Neonatal Intensive Care Unit

Adaptation to motherhood for rural Women With Newborn(s) in the Neonatal Intensive Care unit

Donna Tomasulo West, PhD, RN, FNP-BC Pamela Stewart Fahs, PhD, RN Geraldine R. Britton, PhD, RN, FNP Carolyn Pierce, PhD, RN

n Abstract

The Roy adaptation model (Roy, 2009) serves as a framework for this qualitative descriptive study. Participants resided in rural areas of Upstate New York and had given birth within the last month to a baby who was admitted to the neonatal intensive care unit (NICU). Through semi-structured interviews, they expressed their needs, concerns, and experiences. The purpose was to gain an understanding of the experience of how women from rural areas adapt to motherhood when their newborn requires care in the NICU. In total, seven themes emerged. The meta-theme was trust, found to be an integral part of their adaptation to motherhood. The findings have implications for nursing, as they will help inform the best care at a crucial developmental time in the lives of this vulnerable group of women. This aligns with the goal of nursing, which is assisting to promote a state of integrated adaptation, which is health according to Roy (2009).

Keywords: Roy adaptation model, qualitative study, trust, therapeutic relationship

background

The purpose of this qualitative descriptive research was to gain an understanding of the experience of adapting to motherhood for rural women when they have a newborn in the neonatal intensive care unit (NICU). Becoming a mother is generally considered a normative transition for many women in adulthood (Aber et al., 2013). Adaptation to the role of mother, while challenging, is not considered unusual. However, when a newborn’s condition warrants admission to the NICU, mothers often have limited opportunities for physical contact with them, thus interfering and delaying adaptation to the role of mother. Moreover, there are serious health concerns, often unanticipated, for their babies. Consequently, many mothers experience distress, which contributes to symptoms of anxiety and depression, potentially limiting their ability to care for their newborns and leading to less desirable outcomes (Rossman et al., 2015). Thus, when a non-normative transition to motherhood occurs, it is fraught with additional challenges to adaptation to motherhood.

Providers who treat newborns in the NICu are also engaged in a therapeutic relationship with the parents of their patients.

A newborn’s admission to the NICU has been described as a very stressful (Heinemann et al., 2013; Heydarpour et al., 2017) and even traumatic event for the parents (Aftyka et al., 2017). Regardless of the reason for admission to a NICU, it is an experience accompanied by many challenges to adaptation for a parent (Park & Chung, 2015; Rossman et al., 2015). Providers who treat newborns in the NICU are also engaged in a therapeutic relationship with the parents of their patients, assisting them in adapting to parenting their newborn who is in critical condition.

Donna Tomasulo West, PhD, RN, FNP-BC; Pamela Stewart Fahs, PhD, RN; Geraldine R. Britton PhD, RN, FNP; and Carolyn Pierce, PhD, RN Binghamton University, Decker College of Nursing and Health Sciences, Binghamton, New York

Rurality adds its own challenges to the transition process. Distance from healthcare access and other factors common to rural dwellers uniquely affect health outcomes and experiences of adaptation. While rural mothers have resources, such as the familiarity and sense of community that often exists in rural communities, they face susceptibilities unique to their places of residence (Winters & Lee, 2018).

Rural mothers encounter many obstacles. Since most NICUs exist in metropolitan areas, their newborns often need to be transported a long distance for treatment. Mothers from rural places must adapt to two foreign environments: the urban area where the hospital is located and the NICU. At the same time, they are recovering from childbirth, are concerned about their babies who are in critical condition, and are adapting to taking on the role of mother.

Prior research has shown that rural dwellers often have certain vulnerabilities that are not the same for people who live in urban areas, simply because of the place where they live. Residents of rural areas experience healthcare disparities that may be impacted further by social determinants of health. These include vulnerability factors such as race and ethnicity, socioeconomic status, geographic isolation, and residence in medically underserved areas (Gonzalez et al., 2018). Therefore, understanding how mothers from rural places adapt to having a newborn in the NICU can add knowledge to the discipline about how to best assist mothers, improve care provided to babies, and ultimately, improve family functioning.

