Fathers' Needs and Masculinity Dilemmas in a Neonatal Intensive Care Unit in Denmark.

BACKGROUND: Most healthcare professionals in neonatal intensive care units typically focus on the infants and mothers; fathers often feel powerless and find it difficult to establish a father-child relationship. In family-centered healthcare settings, exploring fathers' experiences and needs is important because men's roles in society, especially as fathers, are changing.
PURPOSE: To describe fathers' needs when their infants are admitted to a neonatal intensive care unit and to discuss these needs within a theoretical framework of masculinity to advance understanding and generate meaningful knowledge for clinical practices.
METHODS: This qualitative study used participant observation, interviews, multiple sequential interviews, and a focus group discussion. Data were analyzed using grounded theory principles.
RESULTS: Analysis of the fathers' needs generated 2 primary themes: (1) Fathers as caregivers and breadwinners and (2) fathers and emotions. Fathers wished to be involved and to take care of their infants but have to balance cultural and social norms and expectations of being breadwinners with their wishes to be equal coparents. IMPLICATIONS FOR PRACTICE/RESEARCH: Health professionals in neonatal intensive care units must be aware of fathers' need and desire to be equal coparents. Nurses should play a key role by, for example, showing that fathers are as important to their infants as are the mothers, helping them become involved in childcare, and ensuring that they are directly informed about their children's progress. Further research in other cultural settings would contribute to knowledge regarding fatherhood and the role of fathers in childcare.

Early parent-child relationships shape a child's development, and fathers' early involvement in childcare has positive effects on children's behavioral, psychological, and cognitive outcomes.1–3 Furthermore, the early father-child relationship has been shown to be protective in the face of family discord, and if the parents are later divorced, the relationship between father and child will likely continue.4

The admission of premature or ill newborns to neonatal intensive care units (NICUs) may make the establishment of the parent-child relationship challenging due to parents' anxiety and despair, medical circumstances, and the physical environments of the NICUs.1,2,5,6 Traditionally, most healthcare professionals have mainly focused on infants and mothers,2,6–8 even though fathers often feel stressed, powerless, and helpless, and find it difficult to establish a father-child relationship.1,6,9,10

Several studies have identified elevated stress levels among parents at NICUs and the ability of various interventional programs (eg, individual support, education, and communication) that investigated how to reduce parental stress levels.11–21 Studies that explored fathers' needs and experiences during their infant's admission to NICUs1,2,7,9,22 found that fathers require interventions that differ from those provided to mothers.17,19

However, no studies that have addressed fathers' specific needs and experiences could be identified. Therefore, a participatory action research (PAR) study23 was instigated to involve fathers, mothers, interdisciplinary healthcare professionals, and managers in designing a NICU that met the needs of both fathers and mothers.24 After initial reading and coding of the material, it became clear that an issue of masculinity was at stake. We, therefore, decided to explore fathers' needs using masculinity as a theoretical framework to gain new insights on the topic.

Masculinity comprises cultural ideals, values, and expectations that form social norms related to men. The social norms of masculinity are changeable, and masculinity varies by culture, ethnicity, time, age, life stage, and group membership.25,26 Connell25,26 has emphasized the need to focus on the relationships and the social practices that men and women are engaged in to define masculinity in specific settings.

Historically, the Danish norms regarding masculinity have implied that men are characterized by their ability to earn a living and protect their families, and this still seems to be the case.27,28 The pride of Danish men is closely associated with being a good provider, and their self-identity and status are influenced by their status in the labor market.27–30

Furthermore, studies have revealed that Danish men suppress their feelings because emotions are culturally perceived as a sign of weakness and boys are brought up to control their emotions. Consequently, men hide their feelings and show a facade of normality and stability when they are psychologically stressed.27,30,31 Most often, men find it hard to talk about their own emotions and if they receive too much compassion, they tend to feel vulnerable. In contrast, when men become fathers, it is more acceptable to discuss their feelings and to show vulnerability; however, it is still important not to lose control. Particularly, when men are in the company of other men, they tend to experience a need for control and autonomy.30

