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Experiences of Fathers Shortly After the Birth of Their Preterm Infants
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Experiences of Fathers Shortly After the Birth of Their Preterm Infants Kevin Hugill, Gayle Letherby, Tilly Reid, and Tina Lavender
Correspondence Kevin Hugill, PhD, RN, School of Health, Brook Building, University of Central Lancashire, Preston, United Kingdom PR1 2HE. [email protected] Keywords emotions emotion work ethnography fathers fatherhood neonatal intensive care unit neonatal nursing
ABSTRACT Objective: To explore the experiences of fathers shortly after the birth of their preterm infants. Design/Method: A focused ethnography conducted over 33 months (2003–2006) in the neonatal intensive care unit (NICU) of a large U.K. National Health Trust (NHS) teaching hospital. Data were collected through participant observation, in-depth interviews with fathers (n = 10), and an ethnographic survey distributed to NICU staff (n = 87). Practices and relationships with fathers were concurrently analyzed thematically through the conceptual perspective of emotion work. Findings: Fathers’ emotional reactions to their experiences were described in three themes: emotional withdrawal and control, stereotyping, and mixed feelings. Fathers’ emotional behaviors were governed by complex, culturally determined conventions and expectations. Conclusions: Fathers engaged in considerable effort to manage their emotions as they attempted to reconcile the tension between what they wanted to feel and what they thought others expected them to feel. The results of this study support the view that focusing on emotional externalities alone tends to underplay the amount of emotion work carried out by less expressive individuals; this “silent emotion work” was characteristic of the fathers in this study.
JOGNN, 42, 655-663; 2013. DOI: 10.1111/1552-6909.12256 Accepted August 2013
Kevin Hugill, PhD, RN, is a senior lecturer at the University of Central Lancashire, Preston, United Kingdom. Gayle Letherby, PhD, is a professor of sociology and the Director of the Institute of Health and Community at Plymouth University, United Kingdom. Tilly Reid, PhD, RN, RM, is a senior lecturer in advanced practice at the University of Cumbria, United Kingdom. Tina Lavender, PhD, RM, is a Dame and professor of midwifery and women’s health at Manchester University, United Kingdom.
The authors report no conflict of interest or relevant financial relationships.
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en’s involvement in family life is changing; increasingly fathers want to become more involved in their children’s lives (Fatherhood Institute, 2011). Despite this, men continue to be viewed as mothers’ supporters or of peripheral importance (Steen, Downe, Bamford, & Edozien 2012). In neonatal intensive care units (NICUs), organizational, interpersonal, and gendered cultural barriers restrict fathers’ greater involvement (Deeney, Lohan, Spence, & Parkes, 2012; Feeley, Sherrard, Waitzer, Boisvert, & Zelkowitz, 2012; Johnson, 2008). Results of neonatal parenthood studies continue to highlight the intensity of feelings that parents experience following preterm birth (Obeidat, Bond, & Clark Callister, 2009). These experiences can have long-lasting social and health implications (Goutaudier, Lopez, Sejourn e, ´ ´ Denis, & Chabrol, 2012; Treyvaud et al., 2011). However, in the past neonatal parenthood researchers infrequently reported fathers’ perspectives. Consequently their voices were often absent or muted from research accounts.
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Several studies suggested that fathers find preterm birth and admission to a NICU a distressing experience that provokes feelings of in-
tense anxiety, fear, and helplessness (Alderson, Hawthorne, & Killen, 2006; Lee, Miles, & HolditchDavis, 2006; Lundqvist & Jakobsson, 2003). In some cases this might be because they witnessed the resuscitation of their infants (Harvey & Pattison, 2012), sensed they lost control over events (Arockiasamy, Holsti, & Albersheim, 2007), or felt alienated from the experience of fatherhood (Pohlman, 2009). A common worry reported by fathers is the strain relating to difficulties in prioritizing roles of partner, father, and family wage earner ¨ (Lindberg, Axelsson, & Ohrling, 2007; Pohlman, 2005). Conversely other fathers highlighted positive aspects. For example, Lindberg, Axelsson, ¨ and Ohrling (2008) reported that some fathers described preterm birth as giving them greater opportunities to form attachments with their infants because of spending time in the unit. In general, fathers’ courses through their NICU experiences have been described as moving from physical and emotional distance toward closeness (Lundqvist, Hellstrom-Westas, & Hallstrom, ¨ ¨ 2007). Evidence about the usefulness of interventions to support fathers, increase their involvement, and reduce stress experience is mixed. Researchers
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Men’s unique experiences are not well understood, and little is known about how their emotional world views interact with their experiences.
reported few or no effects or different responses to interventions by mothers and fathers (Matricardi, Agostino, Fedeli, & Montirosso, 2013; Ravn et al., 2012). In contrast, others reported measurable positive effects on stress (Lee, Wang, Lin, & Kao 2013). Potential reasons for this could be that mothers and fathers need different interventions or they are context specific. Clearly the culture of fatherhood in NICUs is complex and influenced by individual difference, cultural, and contextual factors. There is a need to better understand fathers’ experiences on NICUs to inform the development of effective initiatives to meet fathers’ needs. Most researchers have paid little attention to how men’s emotional worldviews interact with their experiences of having infants in NICUs. This was the main aim of this study. Specifically, we used the concept emotion work (Hochschild, 1979, 2003) as the theoretical perspective with which to examine fathers’ experiences.
response to the physical, psychosocial, and cultural situations that impose demands on individuals to emotionally react in a particular way. Although some researchers have explored aspects of men’s emotion work in the home and work (Duncombe & Marsden, 1999; Hochschild, 2003, 1994), little is known about men’s emotion management in other settings. We sought to explore fathers’ emotion management in relation to neonatal care.
Methods Ethnography originating from anthropology is a form of social inquiry that is used to understand cultures (Creswell, 2013). Since its beginnings, ethnography has developed numerous distinct forms and traditions and has become a flexible and wide ranging approach to research (Hammersley & Atkinson, 2007). It involves collecting data from multiple sources and emphasizes the exploration of people’s behavior in everyday contexts (Madden, 2010). This method was chosen because it enabled us to study the experiences of fathers following a preterm birth within the culture of a NICU during the first 2 weeks after admission from multiple points of view to gain a more complete picture.
Emotion Work The concept of emotion work was developed by Hochschild (2003) to describe the effort individuals exert while managing their own and the emotions of others. This concept belongs to a group of sociological ideas about emotion labeled “dramaturgical theories of emotions” (Turner, 2009). These ideas draw upon the work of Goffman (1959, 1967) and his notion that society could be explained through the metaphor of a theatrical play in which people act to an audience. Culturally determined rules (normative, feeling, and display rules) about emotion management are learned through socialization (Hochschild, 1979). Crucially these rules are not fixed; they can differ with age, gender, time, place, and social context (Bolton, 2000).