In the Roy adaptation model (RAM) (Roy, 2009), the environment is known to have three types of stimuli: focal, contextual, and residual. Focal stimuli are those that are most immediately affecting the person, which in this study means having a newborn in the NICU. Contextual stimuli are those that contribute to the effect of the focal stimuli. Contextual stimuli which have been previously measured include variables such as age, race, parity, type of delivery, planned vs. unplanned pregnancy, severity of the newborn’s condition, support of the newborn’s father, family support, financial situation, ability to be with the newborn while in the NICU, and feeding method (Bailey et al., 2014; Chen et al., 2016; Chourasia et al., 2013; Foster et al., 2016; Heydarpour et al., 2017; Korukcu et al., 2017; Premji et al., 2017; Roque et al., 2017). There was, however, found to be a dearth of research that focused specifically on NICU experience and the contextual stimulus of rural residency. Residual stimuli are present in the environment, but they are not measurable in the particular study or situation, are often unknown, and their effects are unclear (Roy, 2009).

Roy (2009) described four modes of coping in her model. The physiologic mode of coping refers to physical response to stimuli and is inextricably involved in the postpartum period as mothers are recovering from labor and birth. There are physiologic responses to emotional and social stressors as well. The self-concept mode of coping signifies how a person views themselves. Coping in the role-function mode connotes the knowledge of how one functions within societal roles or categories in relation to others – in this case their newborn, their partner, and the medical professionals. The fourth coping mode, interdependence, represents the subjects’ relationships with significant people in their lives.

Roy (2009) further explicated the levels of adaptation to be integrated, compensatory, or compromised. Adaptation level is “a changing point influenced by the demands of the situation and internal resources” (p. 31). During periods of great stress and change, the level of adaptation is not

While rural mothers have resources, such as the familiarity and sense of community that often exists in rural communities, they face susceptibilities unique to their places of residence.

likely to be integrated for some time. Integrated adaptation “describes the structures and functions of the life process working as a whole to meet human needs” (p. 37). At the compensatory level of adaptation, the modes of coping “have been activated by a challenge to the integrated processes” (p. 37), such as having an infant who requires care in the NICU. A person is noted to be in the compromised level, and adaptation problems are seen, when an individual’s integrated and compensatory processes are not adequate to effectively respond to the environmental stimuli. The care nurses provide is directed at promoting adaptation (Roy, 2009), either by changing the stimuli of the environment or by aiding one’s coping processes.

In their review of the literature, Romero and colleagues (2012) looked at research articles pertaining to components of the RAM (Roy, 2009), specifically, coping and adaptation, and the puerperium, which is a time requiring great coping and adaptation by the woman and the whole family unit. They concluded that activities that promote maternal adaptation also, consequently, enhance the maternal-child bond and enhance all family adaptation. In Roy’s model, this refers to the interdependence mode of coping, which involves those relationships that are closest to people and which “…satisfy needs for affection and development of relationships” (Roy, 2009, p. 385). Interdependent relationships, according to Roy, may also be with support systems, such as the healthcare professionals caring for a high-risk infant.

There is much research about NICU and postpartum adjustment (Cleveland & Bonugli, 2014; Hawes et al., 2016; McGowan et al., 2017; Northrup et al., 2013; Roque, et al., 2017;), but little relating the RAM to the experience, nor any specifically focused on rural mothers’ experiences within the NICU environment. People living in rural areas have different strengths and vulnerabilities that contribute to their healthcare experiences (Brown & Schafft, 2019; Winters & Lee, 2018), presumably including their experience of having a newborn in the NICU. Information about the NICU experience for rural mothers provides new insight to better enable nurses and other healthcare workers to assist them in adapting to parenting their newborn in the NICU. Theory-based interventions may be developed to promote rural mothers’ adaptation. That, in turn, can promote more effective parenting and family functioning at this critical time and moving forward.