Men's roles in Danish society, particularly as fathers, are changing. The trend seems to be that fathers wish to be involved in their children's upbringing and to have a close relationship with them. Today, couples are likely to equally take part in childcare.27,32–34 However, many fathers express concern about their own abilities in relation to these qualities including having enough time for their child and the ability to fulfill the role as a father.27 Traditionally, leave from work after childbirth was reserved for mothers, and the role of fathers during childbirth was to support their wives.27,28,30 Today, the Danish state supports fathers to take paternity leave for up to 2 weeks during the first 14 weeks after the birth of their child. Afterward, the parents can decide whether and when the fathers should take leave and how much (see Box 1).35 However, it can be difficult to take paternity leave, especially if the management and culture of the workplace do not support it.36

BOX 1. Danish Legislation on Leave Provided for Fathers

Two weeks of paternity leave during the first 14 wk after birth of their child (fully compensated).

After week 14, parents are entitled to take in total 32 wk of parental leave (during the first year of the child's life) or childcare leave (after the first year) (fully compensated). It is up to the parents themselves to decide whether, when, and how much leave the fathers should take.

If infants are expected hospitalized for more than 12 wk, fathers have the right to basic security benefit during the hospitalization period too.17

Fathers on paternity leave often stimulate considerable debate about masculinity, particularly in relation to whether this practice weakens masculinity and their traditional role as fathers.4,27 This demonstrates, despite the Danish legislation (Box 1) and the fact that the father's role has undergone a significant change in previous years, that traditional role expectations remain.30

This article presents within a theoretical frame of masculinity, Danish-speaking fathers' needs when their infants were admitted to the NICU. We aim to facilitate understanding and generate meaningful knowledge for clinical practices.

What This Study Adds

Contributes to a better understanding of the needs of fathers whose infants are in neonatal care units

Elucidates the traditional and cultural norms of men as fathers.

Broadens the basis for a family-centered healthcare practice.

METHODS

This PAR included different qualitative methods across time and contexts and was conducted from August 2011 to January 2013.24

Sample

Fathers to infants admitted to the NICU participated in the study. Initially, several fathers were included through participant observation. Five of the observed fathers were afterward invited to participate in semistructured interviews, and to expand our knowledge, an additional 4 fathers were invited to participate in multiple sequential interviews and all accepted to participate. Furthermore, 12 fathers were invited to participate in a group discussion and 3 accepted. Table 1 presents information about the 12 fathers participating in interviews and the focus group. Two participants (fathers 2 and 3) had earlier NICU experiences.

TABLE 1.

Presentation of the Participants

No.	Age	Infant Born at Week of Gestation	Siblings	Days in NICU	Methods SM/MSI/FG	Number of Interviews	Length of Interviews (min)	Days in the NICU at the Time of Interviews
1	29	Female (35 + 5)	0		SM	1	33	4
2	39	Female (26 + 2)	4		SM	1	25	90
3	31	Male (34 + 0)	1		SM	1	42	8
4	37	Twin female (31 + 2)	0		SM	1	32	38
5	41	Twin male (28 + 5)	0		SM	1	27	57
6	37	Twin male (27 + 0)	1	82a	MSI	11	5-60	2, 6, 7, 12, 18, 21, 24, 25, 26, 33, 59
7	48	Female (32 + 2)	2	29	MSI	7	10-30	14, 21, 23, 24, 25, 29, 32
8	33	Twin male (36 + 0)	0	16	MSI	3	45-60	7, 10, 15
9	30	Male (37 + 1)	2b	64c	MSI	7	15-60	2, 4, 14, 19, 29, 2d, 14d
10	28	Male (26 + 2)	1		FG	1	60	56
11	28	Male (34 + 1)	0		FG	1	60	15
12	31	Female (36 + 5)	0		FG	1	60	13

Abbreviations: FG, focus group; MSI, multiple sequential interview; NICU, neonatal intensive care unit; SM, semistructured interviews.

aThe infants had been admitted at the university hospital for 4 days before moved to the study ward.

bFathers' first child.

cThe infant was hospitalized for 25 days; afterward, he had 2 readmissions (6 and 33 days).

dInterviews were carried out in the readmission period.