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Emotion work has been widely used to explain how people manage their emotions, particularly within organizational and work environments (Bolton, 2005). Early studies in health care settings highlighted the importance of emotional management in nursing and midwifery practice, and that at times the need to manage one’s own and the emotions of others could be a source of dissonance (Hunter, 1999, 2004; James, 1992; Smith, 1992). In summary, emotion work is a
Many nurses study topics that relate to their practice experiences, and this was the case in this study. In ethnography this is often referred to as “practitioner ethnography” (Barton, 2008). Ethnographic study has many perspectives, including the researcher’s, which is often incorporated through reflexivity. Researcher reflexivity is a particular type of reflection (Alvesson & Skoldberg, ¨ 2009) that can help to balance inside and outside perspectives. In this study, reflexivity took the form of critical self-reflection through that we aimed to account for our subjectivities and research conduct in a transparent manner, a sometimes challenging but ultimately productive process (Hugill, 2012). The lead author is an experienced neonatal nurse and father of preterm children and was the only one who had previously worked on the study unit. The other authors are all female and a midwife, neonatal nurse, and sociologist who brought their own experiences, perceptions, and views to the study, analysis, and representation of the data. This broad base of experience helped to balance insider and outsider perspectives. The study was approved by National Health Service (NHS) and University Research Ethics Committees and all research ethical procedures were followed.
JOGNN, 42, 655-663; 2013. DOI: 10.1111/1552-6909.12256
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RESEARCH
Hugill, K., Letherby, G., Reid, T., and Lavender, T.
Setting The study was conducted in the NICU of a NHS teaching hospital in England. The hospital is in a medium-size (population 300,000), ethnically diverse city. The unit has 11 intensive and high-dependency care cots, 12 low-dependency cots, and admitted around 500 infants per year of all gestational ages.
Data Collection Data were collected between November 2003 and July 2006 by the lead author. Field notes were recorded (Hammersley & Atkinson, 2007), including observations on dimensions of the social situation such as the setting, who was present, and what were they doing. Data collection took place at all times of the day and week and involved 260 hours of observation and 206 informal conversations with 68 fathers, 44 mothers, 38 mothers and fathers together, and 56 health care professionals. This activity provided insight into the NICU culture and the behaviors of those present, particularly with respect to how fathers behaved and how they were treated by unit staff. Individual semistructured interviews with 10 fathers lasting between 30– and 108 minutes were carried out and later transcribed by the lead author between 2005 and 2006 in a private room on hospital premises. Five of the men were first-time fathers, and all births except one were singleton with a mean gestational age at delivery of 30 weeks (range 27–35 weeks). Infants were on average nine and a half days old (range 3–15 days) at the time of interview. Fathers’ ages ranged from 20– to 37 years (mean 26 years). Ethnicity was self-attributed and consisted of six White British, one Asian British, one Black British, one mixed Asian/White, and one Mixed White/Black Caribbean. All except one was in paid employment. A broad opening question, “How do you feel about being a father?” was used with all fathers to establish rapport and enable them to tell their stories in a nondirective way. After this, fathers invariably talked at length about their experiences on the NICU. No additional structured questions were included, and any further questions were used to prompt in-depth exploration of pertinent points or clarify and verify meanings of what was said by fathers. After the final interview all staff were invited to participate in an ethnographic survey (Schensul, Schensul, & LeCompte, 1999) that consisted of a series of short statements about fathers’ ex-
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periences drawn from our preliminary analysis of earlier data. The survey tool emerged from our analysis and not a priori. Space was provided for respondents to comment upon each statement in detail with additional space for any further comments about the study. This approach to data collection had two purposes: first, to enable all staff to comment anonymously (because the lead author was known to many of them) on their views, and second by sharing our preliminary interpretive consensus of the data we sought to validate that it reflected what was occurring in the unit.
Data Analysis We used thematic networking techniques to organize the data (Braun & Clarke, 2006) and took a reflexive approach to analysis. Early on in the study all coauthors spent time, individually and together, reflexively developing an understanding of how our backgrounds as researchers, parents, and midwives or neonatal nurses affected the research. This autobiographical, reflexive approach can make useful contributions toward rigor and serve to account for the effects that researchers have on the research design, conduct, and findings (Hugill, 2012). The analysis followed established conventions for qualitative research (Denscombe, 2010), and this process together with extensive reflection on the data, its patterns, and meanings contributed insight into respondents’ thinking and enabled agreement on emergent themes. After analysis of the complete data set, we identified a number of interrelated thematic areas, and in this article we discuss the global organizing theme of fathers’ emotion work.
Findings Our analysis revealed three interrelated themes related to fathers emotion work: (a) emotional withdrawal and control, (b) stereotyping, and (c) mixed feelings.
Emotional Withdrawal and Control For some fathers their first encounter with the NICU provoked what they perceived as a serious loss of control over their emotions, “When I first saw him I broke down, didn’t know what to do, I’ve never done that before” and “I stood there, I looked at him and I cried with joy.” In contrast we found that the majority of fathers were often initially reluctant to reveal their emotions when they first come to the NICU, a situation acknowledged by some staff, as one nurse explained, “Fathers are very unsure of how they should behave; it appears that there is
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often a minimum of emotions.” Indeed many fathers reported how they felt unable to cry. One father gave a detailed account of his internal tension as he sought to control his emotions, demonstrating the dynamic and stressful nature of emotion work: The night he was born, I stood in there; I stood in the intensive care while they were doing what they were doing. I didn’t quite know whether to burst into tears or just stand there. I didn’t cry, but I almost did [short pause]. “Why didn’t you cry?” [Interviewer asked] I don’t know I thought to myself are you going to cry because it’s all emotionally too much with everything that’s happened or is it a bit of a relief that he’s OK or that he’s in distress. I think it might have been a bit of everything, but perhaps I didn’t want to cry in front of other people. Nobody would have batted an eyelid; they must see it all the time. I remember ringing the mother-in-law up, she was at home, just to say everything is fine and I did choke a bit then. Yes and I said to her: “I’m going to cry now” and she said, “it’s all right don’t worry about it you need to let it out a bit, you know.”
upon them was difficult and emotional trying: She [partner] blames herself thinking “oh it’s my fault again he came early,” you know all the usual emotional stuff, the hormones and stuff, so it’s been a pretty trying couple of [short pause], well last few days have been very trying. You know, dealing with her and all that as well as everything else that is going on with . . . [infant name] and still keeping the house going. And work as well, ha [laughs]. Many fathers found it difficult to balance the emotional and physical demands placed upon them following preterm birth. Some sought to protect themselves for emotionally distressing events by hiding their emotions from people, particularly health care staff, who they were unfamiliar with, often seeking solace in privacy. Others were motivated to control their emotions to protect their partners and other family members from further upset and fulfill their self-ascribed role of protectors.
