JOGNN RESEARCH

Mothers’ Different Styles of

Involvement in Preterm Infant Pain Care
Anna Axelin, Liisa Lehtonen, Tiina Pelander, and Sanna Salanterä

Correspondence
Anna Axelin, RN, MNSc,
Finnish Post-Graduate
School in Nursing Science,
University of Turku,
Department of Nursing
Science, 20014 Turku,
Finland
anna.axelin@utu.fi
Keywords
preterm infant
parent
pain
facilitated tucking by parents
maternal attachment
NICU
stress
ABSTRACT
Objective: To describe and understand how mothers utilize the opportunity to actively participate in their preterm
infants’ pain care using facilitated tucking by parents (FTP).
Design: Descriptive and exploratory study with postintervention interview.
Setting: Finnish level III Neonatal Intensive Care Unit (NICU).
Participants: Twenty-three mothers who had preterm infants born at gestational ages of 32 to 34 weeks.
Methods: The parents (N 5 45) of 29 preterm infants were taught to use FTP. In addition, all nurses in the NICU
(N 5 76) received the same education to support the parents’ use of FTP. After 2 to 4 weeks of FTP use, the mothers
(n 5 23) were interviewed using the Clinical Interview for Parents of High-Risk Infants with additional questions related
to the infants’ pain care. The interviews were analyzed inductively with cross-case analysis and deductively with a
previously developed coding scheme.
Results: Facilitated tucking by parents was perceived positively and was used by all participating mothers. Three
different styles of involvement in preterm infants’ pain care with FTP were identified. They formed a continuum from
external to random and finally to internalized involvement. In external involvement, the pain care with FTP was
triggered by outside factors such as nurses, whereas in random and internalized involvement the motivation emerged
from a parent. Mothers with external involvement thought that any person could apply the FTP. In random involve-
ment, mothers were mainly absent during painful procedures, although they saw themselves as the best caregivers. In
internalized involvement, the responsibility for infant pain care was shared within the family. Mothers’ NICU-related
stress and maternal attachment were associated with this variation.
Conclusion: This study showed that mothers’ are willing to actively participate in their preterm infants’ pain care.
However, the participation is unique according to mother and her experiences before and during NICU admission.
Nurses need to consider these differences in mothers when involving them in preterm infants’ pain care.
JOGNN, 39, 415-424; 2010. DOI: 10.1111/j.1552-6909.2010.01150.x
Accepted March 2010

Anna Axelin, RN, MNSc, is
a doctoral student in the
Finnish Post-Graduate
School in Nursing Science,
Department of Nursing
Science, University of
Turku, Finland.
Liisa Lehtonen, MD, PhD,
is the head of the Division
of Neonatology,
Department of Pediatrics,
Turku University Hospital,
Turku, Finland.
Tiina Pelander, RN, PhD,
University of Turku, Turku,
Finland.
(Continued)
arents have expressed a wish to be more
P involved in their preterm infants’ pain care.
(Franck, Allen, Cox, & Winter, 2005; Franck, Cox,
Allen, & Winter, 2004). They have given several rea-
sons for wanting to participate, including sta¡’s lack
of sensitivity regarding infant pain, the parental pro-
tective role, and the fact that participation in pain
care alleviates their own stress levels (Axelin, Salant-
era, & Lehtonen, 2006; Gale, Franck, Kools, & Lynch,
2004). Rationales for active parental participation
could also be retrieved from research on infants’
needs in relation to pain care. Preterm infants are ex-
posed to a considerable amount of untreated pain
during their stay in the Neonatal Intensive Care Unit
(NICU) (Carbajal et al., 2008). Further, the harmful ef-
fects of pain are still seen in preterm infants’ cognitive
and motor development at age 18 months (Grunau
et al., 2009). Parents can positively a¡ect this nega-
tive course of events as they are able to e¡ectively
alleviate preterm infants’ pain (Axelin, Salantera,
Kirjavainen, & Lehtonen, 2009). In addition, low par-
enting stress in the mother positively modulates the
deleterious e¡ects of pain later in the preterm infant’s
life (Grunau et al.; Tu et al., 2007).
The mother’s readiness for participation in her pre-
term infant’s pain care is inseparable from other
elements of motherhood in the NICU environment.
During pregnancy, maternal attachment to the fetus
increases simultaneously with fetal development.
Ideally, the mother’s physical, biological, cognitive,
and emotional changes during pregnancy enable
her to create an emotionally secure and safe
environment for her baby (Cohen & Slade, 2000).

