the nursing and physician work-force in each NICU. Three questionnaires were subse-

quently excluded due to missing data. In the final sample of221 health professionals, there were 178 nurses (81%) and43 physicians (19%). Characteristics of the health profes-sionals are shown in Table 2.

Nurses’ and physicians’ perception of their support forparentsNurses evaluated their support for parents at a mean scoreof 4.43 SD (0.38) of five, indicating a belief that theyprovided support most of the time or almost always. Nursesrated their support as most frequent on item 15 ‘I providegood care to babies in my care’ with a mean score of 4.83SD (0.40). They evaluated their support as least frequent onitem 5 ‘I let parents decide whether to stay or leave duringmedical procedures’ with a mean score of 4.00 SD (0.92). Inthe four dimensions of support, the nurses rated theirsupport as occurring most often on the instrumentaldimension, with a mean of 4.57 SD (0.44), and leastfrequently on the emotional dimension, with a mean of 4.31SD (0.50) (Table 3).

Physicians evaluated their support for parents with amean score of 3.85 SD (0.38), indicating a belief that theyprovided support some or most of the time. Physicians ratedtheir support as most frequent on item 6 ‘I answer parentsquestions satisfactorily or find someone else who can’ witha mean score of 4.74 SD (0.44). They evaluated their

Nursesn = 178

Physiciansn = 43

Parentsn = 227

Figure 1 The number of returned questionnaires with <20% of missing databy different participants. ↔ Parents evaluated nurse support with the NPST andnurses evaluated their support to parents with the NPTSpro. → Physiciansevaluated their support to parents with the NPSTpro.

Table 1 Parent and Infant Characteristics

Parent (n = 227)

Gender, n (%)

Mother/Father 192 (84.6)/35 (15.4)

Age, year., Mean (SD) 32.02 (6.36)

Ethnicity, n (%)

White 141 (63.8)

Asian 23 (10.4)

Black 40 (18.1)

Other 17 (8.0)

Tertiary-level education, n (%) 130 (62.2)

Employed outside home, n (%) 158 (71.2)

Able to see/hold the baby >24 h after birth,

n (%)

17 (7.7)/132 (60.3)

Able to visit infant several times per day,

n (%)

163 (72.8)

Satisfaction with care, Mean (SD), n = 223

Very satisfied (1) – Very unsatisfied (5)

1.50 (0.79)

Stressfulness of the NICU stay, Mean (SD),

n = 215 Never stressful (1) – Extremely

stressful (5)

3.77 (1.19)

Perceived illness of infant, Mean (SD), n = 223

Not (1) – Very sick (5)

1.26 (1.38)

Infant (n = 227)

Infant gender, n (%)

Female/Male 119 (52.4)/108 (47.6)

GA, weeks, Mean (SD) 31.37 (4.91)

Birthweight, g, Mean (SD) 1 640 (860)

Infant’s length of stay, days, Mean (SD),

n = 224

45.80 (42.25)


Views about NICU parent support Franck and Axelin

support as least frequent on item 3 ‘I teach parents how togive care to their baby’ with a mean score of 2.34 SD (0.99).In the four dimensions of support, physicians rated theirsupport as occurring most often on the instrumentaldimension with a mean of 4.20 (0.37) and least frequentlyon the informational dimension with a mean of 3.66 SD(0.66) (Table 3).

Comparisons between health professional groupsThe nurses rated the frequency of their support for parentssignificantly higher compared to the physicians’ evaluationof their own parental support (mean difference 0.58, 95%CI 0.45–0.71, p < 0.001; Table 3). The difference betweenthe nurses’ and the physicians’ NPSTpro scores was mostpronounced for item 3 ‘I teach parents how to give care tobaby’ 2.25 (95%CI 1.92–2.57, p � 0.001); item 10 ‘I helpparents know how to comfort their baby during or afterprocedures’ 1.34 (95%CI 0.99–1.69, p � 0.001); and item 9‘I help parents understand their baby’s behaviours andreactions’ 1.06 (95%CI 0.76–1.37, p � 0.001) (Supportinginformation, Appendix S1). Of the four dimensions ofsupport, the mean difference between nurses’ and physi-cians’ perceived frequency of support was largest for

informational support (0.75, 95% CI 0.60–0.91, p � 0.001;Table 3).

