1. Toly, Valerie Boebel PhD, RN, CPNP
  2. Blanchette, Julia E. PhD(c), RN, CDE
  3. Liu, Wei MS
  4. Sattar, Abdus PhD
  5. Musil, Carol M. PhD, RN, FAAN
  6. Bieda, Amy PhD, RN, APRN, PNP-BC, NNP-BC
  7. Em, Sarah BSN


Mothers of infants in the neonatal intensive care unit (NICU) face stressors including turbulent emotions from their pregnancy/unexpected preterm delivery and their infant's unpredictable health status. The study purpose was to examine the psychological state of mothers prior to the discharge of their technology-dependent infants (eg, feeding tubes, supplemental oxygen) from the NICU to home. The study sample consisted of mothers (N = 19) of infants dependent on medical technology being discharged from a large Midwest NICU. A descriptive, correlational design using convenience sampling was employed to recruit mothers to examine associations of infant and maternal factors, resourcefulness, and stress with psychological state (depressive symptoms, posttraumatic stress symptoms). Forty-two percent of mothers were at high risk for clinical depression, with 37% in the clinical range for posttraumatic stress disorder. Increased maternal depressive symptoms were significantly associated with the increased frequency and perceived difficulty of their stress and posttraumatic stress symptoms. Increased posttraumatic stress symptoms were significantly associated solely with elevated depressive symptoms. This study identified factors associated with the mothers' increased psychological distress, providing beginning evidence for future interventions to employ prior to their technology-dependent infant's NICU discharge.


Article Content


Across the United States, 9.85% of all infants born in 2016 were born preterm (prior to 37 weeks' gestation) and spent time in the neonatal intensive care unit (NICU).1 Some of these infants have complex, chronic conditions that include genetic disorders, congenital anomalies, or respiratory distress that require a prolonged stay in the NICU. Approximately 3% of infants with these conditions experience a long-term dependence on medical technologies such as mechanical ventilation, supplemental oxygen, or feeding tubes that are managed at home following discharge.2 Infants who spend time in the NICU comprise one-third of the population of technology-dependent children.3 Once discharged, they require vigilant monitoring and care from parents at home. Typically, mothers take on the role as the primary caregiver for their technology-dependent infants during and after the transition to home.4 Therefore, they must learn how to manage their infant's chronic conditions, medical technologies, and daily care prior to discharge.5-8 For many, caregiving responsibilities continue for several years while the child remains technology-dependent.9,10


Mothers of neonates admitted to the NICU are at high risk for psychological distress including greater anxiety, stress, and indecisiveness11,12 and higher rates of postpartum depression13-15 and posttraumatic stress disorder (PTSD)16-22 than mothers of healthy full-term neonates.17,23,24 This distress may be attributed to their child's unstable and unpredictable health status and appearance,25,26 parental role alteration,26-28 and emotional trauma from their unexpected preterm delivery. While some studies have focused on the high levels of anxiety in parents of neonates with complex conditions such as congenital heart disease admitted to the NICU,25-28 few have focused on mothers caring for technology-dependent infants discharged from the NICU to home.13,29 This transition stage is particularly important since these mothers are already at high risk for depression and PTSD following the NICU stay and must maintain constant vigilance as they monitor their infant's condition and manage the life-supporting technology for an indefinite period of time.3,30


Preparing for the infant's transition out of the hospital to home without the security and support from healthcare staff can be overwhelming.31,32 The limited number of investigations concerning mothers' psychological state prior to the discharge of their technology-dependent infant from the NICU to home is a major gap in research that interferes with the development of effective methods to support high-risk families. Postpartum depression and PTSD are associated with a large cost burden from expenditures for both psychiatric and nonpsychiatric healthcare, as well as lost wages and productivity for the mothers, estimated to be approximately $1 billion in the United States.33,34


Postpartum depression

The overall risk of postpartum depression is estimated to be 13% to 19% within 3 months after giving birth35,36 and is considerably higher in mothers with babies admitted to the NICU (39%-63% prevalence).13-15,20,37,38 Mothers at highest risk for postpartum depression are older,14 delivered by cesarean sections,18 report increased stress, and had infants born at lower birth weights and gestational age, higher severity of illness, more medical complications (eg, prolonged mechanical ventilation), and longer hospital stays.14,24 Urban low-income mothers with an infant in the NICU who are not living with the infant's father are at particularly high risk for elevated postpartum depressive symptoms regardless of their stress level or their baby's illness.14 Thus, mothers of infants who are discharged home dependent on medical technology exhibit many of these high risk factors, particularly due to their infant's severity of illness and medical complications.