http://jognn.awhonn.org & 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 415
RESEARCH
Mothers are not actively involved in their preterm infants’
pain care.
Sanna Salanterä, RN, PhD,
is a professor of Clinical
Nursing Science and the
head nurse of the Hospital
District of Southwest
Finland, Department of
Nursing Science, University
of Turku, Finland.
416
Preterm birth poses challenges to mothers due to
the interrupted process of preparation for mother-
hood. Accordingly, the emotional bond between
mother and preterm infant can be un¢nished at the
time of admission to NICU. The mother has to bond
with her sick infant in an unexpected environment
after birth (Aagaard & Hall, 2008). Possible inability
to ful¢ll her parental role in the restrictive intensive
care environment (Miles, Funk, & Kasper, 1991) and
related stress (Singer et al., 1999) impose further
challenges on the mother. Moreover, it is known that
parental distress is positively related to parental
concerns about infant pain (Franck et al., 2005).
Nurses have a unique opportunity to help mothers
experience meaningful motherhood in NICU set-
tings. Being a mother of an infant in the NICU has
been described as a process of growth from out-
sider to engaged parent. During this process,
knowing the infant leads to a greater and infant-
driven involvement in care (Heermann, Wilson, &
Wilhelm, 2005). Nurses can facilitate or hinder this
process by giving the mother opportunities to be
the primary caregiver or by excluding her from the
infant’s care (Wigert, Johansson, Berg, & Hellstrom,
2006). In general, parents are more willing to
take responsibility for infants’ care than nurses and
neonatologists have thought. However, parents
and health care professionals see that parents can
alleviate infants’ pain, although this is not yet prac-
ticed in clinical work (Nyqvist & Engvall, 2009).
Active parental participation in infants’ pain care
presumes open communication and active guid-
ance from NICU sta¡ (Franck et al., 2005; Gale et al.,
2004). One barrier to parents carrying out their pro-
tective role is infants’ regular exposure to pain while
their parents are absent from the NICU (Franck
et al., 2005; Gale et al.). In addition, sta¡ could
improve their approach by giving parents more infor-
mation on means of detecting and alleviating pain
(Franck et al., 2004, 2005). In the presence of infants’
pain, sta¡ should be sensitive to parents’ wishes.
Some parents want to participate as much as possi-
ble, some need encouragement, and some might
wish to withdraw during painful procedures or pain
(Franck et al., 2005). However, we lack knowledge
of the factors that could explain parents’ di¡erent
preferences for participation.
Studying the process of involving parents actively in
preterm infants’ pain care may provide us a deeper
JOGNN, 39, 415-424; 2010. DOI: 10.1111/j.1552-6909.2010.01150.x
Mothers’ Involvement in Preterm Infant Pain Care
understanding of the matter. Facilitated tucking by
parents (FTP) is one option to enable active paren-
tal participation in pain care. In FTP, a parent holds
the infant in a side-lying, fetal-type position, o¡er-
ing support and skin-to-skin contact with her or his
hands during a stressful or painful situation. It alle-
viates preterm infants’ pain, is safe in terms of short-
term adverse e¡ects (Axelin, Kirjavainen, Salantera,
& Lehtonen, 2009), and does not have long-term
e¡ects on preterm infants’ sleep like opioids (Axelin
et al., 2009). Parents have preferred participation
with FTP compared to passive observation in pre-
term infants’ pain management. Some of these
parents felt uncomfortable in these situations; how-
ever, despite their discomfort they wanted to
participate and help their infants during pain. Par-
ents felt that they had an important role in their
infants’ care (Axelin et al., 2006). Apart from its pre-
liminary acceptance by parents, parental ways of
applying FTP are still mainly unknown.
Parents’ expectations of preterm infants’ pain care
could be taken into account more carefully and un-
derstood in depth. In this study, we increased
parents’ participation in preterm infants’ pain care
by teaching them to use FTP. The aim of our study
was to describe and understand how mothers uti-
lize the opportunity to actively participate in their
preterm infants’ pain care with FTP.
Method
Setting
The NICU in which this study was conducted has a
family-centered care philosophy that aims at pa-
rental competence in infant care prior to discharge.
Parents are encouraged to participate actively
in their infants’ care immediately after birth. The
responsibility for care is changed progressively
from nurses to parents during the hospital stay. The
nursing interventions that promote this transition
include, for example, free visiting for parents, regu-
