Introduction
ore than 15% of newborns are admitted to Neonatal Intensive Care Units (NICUs) because of prematurity [1]. The rate of infant prematurity in Iran is 10% [2]. The premature infant is a baby born before 37 weeks of pregnancy [3]. Many infants after birth experience problems and need special care. Premature birth creates a stressful and critical situation for parents [4]. They are often confronted with challenges to play their parental role; the challenges that may have a long-lasting impacts on the family function [5]. Nurses have a unique opportunity to help parents during this situation. Parents of premature infants, because of these challenges and stresses, need social support [6]. It is important to reduce their stress during hospitalization of their premature infants. If sufficient social support is provided during the hospitalization, their stress can considerably decrease [5]. 
The active involvement of parents in caring for their infants is one of the best and most effective ways to reduce parental stress [7]. Support of parents is in line with family-centered care and aims to enable them to play their parental roles and support them in stressful situations [8]. Therefore, different organizations should support the parents to positively influence and promote infant health [3]. One of the important responsibilities of nurses in NICUs is to provide family-centered care and increase the favorable outcomes. For this purpose, perceiving the needs of parents are very important. Inappropriate response to parents may cause anxiety and fear in family members [9]. Parents’ anxiety increase with the prolongation of their infants’ hospitalization. In this regard, they require social support and attention due to suffering high stress and anxiety [10, 11].
Social support is defined as interpersonal transactions that include emotional support, affirmational support, and concrete support. Emotional support is the sense of liking, admiration, and respect and involves care, sympathy, love, and trust. Affirmational support affirms functions and statements. Concrete support includes financial and informational aids and giving time [12]. Social support may has a facilitating role in stress tolerance and a prominent role in the individual health [12, 13], and can reduce postpartum depression, increase self-confidence in coping with stress, have positive effects on physical and mental health and increase the parent›s life satisfaction [14, 15]. 
One of the most important aspects of nursing profession is the quality of communication between nurses and parents [15]. The balance between meeting the needs of patients and providing social support to their families can have great influence on the treatment satisfaction as well as improving the environmental quality of the care for the newborns [16]. A study showed that parents of preterm infants hospitalized in the NICUs experience higher levels of stress and a feeling of hopelessness, and some measures are needed for providing support to them during this critical period [17]. However, Abedyazdan’s study showed no relationship between supporting the parents of premature infants and parental stress and satisfaction [18].
Various aspects of social support, especially emotional support, have a protective effect on mental health. Social support also plays an important role in treatment satisfaction. Since the patients and their families are at the center of care, their satisfaction can indicate the correct process of providing care services [19]. This study aimed to examine the relationship between social support and parental satisfaction with the treatment of premature infants admitted to NICUs. The results can help nurses encourage parents to talk about their emotions, stress, and concerns more easily. Moreover, by identifying related factors, a higher level of nursing care quality can be achieved.

Materials and Methods
This is an analytical/correlational study. The study population consists of all parents with premature infants admitted to the NICUs in three hospitals affiliated to Tehran University of Medical Sciences (TUMS). Of them, parents of 130 premature infants were selected using a convenience sampling method and based on inclusion criteria (having a premature baby aged 28-37 weeks, the ability of parents to read and write in Persian, no congenital and neuromuscular anomalies in infants, no previous experience of having a baby admitted to the NICU or a premature infant, admission of the infant to the NICU at least in the past 3 days, availability of parents) and exclusion criteria (critical conditions that can lead to instability in parents or infants, and unwillingness to participate in the study). The sample size was determined considering α=0.05, test power (1-β)=0.8 and r=0.25 [19]. Sampling was performed from January to May 2015 for about 6 months.
Their demographic characteristics including infants’ gender, type of delivery, birth rank, infant’s weight, duration of hospitalization, and parents’ occupation and educational level were first recorded according to the parents’ reports or the infants’ records. After obtaining a written informed consent from the parents and ensuring the confidentiality of their information, two questionnaires were distributed among them including: Social Support questionnaire [19] and Neonatal Index of Parent Satisfaction (NIPS) [20]. The social support questionnaire has 21 items; the first 7 items are about the affirmational support; next 6 items are related to concrete support, and 8 remaining items measures emotional support. Its total scores ranges from 0 indicating no need for social support, to 6 indicating the highest level of need for social support. The content validity for the Persian version of this tool was evaluated by ten faculty members of the School of Nursing and Midwifery at TUMS and the necessary modifications were made according to their comments. The Cronbach’s alpha for its reliability was measured by participation of the parents of 25 premature infants. The obtained value for its sub-scales varied from 0.76 to 0.8. The NIPS evaluates the parental satisfaction with medical care provided in the NICU containing 24 questions rated on a Likert scale from 1 (always or not satisfied) to 7 (never or completely satisfied). The total score ranges from 24 to 168, where the higher score indicates more satisfaction. This questionnaire was used in Iran by Kadivar et al [21] and they reported a Cronbach’s alpha of 0.7. In our study, the Cronbach’s alpha coefficient for the subscales of NIPS varied from 0.86 to 0.9.
The collected data were analyzed in SPSS V. 20 software using descriptive (frequency, mean and standard deviation) and inferential statistics (t-test, chi-square, and ANOVA) to analyze the relationships between variables. Correlation between variables was considered significant if P<0.05.