Setting

This study was conducted in a 22-bed level II NICU37 at a regional hospital in Southern Denmark, which was providing care for ill newborn infants at gestational age of 28 weeks or more. Per other Danish level II NICUs, immature infants were always resuscitated from gestational age of 24 weeks with the option to resuscitate even 1 week earlier; however, the smallest, immature infants were transferred to the regional level III NICU as soon as possible after birth. The NICU has approximately 600 admissions per year. Most the infants were admitted directly from the delivery room and some from the maternity ward. The presence of parents and siblings was typically unrestricted except in cases with contagious disease. Basic maternal care was possible inside the department while more complex or intensive maternal treatment could necessitate admission to a nearby facility that specialized in maternal diseases. In these cases, the mothers and their infants were together as often as their state of health permitted, and the mothers were later transferred to the neonatal department.

Ethics

In accordance with Danish law, the study was approved by the Danish Data Protection Agency. All the participants were personally informed about the study in writing before consenting to participate. They were informed that participation was voluntary, and not participating would not affect the care of their infants, and that they could withdraw at any time. All the participants' information was anonymized.

Methodology

Multiple methods were used to provide various forms of knowledge on the topic. The data obtained were continuously employed during the next encounter or interview with the fathers or in a new context to gain a deeper knowledge and understanding. The methods used were guided by the wish to generate (1) knowledge of the everyday lives of fathers and the attitude toward fathers in the unit; (2) detailed knowledge of the fathers' experiences, needs, and wishes; (3) new ideas and inspiration; and (4) actions toward a father-friendly NICU. The data for this article were obtained by the methods described later.

The details of the PAR method are described in another article.24

Participant Observation

Participant observation38,39 was conducted to elucidate the everyday lives and cultures of fathers in the NICU. The observer spent time at the clinic, observed the activities of fathers, and talked with them about their daily lives. Besides, the observer talked with the nursing staff about how they involved fathers in childcare activities. During participant observation, field notes were written both as part of data collection and for the observer to reflect on. Observations took place during the day, evening, and night shifts. A student of master's degree in educational anthropology conducted the participant observation and the semistructured interviews, as described later.

Semistructured Interviews

The purpose of the interviews was to elicit fathers' thoughts and expectations of fatherhood, as well as their experiences and needs at the admission in the NICU. During the participant observation, the observer enrolled interviewees with a variety of family constellations in the study; these included both first-time fathers and fathers with older children, like fathers of single infants, and of twins. To gain the fathers' confidence, the observer had informal conversations with them 3 or 4 times before inviting them to participate in semistructured interviews40; 5 fathers were invited and all agreed to participate and provided written consent.

The interviews were structured as informal dialogues with open-ended questions and they took place in an office adjacent to the NICU at a time chosen by the fathers. An interview guide was developed (Box 2). The interviews were subsequently transcribed.

BOX 2. Interview Guide (Semistructured Interviews)

What are your thoughts on fatherhood?

What are your thoughts of being a father your selves?

Please tell me about your experiences and thoughts during the birth of your infant/infants.

Please tell me about your experiences and thoughts at the admission to the neonatal intensive care unit.

Multiple Sequential Interviews

The fathers' needs might change during hospitalization; therefore, the first author (B.N.) invited an additional 4 fathers for multiple sequential interviews and41 all accepted to participate. The purpose was to obtain a broader and more detailed account of the fathers' needs and to explore the researchers' reflections and preliminary knowledge obtained from the participant observation and semistructured interviews in a new context. The 4 interviewees were recruited with the intention of including a variety of family constellations to explore multiple dimensions of fatherhood. The interviews were conducted regularly throughout the hospitalization. The interview locations were chosen on the basis of the fathers' preferences, for example, in the patient rooms, when the fathers cared for their infants, during walks, or in the parents' living room in the NICU. Occasionally, both parents were present at the first meeting because mothers were often the gatekeepers. Intentionally, the mothers were not present during the follow-up interviews because we wanted the fathers to be able to speak freely about their positive and negative experiences without having to consider their partners' opinions.