lar kangaroo care, and the primary nursing care
model. However, before 2008 it was not common
practice for parents to participate in their infants’
pain care. To understand whether parents are
willing to participate in this area of care, FTP was
introduced for parents and nurses. The implications
of this new practice were evaluated from the moth-
ers’ point of view.
Sampling and Participants
Mothers whose preterm infants were born between
32 and 34 weeks of gestation and were cared for in
the NICU were eligible to participate in the study.
Exclusion criteria were as follows: mother’s in-
http://jognn.awhonn.org
Axelin, A., Lehtonen, L., Pelander, T. and Salanterä, S.
Figure 1. In Facilitated Tucking by Parents, parent holds the infant in the side-lying, flexed fetal-type position.
ability to participate in infant care on the third
postpartum day, mother’s native language being
other than Finnish or Swedish, infant’s planned
hospital transfer before discharge, and infant’s life-
threatening illness. Twenty-nine families were ap-
proached for participation, of whom six refused.
Mentioned reasons for refusal were the stressful sit-
uation for the family and unwillingness to be
recorded by video during the interview. Informed
written consent was obtained from both parents of
each infant. After providing written and verbal infor-
mation on the second or third postpartum day, the
parents were given 1 day to consider their participa-
tion in the study. The study protocol was approved
by the Joint Commission on Ethics of the Hospital
District of Southwest Finland and Turku University
Hospital.
Twenty-three mothers (N 5 23) participated in the
study. Six of them had twins. Mothers’ mean age was
31 years, and the length of their education after ele-
mentary school was a mean of 6 years. Only ¢ve of
them had previous child or children. Every mother
visited and participated in her preterm infants care
at least twice a day. Preterm infants of these mothers
did not have complications but were generally
healthy. Their mean gestational age was 32 67 weeks
and the mean birth weight was 1 960 g. Only 6 out of
29 infants were on the ventilator for a mean of 2 days.
The mean number of painful procedures was three
per day per infant during the ¢rst 2 weeks of life.
Intervention
The study intervention included written and verbal
information for both parents regarding how to alle-
viate infants’ pain with FTP. In FTP, a parent holds
JOGNN 2010; Vol. 39, Issue 4
RESEARCH
the infant in a side-lying, fetal-type position, o¡er-
ing support and skin-to-skin contact with her or his
hands during a stressful or painful situation (Figure
1). The FTP procedure was also practiced with the
parents during the third postpartum day. Special at-
tention was paid to the ¢rmness of the holding and
having warm hands during the FTP. It was hoped
that the parents would use FTP every time when
the infant was in pain or stress according to their
own opinions. Every nurse in the NICU (N 5 76) re-
ceived the same education personally from the
main researcher before the beginning of the study.
New nurses were educated to use FTP during their
orientation period. Parents were encouraged to
consult the nurses about FTP as needed. Within a
few days, the researcher ensured that the parents
had understood the procedure.
Interviews of Mothers and Data Collection
The Clinical Interview for Parents of High-Risk Infants
(CLIP) (Meyer, Zeanah, Boukydis, & Lester,1993) was
used to understand the mothers’ experiences of in-
fant pain care in relation to a broader context. The
CLIP is a semistructured clinical interview that as-
sesses early parental adaptation to parenthood and
to the NICU environment. It is designed to elicit the
parent’s story of the pregnancy, birth, relationship
with the infant, feelings as a parent, reactions to the
NICU environment and sta¡, and expectations about
the future. Additional questions related to infant pain
care and FTP were integrated in the CLIP. In these
questions, the mother was asked to describe a situ-
ation when her infant was in pain and to specify her
feelings and actions in relation to it. Mothers were
also asked about their experiences of using FTP
and its feasibility.
417
RESEARCH
Mothers were interviewed just before their infants’
discharge after they had used FTP for 2 to 4 weeks.
The interviews were conducted by one researcher
(AA) in an undisturbed room during a 1-year period
in 2008 to 2009. All the interviews were videotaped.
The interview technique was practiced with three
mothers. These pilot interviews were assessed and
discussed with a psychologist experienced in the
use of CLIP. After the discussions, some minor revi-
sions such as minimizing prompting were made to
the interview technique. Interviews lasted from half-
hour to 11/2 hours depending on the richness of the
mother’s expression. After 19 interviews, data satu-
