Communicating with Supporting Fathers During Stressful Times in the Nursery: An Evidence-Based Review

Michael T. Hynan, Ph.D.

Dr. Michael Hynan is a Professor of Clinical Psychology at the University of Wisconsin-Milwaukee, P.O. Box 413, Milwaukee, WI 53201. add email address if you wishe-mail:hynan@uwm.edu

This work was completed at the U. of Wisconsin-Milwaukee.

Abstract

This paper reviews research on gender differences in communication with a focus on communicating with fathers and mothers in the nursery during times of stress. Summaries of meta-analytic research are presented. This review indicates that similarities between the genders clearly outweigh differences in men’s and women’s responses to and provision of supportive communication. Both men and women report that messages with a high level of person-centeredness are most sensitive and supportive. Examples of these messages include engaging in empathic understanding, helping the troubled person verbalize feelings, providing justifications for the intensity of feelings, and contextualizing the reasonableness of the person’s feelings. Suggestions are also provided for communicating with mothers and fathers in the stressful environment of the neonatal intensive care unit

Communicating with Fathers During Stressful Times in the Nursery

Imagine this scene:

As you come in for your shift in the nursery you are told that the intubated, 24 weeker in the isolette was recently delivered by emergency C-section. The baby’s mother, who is still under anesthesia, is a 32 yr. old cashier, who is married to the rather shocked looking father standing besides his son. Dad is a 33 yr old factory worker. He and his wife also have two other healthy children, ages 2 and 6. The neonatologist is explaining the baby’s condition, the rationale for current medical decisions, and expectations for the future. The father is told that he may have to participate in making some difficult decisions. You have been a nurse for 12 years, so you know that you will have to repeat to the father everything you hear the neonatologist tell him. And probably repeat some of it more than once. You also know that treatment planning, including discharge planning, starts now. As you mentally begin this process, what do you expect from the father? How might your expectations influence what you will do? What does the research say about fathers, communicating with them, supporting them? And compared to your considerations for the infant and the mother, how much time do you spend thinking about the father in your treatment planning?

Introduction

My colleagues and I have been conducting psychological research on high-risk parents for over 15 years [1, 2, 3, 4, 5, 6, and 7]. The experience of having a baby hospitalized in a neonatal intensive care unit (NICU) produces significant emotional distress in parents. Symptoms of NICU-related distress include anxiety, depression, dissociation, and post-traumatic stress [8, 9, 10 and 11]. A review of the studies I have cited so far will produce a noted gender imbalance in research participants. The participants are mostly mothers; hardly any fathers. (For notably exceptions; see Affleck, Tennen, and Rowe [12] and Jeffcoate, Humphrey, and Lloyd. [13]). Where are the fathers?

These studies reflect my experience attending perinatal meetings for over 15 years. Attendees at these meetings have been primarily (a) high-risk parents or (b) perinatal professionals with inclusion of some high-risk parents. In both cases I see a gender ratio of participants that is comprised of 10 to 20 women for each man. As a father of a high-risk infant, I have been often asked, “Where are the other fathers?” I have also been asked, “What can we do to help fathers?”

I believe that there are a number of reasons why we have a larger data base for mothers than fathers in the perinatal setting and a larger participation by women at perinatal meetings. These reasons include: (a) some real differences between men and women, (b) the relative neglect of fathers in the field of “Maternal-Child Health”, and (c) stereotypic myths that exist about differences between men and women. I believe that these three reasons are also interrelated.

Real gender differences have become exaggerated into myths that communicate an enduring distortion of reality; for example, “Men are from Mars, Women are from Venus.” [14] Once adopted as “truth”, these myths can affect expectations of men’s attitudes, emotions, communication styles, and behaviors. These expectations can, in turn, affect how fathers are approached and treated in perinatal medicine.

In this paper I will first review the stereotypic differences between men and women. Next, I will review research evaluating what I call the “Mars-Venus Hypothesis” (MVH). This research examines gender differences across a number of psychological dimensions. I will provide a focus on the similarities and differences between the gender’s communication styles. I will also provide suggestions about communicating with both mothers and fathers in the NICU.