Parent perceptions of nurse support and their agreementwith nursesParents evaluated nursing support with a mean score of3.79 SD (0.79), indicating that nurses provided them withsupport some or most of the time. Parents rated nursingsupport as most frequent for item 15 ‘Nurses provide goodcare to my baby’ with a mean score of 4.63 SD (0.62) and asleast frequent for item 8 ‘Nurses support my inclusion indiscussions when decisions are made’ with a mean of 3.05SD (1.39). Of the four dimensions of support, the parentsrated the nursing support as most frequent for the instru-mental dimension, with a mean score of 4.31 SD (0.62), andas least frequent for the emotional dimension, with a meanof 3.49 SD (1.00) (Table 3).

Nurses also rated the frequency of their support forparents as higher than the parents perceived it to be (meandifference 0.64, 95% CI 0.53–0.76, p < 0.001; Table 3).Nurses’ ratings were significantly more frequent than theparents for 19 out of the 20 items. Optimism about theinfant was the only item in which the two groups agreed onthe frequency of nursing support. The differences betweenthe parents’ and the nurses’ ratings of support were greatestfor item 11 ‘let parents know they are doing a good job inhelping their baby’ 1.27 (95% CI 1.07–1.47, p � 0.001);item 10 ‘help parents know how to comfort their babyduring or after procedures’ 1.17 (95% CI 0.96–1.38,p � 0.001); item 13 ‘show concern on parental well-being’1.03 (95% CI 0.84–1.23, p � 0.001) and item 8 ‘includeparents in discussions when decisions are made’ 1.02 (95%CI 0.80–1.24, p � 0.001) (Supporting information, Appen-dix S2). Of the four dimensions of support, the differencebetween parents’ and the nurses’ perceptions of supportwas largest for the emotional support dimension, with amean difference of 0.82 (95% CI 0.67–0.97, p � 0.001)(Table 3).

Reliability of the NPST and NPSTpro tools was sup-ported by the high intercorrelations among the all items andthe intercorrelations for subscales (Supporting information,Appendix S3).

Table 2 Health professional characteristics

Health professional Nurses (n = 178) Physicians (n = 43)

Gender, n (%)

Female 172 (96.6) 18 (41.9)

Male 6 (3.4) 25 (58.1)

Age <50 years, n (%) 158 (89.3) 33 (76.7)

Bachelor Degree, n (%) 83 (50.9) N/A

Work experience in NICU, year

Mean (SD)

8.96 (6.27) 6.90 (7.35)

Work experience in the current

NICU, year

Mean (SD)

4.56 (4.51) 2.27 (3.28)

Job situation, n (%)

Full time 152 (86.4) 37 (86.1)

Part time 24 (13.6) 6 (13.9)

Table 3 Nurses’, physician’ and parents’ NPSTpro/NPST total mean scores, total mean subscale scores and the mean differences between the nurses’ and physicians’ scores andthe nurses’ and parents’ scores.

NPSTpro/NPST scoresMean (SD)

Nurses(n = 178)

Physicians(n = 43)

Parents(n = 227)

Mean difference(95%CI) Nurses & Physicians

Mean difference(95%CI) Nurses & Parents

Emotional support 4.31 (0.50) 3.88 (0.66) 3.49 (1.00) 0.43 (0.21–0.65)*** 0.82 (0.67–0.97)***

Informational support 4.41 (0.44) 3.66 (0.66) 3.65 (0.88) 0.75 (0.60–0.91)*** 0.76 (0.63–0.89)***

Appraisal/Esteem support 4.45 (0.46) 3.86 (0.60) 3.77 (0.95) 0.59 (0.39–0.78)*** 0.68 (0.54–0.82)***

Instrumental support 4.57 (0.44) 4.20 (0.37) 4.31 (0.62) 0.37 (0.24–0.51)*** 0.26 (0.16–0.36)***

Total

Mean (SD) 4.43 (0.38) 3.85 (0.38) 3.79 (0.79) 0.58 (0.45–0.71)*** 0.64 (0.53–0.76)***

