Susceptible to disruption of the interactive process between parent or significant other and child that fosters the development of a protective and nurturing reciprocal relationship

NANDA-I approved*

Treatment Related

Related to interruption of attachment process secondary to:

Parental illness

Infant illness

Related to barriers to attachment secondary to:

Anxiety *

Child's illness prevents effective imitation of parental contact*

Disorganized infant behavior*

Inability of parent to meet personal needs*

Insufficient privacy*

Parental conflict resulting from disorganized infant behavior*

Physical barrier*

Substance misuse*

Parent-child separation*

Restricted visitation policies

Situational (Personal/Environmental)

Related to unrealistic expectations (e.g., of child or self)

Related to unplanned/unwanted pregnancy

Related to disappointment with infant (e.g., gender, appearance)

Related to ineffective coping associated with new infant and other responsibilities secondary to:

Health issues

Mental illness

Relationship difficulties

Economic difficulties

Related to lack of knowledge and/or available role model for parental role

Related to physical disabilities of parent (e.g., blindness, paralysis, deafness)

Related to being emotionally unprepared due to premature delivery of infant

Maturational

Adolescent Parent

Related to difficulty delaying own gratification for the gratification of the infant

Premature infants

AUTHOR'S NOTE

This diagnosis describes a parent or caregiver at risk for attachment difficulties with his or her infant. Because the hospital stay will be limited, a home health nurse or the postpartum office follow-up will be addressing this diagnosis in the home. Barriers to attachment can be the environment, knowledge, anxiety, and/or health of parent or infant. This diagnosis is appropriate as a risk or high-risk diagnosis. If the nurse diagnoses a problem in infant-parent attachment, the diagnosis Risk for Impaired Parenting related to difficulties in parent-child attachment would be more useful so that the nurse could focus on improving attachment and preventing destructive parenting patterns.

Level 1 Fundamental Focused Assessment (all settings)

Does the parent make eye contact with the infant?

When the infant is brought to the parent, do they reach out and call the infant by name?

Do the parents talk to the infant and describe family resemblances?

When holding the child, what kind of body contact is observed? Closeness?

Do the parents talk to the infant? Maintain eye contact with the infant?

What kind of affection do the parents demonstrate as they are smiling, talking, rocking?

How do they comfort the fussy infant? Rocking, stroking, kissing, talking?

The parent/primary caregiver will demonstrate increased attachment behaviors, such as holding the infant close, smiling and talking to the infant, and seeking eye contact with the infant, as evidenced by the following indicators:

• Be supported in his or her need to be involved in infant's care.
• Begins to verbalize positive feelings regarding infant.
• Engages in infant/child care.

Level 2 Extended Interventions (delivery room, postpartum, primary care, community)

Identify factors that can negatively influence the bonding process. When risk factors have been determined prenatally or postpartum, a referral should be made to engage a community health nurse for post-transition to home.

Maternal Considerations

• Unwanted pregnancy
• Prolonged or difficult labor and delivery
• Postpartum pain or fatigue
• Lack of positive support system (mother, spouse, friends)
• Lack of positive role model (mother, relative, friends/neighbors)
• Inability to prepare emotionally (e.g., an unexpected delivery)

Inadequate Coping Patterns (One or Both Parents)

• Financial/economic stress
• Alcoholism
• Drug addiction
• Marital difficulties (separation, divorce, violence/abuse)
• Change in lifestyle related to new role
• Adolescent parent
• Career change (e.g., working woman or mother)
• Illness in family

Infant

• Premature birth, congenital anomalies, illness
• Multiple births

Promote Bonding Immediately after Delivery and during the Postpartum Phase (Durham & Chapman, 2014)

• Encourage mother to hold the infant after birth (mother may need a short recovery period).
• Provide/encourage skin-to-skin contact, such as touching, stroking hair, or holding a diapered infant next to her bare chest.

R:Phillips focused on the first hour after birth and reported skin-to-skin contact influences the release of the hormone oxytocin, which was shown to "increase relaxation, attraction, facial recognition, and maternal caregiving behaviors" (2013, p. 68).

• Praise the mother/father for care provided to the infant.
• Explain that an infant can recognize his or her mother's voice and to speak to the infant in a soft, soothing tone.