When you examine the case study above, what do you expect from the father? You can see that he is obviously stressed by the premature birth of his son. If you conceptualize according to stereotypes, you would expect him to attempt to be as emotionally strong as possible as the breadwinner and protector of his family. When provided with the details of the physical conditions of both his baby and wife (and any decisions regarding treatment options), he will display few emotions while acting in the most rational manner possible. Because he is a problem solver, he will make unwavering judgments based on the best possible evidence. In the early stages of his wife’s recovery, he will visit the hospital often. He will find it difficult to tell you how he is feeling. As his wife gets physically better, he will visit the nursery less often (because that’s a mother’s job). He will spend his time caring for or arranging care for his other children. He will also begin working overtime at the factory to help pay for the hospital bills. He will not want you to attempt to comfort or console him. Instead, he would rather that you give him something to do. He needs to feel useful.

What do you expect from the baby’s mother? In contrast to dad, the stereotyped mother should be more verbal and more emotion-focused. As a primary caregiver, she will show concern for the emotional well being of her own family and her new nursery family. In addition to being able to tell you how she is feeling, she will ask you how you are doing. In making decisions, she should be more persuadable than her husband. She will look to you for comfort and consolation. And because she will be hospitalized for a while, you will have a better opportunity to observe her personal characteristics and form an impression about whether she “fits” the stereotype, or not. You may not have this opportunity with the father.

As an experienced nurse, I expect that you have seen both this father and this mother. I also expect that you have seen many mothers and fathers that do not fit into the stereotypes I provided. Stereotypes typically represent the outward boundaries of dimensions of personality and behavior. The difficulty in conceptualizing with stereotypes is that the stereotype represents neither the average husband/wife nor the unique parent who is under your care. Most people are aware of this difficulty, although stereotypic thinking about gender differences is quite common.

I teach courses in Personality to large classes of undergraduates. Every semester I ask for a show of hands for how many of my students really believe that “Men are from Mars” and “Women are from Venus.” Over 75% raise their hands, believing that this stereotypic conceptualization is an accurate reflection of reality. Then I present data that indicates that, on most dimensions, men and women are much more similar than different. After I have presented the data, I am not sure that I have changed many minds. I will be presenting the data to you, and you will form your own opinions.

I wish to stress that I believe that your opinions about men and women will be related to your expectancies of how fathers and mothers will react in the perinatal setting. I also believe that those expectancies can have an effect on how mother and fathers react. If you expect stereotypic fathers to disappear from the nursery over time, they just might do so. I happened to visit my son just about every one of the 42 days he was hospitalized in the NICU. I also read the charts daily. I came to discover that I was viewed (by at least one caregiver) as an “overly involved” father. I guess I violated that person’s “father norm.” I have also talked with high-risk mothers, who occasionally have dreaded the visit to the NICU on a particular day. Why? Because the experiences of the last few days were horrible, and today held no promise of being uplifting. Yet, most of these mothers dragged themselves, privately kicking and screaming, in for a visit. Why subject themselves to more torture? Because they were expected to visit their baby. Because, if they didn’t visit, they might be labeled as uncaring or neglectful mothers. I believe that most people can think of many instances when someone else’s expectations had an impact on a person’s behavior.

The “Mars-Venus Hypothesis (MVH)”

The MVH states that there are large, significant differences between the genders. In this hypothesis, mMen and women represent dichotomous groups with little or no overlap. Put in other words, proponents of the MVH believe, “Men and women differ in all areas of their lives. Not only do men and women communicate differently but they think, feel, perceive, react, love, need, and appreciate differently. They almost seem to be from different planets, speaking different languages, needing different nourishment.” [John Grey14, p. 5] The MVH also has been represented as a perspective that men and women are so different that they should be regarded as members of “different cultures.” [15]

