The PI scheduled an interview session with each participant at a time convenient to the father. Six interviews were conducted in a private room near the NICU. One interview was conducted outside the hospital secondary to the unexpected discharge of the newborn. The interview room was standardized with a tissue box, bottled water, 2 digital recorders, and a note pad and pen on the table. After greeting the father and obtaining informed consent, the father was asked to complete a demographic form. The session was structured using an interview guide designed for the purposes of this study. All recorded interviews were started with the question, “Please tell me about the birth of your baby and how you felt when you were told he/she needed to be admitted to the NICU.”
Field notes were also used to allow the researcher to document observations to enhance the transcript. Observations such as expressions, changes in position, unease, or even how the researcher felt at that moment were captured with field notes to provide validation or emphasis on emerging themes during data analysis.21 Upon completion of the taped interview, the researcher thanked the participant for their time and gave each a thank-you card containing a $20 gift card.
The Gadamerian Hermeneutic method guided systematic interpretation of the data. The focus of this method is to delineate the meaning of the experience. It is important to note that meaning was not about the interpretation by the researcher, but more about meaning within the text of the experience. Using Gadamerian Hermeneutics, the researcher was enmeshed in the text to come to know and understand meaning of the message conveyed. To reach this level of understanding, the researcher engaged the text in an open and ongoing dialogue examining relationships between the parts and the whole of the text.22 , 23 This process involved iterative cycles of reading, listening, and writing. Using this circular approach, the Hermeneutical Circle, the researcher returned to the data multiple times to seek vivid meaning from the text.
Rigor and Trustworthiness
Data triangulation was used in the analysis phase of the study to evaluate trustworthiness and rigor. Triangulation was completed by using both field notes and the transcripts to interpret the data collected during the interviews. Following analysis of the sixth interview, it was determined a seventh interview should be scheduled to validate themes emerging from the coding process. Finally, to maintain trustworthiness and integrity of the study, “member checking” by the participant was used to verify the transcript was correct.24
The data obtained from interviews with 7 fathers yielded 4 themes: looking in, persevering, holding, and finding my way. In addition, 15 subthemes were uncovered. Figure 1 provides a visual representation of these themes and subthemes.
Theme 1: Looking in
The first theme to emerge centered on the delivery and initial NICU admission, as the fathers were becoming aware of the new world they were being forced into. When asked about the birth of their infant, 5 of 7 fathers began with the delivery itself and the traumatic experience of a preterm delivery and subsequent NICU admission. Two fathers, however, began describing the difficulty with conception, preterm complications, and then described the delivery and NICU admission.
“You Go Home With Nothing”
Many described feeling disappointed in leaving the infant at the hospital as though “you go home with nothing.” One father summed it up, “... nobody wants to go home and leave their kid in the hospital. It's just not supposed to be that way.” Interestingly, many fathers were primarily concerned with their wives' distress at going home without the infant. One father explained how difficult it is to “leave them here at night ... and go home.” Another father worried about leaving the infant at the hospital alone; “I ... feel bad leaving Ava here by herself. She's kind of here by herself now, you know. So, I mean, she probably doesn't know it, but it makes you feel bad for her that she's here alone.”
All fathers reported going back to work and returning to the schedule they were used to prior to the birth. The push and pull between maintaining the home, working, and having a presence in the hospital added to the stress of the NICU experience. Others also reported running the household was a limitation to visitation as well, stating, “We still got a home to run.” Conflicting priorities emphasized the unique experience of fathering in the NICU. As one father stated, “It's not ... it's not really the same as being at home”
A Different World
The NICU environment was truly a new world for each father. Comments such as “I'm in new territory ... I don't feel comfortable” and “we did not have a clue (about the NICU)” reveal the uncertainty of being in this environment. One father stated, “You know, you think, you see this stuff on TV ... but then the time comes and it is nothing like what you expected.” Another stated it was “pretty emotional ... didn't know what to expect when we walked in ... hearing monitors go off, looking around trying to figure out what everything is.” Others described seeing the infant in the Isolette for the first time, “Seeing him in the plastic encasing was really rough.” Seeing the tubes and lines and monitors and instantly wanting to know what everything was and making decisions about care was overwhelming for fathers. One father summed it up, “Going to the NICU is not normal. It's not normal, but it became normal to us.”