At each interview, an appointment for the next meeting was scheduled. The interviewer encouraged the fathers to talk about their thoughts, worries, and needs associated with having their wives and newborns hospitalized. The interviews were conducted as an informal dialogue beginning with opening questions such as, “How are you today?” and “What are you doing?” Afterward, the conversation evolved through open-ended questions such as, “What do you think?” and “What is in it for you?” Immediately after the interviews, summaries were written. Furthermore, memos were written regarding the researchers' reflections as well as questions to be explored at the next interview or when interviewing other fathers.41

Focus Group

The purpose of this activity was to stimulate discussion, reflection, and to confirm the researcher's reflections and analysis of the data obtained from the different activities provided.42,43 Twelve Danish-speaking fathers, whose infants were admitted in the NICU the week before the focus group was scheduled, were invited to participate in focus group verbally and in writing by the families' contact nurses and the researcher. Three agreed to participate and they provided written consent. B.N. served as moderator. As this group was small, the last author participated in the focus group to ensure that the informants felt comfortable, instead of just being an observer. The focus group was recorded and partially transcribed.

Analysis

As the field of study was relatively unexplored, and the aim was to uncover what was at stake for the participants, the analytical approach followed the principles of Grounded Theory as defined by Charmaz.41 According to this approach, it was important to follow participants' understanding of the matter as well as to investigate what concerns participants might have.41 Through a consistent investigation of what participants express in combination with reading relevant theoretical literature, grounded theoretical concepts slowly emerged.41,44 We pooled transcripts from all 4 approaches and in the first step, the field notes, transcriptions, and summaries were repeatedly read to enable familiarity with the text. The next step was initial open coding, which was done to reveal the informants' views (ie, “what is happening”). Then, focused coding, within and across the different data sets, was performed to enable categorization of the initial codes into more abstract, general, and analytically inclusive codes pointing to themes.41 As our first coding pointed toward a gender theory, we reanalyze our data using a theoretical framework of masculinity in relation to norms in Danish culture as identified by the Danish researchers Reinicke and Madsen.27–31 Analyses were performed by B.N. Data collection, analyses, and results were discussed with the coauthors.

RESULTS

Based on the analysis, 2 main themes, each with a number of subthemes, were generated (Table 2). These main themes and subthemes are presented in the section later and illustrated with quotations from the interviews.

TABLE 2.

The Main Themes and the Subthemes Generated From the Data

Main Theme	Subthemes
Fathers as caregivers and breadwinners	Gender role “If it had been a normal delivery I think the mother would have just taken the lead, and I would have been left out thinking ‘oh well, everything is fine.’” Being a father to the infant “I think it is difficult to handle the young boys. Changing diapers and washing. Am I doing it the right way? They are so small, and I am afraid hurting them?” Need for direct information from staff “I think uncertainty is worst—you do not really know how long time you need to continue. If I knew that it would last two months and what would happen in that time, I would better be able to handle it.” A man does his job and earns the money “I can't just stay here during the night; I have to take care of my job.”
Fathers and emotions	Fear of experiencing loss “My child was born by caesarean section, and mother and child were admitted to different wards, so I went back and forth between the two wards.” Want to be the stronger partner “I wish only the first responsible nurse asked me about how I felt, instead of all of the nurses. Thus, everyone in the unit knew that I did not feel quite well, and it was overwhelming.” Talking about feelings “The admission at the university hospital was tough, but I was enable to overcome it. I had a good talk with my relatives and friends and had to come to terms with my experiences.” Need for time-out from the hospital “It is also nice to get to work—to get out and talk to other people.”

Fathers as Caregivers and Breadwinners

Gender Role

From the interviews, the focus group, and the observations, it became clear that most fathers wished to have paternity leave during the first 2 weeks after delivery while their infants were in a critical condition. The families' lives changed and the fathers felt a need to stay in the NICU as much as possible, sharing childcare responsibilities with their partners. However, they were mindful of having to save their paternity leave for later period. One father expressed this by saying,

I think that it is hard not to be in the NICU, and it is hard to leave it all to my wife, but I also want to save my paternity leave for when they get home; it is difficult. (F8)

The fathers expressed their wish to equally partake in childcare, even though they often felt left out if the mothers were healthy, because in that case, the mothers would take the lead in childcare. Moreover, the fathers felt that the staff mainly focused on the mothers and the infants. As one father said, “The focus is on the infant and the mother. As a father, you feel left out” (F11). In contrast, several fathers stated that the mothers were the main and natural caregivers. As expressed by one father, “It is natural that the mother cares for the child. She breastfeeds and everything; it is natural that it is the mother who handles the child” (F11).