R:DeCasper and Fifer (*1980) reported that a newborn could discriminate between different recorded female voices and showed a preference for his or her mother's voice. Providing these data to mothers can increase verbalization, which increases bonding development.

• Provide the mother with an opportunity to breastfeed immediately after delivery if possible.
• Give the family as much time as they wish together with minimum interruptions from staff.
• Encourage the father to hold the infant.
• Provide culturally appropriate support to the family.
• Check the mother regularly for signs of fatigue, especially if she received anesthesia.
• Offer flexible rooming-in to the mother; establish with her the care she will assume initially and support her requests for assistance.

R:The strength or weakness of maternal-newborn bonding will positively or negatively impact many aspects of the mother and child's lives (Barker et al., 2017).

Attempt to Eliminate or Reduce Barriers to Effective Bonding/Parenting

The majority of the following interventions will occur in the community (e.g., ambulatory health, primary care, or home setting).

Illness/Fatigue

• Establish with the parent/caregiver what infant care activities are feasible.
• Provide the parent/caregiver with uninterrupted sleep periods of at least 2 hours during the day and 4 hours at night. Provide relief for discomforts.

Lack of Experience or Positive Parenting Role Model

• Explore parenting feelings and attitudes concerning their own parents.
• Assist the parents/caregivers to identify someone who is a positive parent; encourage the parent/caregiver to seek that person's aid/advice.
• Outline the teaching program available during and after hospitalization.
• Determine who will assist the parent at home initially.
• Identify community programs and reference material that can increase parental learning about childcare after discharge (e.g., support groups, mother/baby group activities).

R:The person can learn the expectations and responsibilities of each role as they grow by observing others of those same roles around them. By identifying those role models and how effective/positive they are, the new parent/caregiver can transition into their newest role (Durham & Chapman, 2019).

Lack of Positive Support System (Ball et al., 2017)

• Identify the parent's support system; assess its strengths and weaknesses.
• Assess the need for counseling.
• Encourage parents to express feelings about the experience and about the future.
• Observe the parents interacting with the infant.
• Assess for resources (financial, emotional, and cultural) already available to the family.

Explore with Parent(s) Cultural Beliefs That May Affect the Family Unit during Hospitalization

Communicate cultural preferences to nursing staff. If uncertain, explain the intervention and seek their opinions.

• Support mother-infant-family cultural beliefs.
• Integrate culture and traditions into routine care when possible.
• Identify community resources.

R:Nurses should be aware of the cultural diversity among their populations and know how to attain information and resources concerning culture beliefs or practices that he/she is not familiar with (Kyle & Carman, 2013).

Explore the Birthing Experience and Provide Clarification and Support to the Parents (Durham & Chapman, 2019)

• Listen to the mother's replay of her labor and delivery experience and evaluate for possible red flags or concerning statements.
• Allow for verbalization of feelings.
• Indicate acceptance of feelings.
• Point out the infant's strengths and individual characteristics to the parents/caregivers.
• Demonstrate the infant's responses to the parents/caregivers.

Assess the Need to Support the Parents/Caregivers' Emerging Confidence in Child Care (Durham & Chapman, 2019)

• Observe the parents/caregivers interacting with the infant.
• Support each parent/caregiver's strengths.
• Help parents understand the infant's cues and temperament.
• Assist each parent in those areas in which he or she is uncomfortable (role modeling).
• Assess the parents for their level of knowledge in growth and development; provide information as needed.
• Provide handouts, audiovisual aids, and appropriate Internet resources for the parent/family at their level of understanding and language.

For Adoptive Parents

• Counsel adoptive parents that many emotions are normal on the first interaction with their children.
• Counsel adoptive parents about the possibility of postadoption depression.
• Encourage adoptive parents to seek parenting classes before receiving their infant.

R:Adoptive parents do not always have the same opportunities to prepare for the child's arrival as their biologic parent counterparts do. There are not always as many resources available to them. The nurse can help connect the adoptive parents with available resources in their area. The sooner the adoptive child is able to be placed into the care of their adoptive parents, the sooner child-adoptive parent bonding can be enhanced. (Hockenberry, Rodgers, & Wilson, 2018).

Initiate Appropriate Referrals

Consult with community agencies for follow-up visits if indicated.

• Refer parents to pertinent organizations/specialists in their area.