Stereotyping Other fathers waited for a degree of privacy before any overt emotional expression. During conversations three fathers independently recalled that having left the NICU following their first visit they took a short detour before returning to their partners. This detour was to a public toilet where they had cried in private before continuing back to their partners. Some nurses attributed fathers’ reluctance to express emotions to the female dominant gender mix of the unit, a situation in everyday life fathers were unfamiliar with. Alternately some suggested that fathers did not know how to behave because they did not know how the NICU operated and they fell back upon stereotypically masculine norms: “The NICU being a mostly female environment can be overbearing, leaving dads feeling uncertain about what to do.” In contrast some fathers felt their primary role at this time was to be strong for the sake of their families: “I guess the thing is that if I am with my wife or my mother and she is upset I try and play the figure that’s the strong one and hold it all together, look after my children because you can’t do that if you are crying your eyes out.” Some fathers reported that managing the many demands
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During data collection mothers, health care professionals, and some fathers referred to broad gender-based explanations for the way fathers behaved. This prompted us to use the term stereotyping to describe the explicitly gendered aspects of fathers experiences and its effects upon their emotion work. Typically men are characterized as emotionally inexpressive (Seidler, 2007). This point of view was seemingly supported by one less experienced (<2 years neonatal practice) nurse’s comment, “a typical man does not know how to display emotions.” However, in contrast, some of the more experienced nurses recognized that fathers were often experiencing emotions, but that they were different and more subtle than those expressed by mothers: “Fathers experience and display emotions very differently to mothers.” During conversation one father gave credence to assumptions about men’s emotionality suggesting that his apparent lack of emotional upset was due his emotional distance from the birth and typically more masculine rational outlook: I am not as upset as her [mother of infant], not because I’m cold or anything but because I can see it more logically than a mother would, because a mother’s emotions are tightly tied into it [childbirth]. It’s not that
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Hugill, K., Letherby, G., Reid, T., and Lavender, T.
fathers don’t feel things, but they can see things more logically than a mother can. Even when fathers said they were more emotional than other men, they sought to characterize this emotionality as a feminine trait rather than attribute different emotional world views it to individual difference: I am very much like my mum in terms of personality and emotions. I do try and stem that but it doesn’t always work . . . . My brother is very much like my dad he sees things perhaps a little more clinically I guess, so that it’s more black and white and there is not quite the emotion there. During observation one father was asked by a female nurse if he wanted to change the diaper on his infant who was in an incubator. His response, directed towards a male clinician who had not spoken, was, “No . . . start as you mean to go on I say.” Several interpretations of this response are possible. It could have represented an attempt at humor, though his demeanor did not suggest this, that he was sexist, or that he was fearful of a perceived challenge to his ideas about the role of men in child care. During conversation with the lead author, some staff speculated as to the reasons behind this father’s behavior simultaneously revealing ideas that they held about masculinity: “[I] find that some dads feel it would spoil their ‘macho’ image.” Another suggested wider influence: “Society and its attitudes of course play a part in how fathers are treated/want to be treated on the neonatal unit.” Later observations of the same father holding his infant suggested that his earlier reticence was perhaps driven by fear. One father recalled his feelings during the admission of his infant: “I wasn’t shocked, I wasn’t scared, I wasn’t frightened, I was a little concerned for both . . . [wife’s name] and the baby but nothing overly worried you know.” This recollection concerning the events that took place during his infant’s admission to the NICU, an event characterized by rapid deterioration and emergency intervention are somewhat at odds with observational field notes taken during this time: Once in the allocated cot space the infant’s clinical condition quickly deteriorates over the space of several minutes . . . . In response to this clinical deterioration the nurse practitioner begins endotracheal intubation of the infant assisted by the doc-
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tor. During all this activity, another nurse has moved into the vicinity and stood next to the father. She is giving an explanation and commentary of the events and situation. The father looks visibly very pale and his facial expression gave every indication that he was frightened. He is given a chair to sit on because he became unsteady on his feet. These accounts reveal some of the intense inner turmoil that fathers often experience and how they attempt to deal with the threats and challenges this presents them, often by retreating into previously learned gender based behaviors of emotional disconnection to seemingly protect them from further anguish.
Mixed Feelings Virtually all fathers talked about the tensions they experienced trying to reconcile simultaneously occurring different and opposing emotional states such as joy of birth tempered with anxieties about the welfare of their infants and partners: When I went home that first night I couldn’t sleep at all, not sure if it was because I was excited about being a father or worried about what was happening here [on the neonatal unit]. You know it’s all a bit scary; the first few days were a bit too emotional for me. Another father noted: I was really looking forward to being a father, but not this [points around the unit]. I’m happy being a father. I don’t think it was until probably we came down, [to the neonatal unit], I came down went back to the wife then came back a couple of other times then I went home [short pause], that’s when it hits you, I didn’t know what to do I was really happy and scared for the baby and . . . [partner name] at the same time. In the United Kingdom, transition to fatherhood is often marked by culturally and socially determined celebrations. In conversation many fathers spoke about their plans to delay birth celebrations: “I shall go out with my mates for a few beers when he [infant] comes home. Then I know everything is going to be OK, right now there is too much to worry and think about.” One father recalled going out to celebrate the birth but remarked on the
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Fathers’ experiences are influenced by a complex interplay between events, their relationships with others, and their perceptions of role responsibilities.
apprehension he felt as he tried to reconcile the joy of celebrating becoming a father and having to suppress his fears about his partner’s and infant’s health at the same time: Had a quick drink down the local pub [bar], but I wasn’t ready for a celebration yet. I was talking to people explaining what was happening; I found that I was getting myself worked up again, people in the pub and my friends phoning up as well to see how . . . [partner name] was and how the baby was. To tell them what was going on was all a bit, well it brought it all back and I kept trying to put it at the back of my mind as best I could. But when you were talking about it again it felt quite emotional. For some recollections from around the time of birth seemed to be upsetting: Baby was moving around and everything until what happened. The Midwife broke her waters for her and when that happened the umbilical cord fell down first [cord prolapse – an obstetric emergency] that was a bit of a problem; [long pause, 45 seconds] when he came out he was virtually dead, he just had a heartbeat but weren’t breathing for himself or anything. That was horrible [long pause, 20 seconds].