methods

Theoretical Framework

Sandelowski (2010) suggested that qualitative descriptive studies utilize a theoretical framework to guide the initial interview focus and questions. The RAM (Roy, 2009) was found to be well suited to guide nursing research in this subject area because it addresses human adaptation. As a nursingbased model, the Roy model provided a framework for the structure of

inquiry, leading to results that may expand nursing science. It is a systems model which reflects incoming stimuli, modes of coping, and outcomes of varying levels of adaptation, which in turn may reenter the system as additional stimuli. Persons are described holistically as biopsychosocial beings who are continuously adapting to internal and external stimuli, i.e., their environment, to maintain an integrated level of adaptation, which Roy defines as health. The goal of nursing, according to Roy (2009), is the promotion of adaptation.

Design

The philosophy of qualitative descriptive research is naturalistic inquiry with the goal of “…describ[ing] individuals’ experiences in their own words” (Willis et al., 2016, p. 1193). Sandelowski (2000) provided the seminal literature on this mode of inquiry. She stated that while certainly also interpretive, ultimately “the description in qualitative descriptive studies entails the presentation of the facts…in everyday language” (p. 336). Findings are presented in a “comprehensive thematic summary” (Willis et al., 2016, p. 1193). In other words, the common ideas from multiple individuals are grouped together as themes and re-presented in the findings.

Sample

A purposive sample of women were interviewed for this study. Inclusion criterion were mothers over the age of 18, who had given birth to a baby who was admitted to the NICU for a minimum of 3 days, within the last 3 months. The 13 women were all Caucasian and ranged in age from 18–39 years old, with a mean age of 25.4 years. All were in a supportive relationship both emotionally and financially with the father of their newborn or other significant man. Three of the women were married. Seven were first-time mothers. First-time motherhood was one of the most important contextual stimuli identified in this study. Among the 13 participants, three had given birth to twins, all via planned primary cesarean section, and all between 32- and 36-weeks’ gestation. In total, the 13 participants gave birth to 16 babies. There were nine premature (less than 37 weeks + 6 days gestation) deliveries of 12 babies (three sets of twins) and four more newborns who were admitted to the NICU for reasons not related to prematurity.

Because there are several different ways of defining rural, participants were chosen first if they self-identified as living in rural areas using their own socially constructed definition. Their residence location was then confirmed via an objective measure of rural taken from the Am I Rural? tool. Those areas designated as “Not located in an Urbanized Area or Urban Cluster” were considered rural (Rural Health Information Hub [RHIhub], n.d.).

Procedures

Hospital Institutional Review Board approval was obtained prior to recruiting participants through purposive sampling. The 13 rural mothers were recruited from a level three NICU located in a hospital in the Southern Tier of New York State. Flyers introducing the study were posted and distributed in the NICU and the maternity unit within the hospital. After informed consent was obtained, participants were interviewed. The interviews took place between 1 day and 3 weeks after giving birth. Data were obtained by digital, audio-recorded, semi-structured interviews, which took place in a private location within the hospital. Three of the mothers also had additional, follow-up phone interviews after they were discharged because their babies had not yet been in the NICU for the required (inclusion criteria) 3 days at the time of their first interview. One mother gave her entire interview via telephone. One mother’s infant had been discharged 2 days prior, but she returned to the hospital for the interview. The babies were born at gestational ages ranging from 31 weeks and 3 days to 40 weeks. Interviews ranged in time from 20 to 90 minutes, with an average time of 45 minutes.

An open-ended leading prompt was asked of participants: Tell me about your experience as a new mother to this newborn. Participant interviews also included open-ended prompts guided by the Roy model’s modes of coping (physiologic, self-concept, role function, and interdependence):  Tell me as much as you can about how you are feeling/adjusting physically.  Tell me as much as you can about how you are feeling about yourself at this time.  Tell me as much as you can about how your life roles have changed.  Tell me as much as you can about your relationships.