Posttraumatic stress disorder

Mothers of infants in the NICU are also at high risk for PTSD,19,39 with a reported prevalence between 15% and 23%19,40 compared with the lifetime prevalence of 8% in the general population.41 This may be due to a loss of personal control over events, especially survival of the vulnerable infant. The mother may also experience the loss of caregiver and decision-maker roles, apprehension about the infant's fragile health state and appearance, and intrusive memories of traumatic emergency and resuscitation efforts.42 PTSD is characterized by 8 criteria as described in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]): (a) exposure to death, threatened death; (b) the traumatic event is persistently reexperienced; (c) avoidance of trauma-related stimuli after the trauma; (d) negative thoughts or feelings that began or worsened after the trauma; (e) trauma-related arousal and reactivity that began or worsened after the trauma; (f) symptoms last more than 1 month; (g) symptoms create distress or functional impairment; and (h) symptoms are not due to medication, substance use, or other illness.43



Resourcefulness is a set of cognitive and behavioral skills used to attain, maintain, or regain health and involves the ability to perform daily tasks despite potentially adverse situations (ie, personal resourcefulness) and to seek help from others as needed (ie, social resourcefulness).44 Since resourcefulness is thought to mediate the relationship between stress and mental health, examining the role of resourcefulness in mothers with technology-dependent infants is important, particularly during the critical time period of the infant's discharge home from the NICU. Cognitive-behavioral strategies such as resourcefulness have been associated with better mental health outcomes. Lower levels of resourcefulness are a predictor of mothers' elevated depressive symptoms in past research.45 An individual's level of resourcefulness has been shown to be amenable to change and may be enhanced through resourcefulness interventions.46 Thus, resourcefulness is a promising factor to target for intervention work in the quest to reduce the level of depressive and stress-related symptoms in mothers of technology-dependent infants.46 To date, no research has explored resourcefulness of mothers with infants in the NICU and its effect on maternal mental health and stress.


The purpose of this study was to examine mothers' psychological state prior to discharge of their technology-dependent infant from the NICU to home. Specific research questions were as follows: (1) What is the psychological state (depressive symptoms, posttraumatic stress symptoms) of mothers who will be caring for infants dependent on medical technology prior to discharge from an NICU to home? and (2) How do neonatal factors (gestational age, birth weight, functional status, type of technology) and maternal factors (age, partner status, household income), stress, and resourcefulness affect mothers' (a) depressive symptoms and (b) posttraumatic stress symptoms prior to discharge? Findings will provide information to aid nurses and other healthcare providers as they prepare mothers of technology-dependent infants for initial discharge from the NICU to home.



Transition theory helps promote an understanding of the nature and pattern of human response to change, as well as factors to examine during such transitions.47 These factors are important considerations for nurses who prepare individuals to cope with developmental, situational, and health-illness transitions in a positive fashion that promotes their health and well-being. In this study, transition is a process triggered by the technology-dependent infant's discharge from the NICU that requires intervention by the nurse and other healthcare professionals to facilitate optimal caregiving to the infant. Such interventions promote role mastery and facilitate better outcomes by integrating nursing and social support. Transition theory was used to examine factors affecting mothers who are planning to assume caregiving responsibilities following the discharge of their technology-dependent infant from the NICU to home.47 Transition theory concepts that were used in this study were the transitional maternal factors (age, partner status, household income) and infant factors (gestational age, birth weight, functional status, and type of technology) that facilitate or hinder achievement of healthy maternal psychological outcomes (depressive symptoms, posttraumatic stress symptoms).



Research design

A descriptive, correlational design was used to examine the psychological outcomes of mothers prior to the discharge of their technology-dependent infant from the NICU to home.


Setting and sample

The setting for this study was a 44-bed NICU transitional care unit in a large children's hospital located in the Midwest United States that has approximately 1000 admissions per year. Mothers (primary female caregiver) aged 18 years or older were eligible to participate if (a) their infant was to be discharged from the NICU to home within 2 to 3 weeks for the first time and was dependent on medical technology (mechanical ventilation, intravenous medication, supplemental oxygen, tracheostomy, feeding tubes); and (b) they were able to read and speak English. Mothers of infants with a terminal diagnosis were excluded because of the profound grief reactions associated with these diagnoses that might be confounded with the main psychological states under study. Convenience sampling was used to obtain a sample of mothers.



The 14-item interval scale ([alpha] = .86) Functional Status II-Revised (FS II-R) was used to measure a child's functional status.48 Lower scores indicate poorer functional status. Concurrent validity was established by physician assessments and the number of hospital days.48


The investigator-developed Technology Dependency Questionnaire, based on the Office of Technology Assessment49 rubric for technology dependence, constructed as binary questions (yes/no), was used to determine the type of medical technology used by each infant.


Mothers' depressive symptoms were measured using the 20-item Center for Epidemiological Studies-Depression Scale (CES-D) ([alpha] = .85).50 Respondents at increased risk for clinical depression had a score of 16 or more.50 Concurrent validity was established by the clinician's ratings.50


Mothers' posttraumatic stress symptoms were assessed using the 14-item self-report Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) ([alpha] = .85) that asks about symptoms related to childbirth and the postnatal period.18,51 Scores of 19 or more points indicate clinically significant distress that warrants a mental health referral.18,51 Convergent validity was supported by strong correlations between the PPQ and the Impact of Events Scale and the Beck Depression Inventory-II.18,51


