The Effect of Narrative Writing of Mothers on Their Stress With Care in the Neonatal Intensive Care Unit

Objective Premature birth and hospitalization in the intensive care unit cause many crises and stresses for mothers. In the meantime, narration writing is a method of counseling to reduce mothers' stress. Therefore, we aimed to study the effect of maternal narration on the stress of mothers of premature infants admitted to the neonatal intensive care unit. Methods This experimental study was performed on mothers of neonates admitted to the intensive care units. The experimental and control groups were selected by simple random sampling method. In the experimental group, based on the instructions given, the mothers recorded their daily events 3 times a day. The obtained data were analyzed in SPSS V. 21 with descriptive statistics (mean and standard deviation) and inferential statistics (paired t-test, independent t-test, ANCOVA test). Results The Mean±SD score of stress was 97.43±2.66 in the experimental group and 95.26±5.76 in the control group before the intervention. The stress level of mothers was 84.9±5.35 in the experimental group after the intervention and 87.1±5.25 in the control group. The covariance test showed a significant difference between the experimental and control groups (P=0.03 and Eta= 0.07) so that 7% of stress reduction changes are related to mothers' narration. Conclusion This study showed that narrative writing as an effective supportive intervention has a vital role in reducing stress in mothers of neonates admitted to the intensive care unit.


Introduction
remature birth is the leading cause of death and morbidity worldwide in infants without congenital anomalies. With the advancement of technology and neonatal intensive care in recent decades, the survival rate of low birth weight pre-P term infants has been increasingly improved. Of course, by reducing the infant mortality rate, those who survived premature infants become an at-risk group of community and experience more physical, mental, and developmental problems than normal infants.
Because of the developmental and medical conditions, the hospitalization of premature infants for several days to a few months can severely affect not only the infant but also their parents and cause serious mental stress. Factors such as fear of inadequate medical care, non-acceptance of the present event, and limitation of physical and mental interactions between infants and mothers aggravate these tensions and stresses, especially for the mother.
Therefore, to minimize the negative consequences of this condition, different therapeutic-supportive approaches such as spiritual self-care, kangaroo care, narration, etc., have been suggested. Despite the complicated and sometimes painful experience of writing stressful experiences by this group of mothers, it has been shown that in the long run, relieving the stresses and strains of a premature infant can improve mood and help stress management in these mothers. However, the cultural context of Iranian society and the vulnerable and shaky mental conditions of mothers with premature infants limit the possibility of many psychotherapy interventions.
So the present study investigates the impact of maternal narration as a relatively accessible and feasible way to manage stress on the stress and anxiety of mothers of premature infants admitted to the neonatal intensive care units.

Materials and Methods
This research is a cross-sectional study with two comparable groups (case and control) to assess the level of impact or effectiveness of the approach (narration) on stress and distress tolerance in the studied mothers. Therefore, 60 mothers were selected with premature infants in Taleghani Children's Hospital in Gorgan City, Iran. They met the least inclusion criteria of personal consent; a single baby less than 37 weeks; a history of at least 4 days of hospitalization; maternal age between 18 and 40 years; having the lowest literacy; but without a sick child at home, history of a child hospitalized in the intensive care unit, acute and severe stress during the last 2 months, drug and mental addiction and infant with the genetic disease. The sample size of 27 cases and 27 controls of the present study was determined using the data of Farahani et al.'s study by G Power software with effect size 1 and test power of 95% by simple random sampling method using a table of random numbers (To ensure the adequacy of the sample size and the possibility of sample loss during the study, 30 people were enrolled in each group).
Maternal and neonatal demographic information was collected by questionnaires whose validity and reliability had previously been confirmed by related experts. Data on parental stress levels were also obtained using a 22-item Miles questionnaire. Finally, the Maternal Anxiety Scale was extracted using the Simmons and Gaher scales. The matter has been confirmed. This study was conducted after the proposal was approved by the Regional Committee of Ethics in Research and registered in the IRCT system.
Finally, the data were entered into SPSS version 16, and the Kolmogorov-Smirnov test and the Shapiro-Wilk analyzes were conducted to check the normality of the data. Data description was performed using central and dispersion indicators. Comparison of data mean the difference between case and control groups was performed using inferential statistics of two-sample t-test, Mann-Whitney, ANOVA, Kruskal-Wallis, and Spearman test (for data With normal distribution). The Pearson correlation coefficient-tests (for data with abnormal distribution) were used for measuring the relationship between variables within a group. The statistically significant level for all analyzes was a P-value less than 0.05.

Results
Mean±SD of stress was 97.43±2.66 in the experimental group and 95.26±5.76 in the control group before the intervention, and it reached 84.9±5.35 in the experimental group and 87.10±5.25 in the control group and after the intervention. By removing the pre-test effect, a significant difference was observed between the two groups (P = 0.03 and eta coefficient = 0.07) so that 7% of the stress reduction changes were related to mothers' narration. Despite the lack of significant differences in age, level of education, and other demographic characteristics between the case and control groups (which indicated proper matching of the study groups), the narrative writing could significantly reduce the dimensions of stress in the mothers of the case group before (97.43±2.66) and after (84.9±5.35) the intervention (P <0.01). As a result, 7% stress reduction was confirmed in relation to mothers' narration. This decrease had a statistically significant effect on the other studied variable, i.e. anxiety tolerance (P<0.01). This change was a significant 13% for the distress tolerance variable.

Conclusion
The experience of having a premature baby can affect different aspects of life, especially for the mother. A comparison made by the mother of the conditions governing her baby with other full-term babies, especially in relatives and dependents, causes feelings of frustration, lack of selfconfidence, resentment, and accusations of incompetence in childbirth. Severe limitations and even no physical and emotional connection between the mother and such a baby worsens the situation. Failure to release momentary emotions and environmental tensions by the mother and the ac-cumulation of these emotions can cause irreparable damage to the mental health of the mother. Other problems can be caused by the lack of mutual understanding of the conditions by the mother and the nursing staff. Thus, when the mother's distress is combined with fatigue and confusion of the nurse, it can cause problems in establishing trust and mutual communication and lead to tension in the infant's hospital environment. Therefore, using psychological methods to empty the emotions and share experiences by the mother during this period, especially those who are more able and easy to do, can be an effective and efficient approach to manage stress and anxiety in mothers with premature babies.
Given the low cost, feasibility, and effectiveness of this supportive-counseling approach, it seems that using this method to evoke self-awareness in this stressful period of mothers' lives can be useful. In this approach, due to the sharing of annoying experiences and feelings between mother and nurse, the nurse is more aware of the current situation and the mental process of the mother. By strengthening this mutual relationship, we can expect better service with mutual understanding and respect.

Compliance with ethical guidelines
This research has been carried out according to the regulations of animal protection (the Helsinki Declaration) and with the approval of the Ethics Committee in the Islamic Azad University Aliabad-e Katul Branch, Aliabad-e Katul, City, Iran (Code: IR.IAU.CHALUS.REC.1398.022).

Funding
This research is extracted from the MA. thesis of Atosa Tavassoli, in Pediatric Nursing at the Islamic Azad University, Aliabad-e Katul Branch.

Conflicts of interest
The authors declared no conflict of interest.