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Discussion In a recent meta-analysis of studies measuring parental stress in NICUs (Schappin, Wijnroks, Uniken Venema, & Jongmans, 2013), the authors argued that preterm birth is not in itself a source of stress. However, in common with other studies in NICUs we found that stress, fear, anger and anxiety were apparent in fathers (Lindberg et al., 2007; Reid, Bramwell, Booth, & Weindling, 2007; Sloan, Rowe, & Jones, 2008). Health care professionals recognized that becoming a father in a NICU involved experiencing a distressing and stressful life event. Seidler (2007) argued that for some men such emotionality can pose unacceptable risks to their self-identies and well-being. We found that some fathers sought to protect themselves from emotional harm by adopting previously learned stereotypical masculine behaviors and emotional withdrawal. Often during these early encounters their demeanor was inexpressive, seemingly supporting existing ideas about men’s emotional inexpression. We noted this behavior, particularly during the period of infant admission, when fathers were unfamiliar with the culture of the unit. Hochschild (1979; 2003) suggested that this is time when fathers lack insight into the “feeling rules” or what was deemed acceptable behavior for their gender.
This father was clearly very upset by these recollections and experiencing some inner turmoil. During the long silences he did not make eye contact with the interviewer and immediately after the second silence redirected his talk to a more positive aspect of his story.
It is possible that some fathers avoided displaying emotions which they deemed were potentially unacceptable to those around them like nurses; Jugger (1989) referred to these as “outlaw emotions” to highlight their unacceptability in some social contexts. In effect, fathers’ previous life experiences had not prepared them for the events they were experiencing, and feeling less assured, they sought refuge in what they felt would be recognizably conventionally prescribed emotions for their gender. In private they were able to acknowledge these hidden unexpressed or silent emotions. However later with the benefit of some insight into the culture of the unit, fathers realized that what they initially categorized as outlaw emotions were in fact actually permissible within the unit’s feeling rules.
Few staff seemed to incorporate the realities of fathers mixed feelings about preterm birth into their interactions with fathers during the time shortly after admission. However, as time went on many nurses made references during conversations with fathers to balance their concerns with more favorable feelings. To promote this, nurses were observed to encourage beneficial father/infant interactions through interventions like skin-to-skin care.
Men’s behaviors exist within wider sets of general social relationships and ideas about masculinity that sometimes are unquestioned (Hearn, 1996). Prevailing ideas about dominant forms of masculinity requires men’s detachment. Fathers’ desires to be emotionally robust for their partners reveals one of the myths of manhood, that is, men do not have needs of their own because they are strong (Seidler, 2007). Contemporary ideas about
JOGNN, 42, 655-663; 2013. DOI: 10.1111/1552-6909.12256
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what good fatherhood position child care and involvement with family life as important (Fletcher & St. George, 2011; Henwood & Procter, 2003). It is against this confused and conflicting background that fathers are seeking to establish their ideas about fatherhood. The way that individual health care professionals conceptualize (either consciously or not) fatherhood has implications for how they view and judge men’s behaviors. Emotional experience is inherently subjective and its study generates considerable debate (Theodosisus, 2006). Questions about the control of emotions and which emotional displays are condoned are integral to our understanding of fathers’ experiences. Nevertheless, though emotions have social value and that sharing or suppressing them can have important social functions, they are simultaneously private. Emotion management takes place within a complex social and contextual environment (Burkitt, 2002). Ekman (1992) argued that certain basic or core emotions like joy and fear appear to be culturally universal and innate to all. However, built on these basic emotions there is a vast array of culturally determined gender based emotional experiences and behaviors learned through socialization. Kim (2009) suggested that verbal sharing of emotion in social contexts can be suggestive of trust and intimacy. Ideas about dominant forms of masculinity continue to define men’s self identities as self sufficient and independent; consequently, it can be difficult for men to acknowledge and express their emotions (Seidler, 2007). Nevertheless, both men and women constantly engage in internal conversations and personal adjustments to manage and regulate their emotions. In early work, Hochschild (2003) sought to explore the commercialization of emotion management and its consequences for individuals, which placed considerable emphasis on the externalities and interactional aspects of emotion management at the expense of unconscious emotional processes (Burkitt, 2002). This imbalance has led to accusations of conceptual weaknesses (Bolton & Boyd, 2003; Theodosius, 2006). Long silences, a feature of many father’s accounts, suggest a hidden facet of emotion management, one that does not easily transcend into overt expression. The term silent emotion work seems to be a useful label to capture these mutely endured emotions. We suggest this term to acknowledge that emotion management is a conscious and unconscious, expressed and unexpressed emotional process (Theodosius) and to differentiate it from
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Increasing health professionals’ awareness of father’ experiences and emotional management behaviors could help them to better meet fathers’ needs.
Hochschild’s (1979) original conception of emotion work. This study provides insights into the emotional worlds and emotion work of men who are fathers of infants on NICUs. Findings suggest that fathers engaged in a considerable degree of emotion work as they attempted to balance the tensions between what they wanted to feel, what they felt, and what they perceived others wanted their feelings and behaviors to be. Clearly the findings from this single study with a mixed group of respondents, who might have different ways of expressing their emotions, are limited in the ways they expose the early emotional experiences of all fathers of preterm infants. It is also possible that observational data collection influenced behavior. However, we sought to counter this by observing over a prolonged period of time and using additional data collection tools. A further limitation is that the study was restricted to the early period following admission while infants were still residents on the NICU. How fathers’ emotional management evolved beyond this early stage was not the focus of this study. In future research there is a need for additional longitudinal data about how fathers’ emotional experiences and management evolve over time and how fathers manage their emotions in the different macro cultural contexts. Further research is also required to explore factors that facilitate or impinge upon fathers emotional disclosures and how they juggle the competing demands placed upon them after preterm birth. We believe our findings resonate with other studies and suggest that fathers’ experiences in NICUs and their emotion management are more complex than previously suggested.
Conclusion This study was developed to explore fathers’ early experiences with infants in the NICU, and findings reveal some of the sources of father’s emotion work and raise questions about unexpressed emotions and the nature of feeling rules in NICUs. Our analysis adds to the debate about the need to enlarge the concept of emotion work to encompass the inner elements of emotion management that we have labeled “silent emotion work.”
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There are also implications for practice arising from the study. Having an understanding of fathers’ emotional responses to preterm birth and how they seek to manage these emotional demands is paramount to ensure due regard for fathers’ needs. Fathers’ emotional reactions were influenced by interactions between their own, mothers’, and health professionals’ attitudes and behaviors, together with perinatal events and perceptions of father responsibilities. There is potential for nurses to make use of this information to improve interaction and communication with fathers. For example, we suggest that if health care professionals reflect on how their beliefs affect how they interact with fathers, this information could help them provide better support for fathers and the transition to fatherhood. In conclusion, we found a number of enduring features of men’s experiences following preterm birth that support the normative dimensions of men’s emotion work. Furthermore, our results also revealed an unappreciated aspect of men’s emotion management, in particular their silent and unexpressed emotion work.
