Reprinted with permission from Journal of Perinatal & Neonatal Nursing 2009;23(4):363-371.

J Perinat Neonat Nurs

Vol. 23, No. 4, pp. 363371
c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright 

Relationships Between Environmental

Stressors and Stress Biobehavioral
Responses of Preterm Infants in NICU
Niang-Huei Peng, PhD, RN; Jean Bachman, DSN, RN; Ruth Jenkins, PhD, RN;
Chao-Huei Chen, MD; Yue-Cune Chang, PhD; Yu-Shan Chang, BSN, RN;
Teh-Ming Wang, MD
Although research has demonstrated that the neonatal intensive care unit (NICU) is a
stressful environment for preterm and high-risk infants, little research validates the
suspected relationships between infant biobehavioral responses and environmental
stress in the NICU. This exploratory study examined the relationship between
environmental stress and biobehavioral responses of preterm infants. The study used a
repeated-measures research design to examine research variables in one group of
preterm infants. Measurements of research variables were recorded every 2 minutes
during two 60-minute observation periods for each research day (1 hour in the morning
and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37
preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164
observations were made and recorded during the study. There was a statistically
significant (P < .05) relationship between environmental stressors and changes in
physiological signals. There were also statistically significant (P < .05) relationships
between environmental stress and some specific stress behaviors. This research is
applicable to neonatal clinical practice because it demonstrates the importance of
recognizing the preterm infants biological stress responses to environmental stressors,
allowing for early interventions to reduce the possibility of more serious physiological
or pathological changes in the status of the preterm infant. Key words: environmental
stress, preterm infant, stress behavioral responses, stress physiological signals

Author Afliations: Department of Nursing, Central Taiwan

University of Science and Technology, Taichung, Taiwan (Dr
Peng); College of Nursing, University of Missouri, St Louis (Drs
Bachman and Jenkins); Department of Pediatrics, Taichung
Veterans General Hospital, Taichung, Taiwan (Dr Chen and
Ms Wang); Department of Mathematics, Tmkang University,
Tamsui, Taiwan (ROC) (Dr Chang); and Children Hospital,
China Medical University, Taichung, Taiwan (ROC) (Ms Chang).
The authors thank Dr Victor Battistich for his many contributions
to our research. His death was our great loss and would like to
dedicate this research report to him.
Corresponding Author: Niang-Huei Peng, PhD, RN, Department
of Nursing, Central Taiwan University of Science and Technology,
No 11, Pu-Tzu Lane, Pu-tzu District, Taichung city 406, Taiwan
(Republic of China) (gingerlily.peng@gmail.com)
Submitted for publication: August 25, 2008
Accepted for publication: August 24, 2009

he neonatal intensive care unit (NICU) provides

treatments for maintaining the vital functions of
preterm infants because of immaturity of all major
body systems, especially the nervous system.1 However, some researchers24 have pointed out that the
NICU environment involves sensory overload and is
a mismatch to the requirements of the developing
nervous system in preterm infants. In order to not
only assure survival but also foster the development of
preterm infants, it is critical to understand the interaction among the environment and the function and progression of preterm infants. In addition, there is little
research validating the suspected relationships between the environmental stress and infant biobehavioral responses in NICUs.5 Additional research
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examining relationships between environmental stressors in the NICU and the biobehavioral responses of infants is needed to improve the quality of neonatal nursing care.