Navigating This Foreign Land
Navigating the NICU is not easy, but fathers focused on becoming more knowledgeable to navigate as successfully as possible. Acceptance began when fathers realized, “We can't monitor them the way they can here ... we can't provide certain things that they need here ... there's nothing we can do from home for the NICU.” They wanted to know more about the NICU, the technology, and how they could help care for their infant. Becoming knowledgeable meant learning new terminology that became well used in their vocabulary, such as “touch me not,” “bradys,” and names of the equipment used. New terminology in the NICU is a whole new language for parents, but fathers indicated that they learned the language quickly. The fathers also described learning about how to read the monitors and what numbers mean. Finally, fathers acknowledged the importance of knowing blood gas results, daily weight, and feeding amounts. Tracking data gave fathers a concrete focus. It also made them more at ease with the situation itself, “Anything that deals with you or connected or about you, I'm there ... I understand it.”
Throughout the NICU experience, parents must trust the care of their infant to someone they do not know. One father explained, “I put everything in God's hands that way I kept a positive mindset.” In any intensive care situation, family members are compelled to have faith in the strangers caring for their infant. “We had to step aside and trust ... the medical staff here to complete the task.” Another father described the experience in this way: “I had like ... like a lot of faith in the staff there that they knew what they were doing. You just have to accept the expertise of others.”
But trusting strangers was not without its fair share of anxiety. “It would worry you to death because they might get a new nurse that's never had them before, and this nurse over here knows what these babies have been doing so they, you know, kind of seen that it was normal.” Anxiety emerging from this forced trust was best described by one father's worry over the appropriateness of care given to his infant: “I'm sure if there's like a body that sets a guideline, and I'm just hoping that this staff here, uh, like adheres to such guidelines.”
A Woman's World
Another difficulty, many fathers experienced in learning to navigate the NICU, was the focus on the mother of the infant. One father described his role as the “assistant” to the mother. She predominately cares for things, while he is available to assist as necessary. Another stated, “They're just moms, you know, they know things that you don't know.” As the backbone of the family, the fathers in the study described the importance of making sure the mother of the infant got to do most of the care and hold the infant or infants most often. One father described how it was difficult for his wife when he visited alone and was allowed to help with a bath for the first time, “She got upset with me because I was the one to give the boys their first bath.” In recognizing differences between mothers and fathers, one father acknowledged, “It became more important for her to go to the ... to the hospital, as needed, when she started to breastfeed I really wanted her to have a closer connection with my son than I did. Like, I feel like the role of a father is different, and it's a little bit cultural.”
Theme 2: Persevering
All of the fathers in the study described the NICU experience as an emotional roller coaster ride. Fathers indicated that, in the NICU, you never know what to expect with each new day. The rollercoaster experience extracted an emotional toll on the family that could “strengthen or destroy a family.” Each father in this study found his role in supporting the family to persevere, or move forward by focusing on 1 day at a time and by resuming as much of “normal” as possible. In this way, fathers described themselves as the “backbone” of the family, taking care of the mother of the infant, other children, and working.
Fathers felt as though it was their job to stay strong throughout the NICU journey. One father stated, “Of course I let my wife hold first and every time ... because she was having quite a hard time dealing with everything ... I was just trying to keep a positive attitude ... be the backbone of the family.” Others simply stated, “I've got to be strong for her...” and “I was trying to stay strong and not cry.” Although the birth of a premature infant is difficult for the entire family, the fathers in this study reported the need to stay strong for everyone and handle everything themselves. One father summarized staying strong as God giving him “big shoulders to carry everyone else.” Although they all remained strong for everyone else, there were still moments that they were unable to be strong for anyone, even themselves. Even when they did break down, it was only for a moment and then the need to be strong for everyone came about once again. One father summed it up, “I was trying to stay strong and not cry, but that was the point where I just broke down ... just have to deal with that.”
Doing for in caring for everyone and everything constituted the main job for these men. Fathers purported their responsibilities related to returning to work while caring for the mother, other children, the home, and anything else that needed to be done. Fathers felt it was their role to assume such work so that the mother could focus on caring for herself and the infant or infants. A common phrase was, “I'll handle it.” Taking care of, protecting, and providing for the mother of the infant became his main job throughout the NICU journey. One father described putting everyone else's needs above his own throughout this time and felt as though he was constantly playing “Russian Roulette in a sense.” Another father summed it up in discussing the need to do for his wife, “Mom was dealing with something. Mom was the weak link. She's not ... as strong as she used to be. She's more damaged than I am.” Anything he could do for her would help her cope and in turn help their relationship. But, fathers also wanted to do things for their infants. One expressed this desire as, “You wish you could take her pain away but you can't. Like, I try to like, “Can I... Can they poke me? Don't poke her, like poke me ...”