Maternal stress was assessed using the Pediatric Inventory for Parents (PIP), a 42-item self-report questionnaire ([alpha] = .80-.96) rating of stress events associated with caring for a child with medical illness.52 It includes a list of difficult events faced by parents of children with serious illness related to communication, medical care, emotional distress, and role function. Parents report how frequently the event occurred over the past week and then rate on a 5-point scale how difficult it was for them. Ratings for frequency and difficulty are summed for PIP-Frequency and PIP-Difficulty scores. Higher scores indicate greater stress. Construct validity was shown by strong correlations between the PIP and state anxiety.53


The mothers' resourcefulness was measured using the Resourcefulness Scale, a 28-item scale ([alpha] = .85) that assesses both personal (16 items) and social (12 items) resourcefulness.54 Higher scores indicate increased resourcefulness. Construct validity was shown with confirmatory factor analysis.54


The demographic characteristics of mothers and their technology-dependent infants were measured using an Enrollment Form. This instrument includes questions about the infant's gender, gestational age, and birth weight, multiple birth, NICU admitting diagnosis, length of stay in the NICU, as well as mother's age, education, partner status, race/ethnicity, and household income. Any question that the mother was uncertain about was verified from the infant's chart.



Following institutional review board (IRB) approval, the NICU staff identified potential participants and invited them to hear more about the study. The study was described and informed consent was obtained from the participant on IRB-approved forms. HIPAA authorization was obtained to conduct medical record reviews for the infant's demographic data. Interviews took place in a private place of the mother's choosing on the NICU.


The FS II-R and the Technology Dependency Questionnaire were administered by a member of the research team, but the remaining scales were self-administered to decrease social desirability of responses. Participants received a $15 gift card at the completion of data collection. Mothers who scored 16 or more on the CES-D and/or 19 or more on the PPQ were given a sheet with mental health resources. Mothers with a CES-D score of 23 or more were screened for suicide risk, with the plan that a mobile crisis unit would be called if indicated.


Data analysis

All data were summarized using descriptive statistics, for example, means and standard deviations for continuous variables and frequencies and percentages for categorical variables. The primary outcome was the psychological state (depressive symptoms and PTSD symptoms) of mothers who cared for technology-dependent infants prior to their discharge from the NICU to home. Spearman's rank correlation coefficients were used to examine associations among continuous variables of interest. To examine the association between psychological outcomes of mothers and some categorical variables, such as household income, we used the Wilcoxon rank sum test. Furthermore, simple linear regression models were applied to study the effect of neonatal factors and maternal factors on the psychological outcomes of mothers. A covariate with P <= .05 was considered to be a statistically significant association with the underlying response variable. All analyses were conducted using statistical software R 3.4.0 and Stata 14.0.



Sample characteristics

Study recruitment took place over a period of 15 months. Of the 38 mothers eligible and invited by an NICU staff member to hear more about the study, 12 declined and 26 agreed to consider the study, with 19 mothers participating for a participation rate of 50%. Mothers in this study ranged in age from 18 to 41 years (M = 25.63 years; SD = 6.27). Approximately half of participants were African American; the majority had a high school education or less (see Table 1). Almost two-thirds were single, never married. The household income varied, but about half had an income of $20 000 or less per year.

Table 1 - Click to enlarge in new windowTable 1. Maternal and infant demographics (

The gestational age of the infants ranged from 23 to 39.29 weeks (M = 29.78 weeks; SD = 6.43); birth weight ranged from 500 to 3765 g (M = 1546.1 g; SD = 1151.8). About one-third of the infants had a primary medical diagnosis of prematurity, with another one-third were diagnosed with either respiratory failure or respiratory distress. Most infants had either a gastrostomy tube or nasogastric tube, and about half required supplemental nasal oxygen; however, 15.8% had a tracheostomy and 10.5% required mechanical ventilation. A majority of infants (63.2%; n = 12) required one type of technology; however, 36.8% (n = 7) required 2 or more types of technology. The total length of hospital stay ranged from 33.9 to 270.9 days (M = 149.7 days; SD = 68.7).


Descriptive statistics for key study variables

Scores for depressive symptoms on the CES-D ranged from 2 to 39 (M = 14.53; SD = 9.90) out of a maximum score of 60; 42% (n = 8) scored 16 or more, a cut score indicative of elevated risk for clinical depression, and were given a mental health resource sheet with telephone numbers for local sources of support.50 Three mothers scored more than 23 on the CES-D and required screening for suicide risk; all denied thoughts of suicide or hurting themselves in any way. The posttraumatic stress symptoms scores on the PPQ ranged from 2 to 37 (M = 16.52; SD = 12.11); 37% (n = 7) scored 19 or more, within the clinical range for reported PTSD.18,51 The PIP scores for frequency of stress ranged from 72 to 159 (M = 114.37; SD = 21.85), and the PIP scores for perceived difficulty of stress scores ranged from 52 to 167 (M = 101.37; SD = 30.60). Both subscales had a maximum score of 210. The scores for the Resourcefulness Scale ranged from 12 to 48 (M = 31.11; SD = 9.16) for social resourcefulness from a maximum possible of 60 and from 17 to 75 (M = 51.95; SD = 13.51) for personal resourcefulness out of a maximum of 80. Mothers' total resourcefulness ranged from 36 to 112 (M = 83.05; SD = 17.54) out of a maximum of 140.