LITERATURE REVIEW
Light, sound, and caregiving interventions are the main
environmental stressors that are harmful to preterm
infants in NICUs.68 Preterm infants have often been
cared for in NICUs typically illuminated 24 hours a day
by a mixture of natural and artificial light. According to
one investigation,9 the ambient light levels range from
12 to 99 foot-candles (ft-c) with a mean light illumination of 46.29 ft-c in the NICU; the mean light level
inside incubators partially covered by blankets was
26.48 ft-c. Slevin et al10 also found that the mean light
illumination in the NICU decreased significantly from
254.5 lux to 3.0 lux during quiet periods when the
NICU was darkened by switching off all the lights and
pulling down all blinds.
Sound levels in the NICU have also been a major
source of environmental stress for premature infants.11
The American Academy of Pediatrics12 recommended
that noise levels should not exceed 40 to 45 dB in the
NICU and basic sound levels should be less than 35 dB
to promote infant sleep. Johnson13 reported an average
mean sound level of 58.5 dB inside covered incubators.
A more recent study14 found that the mean sound level
was 54.90 dB in the NICU during application of developmental care. Researchers have reported that NICU
sounds average between 50 and 90 dB.15
Caregiving interventions in the NICU often combine
multiple stimuli that include sound, light, tactile stimuli, and pain.4 In interventions that require opening
the plastic sleeve of the incubator, the mean decibel
level has been found to be 67 to 86 dB.4 Nursing and
medical interventions sometimes include painful stimuli. These painful interventions may produce a physiological response and induce stress behaviors in preterm
infants.2,3 Moreover, neonatal nurses and physicians do
not always consider infant sleep-wake states and other
behavioral cues when choosing the time for routine interventions. Therefore, it is important to study these
potentially harmful stimuli in preterm infants.
In this research, the biological stress responses in
preterm infants included physiological stress signals
and behavioral stress responses. Physiological stress indicators and pain are similar and include changes in
heart rate (HR), respiratory rate (RR), blood pressure,
transcutaneous oxygen levels (tcPO2 ), oxygen saturation (O2 Sat), intracranial pressure, vagal tone, skin

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ANC-D-13-00105.indd 3

blood flow, and palmar sweat.16,17 Because HR, RR,

and oxygenation levels (O2 Sat) can be measured directly from electrocardiogram (ECG) monitoring equipment and are available in the NICU setting, in this study,
the physiological stress responses measured were HR,
RR, and O2 Sat Preterm infants experience frequent
changes in cardiac and RRs to cope with environmental stress.16 Environmental stimuli in the NICU can
cause initial increases in heart and RRs in acutely ill
infants, along with possible increases in oxygen consumption and caloric requirements.18 If the stressful
stimulation continues without any intervention, the initial increases in cardiac and RR ceases and the infant
will become apneic and bradycardic.19
According to research,16 preterm infants show behavioral stress responses when sensory inputs are too
intense, too frequent, too long, or too complex. The
preterm infant has poor balance of flexion and extension that produces some distinctive behavioral responses, such as jerking and twitching, when the
infant is stressed. These behavioral responses occur
because preterm infants are often unsuccessful in inhibiting these overshooting responses.20 Behavioral responses of preterm infants include self-regulatory behaviors, such as sucking, suck search, grasp, and stress
behavioral cues, such as arching, finger splay, leg extension, kicking, and arm waving. The function of selfregulatory behaviors is to help the preterm infant cope
with stress and demonstrates strategies that the infant
uses to maintain balance, such as sucking, suck search,
and grasp.21 Stimulation, in the NICU environment, can
initially increase self-regulatory behavioral responses
in preterm infants, and the behavioral stress cues indicate the behaviors of the failure of self-regulatory
mechanisms.2 VandenBerg and others22 described that
most preterm infant sleep-wake states are easily disturbed by environmental stressors, causing the infant
to demonstrate disorganized behavioral states. Fussing,
crying, hypoalert, hyperalert, gaze averting, upward
gaze, staring, and grimace are special disorganized state
behaviors preterm infants demonstrate when stressed.

