1.       Introduction

The Neonatal Intensive Care Unit (NICU) is an intensive care unit that specializes in the care of premature or sick full-term infants. It combines advanced technology and trained health care providers to provide specialized care to sick babies. The NICU is typically directed by one or more neonatologists and staffed by nurses, nurse practitioners, pharmacists, physician assistants, resident physicians and therapists. A neonatologist is a pediatrician with additional training in the care of sick full-term and premature babies. The NICU environment is a source of stress for parents and infants. It has increased the survival of premature and sick full-term infant and has increased parental stress, altered the expected parental role and created feelings of separation that may delay parental attachment and bonding. Parents worry about the cost of care and the day to day health progress of their child [1].

Fathers are now expected to assume multiple roles of provider, nurturer and caregiver. They struggle with assuming these multiple roles which may limit the time they have to visit the NICU. In most cases, if fathers do not feel encouraged and supported by nurses, they will not visit the NICU. Some are willing to be involved but are fearful of holding the fragile infant. Others are reluctant to participate in the care of the infant and are comfortable playing a supportive role because they see the mother as a primary caregiver. Fathers need to be encouraged to visit and participate in the care of their infant in the NICU which will improve parent-infant bonding and attachment and increase parental role confidence [2]. Care in the NICU has become so complex that professionals believe that they have to protect the infants from their families, which prevents parent-infant bonding and attachment [3]. This study explored the lived experience of fathers in NICUs in South Florida to gain an understanding of the essence of their experience caring for their infant. A qualitative approach was used because not much information is known about the phenomenon of interest. Hermeneutic phenomenology is the philosophical framework that was used to guide this study. Fathers in the Neonatal Intensive Care Unit

In the NICU, fathers struggle with working and taking care of the household while supporting the mother. They may not express their emotions because they want to be viewed as the strong, supportive parent. Some fathers are motivated and want to be involved in the care of their infant but are fearful of holding the fragile infant. Some fathers are reluctant to be involved in the care of the infant because they think their primary role is supporting the mother. The mother’s presence can encourage the father’s lack of interaction in the NICU because he sees her as a primary nurturer for the baby. Fathers may stay away from the NICU if their needs for encouragement and support are not met. Their feelings need to be explored by the nurse. Nurses need to teach the fathers positive coping skills and communicate with them and encourage their presence and participation in the care of their infant. Nurses need to encourage fathers to perform infant care tasks such as changing and feeding the infant and encouraging their participation in healthcare decisions [2]. Men do not feel like they are a father to their infant unless they are able to touch or hold their infant and have physical or eye contact [4]. Bonding between father and infant may be affected if the father is not involved in the care of the infant.

The terms bonding and attachment are used synonymously, even though, they have different properties. Essentially, bonding starts shortly after birth and reflects feelings of parent toward newborn, whereas attachment is a reciprocal process between parent and infant that occur gradually over the first year of life. Attachment is the capacity to form selected and enduring bonds and is part of the bonding process. Attachment occurs gradually after bonding has taken place. The process of attachment is not as automatic. The admission of the infant to the NICU due to prematurity or illness interferes with the attachment process. Father-infant bonding is facilitated by the father’s involvement in the care of the child. Closeness and involvement in infant care enhances attachment and bonding and decreases parental anxiety. Studies associated with bonding and attachment has focused primarily on the relationship between the mother and the infant [5].

Fathers are often the first to see the baby because the mother is usually separated from the infant after birth. Still, nurses do not communicate well with fathers and do not encourage them to participate equally in the care of the infant in the NICU. This can affect parental confidence and disrupt parental involvement. Societal norms that support that the mother is the primary caregiver may contribute to this treatment of the father. The nurse and the mother need to encourage the father’s interaction in the care of the child which will encourage infant growth and development as well as parental well-being. Fathers play an important role in supporting mothers during and after pregnancy, and they can play a major role in the growth and development of children [2]. A study of the nature is warranted because there is need to understand the experience of the father in the NICU.