Additional probes by the researcher were utilized to increase the depth of descriptions provided by the subjects (Sandelowski, 2000).

Data Analysis

Qualitative content analysis-synthesis was conducted using methods described by Parse (2001). Interviews were audio recorded and later transcribed. There were 135 pages of transcripts generated, the shortest was 4 pages and the longest was 26 pages in length. The transcripts were reviewed multiple times by the researcher in order to discern major ideas and common themes. Themes were then related to the RAM and presented in the findings. Review of the data, by other researchers (PhD prepared nurses in this case) was employed to ensure internal validity and credibility (Willis et al., 2016, p. 1194). After 13 interviews, many of the same ideas were repeated by most of the mothers. When no new ideas emerged, saturation was reached, thus capping the sample at 13 women.

Demographic information was used to examine and consider the possibility that those contextual factors were in some way related to the adaptation process. Expressed in a different way, demographics were collected to be potentially useful in the understanding of the participants’ experiences. Themes were also interpreted as they relate to the theoretical framework of Roy’s model.

results

After thoroughly reviewing the transcripts and considering their content, both verbal and nonverbal, the major ideas women spoke about were sorted into seven common themes that emerged. If all or most mothers talked about those themes, then they were considered by the researchers to be of importance. The themes were then summarized once more into one overarching theme that permeated every interview – the meta-theme. Every mother talked, to some extent, about transportation issues related to getting back and forth to the NICU to be with their newborn. As they talked, every mother spoke optimistically and focused on the positive of their situation. Twelve mothers talked about it being difficult to go home

Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit n and not bring their baby or babies with them. Twelve mothers expressed feeling guilty about their baby needing to be in the NICU. Twelve mothers talked about their uncertainty, specifically not knowing what was going to happen next or when they would be taking their baby home.

Identifying as a mother was another universal theme and it was distinctly different for multiparous versus primiparous mothers and for mothers under the age of 21 versus those who were older. A fascinating theme that emerged was that new mothers already identified some things about their babies’ attributes. Finally, and remarkably, an overarching metatheme emerged that was addressed by all the mothers, although it was not articulated by name by most of them. After several weeks immersed in the interviews, the overarching theme of trust was identified. Although not all mothers used the term trust, every mother expressed trust in those caring for their newborn(s).

Seven Themes

Transportation Issues

Given that the participants were rural mothers, not surprisingly, having a significant commute to get back to the NICU to be with their babies was common to all. The average driving time was 60 minutes one way. Driving themselves was not always an option, especially for those who had a cesarean section. Many did not have a car. Public transportation was not available in their rural areas. Additionally, the cost of gas for a long daily drive was reported as a financial concern.

The most remarkable transportation story was told by the mother who delivered precipitously en route to the hospital. She had financial, childcare, and transportation difficulties. The father of the newborn was not able to go to the hospital with her because he needed to stay at home to watch their other young children. Mother and newborn were transported to the hospital without another family member for support. Two days later, her infant was moved to a higher level NICU, even farther away. She had no idea when she would be able to get a ride to go see her baby.

In light of Roy’s model, this theme can be viewed as a contextual stimulus, part of the physical/physiologic and interdependence modes of coping, as well as a level of adaptation. Women who solved the problem of getting to and from the hospital were acting at an integrated level of adaptation in the matter of transportation. Those who relied on others could be said to be at a compensatory level, while those who had not yet figured out how they were going to manage would be at a compromised level.

Focus on the Positive

The mothers were all going through a very stressful life event, but their optimism was remarkable. They talked about counting their blessings. One mother viewed having the newborn stay in the NICU after she [the mother] was discharged as “the best thing for his health, so I can get better and he can get better at the same time.” There was also a feeling of pride in knowing that they were doing the best they could to help their baby, for example, one mother said:

I love providing breastmilk because I know I’m helping contribute to her health…. I know I’ve done my best to make her progress better. I knew that she was getting the right medicine, the right treatment she needed to help her feel better. It was scary, but I handled it so well. Mothers reassured themselves by focusing on the positives:

It’s kind of reassuring, when you’re holding them skin-to-skin, [what] they do just calm to you. That kind of helps with the whole emotional separation part with them. You don’t really think of being able to hold your baby as a huge milestone, but in the NICU, it is.