While work was beneficial and a welcome distraction, it could at times cause added stress to the current situation. All fathers in this study felt pulled to go back to work. “I have to keep working, you know, I'm the breadwinner ... it's important that I keep working.” One father expressed the need to return to a new job while friends told him, “You should've been thinking about your wife and son in the hospital.” Three fathers expressed being self-employed and needing to work out of town, which created difficulty with their partner needing them, in addition to not being able to see their child as often. One father expressed an appreciation for work in that “if I stayed away, I felt like time went by quicker.” Another expressed work as a getaway of sorts because he could not “be engulfed in it all day at home.” While another allowed, that work allowed him to “get your mind off of it for a little bit.” While beneficial, at times working did add stress to the already stressful experience.
One Day at a Time
One day at a time sums up everything involved in this experience. “I've spent a lot of time sleeping in a chair up here, but ... You know, I still get home 11:30, 12:00 at night and get back up at 5:00 the next morning, go to work, come do it all over again.” Fathers described days of improvement including decreasing oxygenation needs, increasing tolerance for feeding, growing and gaining weight along with days of setbacks with increased oxygenation, sepsis, and new diagnoses including hydrocephaly and brain bleeds. One father managed the roller coaster of stress 1 day at a time; he stated, “Even with going through this, you know, look for that silver lining,” as a way to remain positive when you feel like everything is negative.
Theme 3: Holding
The third theme to emerge changed the focus from the mother of the child to the fathers themselves. Fathers initially used avoidance and expressed anxiety about the infant's size and fear of hurting them. Eventually, fathers found themselves holding the infant and forming a bond. Holding was a way of confirming the connection to their child. After days or weeks of knowing the child was theirs, but only feeling as though they knew that from the name they shared, the moment of holding solidified this connection. For all of the fathers in this study, the specific moment where they held their infant for the first time was particularly meaningful. The impact of this experience is evident in the words of one father: “Oh yeah. I ... I feel like a dad. It's just like ... it feels ... it feels like it's more stronger now. It ... well when I touched her—well I know I will be a dad no matter what. I know I'm gonna love my baby and take care of her no matter what.”
All fathers initially avoided touching, providing care for, and holding their infant. As one father stated, “In the very beginning I was scared to death to even touch” his child. Many fathers also deferred care to the mother stating, “I think it's more important for him to connect with his mother right now, so we're just going to let her do all the touching and the holding ... so, uh, I really didn't hold him for like a month.”
Some fathers justified avoidance behavior as a lack of knowledge in providing care to the infant and of the NICU itself. One stated, “I mean I don't do too much while I'm up there. Kristin, Kristin's actually ‘cause, since she's here pretty much all day, she's, she's gotten really familiar with everything. She changes their diapers really easily.” Interestingly, avoidance was a coping strategy used by each father in this study.
In the Palm of My Hand
In the palm of my hand was the description commonly given by the fathers in this study to describe the size of their child. Fathers raised concern over touching, holding, or caring for their infant based on the size and perceived fragility of the child. Describing the size of his child one father stated, “He was tiny. I put my wedding ring all the way to his knee” to reinforce just the small size of his child. Another opined regarding his initial perceptions of size of the baby: “I held him and he literally fits in ... my hand ... from the top of his head to the bottom of his butt fits.”
As parents were integrated in care of the infant, fathers deferred to the mother of the infant, citing things such as having large hands with big fingers and it being hard to do things like changing a diaper. Their greatest concern, however, was in hurting the infant. One father stated, “I actually didn't do any touch time with him, initially, because he was so fragile to me.” Another father felt that he could not even change the diaper because “my hands are too big.” The fathers' perception of the infant as tiny and fragile compared with the size of their own hands influenced their involvement in care.
