Racial/Ethnic Differences in Stress, Coping, and Distress Among Mothers With a Child in the ICU

Mary E. Ernst, PhD, APRN; Jessica Roberts Williams, PhD, MPH, PHNA-BC; Brian E. McCabe, PhD


Am J Crit Care. 2021;30(4):275-284. 

In This Article

Abstract and Introduction


Background: Having a child in the intensive care unit (ICU) is a stressful event that can cause negative mental health outcomes for parents, but little is known about the experience of parental stress among members of racial/ethnic minority groups.

Objective: To examine the stress and coping process in a racially/ethnically diverse sample of mothers of a child who was acutely admitted to an ICU.

Methods: Participants (N = 103) completed a cross-sectional self-report survey; 86.4% completed it within a week of their child's ICU admission. Analysis of variance was used to examine racial/ethnic differences in perceived ICU-related stressors, coping behaviors, and distress level. Linear regression was used to examine the moderating effects of race/ethnicity on the relationships between stressors, coping behaviors, and distress.

Results: Mothers across racial group experienced similar stressors during the acute phase of their child's ICU admission. African American mothers reported greater overall use of coping behaviors, particularly avoidance coping, and experienced higher levels of distress than did Hispanic or non-Hispanic White mothers. Hispanic mothers experienced the least distress. The interaction of race/ethnicity and emotion-focused coping moderated the stress and coping process.

Conclusions: Racial and ethnic diversity in sampling should be a priority in future studies of the stress and coping process of mothers with a child in an ICU. Critical care nurses should minimize known stressors for these mothers and encourage and support their preferred coping behaviors, recognizing that these may differ across racial/ethnic groups.


Having a child in the intensive care unit (ICU) is a stressful event for parents, who have the potential to develop mental disorders.[1–11] Despite demographic trends in the United States that show increasing numbers of minority children being treated in ICUs—Hispanics and African Americans are the 2 largest minority groups in the United States[12]—most publications on ICU-related parental stress have been focused on non-Hispanic White parents.[1,13–15]

To add to knowledge about the experience of parents from racial/ethnic minority groups, in this study we explored racial/ethnic differences in the stress and coping process of mothers of children who have been acutely admitted to an ICU.

An unexpected illness in or injury of a child that results in an ICU admission is undeniably a stressful experience for the child's parents. The most consistently reported stressors for parents are the child's behaviors and emotions in response to ICU care and the alterations in the parents' role, such as their inability to hold, protect, or comfort their child in the usual manner, causing parents to feel helpless.[8,16–20] Mothers are at the bedside of their critically ill child more consistently, and are more likely to experience distress related to a child's ICU admission, than are fathers.[2,13,14,21,22] Researchers have investigated coping behaviors and their link to stressors and impact on outcomes, with the goal of providing interventions to mitigate negative mental health outcomes in parents, but evidence for and use of specific interventions remain limited.[18,22–26] Research since the early 2000s has been focused on identifying parental predictors of distress and interventions to assist parents in coping.[2,4,5,7,27]

The role that race/ethnicity plays in the experiences of mothers with a child in the ICU is not well established.

Whether race/ethnicity plays a role in the experiences of mothers with a child in the ICU—and if so, what role—is not well established. Research outside the ICU setting has shown race/ethnicity-related differences in how people experience stress, how they cope, and their level of distress.[2,28–30] For example, African Americans use more religious and emotion-focused coping behaviors such as distancing and mental disengagement, whereas non-Hispanic White people more often practice acceptance.[28–30] The few studies comparing the level of distress among racial/ethnic groups have yielded inconsistent results: some found no relationship between race and level of distress, and others showed that posttraumatic stress disorder is more likely to develop in African Americans who experience acute distress than in non-Hispanic White people who experience acute distress.[2,7,29]

We used the Multicultural Model of Stress,[30] an expanded version of the Transactional Model of Stress and Coping developed by Lazarus and Folkman,[31] to inform this study. The Multicultural Model of Stress allows for the explicit inclusion of racial/ethnic diversity in the stress and coping process. In the original Transactional Model of Stress and Coping, an event occurs that leads the individual to a primary appraisal of whether the event is stressful. If it is stressful to the person, a secondary appraisal begins in which the person asks, "What can be done about it?" and implements coping behaviors. The coping behaviors applied affect the adaptational outcome for that individual. In other words, the person changes in a positive way or may experience distress due to the event, depending on how they manage to cope. The Multicultural Model of Stress adds to this appraisal process by considering racial/ethnic variables and their impact on the number of stressors one is experiencing, the way one evaluates the stressful event, available coping options, and one's response to distress.

This purpose of this study was to use a stress process framework to examine race/ethnicity-related differences in the experiences of mothers of a child in an ICU environment. Specifically, we examined stressors that occur in a pediatric ICU (PICU) or a cardiac ICU (CICU) (primary appraisal), coping behaviors mothers use to manage the stress of having a child in the ICU (secondary appraisal), and their level of distress (adaptational outcome). This study evaluated (1) race/ethnicity-related differences in stressors, coping behaviors, and level of distress, (2) the moderating effects of race/ethnicity on the relationship between stressors and coping behaviors when adjusted for socioeconomic factors (ie, age, marital status, education, and income), and (3) the moderating effects of race/ethnicity on the relationship between coping behaviors and level of distress, adjusting for socioeconomic factors. Understanding the impact of race/ethnicity on the stress process in parents is important for informing whether a need exists to adapt interventions in order to support the needs of racially/ethnically diverse parents with a child in an ICU.