RESEARCH CONCEPTUAL FRAMEWORK

The conceptual model for this research draws upon
Epsteins23 model of stress responses in newborn infants and the Synactive Theory of Development.20
Epstein discusses the concept of stressors and organism stress response, noting that stressors can be either in the internal or in the external environment,
and the organism response to stress is directed toward
maintaining system stability. The Synactive Theory of

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Environmental Stress, Stress Biological Responses, Preterm Infant, NICU

Preterm infants
Confounding variables
Gestaonal age
Postconcepon age
Congenital anomaly
Venlaon medicaons
Photo therapy
Sedave medicines
Chronic lung diseases
Hemorrhagic/ischemic white maer
brain injury
Infecous diseases
Environmental stressors
Loud sound
Bright light
Nursing intervenons
Stress responses

365

Setting and subjects

The research settings were 1 level III NICU and an intermediate sick baby care unit at 2 teaching hospitals in a
city in Taiwan. All research subjects were in incubators
at the time of the study. The research sample excluded
preterm infants with major health complications (ie,
chronic lung disease, necrotizing enterocolitis, and serious infectious diseases), a congenital anomaly or with
hemorrhagic/ischemic white matter brain injury above
grade III, and those who needed surgery. Preterm infants who were on mechanical ventilation (ie, intermittent positive pressure ventilation and high-frequency
ventilation), phototherapy, and sedative medicines also
were excluded from this research.
Measurement

Stress behavioral responses

Stress physiological signals
Heart rate
Respiratory rate
O2 saturaon

Self-regulatory behaviors
Change insleep-wake states
a) Regular sleep-wake states
b) Stress sleep-wake states
Stress behavioral cues
(arch, arm wave, nger splay,
leg extension, kicking etc)

Figure 1. Research conceptual framework.

Development focuses on the threats to optimal growth

and development of the preterm infant posed by the
immature neurobehavioral system and the NICU environmental conditions and describes responses to stressors as involving either self-regulatory behaviors or,
when self-regulatory actions are not sufficient for adaptation to stressors, physiological changes and behavioral symptoms indicative of the expenditure of energy
resources. The general conceptual framework is outlined in Figure 1.

RESEARCH METHOD
The research design used a prospective repeated
measuring methodology to examine the relationships
between environmental stressors and biobehavioral
responses in one group of preterm infants. Research
hypotheses were as follows:
1. Increases in environmental stress will result in increases in heart and respiration rate (HR, RR), and
decreases in O2 Sat level in preterm infants.
2. Increases in environmental stress will result in
specific behavioral responses (eg, finger or toe
splay, frown, sitting on air, tongue extension, and
extend arms or legs) in preterm infants.

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The study variables were environmental stress, stress

biobehavioral responses, which included physiological
stress signals, and behavioral stress responses. Measurement of physiological stress signals included HR, RR,
and O2 Sat. Measurement of behavioral stress responses
included sleep-wake states, self-regulatory behaviors,
and behavioral stress cues.
Environmental stress in NICU
In this study, environmental stress was defined as
increases in sound levels, light in the preterm infants environment, and nursing interventions applied
to preterm infants in the NICU. A photometer was used
to measure levels of light illumination, and a phonometer was used to measure sound levels in the incubator.
According to Holditch-Davis et al,16 the caregiver-infant
interactions often have an all-or-nothing quality, ranging from no contact to repeated, frequent, stressful,
and often painful intervention. These interventions often also combine multiple stimuli that include sound,
light, tactile, and pain to preterm infants in the NICU.4
A Likert-type scale was used to measure the degree of
stimulation in nursing interventions: level 1, sound or
light; level 2, sound and light; level 3, sound or light
and handling; level 4, sound, light, and handling; and
level 5, any intervention that causes pain.
Biobehavioral stress responses
The physiological stress signals were measured by a
cardiorespiratory monitor (ECG) to determine HR, RR,
and O2 Sat. According to Holditch-Davis and others,16
painful stimuli might be the most harmful stimuli to
preterm infant in the NICU. Therefore, the operational
definitions of the physiological stress signals were
adapted from several painful assessment criteria,24,25
which are described and summarized in Table 1. In

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Table 1. Stress physiologic signals and operational definitions

Stress
physiological
signals
HR
RR

O2 Sat

Operational denitions
HR < 100 bpm or > 160 bpm, or an
increase in baseline 5 bpm or more
Irregular, less than 40 breaths per minute
or greater than 60 breaths per minute,
or an increase in baseline 7 breaths per
minute or more
<90 mg% or a decrease of 2.5% or more