Love Creates the Connection, Holding Confirms the Connection
Holding the infant for the first time served as a significant moment in developing the father–infant bond. One father described a nurse saying, “Daddy it's time, you're going to touch him and do what they call kangaroo time. So, I took off my shirt, sat in the chairs that they have there, uh, we did skin to skin like for the first time. It, uh, took a month, but yeah I finally did it!” While another father made the decision to hold on his own, “I was like ... that's it. I'm holding my (son) tonight. I have to sit here every night and watch you hold him.”
The father and the infant became family through holding. One father described seeing his name on the crib and knowing the child was his, but holding created that actual connection. It was an emotional and tearful moment for many, and all described truly enjoying the moment. One father described his first time holding, “How did I feel? Uh, I guess that would be like the first feeling of like being a dad, you know?” Fathers felt love for their infant when it was born. But, the infant was made real when he held the infant. One stated for example, “You just never can imagine the love that you have for something, for someone until you have your own children, you know. That's pretty amazing. And then you have them laying there on you, and that's a part of you in a way, and it's... It's pretty cool.” Holding affirmed the father–child connection with an unexpected intensity.
Theme 4: Finding My Way
The fourth and final theme to emerge from the data concluded with the importance of renewing faith, maintaining a relationship with the mother of the child, and finding meaning while fitting into this unexpected role. Although no questions in the interview guide were designed to elicit a response about faith, almost all fathers in this study expressed a renewal of faith. For some, it was becoming stronger in their already solid foundation of beliefs and for others it was the belief that their child or children being alive was a miracle and they needed to be more active in their role as a believer. This final theme centered on this experience and journey becoming “my life now” and fitting into this role that they never expected to be a part of. The journey began with becoming aware of preterm infants and NICU stays and evolved as they learned to navigate and succeed in this new world to the point of it becoming normal for them.
Faith was described as being renewed during this experience and was mentioned by 6 out of 7 fathers. One father described this as putting it in God's hands and that “the good Lord wouldn't have blessed us with them if it wasn't meant to be.” Another described the strength needed for the experience itself, “God gave us this for a reason. Just be strong. Let's be strong with this.” One father described being very religious when he was younger, but with this experience he felt the need to “get back right because this is a miracle.” When the condition of one girl in a set of twins was critical, the father described coming together with his wife, family, and pastor from church to pray for his child, as the staff of the NICU tried to save her. He described the result as a miracle that she did not have a brain bleed after all she went through.
Making It Work
As several fathers described the journey in the NICU, they also made known the fact that this journey could “strengthen or destroy a family.” The stress of the NICU experience was difficult to manage for both parents. Communication throughout this process was key for all relationships. One described it being hard on him and his partner with her hormones changing and he expressed, “I didn't know what to do. I, of course, wasn't doing the right thing. I had to bite my tongue a bunch.” It was extremely important to all the fathers in the study to focus on their relationship with their partner during this difficult time since “neither one of us wanna go through it alone,” reinforcing the reliance on the other and going forth as a team.
Fitting in as a Different Kind of Father
This subtheme described the journey of the father to finding himself and finding the meaning behind this journey he had undertaken, not by choice, but by necessity. One father described explaining to others about the infant, and the questions they ask such as, “Well how do you know all this? Well, I've been dealing with it for five weeks. This is my life now. I know more about NICU stuff and baby stuff than I ever wanna know about.” Fathers indicated that “you gotta learn to be a complete different type person” as the parent of an infant in the NICU. One father indicated that his role at this time was to be “with him, all I can do is be here, and talk to him, and hold his hand.” As the fathers adapted to the new role, they expressed satisfaction in the role of father: “And it feels good to just as a parent that ... you doing something for your baby. It feels ... it feels awesome.” This role was different from what they had imagined and it took time to recognize their importance in this journey.
This subtheme brings the other themes and subthemes together in that each father found a way to fit into this new land with new experiences, as they understood the realities of becoming a father to a premature infant. From being an outsider looking in on this new and foreign land, they were able to fit in the best they could, to be a part of their child's world.
The findings of this study suggest that fathering an infant in the NICU emerges from complex interactions between fathers, their partners, and the healthcare providers. Four themes emerged from this data: looking in, persevering, holding, and Finding my way. Taken together, these themes describe the journey of fathers in transitioning into the fathering role and building a relationship with the infant within the unfamiliar and intimidating environment of the NICU.3 , 25 While other studies have investigated stressors5 , 7 , 8 of fathering in the NICU, this study describes how he comes to know his infant and himself as a father and to know his infant and himself as a father in the NICU.