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Experiences of Fathers Shortly After the Birth of Their Preterm Infants Kevin Hugill, Gayle Letherby, Tilly Reid, and Tina Lavender
Correspondence Kevin Hugill, PhD, RN, School of Health, Brook Building, University of Central Lancashire, Preston, United Kingdom PR1 2HE. [email protected] Keywords emotions emotion work ethnography fathers fatherhood neonatal intensive care unit neonatal nursing
ABSTRACT Objective: To explore the experiences of fathers shortly after the birth of their preterm infants. Design/Method: A focused ethnography conducted over 33 months (2003–2006) in the neonatal intensive care unit (NICU) of a large U.K. National Health Trust (NHS) teaching hospital. Data were collected through participant observation, in-depth interviews with fathers (n = 10), and an ethnographic survey distributed to NICU staff (n = 87). Practices and relationships with fathers were concurrently analyzed thematically through the conceptual perspective of emotion work. Findings: Fathers’ emotional reactions to their experiences were described in three themes: emotional withdrawal and control, stereotyping, and mixed feelings. Fathers’ emotional behaviors were governed by complex, culturally determined conventions and expectations. Conclusions: Fathers engaged in considerable effort to manage their emotions as they attempted to reconcile the tension between what they wanted to feel and what they thought others expected them to feel. The results of this study support the view that focusing on emotional externalities alone tends to underplay the amount of emotion work carried out by less expressive individuals; this “silent emotion work” was characteristic of the fathers in this study.
JOGNN, 42, 655-663; 2013. DOI: 10.1111/1552-6909.12256 Accepted August 2013
Kevin Hugill, PhD, RN, is a senior lecturer at the University of Central Lancashire, Preston, United Kingdom. Gayle Letherby, PhD, is a professor of sociology and the Director of the Institute of Health and Community at Plymouth University, United Kingdom. Tilly Reid, PhD, RN, RM, is a senior lecturer in advanced practice at the University of Cumbria, United Kingdom. Tina Lavender, PhD, RM, is a Dame and professor of midwifery and women’s health at Manchester University, United Kingdom.
The authors report no conflict of interest or relevant financial relationships.
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en’s involvement in family life is changing; increasingly fathers want to become more involved in their children’s lives (Fatherhood Institute, 2011). Despite this, men continue to be viewed as mothers’ supporters or of peripheral importance (Steen, Downe, Bamford, & Edozien 2012). In neonatal intensive care units (NICUs), organizational, interpersonal, and gendered cultural barriers restrict fathers’ greater involvement (Deeney, Lohan, Spence, & Parkes, 2012; Feeley, Sherrard, Waitzer, Boisvert, & Zelkowitz, 2012; Johnson, 2008). Results of neonatal parenthood studies continue to highlight the intensity of feelings that parents experience following preterm birth (Obeidat, Bond, & Clark Callister, 2009). These experiences can have long-lasting social and health implications (Goutaudier, Lopez, Sejourn e, ´ ´ Denis, & Chabrol, 2012; Treyvaud et al., 2011). However, in the past neonatal parenthood researchers infrequently reported fathers’ perspectives. Consequently their voices were often absent or muted from research accounts.
M
Several studies suggested that fathers find preterm birth and admission to a NICU a distressing experience that provokes feelings of in-
tense anxiety, fear, and helplessness (Alderson, Hawthorne, & Killen, 2006; Lee, Miles, & HolditchDavis, 2006; Lundqvist & Jakobsson, 2003). In some cases this might be because they witnessed the resuscitation of their infants (Harvey & Pattison, 2012), sensed they lost control over events (Arockiasamy, Holsti, & Albersheim, 2007), or felt alienated from the experience of fatherhood (Pohlman, 2009). A common worry reported by fathers is the strain relating to difficulties in prioritizing roles of partner, father, and family wage earner ¨ (Lindberg, Axelsson, & Ohrling, 2007; Pohlman, 2005). Conversely other fathers highlighted positive aspects. For example, Lindberg, Axelsson, ¨ and Ohrling (2008) reported that some fathers described preterm birth as giving them greater opportunities to form attachments with their infants because of spending time in the unit. In general, fathers’ courses through their NICU experiences have been described as moving from physical and emotional distance toward closeness (Lundqvist, Hellstrom-Westas, & Hallstrom, ¨ ¨ 2007). Evidence about the usefulness of interventions to support fathers, increase their involvement, and reduce stress experience is mixed. Researchers
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Men’s unique experiences are not well understood, and little is known about how their emotional world views interact with their experiences.
reported few or no effects or different responses to interventions by mothers and fathers (Matricardi, Agostino, Fedeli, & Montirosso, 2013; Ravn et al., 2012). In contrast, others reported measurable positive effects on stress (Lee, Wang, Lin, & Kao 2013). Potential reasons for this could be that mothers and fathers need different interventions or they are context specific. Clearly the culture of fatherhood in NICUs is complex and influenced by individual difference, cultural, and contextual factors. There is a need to better understand fathers’ experiences on NICUs to inform the development of effective initiatives to meet fathers’ needs. Most researchers have paid little attention to how men’s emotional worldviews interact with their experiences of having infants in NICUs. This was the main aim of this study. Specifically, we used the concept emotion work (Hochschild, 1979, 2003) as the theoretical perspective with which to examine fathers’ experiences.
response to the physical, psychosocial, and cultural situations that impose demands on individuals to emotionally react in a particular way. Although some researchers have explored aspects of men’s emotion work in the home and work (Duncombe & Marsden, 1999; Hochschild, 2003, 1994), little is known about men’s emotion management in other settings. We sought to explore fathers’ emotion management in relation to neonatal care.
Methods Ethnography originating from anthropology is a form of social inquiry that is used to understand cultures (Creswell, 2013). Since its beginnings, ethnography has developed numerous distinct forms and traditions and has become a flexible and wide ranging approach to research (Hammersley & Atkinson, 2007). It involves collecting data from multiple sources and emphasizes the exploration of people’s behavior in everyday contexts (Madden, 2010). This method was chosen because it enabled us to study the experiences of fathers following a preterm birth within the culture of a NICU during the first 2 weeks after admission from multiple points of view to gain a more complete picture.
Emotion Work The concept of emotion work was developed by Hochschild (2003) to describe the effort individuals exert while managing their own and the emotions of others. This concept belongs to a group of sociological ideas about emotion labeled “dramaturgical theories of emotions” (Turner, 2009). These ideas draw upon the work of Goffman (1959, 1967) and his notion that society could be explained through the metaphor of a theatrical play in which people act to an audience. Culturally determined rules (normative, feeling, and display rules) about emotion management are learned through socialization (Hochschild, 1979). Crucially these rules are not fixed; they can differ with age, gender, time, place, and social context (Bolton, 2000).