ration was obvious because no clearly new issues
related to FTP or infant pain care were identi¢ed.
The last four interviews were conducted to ensure
saturation.
Analysis
The mothers’ interviews were analyzed in three
phases: inductively with cross-case analysis (Miles
& Huberman, 1994), deductively with a coding
scheme by Keren, Feldman, Eidelman, Sirota, and
Lester (2003), and by drawing the two earlier
analyses together.
In the ¢rst phase, the inductive cross-case analysis
started by transcribing verbatim the sections of
mothers’ interviews concerning the use of FTP and
infants’ pain care. Then cross-case analysis was
used for a descriptive approach (what and how)
and an explanatory approach (why). The descrip-
tive approach showed that all the mothers
regarded FTP as a positive tool and had used it.
The explanatory approach revealed that the moth-
ers’ uses were based on di¡erent reasons and had
di¡erent meanings for them. Therefore it was de-
cided to create a typology from the mothers’
di¡erent ways of being involved in infants’ pain care
with FTP. The themes that cut across the interviews
such as primary caregiver in pain management, the
e⁄cacy of FTP, and nurses’ role in FTP usage were
recognized by a variable-oriented strategy. The de-
scriptions of themes were based on patterns that
appeared in the data (Patton, 1990). Using the con-
ceptually ordered display, we analyzed which
interviews shared similar characteristics and how
the content of themes di¡ered across them. The
mothers’ experiences concerning infant pain care
were organized according to the use of FTP and
their explanations for its use. The result of the ¢rst
phase was a typology of mothers’ three di¡erent
styles of involvement in preterm infants’ pain care
with FTP. To con¢rm the credibility of cross-case
analysis, the data of seven mothers were given to
another researcher (SS), who was able to identify
418 JOGNN, 39, 415-424; 2010. DOI: 10.1111/j.1552-6909.2010.01150.x
Mothers’ Involvement in Preterm Infant Pain Care
the involvement styles of the mothers. In addition,
all of the data and the cross-case analysis were in-
troduced to this researcher and she was able to
con¢rm the analysis with some suggestions. The ¢-
nal analysis is a consensus of the views of these two
researchers (AA & SS).
In the second phase, with deductive coding, the
data were viewed again from the perspective of sin-
gle cases. One researcher (AA) coded the separate
CLIP interviews from video recordings according to
the coding scheme developed by Keren et al.
(2003). The coding scheme included 20 items: (1)
Fear of loss of the infant, (2) ¢rst reaction to preg-
nancy, (3) was the pregnancy planed, (4) the
course of pregnancy, (5) the timing of ‘‘pregnancy
feeling real,’’ (6) readiness for delivery, (7) fear of
loss of the infant or herself during labor, (8) ¢rst
feelings toward the baby, (9) present feelings to-
ward the baby, (10) the feeling of mutual
recognition, (11) parental self-image, (12) reaction
to sta¡, (13) reaction to NICU setting, (14) reaction
to lack of control over baby, (15) support system,
(16) foreseen future for the baby, (17) readiness for
discharge, and mother’s general characteristics
during interview; (18) a¡ect, (19) organization, and
(20) the richness of the content. Every item had from
two to four options according to which the mother’s
story could be coded. The coding manual was
obtained from Dr. Keren. Double-coding was con-
ducted on seven interviews (TP), and the interrater
reliability between coders on all items was 0.79
(kappa coe⁄cient).
In the third phase, the two earlier analyses were
drawn together. The typology of the mothers’ three
di¡erent styles of involvement formed in the ¢rst
phase, was used to examine whether some of the
20 deductively coded CLIP items were typical for
the di¡erent involvement styles.To understand possi-
ble patterns of CLIP items in relation to typology, a
typology based case-ordered descriptive matrix
was generated on CLIP items (Miles & Huberman,
1994). In this matrix, on the left was the mother who
represented the strongest characteristics of external-
ized involvement, and on the other end was a mother
with the strongest elements of the internalized in-
volvement. The following 6 out of 20 CLIP items
varied systematically across the three involvement
styles: (1) the timing of ‘‘pregnancy feeling real,’’ (2)
¢rst feelings toward the baby, (3) present feelings to-
ward the baby, (4) the feeling of mutual recognition,
(5) reaction to sta¡, and (6) NICU setting.These items
were used to make interpretations about the nature
of motherhood and adaptation to the NICU environ-
ment in relation to involvement in pain care with FTP.
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Axelin, A., Lehtonen, L., Pelander, T. and Salanterä, S. RESEARCH