Correlates of depressive symptoms and posttraumatic stress symptoms

Three factors significantly correlated with elevated maternal depressive symptoms (see Table 2): lower total resourcefulness, greater perceived frequency, and difficulty of care-related stress events. Only partner status (partnered) and lower household income had a significant positive correlation with posttraumatic stress symptoms (see Table 3).

Table 2 - Click to enlarge in new windowTable 2. Spearman correlation among mothers' psychological state and continuous factors (
Table 3 - Click to enlarge in new windowTable 3. Mean differences of maternal psychological state by infant's technology type and maternal partner status and household income (

Simple linear regression of depressive symptoms and posttraumatic stress symptoms

The results indicate that depressive symptoms in mothers (see Table 4) were significantly associated with increased perceived frequency (P = .01) and difficulty (P <= .01) of stress events, as well as higher posttraumatic stress symptoms (P <= .01). Higher posttraumatic stress symptoms in mothers (see Table 5) were significantly associated solely with higher depressive symptom levels (P <= .01).

Table 4 - Click to enlarge in new windowTable 4. Associations among mothers' depressive symptoms, and infant and maternal factors using simple linear regression models (
Table 5 - Click to enlarge in new windowTable 5. Associations among mothers' posttraumatic stress symptoms, and infant and maternal factors using simple linear regression models (


The goal of this study was to examine mothers' psychological state prior to the discharge of their technology-dependent infant from the NICU and is the first study to simultaneously examine the depressive symptoms, posttraumatic stress symptoms, and stress of these mothers.25-27 In the present study, the presence of maternal depressive symptoms prior to their infant's discharge was similar to findings of other studies of mothers with preterm infants.14,23,29 However, these scores were higher than those found by other researchers,55 who examined a group of mothers whose infants were dependent on respiratory or nutritional support in a Canadian NICU. While 42% of mothers in this study scored 16 or more on the CES-D, indicating elevated risk for clinical depression, other studies have found similar depressive symptom prevalence (39%-48%) in mothers with infants in the NICU.13,14,23,56 Therefore, the high level of depressive symptoms is a consistent issue in mothers with infants in the NICU prior to discharge that often remains undetected unless objectively measured in a consistent manner.


Mothers of infants to be discharged home from the NICU remain at high risk for PTSD symptoms.19,39,51 In the present study, a little over one-third of the mothers scored within the clinical range for posttraumatic stress symptoms, similar to that reported by DeMier et al57 but considerably higher than past reported prevalence of 15% to 23% for mothers of infants in the NICU.19,37,40 The elevated posttraumatic stress symptoms in mothers in our study may reflect the increasing complex, medically fragile, vacillating health state of their infant over the NICU course that necessitated the continued use of lifesaving technology. These technology-dependent infants comprise approximately 3% of all infants admitted to the NICU.2


Findings in this study related to the high frequency and difficulty of stress experienced by these mothers are similar to those of parents of older children requiring gastrostomy tubes, the most prevalent technology used.58 The high stress is concerning because past research indicates that better parental adherence to their children's treatment regimen is associated with decreased frequency and perception of less difficult stress,59 suggesting that caregiving may be compromised during periods of high stress. Therefore, the increased maternal stress places the already vulnerable infant at further risk for illness and subsequent emergency department visits and hospital readmissions.60,61


There were several maternal and infant factors related to the mothers' elevated depressive symptoms (see Table 4). While the maternal factors with a strong positive association included increased posttraumatic stress symptoms, stress frequency, and perceived stress difficulty, perception of stress difficulty had the strongest association with depressive symptoms. Thus, mothers' perception of the stress difficulty related to their situation is an essential factor requiring assessment and potential intervention prior to their infant's discharge. Other researchers have reported a strong relationship between depressive symptoms and posttraumatic stress symptoms14,38 with stress,15,23,62,63 but the results have not been consistent across studies.14,17


We also found that functional status, number of adults in the household, and total resourcefulness were not significantly associated with maternal depressive symptoms; however, each had a moderate Spearman [rho] correlation. In addition, using Cohen's d analysis, we found a large effect size for functional status (|d| = 1.194), number of adults in the household (|d| = 1.775), and total resourcefulness (|d| = 4.812).64 The lack of significant association may be attributed to the sample size. Because of the small sample size, the standard errors (SEs) of the coefficients of these predictors are relatively large, consequently affecting the P values and evaluation of statistical significance. With a larger sample size, the SEs would be smaller, potentially leading to smaller P values and statistically significant associations among the maternal predictors and depressive symptoms.


While inconsistent with our findings, past studies reported a significant positive relationship between depressive symptoms and resourcefulness.65-67 In one study,45 personal resourcefulness, not social resourcefulness, was positively related to greater depressive symptoms in parents of technology-dependent children. However, it included children of all ages and not exclusively high-risk NICU infants as in our present study. The mean total resourcefulness score of the participants in our sample (M = 83.05) indicates moderate resourcefulness and a moderate need for resourcefulness interventions. Using criteria from past research, 21% (n = 4) of mothers with technology-dependent infants in our study had a very high to somewhat high need and 68% (n = 13) had a moderate need for interventions to boost resourcefulness.