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Emotion work has been widely used to explain how people manage their emotions, particularly within organizational and work environments (Bolton, 2005). Early studies in health care settings highlighted the importance of emotional management in nursing and midwifery practice, and that at times the need to manage one’s own and the emotions of others could be a source of dissonance (Hunter, 1999, 2004; James, 1992; Smith, 1992). In summary, emotion work is a
Many nurses study topics that relate to their practice experiences, and this was the case in this study. In ethnography this is often referred to as “practitioner ethnography” (Barton, 2008). Ethnographic study has many perspectives, including the researcher’s, which is often incorporated through reflexivity. Researcher reflexivity is a particular type of reflection (Alvesson & Skoldberg, ¨ 2009) that can help to balance inside and outside perspectives. In this study, reflexivity took the form of critical self-reflection through that we aimed to account for our subjectivities and research conduct in a transparent manner, a sometimes challenging but ultimately productive process (Hugill, 2012). The lead author is an experienced neonatal nurse and father of preterm children and was the only one who had previously worked on the study unit. The other authors are all female and a midwife, neonatal nurse, and sociologist who brought their own experiences, perceptions, and views to the study, analysis, and representation of the data. This broad base of experience helped to balance insider and outsider perspectives. The study was approved by National Health Service (NHS) and University Research Ethics Committees and all research ethical procedures were followed.
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Setting The study was conducted in the NICU of a NHS teaching hospital in England. The hospital is in a medium-size (population 300,000), ethnically diverse city. The unit has 11 intensive and high-dependency care cots, 12 low-dependency cots, and admitted around 500 infants per year of all gestational ages.
Data Collection Data were collected between November 2003 and July 2006 by the lead author. Field notes were recorded (Hammersley & Atkinson, 2007), including observations on dimensions of the social situation such as the setting, who was present, and what were they doing. Data collection took place at all times of the day and week and involved 260 hours of observation and 206 informal conversations with 68 fathers, 44 mothers, 38 mothers and fathers together, and 56 health care professionals. This activity provided insight into the NICU culture and the behaviors of those present, particularly with respect to how fathers behaved and how they were treated by unit staff. Individual semistructured interviews with 10 fathers lasting between 30– and 108 minutes were carried out and later transcribed by the lead author between 2005 and 2006 in a private room on hospital premises. Five of the men were first-time fathers, and all births except one were singleton with a mean gestational age at delivery of 30 weeks (range 27–35 weeks). Infants were on average nine and a half days old (range 3–15 days) at the time of interview. Fathers’ ages ranged from 20– to 37 years (mean 26 years). Ethnicity was self-attributed and consisted of six White British, one Asian British, one Black British, one mixed Asian/White, and one Mixed White/Black Caribbean. All except one was in paid employment. A broad opening question, “How do you feel about being a father?” was used with all fathers to establish rapport and enable them to tell their stories in a nondirective way. After this, fathers invariably talked at length about their experiences on the NICU. No additional structured questions were included, and any further questions were used to prompt in-depth exploration of pertinent points or clarify and verify meanings of what was said by fathers. After the final interview all staff were invited to participate in an ethnographic survey (Schensul, Schensul, & LeCompte, 1999) that consisted of a series of short statements about fathers’ ex-
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periences drawn from our preliminary analysis of earlier data. The survey tool emerged from our analysis and not a priori. Space was provided for respondents to comment upon each statement in detail with additional space for any further comments about the study. This approach to data collection had two purposes: first, to enable all staff to comment anonymously (because the lead author was known to many of them) on their views, and second by sharing our preliminary interpretive consensus of the data we sought to validate that it reflected what was occurring in the unit.
Data Analysis We used thematic networking techniques to organize the data (Braun & Clarke, 2006) and took a reflexive approach to analysis. Early on in the study all coauthors spent time, individually and together, reflexively developing an understanding of how our backgrounds as researchers, parents, and midwives or neonatal nurses affected the research. This autobiographical, reflexive approach can make useful contributions toward rigor and serve to account for the effects that researchers have on the research design, conduct, and findings (Hugill, 2012). The analysis followed established conventions for qualitative research (Denscombe, 2010), and this process together with extensive reflection on the data, its patterns, and meanings contributed insight into respondents’ thinking and enabled agreement on emergent themes. After analysis of the complete data set, we identified a number of interrelated thematic areas, and in this article we discuss the global organizing theme of fathers’ emotion work.
Findings Our analysis revealed three interrelated themes related to fathers emotion work: (a) emotional withdrawal and control, (b) stereotyping, and (c) mixed feelings.
Emotional Withdrawal and Control For some fathers their first encounter with the NICU provoked what they perceived as a serious loss of control over their emotions, “When I first saw him I broke down, didn’t know what to do, I’ve never done that before” and “I stood there, I looked at him and I cried with joy.” In contrast we found that the majority of fathers were often initially reluctant to reveal their emotions when they first come to the NICU, a situation acknowledged by some staff, as one nurse explained, “Fathers are very unsure of how they should behave; it appears that there is
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often a minimum of emotions.” Indeed many fathers reported how they felt unable to cry. One father gave a detailed account of his internal tension as he sought to control his emotions, demonstrating the dynamic and stressful nature of emotion work: The night he was born, I stood in there; I stood in the intensive care while they were doing what they were doing. I didn’t quite know whether to burst into tears or just stand there. I didn’t cry, but I almost did [short pause]. “Why didn’t you cry?” [Interviewer asked] I don’t know I thought to myself are you going to cry because it’s all emotionally too much with everything that’s happened or is it a bit of a relief that he’s OK or that he’s in distress. I think it might have been a bit of everything, but perhaps I didn’t want to cry in front of other people. Nobody would have batted an eyelid; they must see it all the time. I remember ringing the mother-in-law up, she was at home, just to say everything is fine and I did choke a bit then. Yes and I said to her: “I’m going to cry now” and she said, “it’s all right don’t worry about it you need to let it out a bit, you know.”
upon them was difficult and emotional trying: She [partner] blames herself thinking “oh it’s my fault again he came early,” you know all the usual emotional stuff, the hormones and stuff, so it’s been a pretty trying couple of [short pause], well last few days have been very trying. You know, dealing with her and all that as well as everything else that is going on with . . . [infant name] and still keeping the house going. And work as well, ha [laughs]. Many fathers found it difficult to balance the emotional and physical demands placed upon them following preterm birth. Some sought to protect themselves for emotionally distressing events by hiding their emotions from people, particularly health care staff, who they were unfamiliar with, often seeking solace in privacy. Others were motivated to control their emotions to protect their partners and other family members from further upset and fulfill their self-ascribed role of protectors.