Being a Father to the Infant

All the fathers to infants born through Caesarean delivery described how they were given the opportunity to care for their newborns. They were proud and felt great pleasure in this activity although they recognized that it could be difficult for the mother not to be in charge. One father expressed it this way,

During the first three or four days, I was actually the only one who had contact with him. Of course, my wife was sad that she could not be there, but for me it meant that I became closely connected to him, much more than if his mother had been well. (F11)

Several of the fathers stated that they were afraid to hurt their infants because they were so small and fragile, as one father said,

Oh, such a tiny one at 1000 grams; he is extremely small—1000 grams is nothing! I think it was tough at first because I thought that he would break. It is transgressive. I held back a little because I thought he was so tiny. (F10)

The fathers wished that the staff pushed them to take part in childcare even though their infants were small. Often, fathers did not trust their own ability to provide childcare and they required specific instructions on parenting. Being practically involved taught the fathers how to interpret the infants' signals. A father described a situation in which he was caring for his son. The son had raised his arms and the father wished that the staff had explained how he should interpret his signal.

... Tell me what it means when my son raises his arms. It means, “I want peace.” It is helpful to receive specific instructions. Try to interpret it your way [the nurses say]. What am I supposed to interpret? I have no idea. (F10)

Fathers appreciated the staff's presence, as it provided the opportunity to ask questions if they were unsure or needed help. Most of the fathers needed guidance from staff, so that they could take part in childcare. A few informants expressed that they disliked being watched because they wanted to learn activities by themselves. Changing diapers was an example mentioned by one father. When being guided differently by different persons, the fathers described feelings of confusion and frustration. Despite this, most of them wished to be guided by staff, rather than by their partners. The fathers indicated that when they were alone with staff, they had the opportunity to talk freely about their difficulties and felt free to ask important and difficult questions without having to consider their partners.

The fathers wished to participate in important milestones such as their infants' first bath, ceasing use of continuous positive-airway pressure, or transferring from the incubator to the cradle. When they were directly involved, their infants' progress became obvious and they felt a sense of control. These small milestones in the infants' lives were important for the parents. A father described how upset he was when his infants were nestled in a cradle in his absence. He said, “When my sons were taken out of the incubator, unfortunately, I did not participate. They could not wait for me” (F6).

Despite fear and concern for their newborns, the fathers could benefit from their paternity leave during their infants' admission because they were present and took part in their care. Consequently, they were worried about how they would manage when resuming work. As one father said, “What will happen when I start working? I cannot manage to go to the hospital before taking care of our older daughter. It will be awful if I cannot see my newborns and wife for a whole week” (F6).

Need for Direct Information From Staff

The fathers stated that their main role was to fulfill their wives' needs and expectations. If they received the information they needed, they felt a sense of control and managed to protect and support their partners. Importantly, they expressed a need to be directly informed by staff; as one father said, “When my wife passes on the information, a little modification cannot be avoided” (F11).

Fathers who did not stay in the NICU obtained all information about their infants' health and treatment from their partners because the rounds often took place during daytime when they were at work. The wives retold what they remembered and found to be important. Nevertheless, the fathers needed more detailed and technically accurate answers, such as the actual values of the blood test results and not just that “they look fine.” The fathers wished that staff could schedule status rounds with the primary responsible physician when fathers could be present. The fathers had very busy days and they did not manage to ask for these rounds.

A Man Does His Job and Earns the Money

The fathers expressed a need to be present at the hospital and participate in childcare; however, they also had to go to work. Therefore, the fathers were very concerned, which was reflected in the following statement,

I have a tough time keeping my spirits up and going to work at the same time [he wanted to be at the hospital].... I said that I cannot work this weekend, even though I had difficulties saying it because I am a man who carries out my work. (F9)

Fathers spent a lot of time and energy obtaining information about paternity leave but reported not obtaining help and guidance, as needed.

In families with older siblings, the fathers' stress levels increased. “I have never been this stressed before .... I take care of the other children at home and of my job, but I also need to be here—I want to be here, as well” (F9).