In this study, infant functional status had an inverse relationship with mothers' level of depressive symptoms; poorer infant functional status was significantly related to more maternal depressive symptoms. This is similar to findings from Miles et al15 and Thyen et al68 but contrary to findings by others14,38,45 that may be explained by a difference in the measurement tool14 and age of the children.45


Depressive symptoms was the sole predictor positively associated with posttraumatic stress symptoms in this study. This is consistent with other studies of mothers with infants in the NICU21 including urban mothers with infants in the NICU.22 However, while not significantly associated with posttraumatic stress symptoms, we found that partner status and household income were significantly correlated with maternal posttraumatic symptoms. In addition, using Cohen's d analysis, partner status had a moderate effect size (|d| = 0.766) and household income had a large effect size (|d| = 1.022).64 Again, these values suggest the need for an adequately powered investigation of associations among demographic predictors and posttraumatic stress symptoms, with larger sample sizes.


The transition theory was used to guide this study.47 In particular, transitional maternal and infant factors that facilitate or hinder achievement of healthy maternal psychological state (depressive symptoms, posttraumatic stress symptoms) were examined. Study findings indicate that there are few maternal and infant factors correlated with maternal psychological state that may help predict a difficult transition from the NICU to home. Maternal factors that were significantly correlated with posttraumatic stress symptoms included lower household income and single partner status. However, no maternal or infant factors were significantly correlated with depressive symptoms. Therefore, few maternal or infant factors significantly predicted mothers of technology-dependent infants at risk for elevated depressive symptoms and posttraumatic distress symptoms.



Despite the extension of the concepts of stress, maternal depressive and posttraumatic stress symptoms, and resourcefulness to the population of mothers whose infants will be discharged from the NICU to home dependent on lifesaving medical technology, there are some important limitations to this study. The small sample size may lead to unstable estimates of the relationships between variables and thus reduces confidence in the findings, even with corrections to compensate for low power. However, the sample size, while small, provides beginning evidence for future research with this population.


Relative to accruing the sample, the 50% participation rate underscores how challenging it was to obtain agreement to interview the mothers, and several refused to hear more about the study (n = 7), declined to participate after hearing about it (n = 5), or did not show up for appointments or return calls after agreeing to do so (n = 7). Reasons for declining participation were spontaneously verbalized and related to expected length of stay of the infant, reluctance to talk to any more healthcare professionals, experiences in other research studies, and lack of time due to responsibilities at home, work, or caring for their other well children at home. In past studies, mothers of technology-dependent children have welcomed the opportunity to speak with study staff about their experiences with their child and have had a participation rate of 90% or more.3,10 This study of technology-dependent infants being discharged home from the NICU for the first time had a low participation rate of 50%, however, double that of past studies (21.4%) of parents with high-risk infants in the NICU16 but lower than other prior studies (66% participation rate) of mothers with preterm infants in the NICU.23


Additional limitations are the lack of sufficient variation in geographic location, partner status, and education. Furthermore, while there was some variation in income, 50% of the participants had a household income of $20 000 or less per year that may serve to confound our findings due to an established inverse relationship between income and stress levels. Finally, because of the infant's extended length of stay and number and severity of health-related events the infant experienced that necessitated the use of lifesaving technology, it is difficult to determine causality related to the mother's posttraumatic stress symptoms, that is, prolonged length of stay, resuscitation events, critical illness, or the infant's actual dependence on the technology itself.


Future research

Future research with this population of mothers and their infants being discharged from the NICU must solve issues related to the low study participation rate as experienced in this study as well as past studies. This cohort of women was worried and distracted, which, as shown here, may require different approaches to engage and recruit them such as meeting them at a private place of their choosing away from the NICU, for example, in their home. Given the encouraging findings about relationships between variables, however, a larger study, with a more diverse sample, particularly one with a longitudinal element, would provide greater confidence about relationships and better insights into how mothers proceed on their caregiving trajectory after the immediate transition has passed.


This study did not measure social support, which may correlate with social resourcefulness. Future research should incorporate measures of emotional support and instrumental support (eg, help with childcare, household tasks, transportation) and also assess maternal psychiatric history, including previous challenges with depressive symptoms or clinical depression, use of antidepressant or anxiolytic medications prior to the birth of this infant, and previous episodes of postpartum depression.69 Finally, future research should explore augmenting resourcefulness to address the high level of psychological distress in these vulnerable mothers before and after discharge from the NICU.