Stereotyping Other fathers waited for a degree of privacy before any overt emotional expression. During conversations three fathers independently recalled that having left the NICU following their first visit they took a short detour before returning to their partners. This detour was to a public toilet where they had cried in private before continuing back to their partners. Some nurses attributed fathers’ reluctance to express emotions to the female dominant gender mix of the unit, a situation in everyday life fathers were unfamiliar with. Alternately some suggested that fathers did not know how to behave because they did not know how the NICU operated and they fell back upon stereotypically masculine norms: “The NICU being a mostly female environment can be overbearing, leaving dads feeling uncertain about what to do.” In contrast some fathers felt their primary role at this time was to be strong for the sake of their families: “I guess the thing is that if I am with my wife or my mother and she is upset I try and play the figure that’s the strong one and hold it all together, look after my children because you can’t do that if you are crying your eyes out.” Some fathers reported that managing the many demands
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During data collection mothers, health care professionals, and some fathers referred to broad gender-based explanations for the way fathers behaved. This prompted us to use the term stereotyping to describe the explicitly gendered aspects of fathers experiences and its effects upon their emotion work. Typically men are characterized as emotionally inexpressive (Seidler, 2007). This point of view was seemingly supported by one less experienced (<2 years neonatal practice) nurse’s comment, “a typical man does not know how to display emotions.” However, in contrast, some of the more experienced nurses recognized that fathers were often experiencing emotions, but that they were different and more subtle than those expressed by mothers: “Fathers experience and display emotions very differently to mothers.” During conversation one father gave credence to assumptions about men’s emotionality suggesting that his apparent lack of emotional upset was due his emotional distance from the birth and typically more masculine rational outlook: I am not as upset as her [mother of infant], not because I’m cold or anything but because I can see it more logically than a mother would, because a mother’s emotions are tightly tied into it [childbirth]. It’s not that
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fathers don’t feel things, but they can see things more logically than a mother can. Even when fathers said they were more emotional than other men, they sought to characterize this emotionality as a feminine trait rather than attribute different emotional world views it to individual difference: I am very much like my mum in terms of personality and emotions. I do try and stem that but it doesn’t always work . . . . My brother is very much like my dad he sees things perhaps a little more clinically I guess, so that it’s more black and white and there is not quite the emotion there. During observation one father was asked by a female nurse if he wanted to change the diaper on his infant who was in an incubator. His response, directed towards a male clinician who had not spoken, was, “No . . . start as you mean to go on I say.” Several interpretations of this response are possible. It could have represented an attempt at humor, though his demeanor did not suggest this, that he was sexist, or that he was fearful of a perceived challenge to his ideas about the role of men in child care. During conversation with the lead author, some staff speculated as to the reasons behind this father’s behavior simultaneously revealing ideas that they held about masculinity: “[I] find that some dads feel it would spoil their ‘macho’ image.” Another suggested wider influence: “Society and its attitudes of course play a part in how fathers are treated/want to be treated on the neonatal unit.” Later observations of the same father holding his infant suggested that his earlier reticence was perhaps driven by fear. One father recalled his feelings during the admission of his infant: “I wasn’t shocked, I wasn’t scared, I wasn’t frightened, I was a little concerned for both . . . [wife’s name] and the baby but nothing overly worried you know.” This recollection concerning the events that took place during his infant’s admission to the NICU, an event characterized by rapid deterioration and emergency intervention are somewhat at odds with observational field notes taken during this time: Once in the allocated cot space the infant’s clinical condition quickly deteriorates over the space of several minutes . . . . In response to this clinical deterioration the nurse practitioner begins endotracheal intubation of the infant assisted by the doc-
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tor. During all this activity, another nurse has moved into the vicinity and stood next to the father. She is giving an explanation and commentary of the events and situation. The father looks visibly very pale and his facial expression gave every indication that he was frightened. He is given a chair to sit on because he became unsteady on his feet. These accounts reveal some of the intense inner turmoil that fathers often experience and how they attempt to deal with the threats and challenges this presents them, often by retreating into previously learned gender based behaviors of emotional disconnection to seemingly protect them from further anguish.
Mixed Feelings Virtually all fathers talked about the tensions they experienced trying to reconcile simultaneously occurring different and opposing emotional states such as joy of birth tempered with anxieties about the welfare of their infants and partners: When I went home that first night I couldn’t sleep at all, not sure if it was because I was excited about being a father or worried about what was happening here [on the neonatal unit]. You know it’s all a bit scary; the first few days were a bit too emotional for me. Another father noted: I was really looking forward to being a father, but not this [points around the unit]. I’m happy being a father. I don’t think it was until probably we came down, [to the neonatal unit], I came down went back to the wife then came back a couple of other times then I went home [short pause], that’s when it hits you, I didn’t know what to do I was really happy and scared for the baby and . . . [partner name] at the same time. In the United Kingdom, transition to fatherhood is often marked by culturally and socially determined celebrations. In conversation many fathers spoke about their plans to delay birth celebrations: “I shall go out with my mates for a few beers when he [infant] comes home. Then I know everything is going to be OK, right now there is too much to worry and think about.” One father recalled going out to celebrate the birth but remarked on the
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Fathers’ experiences are influenced by a complex interplay between events, their relationships with others, and their perceptions of role responsibilities.
apprehension he felt as he tried to reconcile the joy of celebrating becoming a father and having to suppress his fears about his partner’s and infant’s health at the same time: Had a quick drink down the local pub [bar], but I wasn’t ready for a celebration yet. I was talking to people explaining what was happening; I found that I was getting myself worked up again, people in the pub and my friends phoning up as well to see how . . . [partner name] was and how the baby was. To tell them what was going on was all a bit, well it brought it all back and I kept trying to put it at the back of my mind as best I could. But when you were talking about it again it felt quite emotional. For some recollections from around the time of birth seemed to be upsetting: Baby was moving around and everything until what happened. The Midwife broke her waters for her and when that happened the umbilical cord fell down first [cord prolapse – an obstetric emergency] that was a bit of a problem; [long pause, 45 seconds] when he came out he was virtually dead, he just had a heartbeat but weren’t breathing for himself or anything. That was horrible [long pause, 20 seconds].