Range 3.10–5.00 3.10–4.60 1.35–5.00

***p < 0.001.



Associations between parent characteristics andperceived nurse supportThe NPST total mean scores were not significantly associ-ated with parent age, ethnicity, education, employment,interval between delivery and seeing their infant or thefrequency of NICU visitation. Parents experienced morefrequent support from nurses if their infants had a highergestational age (r = 0.20, p = 0.002) and birthweight(r = 0.14, p = 0.037). Neither the infant gender nor thelength of hospital stay was significantly associated withparent NPST scores. However, parents reported receivingless frequent support from nurses if they had a longerinterval between delivery and the first time they were ableto hold their infant after birth (r = �0.20, p = 0.004), if theyperceived their infant to be more ill (r = �0.28, p � 0.001),if they were less satisfied with their NICU experience(r = �0.42, p � 0.001) or if they reported greater NICU-related stress(r = �0.27, p � 0.001).

DISCUSSIONIn this study, both nurses and physicians viewed theprovision of instrumental support with regard to infantcare as the most frequent way in which they supportedparents with infants in the NICU, although physiciansgenerally reported providing support to parents slightly lessfrequently than nurses. This is inconsistent with ourtentative hypothesis that physician support would belimited to supportive communication and informationgiving. However, it is consistent with nurses’ having moredirect contact with parents over the course of the infant’sNICU stay (13,17,18).

Parents concurred that they most often received instru-mental support from nurses. However, there was a signif-icant difference between the perceived frequency of supportgiven and received, with nurses reporting they gave all typesof support to parents more frequently than parents reportedreceiving support from nurses. Instrumental support,defined as professionals acting as surrogates for the infant’scare, is a major part of NICU health professionals’ dailywork and is essential for the infant’s survival. However,instrumental support is necessary but not sufficient for thedevelopment of parenting skills and of the parent–infantrelationship, which is essential to infant well-being afterdischarge (19). Parents have expressed a need for atherapeutic relationship with nurses, which will result inmore support for the parent–infant relationship (19,20).

Mothers have desired more involvement in infant careand have valued the work that nurses do to facilitate andsupport the development of their parent role (11,13).Fathers have also described the value of increased infor-mational and emotional support from physicians (21).Parents’ increased involvement in infant care during theNICU stay, such as with skin-to-skin care, NewbornIndividual Development Care and Assessment Program(NIDCAP) or involvement in infant comfort care, may havepositive effects on infant development and/or the parent–infant relationship (6,22,23). Support for parenting skills

and the parent–infant relationship has decreased parentingstress at the infant age of 1 year (24).

Physicians’ gave lower ratings on the frequency ofinformational support they provide to parents, a result thatmay be partly explained by the preponderance of theNPSTpro items related to parental support in bedsidecaregiving, which is often seen as a nursing role (13).Physicians’ role in parent support has traditionally been toexplain infant prognoses and treatments to parents and toinvolve them in decision-making on these issues. Perhaps,this perspective needs to be reconsidered in the contempo-rary culture of family-centred NICU care, wherein physi-cians need more information and context to moreeffectively support and encourage FCC. Mothers havedescribed feeling too intimidated to approach physicians(13), and fathers have felt that they were disturbingphysicians when approaching them (18). Family-centredrounds are an opportunity for physicians to get to knowparents and to involve them in decision-making (16).

The frequency of nursing support reported by parents inthis study was similar to what parents reported in HongKong (7). However, parents in the United States, Canada,Australia, and Italy have reported higher levels of supportfrom nurses (5,8–10). These results may reflect differencesrelated to overall cultures or specific nursing practices.Additional cross-cultural research would be helpful inunderstanding the underlying issues.

Previous qualitative research suggests possible explana-tions for the parental perception of lower nurse support andthe differences between parents’ and nurses’ perceptions.For example, Fenwick et al. 2008 (11) observed that nursesbelieved that parents should strictly follow their guidanceand education. This authoritarian style of nursing practicewas linked to diminished efforts by mothers to build aparent–infant relationship. In another study, nursesdescribed working with parents as rewarding, but they alsodescribed it as occasionally frustrating because of compet-ing demands and too little time to provide the attentionparents expect (13). Moreover, the ability to provideindividual support for parents requires a close relationshipbetween the nurse and parents. This can result in anemotional burden for both parties (25). If not addressed,this emotional burden could create distance rather thancloseness in the relationship. Differences in the perceptionsof support may also occur when nurses intentionallyprovide less frequent support as a means of promoting anindependent parental role in infant caregiving but fail todiscuss their strategy with parents (26).