Effect Sizes to Indicated Differences

Research on gender differences across any dimension typically compares distributions of scores for men and women. Any difference can be expressed in terms of an effect size, whether the difference is statistically significant or not.[16] Meta-analyses that review studies of gender differences typically report average effect sizes (d) based on the studies reviewed. The magnitude of d is calculated by dividing the mean difference between the genders by the standard deviation of the combined distributions for men and women. Over the past few decades, research has compared men and women on just about every conceivable dimension (e. g., math and verbal ability, frequency of smiling, self disclosure, mental rotation, attitudes about sex, physical strength, etc.). If there are no differences between the means for men and women, d= 0.0. Cohen [16] has provided a framework for benchmarking the magnitude of effect sizes; referring to

d = 0.20 ias a “small” effect

]; d = 0.50 ais a “moderate” effect; i.e., group differences that are “visible to the naked eye”; and

d = 0.80 as a “large” effect. Cohen [16] has stated that moderate effects represent group differences that are typically noticeable (“visible to the naked eye” p.26) and large effects represent group differences that are obvious (“grossly perceptible” p.27).

On dimensions where the differences between men and women are “small”, the overlap between the distributions of the two genders is 85% (15% nonoverlapping). Moderate ds indicate an overlap of 67% (33% nonoverlapping); large ds indicate an overlap of 47% (53% nonoverlapping). My reading of the MVH indicates a perspective that there is little or no overlap between the genders, Distributions that are 95% or more nonoverlapping result in ds > 3.33. Distributions that are 50% or more nonoverlapping result in ds > 0.87.

What the Gender Studies Show

The majority of studies of gender differences, if well conducted (i.e., there are sufficient research participants and reliable measures), show significant differences between men and women.[17] Above and beyond the issue of statistical significance is the question of the magnitude of the difference between the genders. This magnitude varies greatly across the different behaviors and aptitudes that are measured. In a review of 171 studies, Hyde and Plant [17] reported that 25% of studies comparing men and women reported ds from 0.00 to 0.10; 35% of studies reported ds from 0.11 to 0.35, 27% of studies reported ds from 0.36 to 0.65; 10% of studies reported ds from 0.65 to 1.00; and 3% of studies reported ds over 1.00. Overall, this review [17] shows little support for the MVH. (Subsequent ds showing that men possess a greater amount of a characteristic than women are described as negative; positive ds indicate that women possess a greater amount of the characteristic.)

Gender differences do appear to vary according to the type of dependent measure studied. Some measures (often associated with biologically related activities or sexual selection) have consistently revealed larger effect sizes. Effect sizes regarding menstruation, pregnancy and childbirth cannot be calculated because the male mean and standard deviation are zero. It would surprise no one that the effect size comparing the adult heights of men and women is very large. More specific examples of large gender differences include: throwing velocity (d = -2.18), throwing distance (d = -1.98) [18], and liberal attitudes towards casual sex. An example of the latter is that in one study men reported that they would like to have more than 18 sex partners in their lifetime; women reported that they would desire between 4 and 5 (d = -0.87). [19] Also, women characteristically smile more than men (d = 0.60). [20]

Most studies of other behaviors and abilities, however, show small to modest differences between the genders. For example, men have a slight superiority over women in math skills (d = -0.15); the reverse outcome is true for verbal skills (d = 0.11). [18] Men tend to have more of the following characteristics than women; aggression (d = -0.30 [21]), helping behavior (d = -.34 [22]), self esteem (d = -0.14 [23]), and impulsiveness (d = -.06 [23]). Women have more of the following characteristics than men; trustingness (d = 0.24 [23]), extraversion (d = 0.04 [20]), depression, (d = 0.16 [20], and leader effectiveness (d = .02) [24]. Thus, my point: Most gender comparison studies show that men and women are much more similar than they are different.