A high percentage of mothers of technology-dependent infants discharged home have increased depressive and posttraumatic stress symptoms, indicating a high risk for clinical depression and PTSD. It is important to perform a mental health assessment of these mothers several weeks prior to their infant's discharge using the same or similar measures as used in this study and refer these mothers to mental health resources and support within the hospital setting. Furthermore, it is vital that members of the interdisciplinary team educate mothers regarding community resources for hospital-based support groups, local support groups, and online support groups prior to discharge.70


In addition to mental health resources, a majority of mothers with technology-dependent infants may benefit from an intervention to promote resourcefulness71 due to low levels of resourcefulness, particularly social resourcefulness, prior to discharge.46 Social resourcefulness skills include relying on family and friends, exchanging ideas with others, and seeking help from professionals and experts.71,72


Preparing a mother for the discharge of her technology-dependent infant from the NICU to home is inherently a time of high stress. Preparation for discharge requires an interdisciplinary team of healthcare professionals and may require weeks of coordinated teamwork depending on the amount of technology the infant will require at home.8 A previous study found that the most frequently reported source of stress by mothers during transition to home from the NICU was not being involved or informed in care or decisions related to their infant.31 Therefore, it is imperative that the mother is included in all discussions and the decision-making process with the healthcare team. Furthermore, provision of an objective mental health assessment and holistic support of mothers whose infants will be discharged home dependent on medical technology is of paramount importance to ensure a smooth transition and optimal caregiving for these vulnerable infants.73




1. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: Final Data for 2016. Hyattsville, MD: National Center for Health Statistics; 2018. [Context Link]


2. Toly VB, Musil CM, Beida A, Barnett K, Dowling DA, Sattar A. Neonates and infants discharged home dependent on medical technology: characteristics and outcomes. Adv Neonatal Care. 2016;16(5):379-389. [Context Link]


3. Toly VB, Musil CM, Carl JC. Families with children who are technology dependent: normalization and family functioning. West J Nurs Res. 2012;34(1):52-71. [Context Link]


4. Phillips-Pula L, Pickler R, McGrath JM, Brown LF, Dusing SC. Caring for a preterm infant at home: a mother's perspective. J Perinat Neonatal Nurs. 2013;27(4):335-344. [Context Link]


5. Lopez GL, Anderson KH, Feutchinger J. Transition of premature infants from hospital-to-home life. Neonatal Net. 2012;31(4):207-214. [Context Link]


6. National Alliance for Caregiving and the AARP. Caregivers of children: a focused look at those caring for a child with special needs under the age of 18. Published 2009. Accessed February 19, 2019. [Context Link]


7. O'Brien ME. Living in a house of cards: family experiences with long-term childhood technology dependence. J Pediatr Nurs. 2001;16(1):13-22. [Context Link]


8. Bowles JD, Jnah AJ, Newberry DM, Hubbard CA, Roberston T. Infants with technology dependence: facilitating the road to home. Adv Neonatal Care. 2016;16(6):424-429. [Context Link]


9. Brehaut JC, Garner RE, Miller AR, et al Changes over time in the health of caregivers of children with health problems: growth-curve findings from a 10-year Canadian population-based study. Am J Public Health. 2011;101(12):2308-2316. [Context Link]


10. Toly VB, Musil CM, Carl JC. A longitudinal study of families with technology-dependent children. Res Nurs Health. 2012;35(1):40-54. [Context Link]


11. Stremler R, Haddad S, Pullenayegum E, Parshuram C. Psychological outcomes in parents of critically ill hospitalized children. J Pediatr Nurs. 2017;34:36-43. [Context Link]


12. Wang KWK, Lin HC, Lee CT, Lee KS. Primary caregivers of in-home oxygen-dependent children: predictors of stress based on characteristics, needs and social support. J Adv Nurs. 2016;72(7):1592-1601. [Context Link]


13. Cho J, Holditch-Davis D, Miles MS. Effects of maternal depressive symptoms and infant gender on the interactions between mothers and their medically at-risk infants. J Obstet Gynecol Neonatal Nurs. 2008;37(1):58-70. [Context Link]


14. Garfield L, Holditch-Davis D, Carter CS, et al Risk factors for postpartum depressive symptoms in low-income women with very low-birth-weight infants. Adv Neonatal Care. 2015;15(1):E3-E8. [Context Link]


15. Miles MS, Holditch-Davis D, Schwartz TA, Scher M. Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr. 2007;28(1):36-44. [Context Link]


16. Aftyka A, Rozalska-Walaszek I, Rosa W, Rybojad B, Karakula-Juchnowicz H. Posttraumatic growth in parents after infants' NICU hospitalization. J Clin Nurs. 2016;26(5/6):727-734. [Context Link]


17. Baia I, Amorim M, Silva S, Kelly-Irving M, deFreitas C, Alves E. Parenting very preterm infants and stress in the neonatal intensive care units. Early Hum Dev. 2016;101:3-9. [Context Link]


18. DeMier RL, Hynan MT, Harris HB, Manniello RL. Perinatal stressors as predictors of symptoms of posttraumatic stress in mothers of infants at high risk. J Perinatol. 1996;16:276-280. [Context Link]


19. Feeley N, Zelkowitz P, Cormier C, Charbonneau L, Lacroix A, Papageorgiou A. Posttraumatic stress among mothers of very low-birth-weight infants at 6 months after discharge from the neonatal intensive care unit. Appl Nurs Res. 2011;24:114-117. [Context Link]