Results
In this study, 130 fathers and mothers of preterm infants were participated. Most mothers were delivered for the first time, with a birth weight > 2000 g (1880.97± 544.85 g) and most of them (86.9%) had cesarean section. The economic status of the most of parents was at moderate level (Table 1).
 

The results indicated that the mean general social support was 3.21±0.56 perceived by fathers and 3.52±0.65 received by mothers. The mothers received more social supports in all three areas of affirmational, concrete and emotional. Also, the most of social support perceived by fathers (3.29±0.57) and mothers (3.65±0.69) was related to emotional support, while the lowest support perceived by the fathers (3.16±0.65) and mothers (3.32±0.80) was related to the concrete support. Mothers had more satisfaction with medical care (3.88±0.81) than fathers (3.63±0.69) (Table 2).



Pearson correlation test results showed that the overall score of social support and its three components had a significant relationship with the mothers and fathers’ satisfaction with medical care (P=0001) (Table 3).



Comparison of social support and satisfaction between mothers and fathers using t-test showed that the level of social support and satisfaction in mothers was higher than in fathers. Chi-square test results showed the lowest satisfaction was in fathers with self-employment and middle school education aged 35-40 years, and in mothers aged 30-35 years with high school diploma and housekeeping occupation. The highest level of social support was reported in mothers and fathers with middle school education and the lowest social support was in mothers with elementary education and fathers with high school diploma. One-way ANOVA results showed that between-group and within-group difference in parental satisfaction and social support was not significant.

Discussion
The results of this study showed that the highest level of social support perceived by parents was related to the emotional support, while the lowest level was related to the concrete support. Fathers received less social support than mothers. Satisfaction with infant care was also reported higher in mothers than in fathers. Regarding the social support of parents with premature infants and its relationship with parental satisfaction, a number of studies have been conducted. Oomen et al. [22] showed that social support is vital for parental with infants admitted to NICUs, and nurses should be encouraged to acquire communicative skills and provide social support for parents. In their study, fathers wanted more help and support from the nurses. Parents needed more concrete support and received more emotional support, which is consistent with our results. We found in our study that parents experience a lot of stress in NICU and it is necessary that nurses pay attention to them and provide support to them. A study reported that mothers experienced more stress than fathers in areas related to the ward’s sounds and lights, staff behavior and communication, NICU-related parental role, and the infant’s health and behavior. The most stressful factor for parents was the change in their role after their infant›s admission to NICU [23]. Another study showed that parents of premature newborns had higher levels of stress and anxiety even two months after discharge of their infants from the hospital compared to the parents of full-term infants [24]. In a meta-analysis, inconsistent with the current study, the stress experienced by parents of premature infants was also reported higher than that of parents with full-term infants [25]. This is consistent with the current study. Most studies, like our study, have shown that mothers in the NICU experience more stress and anxiety than fathers [26, 27, 28]. In our study, mothers had received more support than fathers. A study in Iran showed that the most important support received by mothers were informational-communication support and quality care support. Moreover, the difference between perceived importance and received support were statistically significant for four dimensions of parental support [3]. In another study, it was also shown that the parents of premature infants, especially mothers, experience higher stress in the NICU [29], and the stressors were factors that can cause stress and worry in parents. Therefore, their need for social support is essential. 
Regarding the parents’ satisfaction with the NICU care of their premature infants, our results showed that mothers were more satisfied than fathers; however, parents were not satisfied with the performance of NICU staff in some areas. Ahmadi et al. showed that mothers of preterm infants receive more social support than fathers, and more emotional support is provided to their fathers. Also, parents were satisfied with social support [30]. It seems that it is necessary to provide education for nurses in this field and also for the parents of premature infants. Consistent with our findings, a study concluded that women express their satisfaction more than men, and that the length of their stay in the NICU has a direct impact on their satisfaction [31]. A study by Karlsson et al reported that the highest level of satisfaction in family members was related to psychological support, and the lowest satisfaction was related to feeling comfortable in the department [32]. These findings are consistent with our results.
Regarding the relationship between social support and parents’ satisfaction with provided care to their premature infants in the NICU, results revealed a positive significant correlation between them. The results of Shahkolahi showed that affirmational and emotional support for the parents of premature infants had a positive effect on their satisfaction [33]. Affirmational support is a component of social support that can have a positive effect on the patients’ satisfaction. Finally, the results of this study indicated that most of the parents needed support from the NICU nurses in all dimensions of social support. It is necessary to provide more social support and pay more attention to the needs of parents with premature infants. By developing programs for this purpose, the satisfaction of parents with the NICU services and family-centered care can be improved.
This study had some limitations including high noise level in the NICU and parents’ concentration problems when answering the questions. In our study, factors such as parents’ age and educational level and duration of hospitalization in the NICU could affect the level of perceived social support. Therefore, it is suggested that other factors affecting social support should be studied. Further studies are recommended on evaluating the effect of an educational program for nurses on the quality of social support provided to the parents.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Tehran University of Medical Sciences in Iran (Code: IR.TUMS.REC.1394.215).

Funding
This article was extracted from the master thesis of first author approved by Tehran University of Medical Sciences.

Authors contributions
Conceptualization, funding acquisition, and data analysis: Mona Mohtashami and Zahra Ahmadi; Data collection: Malihe Amerian and Marzieh Faghani Aghoozi; initial draft preparation: Malihe Imeni and Mona Mohtashami; editing & review: All authors

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank all the study participants and personnel of NICUs in three hospitals and Tehran University of Medical sciences for their valuable cooperation.

References