Communication with Mothers and FathersMen and Women

Now, what about the two genders and how they communicate? Does the research provide direction for communicating with fathers and mothers in the nursery. One dimension of general communication, self-disclosure, has been well-researched. The MVH would expect large differences between the genders in self-disclosure. One meta-analysis of 205 studies [25], however, found that women were only slightly more likely to self disclose than men (d = 0.18). An effect size of this magnitude reflects a large degree of overlap between the genders. Put into other mathematical terms, d =0.18 indicates that if 45% of men would disclose a particular piece of information, 55% of women would disclose the same information.

Are there gender differences in communication style during times of stress, such as having a baby in the NICU? There is a large body of literature regarding communication styles when people talk about personal and interpersonal difficulties; such as, death of a loved one, break-up of a relationship, or difficulties on the job. Such conversations have been termed “troubles talk” [15]. As a veteran nurse, you have engaged in a lot of “troubles talk”. The MVH perspective on listening to “troubles talk” believes that men are more likely than women to respond by giving advice, joking, changing the subject, or not responding. Conversely, according to the stereotype, women are more likely than men to respond to troubles talk by sharing a similar problem or expressing sympathy. This different cultural perspective also holds that when receiving sympathy for their troubles, women feel more comforted than men. This view also claims that men and women are similar when they receive advice (both genders tend to react negatively), but men react more negatively to advice than women [15].

In your role in the nursery, you will be trying to provide support for both mothers and fathers. If you believe in the stereotypes of men and women, you might also believe that you should use different types of support for the different genders.

Attempts at supportive communication can differ on a dimension of how person-centered the approach is [26]. Person-centeredness refers to the extent to which messages acknowledge and validate the other person’s perspectives and emotional reactions. High levels of person-centered communication explicitly recognize the other’s feelings. Examples might include engaging in empathic understanding, helping the troubled person verbalize feelings, providing justifications for the intensity of feelings, and contextualizing the reasonableness of the person’s feelings. Moderate levels of person-centeredness would implicitly recognize the other’s feelings by offering sympathy or condolence, distracting the other’s attention away from the problem, and presenting explanations intended to reduce distress. Low levels of person-centeredness would ignore or deny the persons feelings and perspective by making suggestions of how the person should be feeling, minimizing the problem, and commenting on ways the person could get over the problem.

The MVH suggests that women should respond more favorably than men to messages of high person-centeredness. Men, on the other hand, are believed by the MVH to respond by avoiding a discussion of feelings and instead concentrating on fixing a problematic situation or directing attention away from the situation (i.e., messages of low person-centeredness). What do the data say about the validity of the MVH perspective on offering emotional support to men and women?

A recent series of studies of supportive communication have evaluated and rejected the MVH. [27] Specifically, these studies find that both men and women view high person-centered messages of support as a more effective and sensitive means of communicating emotional support than low person-centered messages. In summarizing these findings McGeorge et al. [27, p. 165] have stated, “…highly person-centered comforting messages facilitate the alleviation of emotional distress by establishing a supportive conversational environment, encouraging distressed others to verbalize feelings, and consequently, fostering sense-making about the upsetting event; there is little reason to expect gender differences in the processing of or responses to these messages.” In a second different review of the research literature on emotional support, Kunkel and Burleson [28, p.116] have similarly stated, “Both women and men view highly person-centered comforting messages as most sensitive and effective; both see messages low in person-centeredness as relatively insensitive and ineffective.”

In addition to examining research on how men and women react to different types of supportive communication, it is interesting to examine how men and women provide supportive communication.

Recent research has indicated that there are some differences between the genders in responding to someone else’s troubles. [29 and 30]. Michaud and Warner [29] found that men were more likely than women to discourage worry and change the subject, and that women were more likely than men to express sympathy. These results were essentially replicated by Basow and Rubenfeld [30]. Although the gender differences were significant, they were of moderate magnitude, representing a little more than 40% non-overlapping of the gender distributions. Researchers favoring the MVH view these data as supportive. But examining only male-female differences often results in overlooking important male-female similarities.