In our typology, maternal attachment was apparent
in all styles of involvement but varied between the
di¡erent styles. Maternal attachment was de¢ned
as mother’s bond toward the infant consisting of be-
havioral and emotional dimensions. The behavioral
dimension means providing protection and care for
the infant (George & Solomon, 2008). The emo-
tional dimension, on the other hand, consists of
mother’s special a¡ectionate bond with the infant
and having the infant in her mind (Stern,1998).
Findings
Mothers viewed FTP positively, and it was used by
all participating mothers. Overall, mothers did not
express any negative issues about FTP. However,
they observed that nurses could use the method
more actively. Mothers were surprised that not all
nurses used and o¡ered FTP systematically for
parents to use.
We were able to identify the three di¡erent styles of
involvement in preterm infants’ pain care with FTP.
This typology formed a continuum from external to
random and ¢nally to internalized involvement.
Variation between the di¡erent involvement styles
seemed to be related to maternal attachment
and the level of the mother’s NICU-related stress. In
external involvement, mothers had a strong behav-
ioral dimension in their actions in relation to their
infants, whereas in random involvement the emo-
tional dimension was emphasized more. In inter-
nalized involvement both these dimensions were

External Involvement Random Involvement Internalized Involvement

Pain care Pain care Pain care

1. Mechanical, frequent use of 1. Inconsistent presence during 1. Frequent use of FTP,

FTP originated from outside painful procedures motivation emerged from
factors being a parent
2. Person applying tucking did 2. Mother was the best person 2. Parents were the best persons
not make any difference to to do tucking to do tucking
infant
3. Uncertainty about the 3. Unreserved trust in FTP 3. Reflective view of the pros
effectiveness of FTP and cons of FTP
4. Nurses’ support increased the 4. Nurses’ support needed for 4. Nurses were not needed for
use of FTP the use of FTP FTP use or they hindered it
5. Emotions in response to 5. Infant’s pain was a source of 5. Infant’s pain was a source of
infant’s pain neutral or stress based on mother’s own stress based on empathy for
unclear emotions infant

Motherhood in NICU Motherhood in NICU Motherhood in NICU

1. Pregnancy became real 1. Pregnancy became real 1. Pregnancy became real

during 2nd trimester mainly during 2nd trimester during 1st trimester
2. Negative or neutral first 2. Positive first feelings toward 2. Positive first feelings toward
feelings toward baby baby baby
3. Neutral or positive present 3. Positive present feelings 3. Positive present feelings
feelings toward baby toward baby toward baby
4. Baby did not know mother 4. Baby might or did know 4. Baby knew mother
mother
5. Total confidence in staff 5. Partially confident in staff 5. Totally or partially confident
6. NICU was a source of slight 6. NICU was a stressful in staff
stress environment 6. NICU was a source of slight
stress

Behavioral dimension Emotional dimension Behavioral and emotional

emphasized in relation to emphasized in relation to dimensions in balance
emotional dimension behavioral dimension

Increasing maternal attachment

Figure 2. Typology of mothers’ three different ways of being involved in infant pain care with facilitated tucking
by parents.