20. Freidman SH, Yang SN, Parsons S, Amin J. Maternal mental health in the neonatal intensive care unit. Neonatal Rev. 2011;12:e85-e93. [Context Link]


21. Shaw RJ, St John N, Lilo EA, et al Prevention of traumatic stress in mothers with preterm infants: a randomized controlled trial. Pediatrics. 2013;132(4):e886-e894. [Context Link]


22. Vanderbilt D, Bushley T, Young R, Frank DA. Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit. J Dev Behav Pediatr. 2009;30(1):50-56. [Context Link]


23. Ballantyne M, Benzies KM, Trute B. Depressive symptoms among immigrant and Canadian born mothers of preterm infants at neonatal intensive care discharge: a cross sectional study. Child Care Health Dev. 2013;43(6):783-796. [Context Link]


24. Hall S, Hynan M, Phillips R, Press J, Kenner C, Ryan DJ. Development of program standards for psychosocial support of parents of infants admitted to a neonatal intensive care unit: a national interdisciplinary consensus model. Newborn Infant Nurs Rev. 2015;15:24-27. [Context Link]


25. Lisanti AJ, Allen LR, Kelly L, Medoff-Cooper B. Maternal stress and anxiety in the pediatric cardiac intensive care unit. Am J Crit Care. 2017;26(2):118-125. [Context Link]


26. Busse M, Strongren K, Thorngate L, Thomas KA. Parents' responses to stress in the neonatal intensive care unit. Crit Care Nurse. 2013;33(4):52-59. [Context Link]


27. Diffen J, Spence K, Naramian T, Badowi N, Johnston L. Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery. Early Hum Dev. 2016;103:101-107. [Context Link]


28. Golfenshtein N, Srulovici E, Medoff-Cooper B. Investigating parenting stress across pediatric health conditions-a systematic review. Compr Child Adolesc Nurs. 2016;39(1):41-79. [Context Link]


29. Miles MS, Holditch-Davis D, Burchinal P, Nelson D. Distress and growth outcomes in mothers of medically fragile infants. Nurs Res. 1999;48(3):129-140. [Context Link]


30. Heaton J, Noyes J, Sloper P, Shah R. Families' experiences of caring for technology-dependent children: a temporal perspective. Health Soc Care Community. 2005;13(5):441-450. [Context Link]


31. Ballantyne M, Orava T, Bernardo S, McPherson AC, Church P, Fehlings D. Parents' early healthcare transition experiences with preterm and acutely ill infants: a scoping review. Child Care Health Dev. 2017;43(6):783-796. [Context Link]


32. Hemati Z, Namnabati M, Taleghani F, Sadeghnia A. Mothers' challenges after infants' discharge from neonatal intensive care unit: a qualitative study. Iranian J Neonatol. 2017;8(1):31-36. [Context Link]


33. Dagher RK, McGovern PM, Dowd BE, Gjerdingen DK. Postpartum depression and health services expenditures among employed women. J Occup Environ Med. 2012;54(2):210-215. [Context Link]


34. Stone K. Postpartum depression could cost US more than $1 billion annually. Published 2001. Accessed February 19, 2019. [Context Link]


35. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5, pt 1):1071-1083. [Context Link]


36. O'Hara MW, McCabe JE. Postpartum depression: current status and future directions. Ann Rev Clin Psychol. 2013;9:379-407. [Context Link]


37. Lefkowit DS, Baxt C, Evans JR. Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU). J Clin Psychol Med Settings. 2010;17(3):230-237. [Context Link]


38. Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010;117(5):540-550. [Context Link]


39. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics. 2006;47:206-212. [Context Link]


40. Holditch-Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumatic stress symptoms in mothers of premature infants. J Obstet Gynecol Neonatal Nurs. 2003;32(2):161-171. [Context Link]


41. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52(12):1048-1060. [Context Link]


42. Karatzias T, Chouliara Z, Maxton F, Freer Y, Power K. Post-traumatic symptomatology in parents with premature infants: a systematic review of the literature. J Prenat Perinat Psychol Health. 2007;21:249-260. [Context Link]


43. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. [Context Link]


44. Zauszniewski JA. Resourcefulness. In: Fitzpatrick JJ, Kazer MW, eds. Encyclopedia of Nursing Research. 3rd ed. New York, NY: Springer Publisher; 2012:448-449. [Context Link]


45. Toly VB, Musil CM. Factors related to depressive symptoms in mothers of technology-dependent children. Issues Ment Health Nurs. 2015;35(7):518-527. [Context Link]


46. Toly VB, Musil CM, Zausniewski JA. Resourcefulness training intervention: a promising approach to improve mental health of mothers with technology-dependent children. Appl Nurs Res. 2014;27(1):87-90. [Context Link]


47. Meleis AI, Sawyer LM, Im EO, Messias DKH, Schumacher K. Experiencing transitions: an emerging middle-range theory. Adv Nurs Sci. 2000;23(1):12-28. [Context Link]


48. Stein RE, Jessop DJ. Functional Status II(R). A measure of child health status. Med Care. 1990;28(11):1041-1055. [Context Link]