Even though there were gender differences in these studies, the most frequent response given by men when hearing someone’s troubles was an expression of sympathy. A recent critique [27] of the two articles cited above [29 and 30], provided additional analyses of the data. Out of the six possible behavioral responses to “worry talk” (change the subject, joke, discourage worry, share a similar problem, give advice, and offer sympathy) both men and women were much more likely to express sympathy than to change the subject. Indeed the three most frequently used responses by both men and women were (in order) to offer sympathy, give advice, and share a similar problem. Women and men were very similar to each other in how they tried to support another person with problems.

If you believe in a philosophy of family-centered care in the nursery, you have a number of concerns beyond the health and well being of this premature baby (or any baby). You recognize that it is also your job to educate the mother and father in important parenting skills, and to provide emotional support using your best bedside manners. As I read the research literature on gender differences, the application to the nursery is straightforward. It would be wise to consider mothers and fathers as similar, as caring parents, not as different species. The first strategy of communicating with the father would be gently approaching him by the isolette with messages that are highly person centered, just as you would likely do with the mother. This strategy will not work in all cases because people will respond differently. But being an experienced nurse, you already know this.

If explicit person-centered support does not get through on the first try (with either father or mother), I would suggest that you keep trying for a while. Especially in a NICU setting, little or no communication may get through during the early stages because a parent might be in too great a state of shock to “hear” something. Often this psychological process has been termed “denial” by parents, who don’t want to accept bad news. I believe that many times what is called “denial” is the a different process of “dissociation”. In times of high stress, a person’s attention is narrowly focused. It may take all of the father’s concentration to just focus on his premature son, who does not look like any baby the father has ever seen.

In such times of heightened distress, any additional information that is provided to a parent (whether information on oxygen saturation or person-—centered messages of care) may just not be processed. In order for information to be stored in long-term memory, it must first be encoded and consolidated by the memory processes. During heightened distress, these memory processes are overloaded by the emergency at hand. As an experienced nurse, you know that you have had to repeat many things to parents, especially parents in a NICU. I believe that this is due to a disturbance in brain circuitry, and the information is lost before complete processing. As a caregiver, it may help you to recognize that the parent may be temporarily unable to process the information you are communicating. The parent may also be temporarily unable to “hear” your caring and support, which may be even more important to the parent than what you had to say. Repeating things to parents multiple times can be very frustrating, but it essential to the job of being a family-centered nurse. [31]

Sometimes high person-centered messages will not work, despite repeated efforts. Sometimes nothing will work, but I suggest that you try a number of other strategies of communication to find one or more that will benefit mothers and fathers. All individuals have different strengths and weaknesses in their personality and coping styles. You will find some fathers for whom emotional expression is like a foreign language they failed in high school. You may need to find some things for these fathers to do, in order for them to feel comforted and gain some confidence in parenting. You will also find some mothers who need this same approach.

Communicating with NICU Parents.

What is the relevance of these data for the NICU and your role as a health care provider?. I believe that the data strongly indicate that you should expect that men and women are much more likely to act and respond in a similar fashion. I would encourage you to communicate to fathers that they have an important role as a caregiver in the NICU. Expect the dad to visit just as much as the mom.

Fathers can also be given a special role in the NICU. Tell dads that they have an opportunity for their baby to get to know them as dad. Encourage fathers to gently speak to their infants while stroking them. The baby will come to learn that his father’s parenting is special and feels very different from many of the touches received from the medical staff, which are often aversive. You can tell dad that his baby will learn to recognize his voice as one that only brings comfort.

As an experienced nurse (or as a beginning nurse), you will always be fine-tuning your bedside manner. You may have developed a style of comforting that works well for the person you are. An experienced nurse, however, will have discovered that one style will not work for every parent. In concluding this review, I am going to refer you to a web site created by high-risk parents. [32] It contains a set of “Dos and Don’ts” about communicating with parents in a NICU. These “Dos and Don’ts” represent collective parental wisdom., but obviously following them is not going to bring 100% success in communicating with NICU parents. I encourage you to look at these suggestions, especially if you are finding difficulty in communicating with particular parents.