With their sudden immersion into the intimidating world of the NICU,5 , 26 fathers initially felt as though they were on the outside looking in. Fathers felt like an outsider, as his focus was supporting the infant's mother, and trying to understand the different world of the NICU. Fathers noted that they felt as though the NICU and the birth were a woman's world about which they knew little. Such deferring to the expertise of the mother was also noted in previous studies.26 , 27
While somewhat lost in this different world, fathers reached the poignant realization that you go home with nothing, underscoring the unfair nature of the experience. To begin parenting, fathers had to first learn to trust strangers with the care of their child. The father found that he did not have a choice but to trust. Trusting strangers brought both comfort and anxiety as some fathers worried about adequate preparation of those caring for their infant and their knowledge of current standards of care. Trusting allowed fathers to learn to navigate this foreign land. That is, fathers found that they wanted to learn more about the NICU, medical terminology, and the data related to their infant. Such monitoring, or tracking, of data gave fathers a role or purpose.
Furthermore, to navigate this foreign land, fathers consistently felt that they needed to persevere to maintain the stability of the family. The fathers repeatedly stressed the importance of being the backbone of the family and remaining strong while feeling helpless and inexperienced, a finding supported by prior studies.2 , 5–7 In many ways, persevering represents the traditional male role for fathers. This theme included staying strong, doing for, working, and taking 1 day at a time.
The third theme identified in this study was holding. Holding the infant was identified as pivotal in connecting to the infant. However, initially fathers were acutely aware of the infant's size, noting that the infant fits in the palm of my hand. The size of their own hands and perceived fragility of the infant directly related to avoidance with regard to touching, providing care, or holding the infant. This finding is consistent with previous research indicating fathers are aware of their infant's fragility and the unpredictable nature of their condition.2 , 5 , 6 , 11 , 26 , 28 , 29 Future research is needed to further explore the significance of avoiding; avoidance may serve to protect fathers from connecting to the infant when outcomes are uncertain. At some point in the NICU journey, each father had the pivotal experience of holding his infant. In this study, we found that this 1 experience, holding, was probably the most meaningful moment of the NICU experience for each father. The experience of holding their infant caused them to truly feel like a father and solidified their connection to the infant.
The final theme to emerge from these data was finding my way. Fathers in this study relied on a renewed faith to help them through the experience. They also focused on making it work; specifically, they sought to focus on their relationship with their partner during this time of undue stress. This finding is consistent with previous studies noting that fathers emphasize their importance as the supportive role to their partner.2 , 26 , 30–32 In the end, each father made peace with fitting in as a different kind of father while the infant was in the NICU. They realized that their fathering experience is not the same as that experienced by their friends or family members. But, they found meaning in their experience and contribution of fathering in the NICU.
Practice and Research Implications
Neonatal nurses should actively involve fathers' participation in care of the infant by providing concrete activities. Examples of this include explaining monitors and the significance of laboratory results, changing diapers, comforting the infant, and trending things such as weight and laboratory values. This involvement promotes attachment and cohesion of the family. In this study, participation in kangaroo care was particularly significant for the fathers; fathers should be included in kangaroo care soon after initiating it with the mothers.
The sample for this study represented varying ages, race, ethnicity, education, and singleton, and multiple births. The diversity of the demographics in this study provides an insightful view of the findings, making them suitable for extrapolation in nursing practice through transferability.33 The findings from this study provide more depth to the experience than the instruments that are commonly used to measure parental stress quantitatively, thereby providing theoretically sound direction for initial development of an instrument to measure fathers' experiences in the NICU. In addition, future research should examine stress, including posttraumatic stress disorder, for fathers of infants in the NICU. Future studies aimed at determining best practices to integrate fathers in direct care of the infant should also be identified.
The sample for this study was fathers who were from very traditional family structures, being either married or cohabitating with the mother of the child. In addition, all fathers had achieved, at a minimum, a high school diploma, with many attending college as well. Future research should examine nontraditional family units and those of lower socioeconomic status.
The findings from this study suggest the paternal experience in the NICU is complex, and fathers have unique needs during the journey. Nurses who understand this experience from the father's perspective can help them through strategic support and encouragement.
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Keywords:© 2018 by The National Association of Neonatal Nurses
lived experience; neonatal nursing; nursing; paternal experience; premature infant; qualitative