2.       Statement of the Problem

The NICU is a stressful environment, and caring for an infant in the NICU intensifies the feelings of stress that parents feel. This can affect bonding between parent and child. Fathers visit the NICU less often than mothers because they are often preoccupied with working to support the family or because they are not comfortable being present in the NICU. If fathers are not included in the care of the infant, bonding between father and infant will be affected [6]. The father may neglect the needs of the child if he never bonded with the child. When compared with mothers, fathers cope differently with stress and find different aspects of the NICU experience stressful [7]. The way they cope with this experience is unknown and needs to be explored. The fathers’ experience of having a hospitalized child has been underreported, and as a result, their experience is poorly understood. Understanding the experience of being a father to an infant in the NICU is important for nurses and other health-care providers so that they may provide appropriate interventions for these individuals. In an effort to gain knowledge and understanding of fathers who care for an infant in the NICU, it is crucial to explore the lived experiences of these individuals.

3.       Purpose of the Study 

The purpose of this study was to explore the lived experience of being a father to an infant in the Neonatal Intensive Care Unit (NICU). The aim of this research was to give these fathers a voice to express their individual experiences and feelings regarding the care of their infant in the NICU.

4.       Methodology

Qualitative research is a non-statistical method of analysis of social phenomena in their natural settings. It is a way to gain insights that cannot come from quantitative means [8]. Phenomenological research is a qualitative research design that attempts to explain the experiences that were previously unclear. Phenomenology adds to the body of knowledge and transforms the researcher in the process. The hermeneutic phenomenology of Max van Manen was used to describe the meaning of the lived experience of fathers caring for an infant in the NICU.

5.       Research Design

Van Manen [9] developed his own method of data analysis based on a combination of descriptive and interpretative (hermeneutic) phenomenology. Hermeneutic phenomenology is based on Heidegger’s philosophy and seeks to interpret the lived experience of participants. This method seeks to find the essential meaning of the experience being studied [10]. van Manen’s six research activities offer practical approaches to conducting hermeneutic-phenomenological research. He described these activities as approaches to stimulate insight and not having a specific step by step format. His approach involves an interplay of six research activities to conduct human research. They include turning to the nature of the lived experience, the existential investigation, phenomenological reflection, phenomenological writing, pedagogical relation and research balance. van Manen [9] described human-science research as the “Phenomenological and hermeneutic study of human existence” (p. 38). He described that hermeneutic phenomenology attempts to create a complete interpretive description of some aspect of the four life worlds.

Van Manen described human-science research as the “Phenomenological and hermeneutic study of human existence” (p.38). Van Manen [11] believes that assumptions are always present, and the researcher should suspend or bracket his beliefs. Since little is known about the lived experience of being a father to a preterm infant in the NICU, hermeneutic phenomenological approach will be important to gather experiential information to develop richer and deeper meaning of the phenomenon. Van Manen’s six research activities offer practical approaches to conducting hermeneutic-phenomenological research. He described these activities as approaches to stimulate insight and not having a specific step by step format.

The first of the six research activity include: turning to the phenomena. The researcher will formulate a phenomenological question and participate in bracketing or reflectivity. Second, investigate the experience. Data will be gathered with face-to-face taped interviews. Third, reflecting on the essential themes. Transcript will be reviewed by participant in second interview (member checks). Fourth, describing the phenomenon. The researcher writes and rewrites to make aspects of father’s experience understandable. Fifth, maintaining a strong and oriented pedagogical relation to the phenomena. This influenced the development of research questions and interpretation. Lastly, balance the research context by considering the parts and the whole. The researcher is attentive to show that all parts of the research process are connected (Figure 1).