Abbreviation: bpm, beats per minute; HR, heart rate; O2 Sat, oxygen saturation; RR, respiration rate.

each case, a stress response means outside of normal

limits or a change (increase in HR and RR and decrease
in O2 Sat) when measurements are still within normal
limits.
The operational definitions of these stress behaviors
were adapted from the Manual of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) and the Neonatal Intensive Care Network Neurobehavioral Scale.22,26,27 The 6 stress behaviors related to sleep-wake states were hypoalert,
hyperalert, gaze averting, upward gaze, staring, and
grimace. The 10 self-regulatory behaviors were grasp,
hand clasp, hand to mouth, foot clasp, holding on, leg
brace, sucking, tuck trunk, balance muscularity tone,
and mouthing or suck-searching. The 17 behavioral
stress cues were airplane, arch, diffuse squirm, finger
splay, fisting, grape face, mouthing, salute, sitting on air,
stretch down, tongue extension, tremor, startle, twitch,
yawning, sneezing, and hiccup, spit up or vomit. All
special stress behaviors were coded as present/absent.

searcher and clinician independently coded the segment and discussed any disagreements until consensus
was achieved. Training continued until a minimum criterion of 80% agreement between the researcher and
clinician was obtained. Intercoder agreement was then
estimated by having the clinician independently code a
sample of 10% of the study videotapes and comparing
these codes with those of the researcher for the same
videotapes.
Data collection procedure
The institutional review board approval was obtained
from the university and participating hospitals as well
as parental consent prior to infant enrollment in the
study. Measurements of research variables for each
infant were recorded every 2 minutes during four
60-minute observation periods conducted over 2 days
(1 morning and 1 afternoon observation for each
day for 120 minutes per day). To facilitate detailed
coding of the behavioral variables, 2 separate digital
video recorders were used. Both recorders were placed
inside the incubator, one video recorder placed
to capture the infants facial expressions and hand
movements and the other video recorder placed to
capture the babys trunk and leg movements. The
infants were videotaped during each observation. After double-checking the observed outcomes from direct observations and observed data of videotapes, an
observation checklist was used to code the infant stress
behaviors.

RESEARCH FINDINGS
Descriptive statistics were used to characterize the
sample and the generalized estimating equation (GEE)
models were used to examine 2 research hypotheses.
Demographic characteristics of the sample

Reliability and validity of measurement

The Likert-type scale was used to measure the nursing interventions. A TES-1336 photometer was used to
measure light levels in the incubator and a Rion NL-10A
phonometer was used to measure sound levels. Measurements of HR, RR, and O2 Sat were recorded by the
same cardiorespiratory monitor. Measures of preterm
infant sleep-wake states, stress sleep-wake states, selfregulatory behaviors, and behavioral stress cues were
coded from videotape. Content validity of the assessment instrument was evaluated by 5 professionals.
To assess the reliability of coding, one of these clinicians was trained by the researcher to use the coding system. Using a sample of video segments, the re-

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Research data were collected from September 2007

to February 2008. There were 37 preterm infants recruited for this study. Using the observation checklist, there were 4164 observations of the preterm infants. Of the 37 preterm infants, 4 were accepted into
the study with nasal continuous positive airway pressure to protect them from physiological apnea. Even
though the infants had nasal continuous positive airway pressure, they were not considered to be in a
critical period. There were 10 sets of twins (27%), 4
sets of triplets (10.8%), and 23 (62.2%) single gestation
infants. Table 2 summarizes the demographic characteristics. Environmental stressors included increased
sound, light, and nursing interventions occurring in the

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Findings related to the research hypothesis 1

Table 2. Summary of demographic variables

(N = 37)
Variables
Birth weight, g
Study initial
weight, g
Gestational
age, wk
Initial study
age, d
Apgar score
(1 min)
Apgar score
(5 min)