JOGNN 2010; Vol. 39, Issue 4 419

RESEARCH
clearly recognizable (Figure 2). One mother implied
that it may be possible to move along on this typol-
ogy continuum with the help of FTP. In her case, FTP
seemed to facilitate her bonding with her infant. The
mother had taken care of her infant’s physical
needs immediately after birth. The use of FTP made
her recognize that she was able to help her infant
during painful procedures. Participation also made
her feel better and increased maternal attachment
as she felt that she and her infant also needed each
other emotionally.
External Involvement
These mothers (n 5 6) used FTP mechanically
based on the fact that it had been taught to them
and recommended for use (Figure 2). They did not
consider themselves unique in being able to allevi-
ate pain with FTP but thought that any person
could do it as well. The rationale for this was that
the infant did not yet recognize his or her mother.
These mothers used FTP quite often and found it
especially useful for calming their infants. They were
not always sure whether FTP had helped their in-
fants during painful procedures. On the other
hand, some of these mothers saw that FTP was
helpful and helped their infants. Mothers gave the
impression that they did not totally trust their own
judgment regarding their infants’ pain experiences.
Nurses’ support and active role in involving mothers
made them use FTP increasingly as it reinforced
their trust in its e¡ectiveness.
These mothers’ emotions in response to their infants’
pain were neutral or they were unable to describe
their feelings. They stated that the pain was obvi-
ously not nice but was just a normal part of infant
care in NICU. The explanation for this was the moth-
ers’ di⁄culty in empathizing with infants’ pain from
the baby’s point of view. These mothers were com-
fortable with participating in the pain care but
rarely took the initiative in that direction themselves.
When infants’ pain intensity grew, they sometimes
withdrew from pain management. The rationale for
this was that in these situations, mothers’ own emo-
tions exceeded their infants’ needs. For example, it
was unpleasant for mothers to see needles or
blood. These mothers had the impression that in-
fants’ pain exposure had been low or they had an
unclear picture of it as pain did not play a signi¢cant
role for them during their infants’ NICU stays.
The maternal attachment of these mothers toward
their infants was weak in the NICU. Their pregnan-
cies had become real for them quite late during
their second trimesters. These mothers lacked feel-
420 JOGNN, 39, 415-424; 2010. DOI: 10.1111/j.1552-6909.2010.01150.x
Mothers’ Involvement in Preterm Infant Pain Care
ings of recognition in relation to their infants during
these ¢rst weeks in NICU. Their infants were still dis-
tant to them. Just after delivery, the feeling that the
infant was a stranger was strong, but connected-
ness grew during the hospital stay; however, the
positive feeling was often still lacking at the time of
discharge. One mother said,
I think that it [FTP] clearly helps, but I’m not
able to certainly say; on the other hand, I feel
that it can be just anyone. It doesn’t neces-
sarily need to be personally me who is
present during tucking. But it [FTP] immedi-
ately calms [the infant] though; I think it
clearly helps and I have used it when the
baby is in my arms and starts to whine.
Random Involvement
These mothers (n 5 7) used FTP quite often when
calming their infants, but rarely in pain manage-
ment (Figure 2). The participation in pain man-
agement was minimal. Possible explanations for
absence could be that infant pain and the NICU
environment were stressful for these mothers: ‘‘This
place (NICU) was a shock to me. It was terrible for
me to see him in the middle of all those tubes. I cried
desperately for help. Was there something that I had
done during the pregnancy to have caused this?’’
However, these mothers thought that they were the
best persons to do FTP as their infants needed their
mothers when in pain. These mothers had an unre-
served trust in the e¡ectiveness of FTP. According
to them, FTP alleviated pain and made their infants
feel more secure. This uncritical view could be
based on the rare use of FTP during painful proce-
dures and a strong feeling that the mother can help
her infant in these situations. These mothers
needed support in FTP use from nurses. Positive
experiences and feedback from using FTP encour-
aged active participation and strengthened these
mothers’ parental roles.
These mothers’ emotions regarding their infants’
pain were stressful: ‘‘The painful procedures of the
babies have been the hardest thing for me at the
hospital,’’ and ‘‘I cried during the nasogastric tube
insertion; my baby did not. It is just that she is so
small and they put it in and I think that it feels horri-
ble. But she did not react to it at all. Well, maybe she
did not like it, but she did not even cry or scream.’’
However, at the same time, from the infants’ point of
view pain was described as being a short-term, un-
avoidable experience and therefore tolerable.
Descriptions of infants’ reactions to pain were more
detailed than those given by mothers with external
http://jognn.awhonn.org
Axelin, A., Lehtonen, L., Pelander, T. and Salanterä, S.
involvement but were mainly based on the mothers’
own experiences. They were also able to empathize
with their infants’ pain. They stated, for example, that
infants’ lack of understanding about pain made it
even worse for the infants. In the mothers’ thoughts,
participation was preferred to being absent during
painful procedures because mothers found that
their presence helped or had potential to help their
infants. These mothers had the impression that in-
fant pain exposure had been low during their
absence, although the exposure did not di¡er from
the other infants in this study. These mothers had
more hopes and imagination concerning infant
pain than actual facts and concrete actions to aid
their infants.
Maternal attachment toward the infant was growing
in the NICU. Pregnancy, however, had become real
at a late stage for many of the mothers, and they
found the NICU settings and sta¡ caused them to
feel stressed. However, these mothers were quite
certain that their own infants recognized them. They