In this study, parents considered nursing support as beingleast frequent for involvement in decision-making, infantcomfort care and for emotional distress. These findings arein line with parents’ wishes to be included more often indecision-making (7). As parents view nurses as their mainsource of information on infant care (17), effective inter-ventions to facilitate communication between health pro-fessionals and parents should be encouraged (27,28).

The parental perception of less frequent nursing supportrelated to infant comfort is consistent with previous



research using the NPST (7,8). Specific interventions tosupport parents in meeting the comfort needs of NICUinfants have shown positive effects for parents (6).

However, the largest gap between parents’ and profes-sionals’ perceptions of frequency of support was found inrelation to emotional support. Health professionals may beable to provide increased emotional support for parentsindirectly through the FCC approach as it aims to decreaseseparation between parents and infant and parents’ lack ofcontrol over infant care.

The findings from this study should be considered in thelight of the strengths and limitations. The current study’sstrengths include its multisite sample and multiple infor-mants. Furthermore, we found associations between paren-tal perceptions of support and key demographic and clinicalrisk factors, supporting the construct validity of the NPST.The high intercorrelations among all items for the parents’,nurses’ and physicians’ samples support the reliability ofNPST across the different groups. However, the smallvariation in nurses’ and physicians’ answers reflects apotential lack of sensitivity to detect differences across thefull response range. Parental perceptions of physiciansupport were not measured in this study and remain to beexplored. Finally, our results are based only on self-reportedquestionnaire, and no observations were done to corrobo-rate the findings.

Future research should examine the support needs ofspecific subgroups of parents, such as, parents who havemore emotional distress, first time parents, teenage or singlemothers, with or without support networks and comparetheir perceptions with those of nurses and physicians toidentify specific areas of concordance or dissonance.Potentially influencing factors such as personality, socialor cultural factors need to be studied in relation to bothparents’ and healthcare professionals’ perception of ade-quate support for NICU parents.

In summary, the results of the present study indicate thatthat NICU nurses and physicians should be encouraged tocritically reflect on whether the type and consistency ofsupport they provide to parents is in line with parents’perceptions and needs. Further research is needed oneffective methods for health professionals to support par-ents of NICU infants. A family-centred approach withstrategies such as family-centred rounds and facilitatingparent participation in decision-making may improve par-ents’ perceptions and lessen the gap between nurses’ andparents’ perceptions of support given and received. Ourfindings suggest that the NPST remains an appropriateinstrument to measure parent perceptions of support andthat it has potential use as a clinical tool in patient care. TheNPSTpro is promising as a complementary measure ofhealth professional perceptions of support, but it requiresfurther psychometric testing.

ACKNOWLEDGEMENTThis study was funded in part by a research grant from Bliss,the special care baby charity, London, United Kingdom. Dr.

Axelin was supported in part by the Fulbright, InternationalEducational Exchange Program. The authors wish toacknowledge the support of the Study Coordinator, Dr.Kate Oulton and the Research Nurses, in particular TimBollard, Maria Casumpanga, Anita Ghool, Claudia Huber,Regina Jesudass, Catherine Kelvar and Sue Nderitu. Wethank the parents of the NICU infants and the medical andnursing staff for their participation. We thank Dr. Steven M.Paul for his help with the statistical analyses.

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SUPPORTING INFORMATIONAdditional Supporting Information may be found in theonline version of this article:

Appendix S1 Nurses’ and physician’ NPSTpro item meanscores, total mean scores, and the mean differences betweentheir scores.Appendix S2 Nurses’ and parents’ NPSTpro/NPST itemmean scores, total mean scores, and the mean differencesbetween their scores.Appendix S3 Cronbach’s alpha intercorrelations amongnurses’, physician’, and parents’ NPSTpro/NPST subscaleitems and all the items.



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Differences in parents', nurses' and physicians' views of NICU parent support