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Discussion In a recent meta-analysis of studies measuring parental stress in NICUs (Schappin, Wijnroks, Uniken Venema, & Jongmans, 2013), the authors argued that preterm birth is not in itself a source of stress. However, in common with other studies in NICUs we found that stress, fear, anger and anxiety were apparent in fathers (Lindberg et al., 2007; Reid, Bramwell, Booth, & Weindling, 2007; Sloan, Rowe, & Jones, 2008). Health care professionals recognized that becoming a father in a NICU involved experiencing a distressing and stressful life event. Seidler (2007) argued that for some men such emotionality can pose unacceptable risks to their self-identies and well-being. We found that some fathers sought to protect themselves from emotional harm by adopting previously learned stereotypical masculine behaviors and emotional withdrawal. Often during these early encounters their demeanor was inexpressive, seemingly supporting existing ideas about men’s emotional inexpression. We noted this behavior, particularly during the period of infant admission, when fathers were unfamiliar with the culture of the unit. Hochschild (1979; 2003) suggested that this is time when fathers lack insight into the “feeling rules” or what was deemed acceptable behavior for their gender.
This father was clearly very upset by these recollections and experiencing some inner turmoil. During the long silences he did not make eye contact with the interviewer and immediately after the second silence redirected his talk to a more positive aspect of his story.
It is possible that some fathers avoided displaying emotions which they deemed were potentially unacceptable to those around them like nurses; Jugger (1989) referred to these as “outlaw emotions” to highlight their unacceptability in some social contexts. In effect, fathers’ previous life experiences had not prepared them for the events they were experiencing, and feeling less assured, they sought refuge in what they felt would be recognizably conventionally prescribed emotions for their gender. In private they were able to acknowledge these hidden unexpressed or silent emotions. However later with the benefit of some insight into the culture of the unit, fathers realized that what they initially categorized as outlaw emotions were in fact actually permissible within the unit’s feeling rules.
Few staff seemed to incorporate the realities of fathers mixed feelings about preterm birth into their interactions with fathers during the time shortly after admission. However, as time went on many nurses made references during conversations with fathers to balance their concerns with more favorable feelings. To promote this, nurses were observed to encourage beneficial father/infant interactions through interventions like skin-to-skin care.
Men’s behaviors exist within wider sets of general social relationships and ideas about masculinity that sometimes are unquestioned (Hearn, 1996). Prevailing ideas about dominant forms of masculinity requires men’s detachment. Fathers’ desires to be emotionally robust for their partners reveals one of the myths of manhood, that is, men do not have needs of their own because they are strong (Seidler, 2007). Contemporary ideas about
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what good fatherhood position child care and involvement with family life as important (Fletcher & St. George, 2011; Henwood & Procter, 2003). It is against this confused and conflicting background that fathers are seeking to establish their ideas about fatherhood. The way that individual health care professionals conceptualize (either consciously or not) fatherhood has implications for how they view and judge men’s behaviors. Emotional experience is inherently subjective and its study generates considerable debate (Theodosisus, 2006). Questions about the control of emotions and which emotional displays are condoned are integral to our understanding of fathers’ experiences. Nevertheless, though emotions have social value and that sharing or suppressing them can have important social functions, they are simultaneously private. Emotion management takes place within a complex social and contextual environment (Burkitt, 2002). Ekman (1992) argued that certain basic or core emotions like joy and fear appear to be culturally universal and innate to all. However, built on these basic emotions there is a vast array of culturally determined gender based emotional experiences and behaviors learned through socialization. Kim (2009) suggested that verbal sharing of emotion in social contexts can be suggestive of trust and intimacy. Ideas about dominant forms of masculinity continue to define men’s self identities as self sufficient and independent; consequently, it can be difficult for men to acknowledge and express their emotions (Seidler, 2007). Nevertheless, both men and women constantly engage in internal conversations and personal adjustments to manage and regulate their emotions. In early work, Hochschild (2003) sought to explore the commercialization of emotion management and its consequences for individuals, which placed considerable emphasis on the externalities and interactional aspects of emotion management at the expense of unconscious emotional processes (Burkitt, 2002). This imbalance has led to accusations of conceptual weaknesses (Bolton & Boyd, 2003; Theodosius, 2006). Long silences, a feature of many father’s accounts, suggest a hidden facet of emotion management, one that does not easily transcend into overt expression. The term silent emotion work seems to be a useful label to capture these mutely endured emotions. We suggest this term to acknowledge that emotion management is a conscious and unconscious, expressed and unexpressed emotional process (Theodosius) and to differentiate it from
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Increasing health professionals’ awareness of father’ experiences and emotional management behaviors could help them to better meet fathers’ needs.
Hochschild’s (1979) original conception of emotion work. This study provides insights into the emotional worlds and emotion work of men who are fathers of infants on NICUs. Findings suggest that fathers engaged in a considerable degree of emotion work as they attempted to balance the tensions between what they wanted to feel, what they felt, and what they perceived others wanted their feelings and behaviors to be. Clearly the findings from this single study with a mixed group of respondents, who might have different ways of expressing their emotions, are limited in the ways they expose the early emotional experiences of all fathers of preterm infants. It is also possible that observational data collection influenced behavior. However, we sought to counter this by observing over a prolonged period of time and using additional data collection tools. A further limitation is that the study was restricted to the early period following admission while infants were still residents on the NICU. How fathers’ emotional management evolved beyond this early stage was not the focus of this study. In future research there is a need for additional longitudinal data about how fathers’ emotional experiences and management evolve over time and how fathers manage their emotions in the different macro cultural contexts. Further research is also required to explore factors that facilitate or impinge upon fathers emotional disclosures and how they juggle the competing demands placed upon them after preterm birth. We believe our findings resonate with other studies and suggest that fathers’ experiences in NICUs and their emotion management are more complex than previously suggested.
Conclusion This study was developed to explore fathers’ early experiences with infants in the NICU, and findings reveal some of the sources of father’s emotion work and raise questions about unexpressed emotions and the nature of feeling rules in NICUs. Our analysis adds to the debate about the need to enlarge the concept of emotion work to encompass the inner elements of emotion management that we have labeled “silent emotion work.”
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There are also implications for practice arising from the study. Having an understanding of fathers’ emotional responses to preterm birth and how they seek to manage these emotional demands is paramount to ensure due regard for fathers’ needs. Fathers’ emotional reactions were influenced by interactions between their own, mothers’, and health professionals’ attitudes and behaviors, together with perinatal events and perceptions of father responsibilities. There is potential for nurses to make use of this information to improve interaction and communication with fathers. For example, we suggest that if health care professionals reflect on how their beliefs affect how they interact with fathers, this information could help them provide better support for fathers and the transition to fatherhood. In conclusion, we found a number of enduring features of men’s experiences following preterm birth that support the normative dimensions of men’s emotion work. Furthermore, our results also revealed an unappreciated aspect of men’s emotion management, in particular their silent and unexpressed emotion work.
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