49. US Congress, Office of Technology Assessment. Technology-Dependent Children: Hospital Care vs. Home Care: A Technical Memorandum. Washington, DC: US Government Printing Office; 1987. [Context Link]


50. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. App Psychol Meas. 1977;1:385-401. [Context Link]


51. Callahan JL, Borja SE, Hynan MT. Modification of the Perinatal PTSD Questionnaire to enhance clinical utility. J Perinatol. 2006;26:533-539. [Context Link]


52. Streisand R, Braniecki S, Tercyak KP, Kazak AE. Childhood illness-related parenting stress: the Pediatric Inventory for Parents. J Pediatr Psychol. 2001;26:155-162. [Context Link]


53. Speilberger CD. Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press; 1983. [Context Link]


54. Zauszniewski JA, Lai CY, Tithiphontumrong S. Development and testing of the Resourcefulness Scale for Older Adults. J Nurs Meas. 2006;14(1):57-68. [Context Link]


55. Pinelli J, Saigal S, Wu YWB, et al Patterns of change in family functioning, resources, coping and parental depression in mothers and fathers of sick newborns over the first year of life. J Neonatal Nurs. 2008;14(5):156-165. [Context Link]


56. Chung EK, McCollum KF, Elo IT, Lee HJ, Culhane JF. Maternal depressive symptoms and infant health practices among low-income women. Pediatrics. 2004;113(6):e523-e529. [Context Link]


57. DeMier RL, Hynan MT, Hatfield RF, Varner MW, Harris HB, Manniello RL. A measurement model of perinatal stressors: identifying risk for postnatal emotional distress in mothers of high-risk infants. J Clin Psychol. 2000;56(1):89-100. [Context Link]


58. Didehbani N, Kelly K, Austin L, Wiechmann A. Role of parental stress on pediatric feeding disorders. Children's Health Care. 2011;40(2):85-100. [Context Link]


59. Smith LB, Kugler BB, Lewin AB, Duke DC, Storch EA, Geffken GR. Executive functioning, parenting stress, and family factors as predictors of diabetes management in pediatric patients with type 1 diabetes using intensive regimens. Children's Health Care. 2014;43(3):234-252. [Context Link]


60. Raina P, O'Donnell M, Rosenbaum P, et al The health and well-being of caregivers of children with cerebral palsy. Pediatrics. 2005;115(6):e626-e636. [Context Link]


61. Berry JG, Hall DE, Kuo DZ, et al Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals. JAMA. 2011;305(7):682-690. [Context Link]


62. Bergstrom EB, Wallin L, Thomson G, Flacking R. Postpartum depression in mothers of infants cared for in a neonatal intensive care unit: incidence and associated factors. J Neonatal Nurs. 2012;18(4):143-151. [Context Link]


63. Rogers CE, Kidokoro H, Wallendorf M, Inder TE. Identifying mothers of very preterm infants at-risk for postpartum depression and anxiety prior to discharge. J Perinatol. 2013;33(3):171-176. [Context Link]


64. Cohen J. A power primer. Psychol Bull. 1992;112(11):155-159. [Context Link]


65. Bekhet AK, Zauszniewski JA. Psychometric properties of the resourcefulness scale among caregivers of persons with autism spectrum disorder. West J Nurs Res. 2014;36:685-702. [Context Link]


66. Musil C, Jeanblanc A, Burant C, Zauszniewski J, Warner C. Longitudinal analysis of resourcefulness, family strain, and depressive symptoms in grandmother caregivers. Nurs Outlook. 2013;61(4):225-234. [Context Link]


67. Zauszniewski JA, Bekhet AK, Suresky MJ. Relationships among perceived burden, depressive cognitions, resourcefulness, and quality of life in female relatives of seriously mentally ill adults. Issues Ment Health Nurs. 2009;30(3):142-150. [Context Link]


68. Thyen U, Terres NM, Yazdgerdi SR, Perrin JM. Impact of long-term care of children assisted by technology on maternal health. J Dev Behav Pediatr. 1998;19(4):273-282. [Context Link]


69. McGowan EC, Du N, Hawes K, Tucker R, O'Donnell M, Vohr B. Maternal mental health and neonatal intensive care unit discharge readiness in mothers of preterm infants. J Pediatr. 2017;184:68-74. [Context Link]


70. Edelstein H, Schippke J, Sheffe S, Kingsnorth S. Children with medical complexity: a scoping review of interventions to support caregiver stress. Child Care Health Dev. 2017;43(3):323-333. [Context Link]


71. Zauszniewski JA, Musil CM, Burant CJ, Au TY. Resourcefulness training for grandmothers: preliminary evidence of effectiveness. Res Nurs Health. 2014;37(1):42-52. [Context Link]


72. Zauszniewski JA. Teaching resourcefulness skills to older adults. J Gerontol Nurs. 1997;23(2):14-20. [Context Link]


73. American Academy of Pediatrics, Committee of Fetus and Newborn. Policy statement: hospital discharge of the high-risk neonate. Pediatrics. 2008;122(5):1119-1126. [Context Link]


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mental health; mothers; NICU discharge; technology-dependent infant