6.       Demographic Representation

This study included 12 fathers who cared for an infant in the NICU. The 12 research participants were obtained from two NICUs and one NICU Support Group in South Florida. These participants resided in the following counties: Dade, Broward and Palm Beach. They varied in age from 20-45 with a mean age of 31 years. The participants’ ethnic background and cultural heritage were reflected by one Haitian, one Native American, four African American, two White Non-Hispanic and four Hispanics. The participant’s ethnic background was identified, even though, the demographic questionnaire identified race. Nine of the participants worked full-time and three worked part-time. All participants took time off work when the child/children were born and seven of them had already resumed working; the others were planning to return to work soon. Most of the participants took less than one week off from work before returning. The research participants’ educational levels ranged from high school to professional degree. Five of the participants were single, living together and seven were married and living together. This was the first time in the NICU for all of the participants. The child/children in the NICU were the first child for nine of the participants. The other three participants reported having other children. Five of the participants had a pre-term infant in the NICU; the others had a full-term infant in the NICU.

7.       Findings

The 12 research participants provided thick, rich descriptions of their experience which allowed the researcher to uncover the themes. The researcher read and reread the transcripts several times to find common statements that were the themes. The researcher reviewed the transcripts line by line and highlighted the common statements and reviewed the margin notes to find the themes. The themes uncovered in this study were reflective of the experience of the participants. Four essential themes emerged from writing and rewriting: a) distressing, b) unknowing, c) life- changing and d) reassuring. The four essential themes were connected to the major overarching essential theme of wanting the baby home. These themes reflected what it is like for fathers to care for an infant in the NICU which explored the life worlds of space, time, body and human relation. Figure 2 is the researcher’s conceptual representation of the lived experience of fathers who care for an infant in the NICU as described by the participants in this study. The researcher used a relationship diagram to portray the themes that were reflective of the phenomenon for these fathers. The overarching theme, wanting to take the baby home is at the center of the relationship diagram this was the common thread that could be observed through the voices as being the most recurrent pattern depicting their experience. Distressing, unknowing, life changing and reassuring are the four themes that are connected to the major overarching theme.

The arrows pointing from each theme to the overarching major theme showed that each theme was connected to the major theme. The participants all desired to take their baby home so they remained encouraged and involved in the care of the baby in the NICU despite feeling distressed and uncertain. This birth changed all aspects of their lives and they felt reassured to have support from the nurses and their families to remain involved in the care of the baby so that they would eventually take the baby home. The image of a cloud depicted the major overarching theme and showed that this was an ongoing concern; a common hovering feeling. The explosive shapes represented the themes distressing and unknowing to depict feelings of turmoil. The oval shape represented life changing to depict a positive and negative aspect of the experience. The circle shape represented the theme reassuring which depicted a more positive aspect of the phenomenon. The participant’s responses connected to these themes reflected what these mean. These themes highlighted the experience of multiple participants not just a single participant and the experience of a single participant could belong to more than one theme.

8.       Conclusion

This study sought to explore the lived experience of being a father to an infant in the Neonatal Intensive Care Unit (NICU). Twelve willing participants shared their stories, allowing the researcher to understand their experience, thus accomplishing the goal. Response was slow after posting recruitment flyers, but with the help of the NICU staff and the researcher making multiple visits to the NICU, more participants agreed to participate in the study. The participants were polite and resourceful during the interviews, which made the interviews fairly easy to conduct. Phenomenological principles were applied and four essential themes surrounding a major theme emerged while the researcher immersed herself in the participants’ spoken words. These themes were distressing, unknowing, life changing, reassuring, and the overarching major theme wanting the baby home. The participants openly conveyed their experience despite how distressing the experience was for them. They remained involved in the care of the child in the NICU despite the challenges they faced because they yearned to take the baby home. They wanted to find meaning and purpose in their lives by fulfilling their desire to be a parent to their child and parent the child at home.

Figure 1: Six research activities. Adapted from van Manen [11].

Figure 2: Conceptual Representation of the Lived Experience of Being a Father to an Infant in the NICU.

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