Minimum Maximum

Mean

The GEE methods generalized linear models were used

to address the research hypothesis 1 with a P value
of less than .05 considered as statistically significant.
There was a significantly positive relationship between
environmental stressors and HR (Table 3). In addition,
after adjustment of the effects of environmental stressors, the rate of change of heart beat was 1.097 per day
(P < .001). Similarly, there were significantly increasing
relationships between environmental stressors (interventions levels 14) and RR (Table 4). The RR of female
infants was, on average 5.910, significantly lower than
was the respiratory rate of male infants, after adjustment for the environmental stressor effects. There was
also a significantly negative relationship between environmental stressors (intervention levels 23 and O2 Sat
(Table 5).

SD

950.00
890.00

2635.00
2635.00

1662.351 327.707
1673.243 300.324

27.00

36.00

32.059

2.208

27

10.648

8.373

6.216

2.043

10

8.0541

1.311

incubator with nursing interventions classified into 5

levels. A baseline measure of light (mean = 0.324 ft-c)
and sound (mean = 52.556 dB) was recorded 3822
times when no intervention occurred. The range of
light illumination was 0.94 to 2.3 ft-c and the range of
sound level was 56.12 to 63.62 dB during different levels of nursing interventions.
In the total of 4164 measurements of biological stress
responses, the mean HR was 148.53 beats per minute
(SD = 17.223), and the mean RR was 46.33 breaths
(SD = 14.765). The mean O2 Sat was 96.97 mg% (SD =
3.534). The grimace (n = 103, 30.1%) was the most
common behavioral stress response.

Findings related to the research hypothesis 2

The GEE methods logistic regressions were also used
to examine hypothesis 2. There was a significantly positive relationship between environmental stressors and
7 specific behaviors (Table 6). After adjustment of the
effects of time, light, and sound, there were significantly increasing relationships between different levels of environmental stressors and 8 specific behaviors
including grimace, hand to mouth, holding on, sucking, finger splay, salute, sitting on air, and yawn. In
other words, the odds ratio of these different specific
behaviors being present increased with respect to the

Table 3. Established the relationship between environmental stressors and heart rates by the generalized
estimating equation methods linear regressiona
Variables

Parameter estimate

Standard error

132.413
0.009
0.878
0.067
6.067
7.758
4.922
2.882
1.259
1.797
1.097

2.98
0.043
0.596
0.054
1.374
2.519
2.257
1.3047
2.064
2.381
0.139

Intercept
Times
Light
Noise
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Gender femaled
Age

95% CI
(126.571, 138.256)
(0.095, 0.077)
(0.290, 2.046)
(0.039, 0.173)
(3.373, 8.761)
(2.820, 12.697)
(0.498, 9.346)
(0.325, 5.440)
(2.788, 5.306)
(6.465, 2.870)
(0.823, 1.370)

193.264
0.041
2.170
1.530
19.479
9.480
4.756
4.881
0.372
0.570
61.802

<.001
.839
.141
.216
<.001c
.002c
.029c
.027c
.542
.450
<.001c

a Dependent
b Reference
cP

< .05.

d Reference

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variable: heart rate/2 minutes; Model: (intercept), times, light, noise, interventions, gender, age.
category is intervention (0).
category is male, df = 1.

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Table 4. Established the relationship between environmental stressors and respiratory rates by the generalized estimating equation methods linear regressiona
Variables
Intercept
Times
Light
Noise
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Gender female d
Age

Parameter estimate

Standard error

42.634
0.027
0.578
0.063
1.461
10.681
4.273
5.207
5.606
5.910
0.213

2.402
0.036
0.487
0.033
5.784
3.580
1.924
1.923
2.079
2.235
0.1247

95% CI
(37.925, 47.344)
(0.045, 0.099)
(1.532, 0.377)
(0.003, 0.129)
(9.877, 12.799)
(3.663, 17.698)
(0.501, 8.045)
(1.437, 8.978)
(1.531, 9.682)
(10.292, 1.529)
(0.032, 0.457)

2
314.812
0.538
1.406
3.521
0.064
8.899
4.931
7.328
7.269
6.990
2.908

P
.000
.463
.236
.061
.801
.003c
.026c
.007c
.007c
.008c
.880

a Dependent
b Reference
cP

variable: respirational rate/2 minutes; Model: (intercept), times, light, noise, interventions, gender, age.
category is intervention (0).