had positive feelings toward their babies immedi-
ately after birth as well as at the time of discharge.
Internalized Involvement
Based on descriptions by mothers (n 5 10) with in-
ternalized involvement, both parents used FTP
often and found it e¡ective for infant pain relief and
restlessness (Figure 2). They stated that pain allevi-
ation with FTP made their infants feel more secure
and provided positive long-term e¡ects on infant
development by o¡ering basic security for develop-
ment. Mothers recognized that FTP helped them by
giving an opportunity to bond with their infants and
by supporting parenting in the NICU. In addition,
mothers experienced that the e¡ectiveness of FTP
was individual according to the infant. For example,
they recognized that during the insertion of naso-
gastric tube FTP helped one baby but did not
make any di¡erence to another. These mothers
thought that parents were the best persons to alle-
viate infant pain. The rationale for this was that the
infant needed a parent during painful experiences
and mothers were able to share this responsibility
with fathers. These mothers wanted to protect their
infants from pain and did not need nurses to en-
courage them. They expressed that the nurses
could have used FTP more actively and were some-
times even a barrier to their involvement in infant
pain care with FTP.
These mothers were able to empathize with and ra-
tionalize their infants’ pain. They could describe
their infants’ reactions to it in detail. Pain was viewed
as a short-term, unpleasant experience for the
JOGNN 2010; Vol. 39, Issue 4
RESEARCH
Participation in preterm infants’ pain care was a meaningful
task for mothers and was unique for each mother and her
experiences before and during NICU admission.
infant. Descriptions of infant pain were based on
their own observations of their infants. Participation
was the best option for these mothers, and they
tried to do it as often as possible. During painful pro-
cedures, the mothers’ focus was on their infants’
feelings. For example, although their infants’ pain
was not a pleasant thing to see, these mothers felt
that they had an obligation to help their infants.
The maternal attachment of these mothers toward
their infants was strong. Pregnancy had become
real to these mothers during the ¢rst trimester.
These mothers were certain that their infants rec-
ognized them. Mothers had positive feelings toward
their babies immediately after birth and at the time
of discharge. Fathers also had a clear place in these
mothers’ stories and were seen as important per-
sons for the children:
I feel it is important that I’m able to comfort
my child with my closeness. The closeness
strengthens my motherhood. Unlike when I
have to be separated from my child, I’m able
to really be with my child in these situations. It
really helps, I feel.
Discussion
Our study gives support to earlier reports that sug-
gest that parents want to get involved in preterm
infants’ pain care (Axelin et al., 2006; Franck et al.,
2005; Gale et al., 2004). The active participation
with FTP was a positive experience for all mothers.
The possibility of alleviating infant pain and stress
was a meaningful part of parenting for mothers in
the NICU environment. However, involvement in pain
care di¡ered according to the mother, and mothers
expected appropriate support from nurses.
Our typology concerning the mothers’ di¡erent
styles of involvement in preterm infants’ pain care
with FTP re£ects the process of growth to mother-
hood in the NICU environment (Heermann et al.,
2005). In our study, the mothers were in di¡erent
phases of this process as not all mothers had
reached emotional and behavioral competence in
motherhood at the time of discharge. Readiness for
motherhood has been linked to more optimal
mother/infant interaction in the NICU than interaction
421
RESEARCH
by mothers with maternal rejection (Keren et al.,
2003). This was also seen in our study as mothers
with internalized involvement seem to handle pain
care optimally, whereas mothers with random in-
volvement compromised their involvement possibly
due to NICU-related stress. The mothers with exter-
nal involvement had some elements of maternal
rejection, although they participated actively in
pain care. The di¡erences in involvement in pain
care can be explained not only by the NICU envi-
ronment but also by the mother’s early adaptation
to parenthood during pregnancy. This understand-
ing of the role of maternal attachment in relation to
infant pain care gives more depth to our under-
standing of mothers’ experiences (Franck et al.,
2004, 2005; Gale et al., 2004).
Our typology suggests that involving the mother in
pain care is just the ¢rst important step. The second
phase could be to teach her to recognize infant
cues in these situations. After facilitating interaction
by giving the mother the tools to understand the in-
fant, the ¢nal step may be to support synchrony in
mother/infant interaction during stressful situations
(Melnyk et al., 2006). In di¡erent involvement styles,
this process of participation in pain care should be
adapted according to the mother’s situation.
Mothers with an external involvement style may need
reinforcement in all the above-mentioned phases
when participating in infant pain care. Similar group
of parents needing reinforcement have been de-
scribed before (Franck et al., 2005). These mothers’
maternal attachment was un¢nished (Cohen &
Slade, 2000), and their infants did not yet feel like
their own children (Bialoskurski, Cox, & Hayes,
1999). During painful procedures, nurses may need
to encourage mothers to actively participate in
pain management and show them how to use FTP.
Before and during painful procedures, nurses can
interpret the infant’s cues together with the mother
as she may have di⁄culty in recognizing them.
In addition to participation in pain care, a closer
relationship with the infant can be enhanced
by nursing interventions such as kangaroo care
(Feldman, Eidelman, Sirota, & Weller, 2002) and de-
velopmental care (Als et al., 2003). Encouragement
and positive feedback could help the mother to un-
derstand that her presence bene¢ts the child. When
the mother is willing to participate in pain care, she
protects her infant from the harmful e¡ects of pain.