In RAM terms, providing breastmilk, an obviously physical act, was a positive coping method and way for mothers to physically care for their newborn, if not always in person, then via the milk they provided. Their milk created an alternate means of interdependence with their newborn; additionally, skin-to-skin contact is a physical act which enhances interdependence. Both actions influenced mothers’ self-concept and rolefunction modes.

The Difficulty of Going Home Without Baby

Most mothers interviewed expressed decidedly negative feelings about going home while having to leave their newborn in the hospital. The women described this aspect of their experience as “hard,” “stressful, and “draining.” One mother stated, “I go home, and I feel bad.” It was a refrain expressed by every mother. One of the first-time mothers lamented, “I’m not pregnant anymore, but I can’t take him home. And it’s not something you usually think about when you have a baby.”

In Roy’s model, closely and naturally related to the physical mode of coping, is the interdependence mode. One can understand how the physical act of going home without baby disrupts the interdependence between mother and newborn, as well as the self-concept and role function of the mother.

Feeling Guilty

The theme of feeling guilty reflects our societal notion that motherhood is often fraught with feelings of guilt. Although none of the mothers intended to have their newborn require NICU treatment, they still felt somehow, and to some degree, to blame for that admission. One mother said, “You feel like it’s your fault.” A mother of premature twins said, “Just wish I could have carried them longer. You can’t help it; you get a little like, ‘Did I do something? Did I do too much?’” On a different note, and possibly related to being a rural woman, one mother said, “I hated the thought of getting food stamps because I’m not one to want help from the government. But then I realized – there is a difference between going to social services because you’re lazy and you don’t want to work, as opposed to you can’t work because of the high-risk pregnancy.” Literature (Rasmussen et al., 2018) supports that rural dwellers, while not usually accepting of help from people outside of their community, are much more accepting of outside services when children need care.

Guilt feelings relate to Roy’s coping modes of role function, interrelationship, and self-concept. Heydarpour and colleagues (2017) and Korukcu et al. (2017) discussed feelings of guilt as an interfering factor in women’s adaptation to motherhood in the NICU environment as well.

Uncertainty

Mothers stated uncertainty about many aspects of their experiences. Mothers of preterm babies did not expect to deliver as early as they did: “It just

Trust was a vital, primary element of the NICu experience for all the mothers.

happened so fast; I didn’t have time to absorb any of it. It was shocking. I think she just wanted out.” One mother explained what she said the nurses referred to as the NICU Shuffle, a dance that babies do: progressing, regressing, and then progressing again. She was informed that it is uncertain which babies will do what, but it is expected that most NICU babies will have that sort of pattern. Most notably, when asked about discharge, not one mother knew for certain when that would be and that was especially stressful. In RAM terms, uncertainty about circumstances or the unknown, such as the big question of “When would baby be coming home?” was a major residual stimulus for all participants. It was a weight on all their minds.

Identifying as a Mother

Adapting to the role of motherhood was different, depending on whether they already had children or not. Mothers’ ages were also identified as influencing their readiness to take on the role. Multiparous mothers’ perspectives. Some multiparous women were unfazed by adding another child to their mothering role, despite the implications of that newborn’s stay in the NICU. A mother of three had this to say, “It’s not like new baby overwhelming. It’s not like she’s my first, so I have to get used to doing everything.” Multiparous mothers had the perspective of experience. That seemed to help them cope in a more understanding way. One mother of premature twins, whose first child is a teenager, spoke from that perspective:

We’ll get out of debt later. Spend time with the babies now.… When

I started out with my first child, I wanted to do this and that, but you start seeing the days go by, and I’m like – no, I am going to spend time with him, and I will work out the rest later. Looking back, it went so quick! And I’m sure it will go quick with these babies. Primiparous mothers’ perspectives. In contrast, the women who were becoming mothers for the first time spoke about the difficulty of taking on that role in relation to their newborn’s NICU admission. One mother stated how she felt her situation was surreal:

It’s set in that I’m a mom, but it’s like, not really that I’m a mom yet, because other people are taking care of my child…. I know I gave birth to a child and I know that he’s here, but I’m only here a couple hours a day because we do live so far. In some interviews with first-time mothers, the language they used indicated that their maternal identity was in the process of forming. It was interesting to hear one mother talk about the support her friends gave via Facebook, “They told me how awesome I’m going to be as a mother…” – as though she had not yet become a mother.

It was also evident that first-time mothers were amazed and marveled at their own abilities to mother. Taking on the identity of mother meant that their priorities had changed and they were surprised, as well as pleased with that: “I never had to worry about anyone but myself and now it feels good that I have someone who needs me.” Feeling too young and unprepared. Four of the first-time mothers were under the age of 21. In contrast with the older mothers, every one of them commented on their age as a concern. “I asked for a lot of advice because I am a young mom. I found out when I was 19 and had her when I was 20, so it’s definitely different from somebody who is having a baby at 27 and has been working and has a lot of money saved up.” All of the young mothers credited their own mothers with being their biggest supporters and helping them cope with their unplanned pregnancies for which they felt so unprepared. They said they would not have been able to do it without their moms.

The contextual stimuli of parity and age affected both identifying as a mother and feeling prepared to adopt that new role. These can be viewed as affecting the coping modes of self-concept and role function in the Roy model. This finding was not surprising, as many other researchers have viewed age and parity as contextual stimuli in adaptation to motherhood (Chen et al., 2016; Chourasia et al., 2013; Foster et al., 2016, Northrup et al., 2013; Roque et al., 2017).

Identifying Baby Attributes

Due to the NICU admission, these mothers had spent relatively limited time with their babies since birth. It seems notable that never-the-less, they had definite opinions about some of their newborns’ traits. They already deemed them to be “angel babies” and “a little trooper” and “healthy.” One said, of her son who had been receiving care in the NICU for over a week at the time that “he’s never needed a lot of help.” One mother assured me that her baby has bettered her life and she is certain the baby “will be bettering a lot of other people’s lives.”

This identification of newborns’ attributes is coping in the interrelationship mode. It can also be seen as relating to Mercer’s (2006) stages of acquaintance and increasing attachment, or part of the process of attaining maternal identity which is similar to the coping modes of selfconcept and role-function in Roy’s model.

meta-Theme

After lengthy reflection on the words of these mothers, an overarching meta-theme became apparent in every encounter. While only three mothers used the actual word trust; it was implicit in every interview. Trust was a vital, primary element of the NICU experience for all the mothers. It was implied by every mother in their statements and certainly by their actions. Speaking with a nurse researcher during such a stressful time of their lives required trust. Leaving their precious newborns in the care of other people and going home without them required the utmost trust.

Many mothers reported that they called the NICU several times daily, during the day and night, from their home. Updates from the nurses reaffirmed that their trust was well placed. One mother explained, “Me being able to actually call and ask how she’s doing makes me kind of be able to tolerate not being able to come back all the time.”

In Roy’s model, trust can be viewed as a contextual stimulus. It also is involved in all four of the coping modes. For example, coping in the interrelationship mode certainly changed as mothers adapted to the implications of having a newborn in the NICU. Interactions with the NICU nurses and doctors became new significant relationships that necessarily,

were navigated with trust and mutual respect. Trust can also be viewed as a mediator of level of adaptation in the circumstance of adapting in the NICU.

Discussion

While conducting this research, it was evident that the experience of adaptation to motherhood could readily be related to Roy’s model, just as another researcher has endorsed (Romero et al., 2012). The RAM is well suited to nursing studies of mothers and newborns, because its focus is adaptation, which is a process mothers and newborns are actively engaged in.