< .05.

d Reference

category is male; CI: condence interval, df = 1.

increase of levels of environmental stress. On the other

hand, there was a significantly negative relationship between the environmental stress (intervention 5) and
tone (balanced muscular tone). In other words, with
the increase in the environmental stress to level 5, the
odds ratio of the preterm infants balanced muscular
tone will decrease.

DISCUSSION
Environmental stress in the NICU
In this study, the mean sound and light levels for
preterm infants in the incubators were 52.55 dB and
0.324 ft-c (3.24 lux). The mean noise and light levels
were calculated when there were no nursing interven-

tions and each incubator was covered with a blanket.

Compared with previous studies,13,28 the sound level
was lower in the present research. There are previous
studies where light levels were also low and similar to
the current study.10
Discussion of the research hypothesis 1
In this investigation, there was a relationship between
4 environmental stressors (nursing interventions levels
2, 3, 4, and 5) and an increase in HR in the preterm
infants. This finding is similar to a previous study that
showed that HR changes were the most common physiological stress signal of preterm infants in response
to environmental stressors.29 Other researchers also
found that the stressful NICU environment can cause

Table 5. Established the relationship between environmental stressors and oxygen saturation by the GEE
methods linear regressiona
Variables
Intercept
Light
Noise
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b

Parameter estimate

Standard error

95% CI

98.127
.526
0.015
0.601
1.072
1.691
0.877
0.011

0.645
0.302
0.009
0.969
0.649
0.626
0.440
0.394

(98.862, 99.393)
(1.118, 0.067)
(0.034, 0.004)
(2.500, 1.299)
(2.345, 0.201)
(1.74, 0.013)
(0.783, 0.762)
(0.783, 0.762)

23095.534
3.025
2.324
0.384
2.726
7.283
3.961
0.001

<.001
.082
.127
.535
.099
.007c
.047c
.979

a Dependent
b Reference
cP

variable: O2 Sat.; Model: (intercept), times, light, noise, interventions.

category is intervention (0), df = 1.

< .05.

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369

Table 6. Established the relationship between environmental stressors and stress behavioral responses by
the generalized estimating equation methods logistic regressionsa
Variables names
Grimace (6 stress behaviors related to sleep-wake states)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Hand to mouth (self-regulatory behavior)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Holding on (self-regulatory behavior)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Sucking (self-regulatory behavior)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Tone (self-regulatory behavior)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Finger splay (stress behavioral cues)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Salute (stress behavioral cues)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Sitting-on-air (stress behavioral cues)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b
Yawning (stress behavioral cues)
Intervention level 5b
Intervention level 4b
Intervention level 3b
Intervention level 2b
Intervention level 1b