This understanding of her important protective role
can improve maternal attachment as well.
Mothers with a random involvement style could
bene¢t especially from the reduction of NICU-
422 JOGNN, 39, 415-424; 2010. DOI: 10.1111/j.1552-6909.2010.01150.x
Mothers’ Involvement in Preterm Infant Pain Care
related stress. The psychological stress related to
preterm birth interferes with attachment (Kaaresen,
Ronning, Ulvund, & Dahl, 2006), maternal sensitivity
to infant cues (Zelkowitz, Bardin, & Papageorgiou,
2007), and mother/infant interaction (Muller-Nix
et al., 2004). In other words, the process required
for internalized involvement in infant pain care is
threatened when the mother is under stress. After
becoming comfortable in this new environment,
the mother might be able to participate more often
in the infant’s pain care. However, it may be better
to begin participation in infant care in less intense
situations such as holding, because infant pain
can still be too much for these mothers (Franck
et al., 2005). Mothers’ withdrawal from pain care
should be accepted to help them to avoid feelings
of guilt (Franck et al., 2005). Learning to interpret in-
fant cues and participation in pain care, however,
could reduce mothers’ stress related to infants’ pain
(Axelin et al., 2006). Active support by nurses is a
necessity for these mothers to be able to participate
in infant pain care. A mother’s strong emotional
bond to the infant is an advantage that nurses
should be able to use for the infant’s bene¢t.
Mothers with an internal involvement style are at risk
to be left alone in NICU as they seem to handle
motherhood well. Infant pain and NICU admission
are likely to be stressful to these mothers as well
(Aagaard & Hall, 2008). Strong maternal attach-
ment helps them to adapt quicker to this new
environment for their infants’ bene¢t (Heermann
et al., 2005). Despite knowing their infants best,
these mothers cannot intuitively know good prac-
tices in the NICU. Providing knowledge of good
pain care practices is therefore the responsibility of
nurses (Franck et al., 2005). Besides o¡ering infor-
mation, nurses need to be sensitive to parents’
experiences and opinions and allow them to be pri-
mary caregivers in pain care. There is the possibility
of a mismatch between parents’ and sta¡’s percep-
tions of infants’ pain (Gale et al., 2004). In our study,
this was seen in the mothers’ comments that nurses
can be a barrier to their use of FTP. Their comments
re£ect the dangers of empowering parents before
family-driven values are established among sta¡. It
is important to change the unit culture concomi-
tantly with supporting parents’ empowerment to
avoid con£ict.
The use of FTP has the potential to serve as an indi-
cator of mother’s ability to involve herself in pain
care of her infant. In addition, it can be considered
as an intervention tool for nurses to actively involve
mothers in preterm infant’s pain care in NICU. Moth-
ers’ involvement in pain care with FTP re£ects the
http://jognn.awhonn.org
Axelin, A., Lehtonen, L., Pelander, T. and Salanterä, S.
development of maternal attachment and may give
nurses an idea of how to support mothers. Nurses
have an excellent opportunity to synchronize the
mother’s behavior with the infant, as active support
by NICU sta¡ may help the mother to become closer
and more connected to her infant than she might
have been with a healthy infant in a home environ-
ment (Brisch et al., 2005). The use of FTP with
nurses’ support may also work as an intervention
that increases maternal attachment. This was seen
with the mother who was able to move in our typol-
ogy toward comprehensive involvement in pain
care with FTP.
In the current study, FTP worked only as an inducer
for mothers’ participation in preterm infants’ pain
care and was able to clarify mothers’ experiences
related to this involvement. However, implementing
interventions is demanding, and e¡ort is needed
to embed them in to clinical practice. This was seen
in our study when mothers commented on the
variation in the use of FTP by nurses. The next
step could be to develop tools for identifying di¡er-
ent involvement styles and speci¢c interventions
for mothers. In addition, future research should
pay attention to the fathers’ role in preterm infants’
pain care.
The trustworthiness of our study can be evaluated
in terms of credibility, dependability, and transfer-
ability (Graneheim & Lundman, 2004). The
credibility of our results is supported by our rich
data that can connect mothers’ participation in
infant pain care with the wider context of mother-
hood in the NICU. However, the decision to use the
CLIP interview as a framework could have limited
opportunities for new issues related to mothers’
participation to be brought up. The cross-case ap-
proach gave us a more general understanding of
generic phenomena that occurred across the
cases. Consequently, the substantial synthesis of
the rich data may make our analyses complicated
to follow. The use of parallel coders in di¡erent
phases of the analysis endeavors to lessen this lim-
itation.The dependability of our results was at risk in
the multiphased analyses. However, the process
between the data collection and analysis was
short. The ¢rst general view of the data was not
taken until 19 interviews had been conducted
so that the focus of observation did not narrow
too early. The transferability of our results is dimin-
ished by the fact that our sample represents
a White, well-educated population with average
incomes and relatively healthy preterm infants. In
addition, the caring culture in the NICU was family
centered.
JOGNN 2010; Vol. 39, Issue 4
RESEARCH
Nurses should consider differences in mothers when
involving them in preterm infants’ pain care.
In conclusion this study showed that mothers’ are
willing to actively participate in their preterm infants’
pain care. However, the participation is unique ac-
cording to mother and her experiences before and
during NICU admission. Nurses need to consider
these di¡erences in mothers when involving them
in preterm infants’ pain care. The future research
should pay attention to the fathers’ role in preterm
infants’ pain care.
Acknowledgments
Funded by Turku University Hospital Research
Foundation.
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