When trying to recruit participants for this study, it became apparent that nurses were not aware of where their patients lived. Location of residence was not part of what was considered when planning care for their patients and required a computer search to find. Given the significance of rurality to the experience of adaptation to motherhood, having that information readily available to the nurses would be beneficial to them in providing care to newborns and mothers. This information must not be used to stereotype, but rather to address the unique challenges that mothers who live in a rural place experience.

Knowledge of rural nursing theory and awareness of mothers who are from rural places has implications for the extra significance that health teaching may have for those mothers. “If the nurse can provide adequate health knowledge, the rural dweller’s desire for self-reliance may lead to health-promotion behaviors” (Long & Weinert, 1989, p. 124). Considering the distance from emergency healthcare providers, health-promotion behaviors are even more consequential to rural dwellers, especially with a neonate at home who began life with health problems.

The value that these mothers expressed in being able to care for their own newborns by providing breastmilk, having skin-to-skin contact with their infants, and even something as ordinary as changing diapers is knowledge that nurses should possess. Nurses’ encouragement and support of mothers in those activities can have a profoundly positive impact on a mothers’ self-concept and role function, thus aiding their self-efficacy and consequent adaptation to motherhood, even under the extreme conditions of the NICU. That support in activities can also build the trust that is so necessary for integrated adaptation.

Knowing that their newborn was safe and well cared for was essential for these mothers. The finding that trust was an integral part of maternal adaptation has relevance in nursing education and practice. Nurses must be worthy of that trust. The importance of this needs to be emphasized in nursing education. While teaching the necessary skills and factual knowledge, we cannot overemphasize the importance of building trusting relationships.

limitations

A limitation of this study is that, although the selection of participants was purposive, it was also a convenience and self-selected sample. While this study provides insight into the experiences of these women, it cannot

Nurses were not aware of where their patients lived.

provide that same information about the women who were excluded from the research, either by their own choice or by exclusion criteria.

Conducting this research has led to many more questions. Most pressing is what about the women who were less inclined to talk and those who did not participate in the study at all? There were many more mothers who did not participate during the 3 months of data collection. All of them certainly hold information that would benefit nurses’ knowledge in providing the best possible support for mothers of babies in the NICU.

Only mothers were interviewed for this research because it was an inquiry specifically into adaptation to motherhood. Future research should involve interviews with rural fathers to understand their process of adaptation when a newborn is in the NICU. It would be beneficial to understand fathers’ experiences so that nurses could best support their adaptation.

When reviewing the nursing literature, there was a noticeable lack of recent research on adaptation to motherhood in general. Society is continuously changing and cultural norms change with it. Research on adaptation to motherhood needs continuous updating to more fully understand that experience as time passes. The experience of NICU nurses and their view of how their patients’ parents adapt would also be revealing information. What do they see as the barriers and enhancers of providing care to their high-risk patients while supporting the mothers of those babies as they adapt to their new roles?

Lastly, since trust was found to be an overarching theme for these mothers, there is a need for research into what factors enhance trust between families and those they encounter in health care. Knowledge of those factors would provide important information to nurses to enable better interaction with the public, especially with their patients and patients’ families. Building trust will enhance nurses’ abilities to help parents to cope with whatever stimuli they are facing and thus promote their adaptation.

Conclusion

The experience of adaptation to motherhood for rural women in the environment of the NICU was the focus of this study. The contextual stimulus of residing in a rural area was germane for all participants. Important themes found were transportation issues, uncertainty, age, and parity. Mothers coped in all four coping modes and the modes were shown to overlap with each other as well as with stimuli and level of adaptation, just as Roy (2009) described in her model. Information from this study can benefit nursing, practice, and education, making it possible to provide better care for rural mothers whose babies are in the NICU. This is in sync with the goal of nursing, which according to Roy (2009) is assisting persons in their coping behaviors to promote a state of integrated adaptation or health.

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