Estimate

Standard error

Odds ratio

1.743
1.136
0.813
0.986
0.437

0.799
0.505
0.241
0.192
0.563

.029c
.024c
.001c
.000c
.438

5.712
3.115
2.255
2.681
1.548

2.399
0.146
0.148
0.954
1.489

0.583
1.005
0.520
0.459
0.789

.000c
.885
.777
.038c
.059

11.014
0.864
1.159
2.597
4.432

2.759
1.635
2.014
0.604
1.571

1.004
1.100
0.516
0.747
0.907

.006
.137
.000c
.419
.083

15.777
5.128
7.495
1.830
4.813

0.677
0.934
1.298
0.678
1.438

0.492
0.595
0.359
0.359
0.332

.169
.117
.000c
.025c
.000c

1.969
2.544
3.662
1.970
4.214

1.463
0.384
0.126
0.048
0.566

0.397
0.396
0.269
0.153
0.443

.000c
.333
.639
.756
.202

0.978
0.231
0.681
0.881
0.953

2.813
1.704
1.353
1.502
1.204

0.352
0.3063
0.311
0.260
0.662

.000c
.000c
.000c
.000c
.069

16.659
5.497
4.489
4.489
3.333

1.527
1.354
1.305
1.697
1.243

0.577
0.678
0.322
0.233
0.654

.008c
.046c
.000c
.000c
.058

4.605
3.873
3.688
5.459
3.465

3.050
1.935
2.016
1.089
0.545

1.096
0.683
0.356
0.467
1.113

.005
.005
.000c
.020c
.624

21.116
6.921
7.507
2.971
1.725

2.503
1.902
1.435
1.399
1.440

1.342
0.848
0.547
0.899
0.648

.056
.025c
.009c
.120
.027c

12.972
6.699
4.199
4.051
4.219

a Dependent

variables: stress behaviors; model: (intercept), times, light, noise, interventions.

category is intervention (0).
c P < .05, odds ratio (OR) < 1 is a negative relationship; OR > 1 is a positive relationship.
b Reference

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370

Journal of Perinatal & Neonatal Nursing/OctoberDecember 2009

initial increases in HRs in acutely ill infants.17,30,31 In

this study, there was a relationship between 4 environmental stressors (nursing interventions levels 1, 2,
3, and 4) and increases in RR. Other researchers also
found that the stressful NICU environment can cause
initial increases in RRs in acutely ill infants.17,30,31 There
was a relationship between 2 environmental stressors
(nursing interventions levels 2 and 3) and decreases
in O2 Sat This result is similar to other studies that
found a significant decrease in O2 Sat as due to NICU
environmental stress.9,13,32
Discussion of the research hypothesis 2
Eight stress behaviors, grimace, hand to mouth, holding on, sucking, finger splay, salute, sitting on air,
and yawning,were positively related to environmental
stress. These results are similar to the results of other
researchers who found 4 behavioral responses (finger
splay, salute, sitting on air, and yawning) associated
with an increase in environmental stress.24,33,34
Three self-regulatory behaviors (hand to mouth,
holding on, and sucking) were positively related to the
environmental stress. According to the previous literature review, for preterm infants, these self-regulatory
behaviors are self-comforting and regulating behaviors
in response to environmental stress to regain a state
of neurophysiological subsystems balance. Preterm infants might show some self-regulatory behaviors when
exposed to environmental stress. Neonatal caregivers
should support these behaviors in preterm infants to
help them maintain the neurophysiological subsystems
balance. Research has also found that environmental
stress may cause interruptions in preterm infants balance of muscle tone (P < .05). Other studies found a
similar decrease in tone related to environmental stressors in the NICU.22,26,27

IMPLICATIONS FOR NURSING SCIENCE

AND PRACTICE
This investigation demonstrated observable relationships among environmental stressors, stress physiological signals, and behavioral stress responses.
These study findings are useful to nursing practice.
They demonstrate the importance of recognizing the
preterm infants behavioral responses and physiological stress signals to environmental stressors to allow for
early interventions to reduce the possibility of more serious physiological or pathological change in preterm
infant status.

CONCLUSION
The sources of environmental stress in any modern
NICU are similar; however, what varies between ages
and populations are not the environmental stressors
but are the individual responses to stress.23 Because
the stress affects the as yet immature nervous system
of preterm infants, infant stress responses are different and unique. In addition, the possible impact of repeated stress responses on future neurological development, such as the ability to learn, to speak, or to
move, does not apply to any other population. Therefore, this research has focused on identifying the stress
responses of preterm infants. By closely observing infants biobehavioral stress responses, neonatal nurses
can identify those who are experiencing physiological distress. Once those infants and their biobehavioral
stress responses are identified, measures can be taken
to lessen the effect of environmental stimuli and possibly shorten the length of hospitalization in preterm
infants.

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