Fathers and Emotions

Fear of Experiencing Loss

At admission, all the fathers described their uncertainties because the delivery of their infants differed from what was expected. The fathers usually appeared calm; “but there is chaos inside my mind,” as one father said (F1). The first few hours after delivery, the fathers often sat next to the infants' incubators or cradles because the mothers were either in the recovery room or in the intensive care unit. All fathers felt restless and they were running back and forth to be near their newborns and their wives at the same time. They expressed an inability to relax. The fathers were constantly worried about their infants. What was wrong? What would the infants' future be like? For example, one father stated, “I took four weeks of paternity leave because I did not know if our son would survive. I could not work—I thought of them [mother and child] all the time” (F10). Another father stated,

The following night I had to go home, and it was a long night. I was wondering what was wrong with my son. It was tough to be at home alone and difficult for my wife to be alone in the NICU. (F9)

Want to Be the Stronger Partner

Many fathers did not involve their partners in their anxieties, impatience, and worries because they wanted to protect them and be the stronger partner; however, at the same time, the fathers themselves need support and guidance. Providing and receiving support creates a dilemma for the fathers, as illustrated in the following quotes.

I have to cheer her up, but no one helps me. It is difficult to bear. I do not show that I am burnt out; instead, I suppress my feelings. (F9)

I thought that one of our infants was going to die. I was the only one who knew it. I could not say anything to my wife; she had her own problems and worries ... I could not talk about it until one week later when we talked to a psychologist. (F4)

My wife does not know that I am about to lose patience. I do not dare ask my wife if she is impatient too because she is forced to be in the NICU, as she is breastfeeding the infants. (F6)

Talking About Feelings

Fathers wanted to protect their partners, but they also expressed a need to talk about their own concerns, although it was challenging. “I am not very good at talking about feelings,” as one father said (F11).

Normally, fathers spoke only with their wives and staff during their time in the NICU. Only during prolonged admissions, some of them talked to the other parents. Many of the fathers expressed a need to form part of a network of fathers because they were in the same situation. However, most fathers kept their distance to avoid hurting parents with critically ill infants.

It would be good to have some kind of a network of fathers. We have to be brought together before we can talk to each other, and participation should not be voluntary. (F11)

Fathers wanted to receive social support, hope, and new knowledge and skills through sharing experiences. Clearly, they wished for staff to set up this network. As was told to B.N., after having met in a group session, the fathers knew each other's stories, and this made it easier to start a conversation. A few fathers stated that they received support from colleagues and friends.

Need for Time-out From the Hospital

The fathers had a dilemma between staying in the NICU and the everyday humdrum of life.

Now, all the days are the same, and every day the same things happen. Maybe I am losing patience because nothing happens, and everything has become routine. Of course, it is not like a prison, but maybe it is the perfect time to start working. The situation is stable now. (F6)

The fathers became impatient when their infants' health was stable. They expressed a need for time-out because it was difficult to be in the NICU with little to do; some of them stated that it was a waste of time to be in the NICU.

DISCUSSION

To understand the opinions voiced by fathers in a wider context, a theoretical framework of masculinity in Danish culture provides insight into the expectations of men, fathers, and fatherhood in Denmark.

Gender Roles

Over 3 generations, fathers' desire to have a father-child relationship proves to have become more important and very central today. However, present day fathers are still facing an enormous challenge considering the traditional expectations of men and their roles as fathers.32,33 The dominant discourse in society describes men as the main breadwinners, and only 1 in 3 fathers takes paternity leave beyond the initial 2 weeks when the child is aged 0 to 1 year.45 Managers and other men at the workplace influence new fathers when they negotiate about how much and when they take leave. However, fathers are also influenced by their own ideas of working life, careers, and fatherhood.36 Therefore, it is important to acknowledge that fathers on paternity leave wish to be respected as caregivers by other men.33,36,45

At the same time, as the fathers in our study expressed a wish to abide to culturally sanctioned norms of fathers as breadwinners, they also wanted to be equal coparents, as they required being involved in childcare and taking responsibility for their infants. They wanted to have a close relationship with their infants despite being breadwinners, even though they expressed a dilemma between being with their infants and wives at the hospital and the humdrums of everyday life in the NICU.4,27,30,34 In accordance with the traditional Danish gender roles, some of the interviewed fathers found it natural that mothers were the primary caregivers. Allowing the mothers to be in front could also be a sign of positive masculine values such as sacrificing, loving, and suffering for others coming into play.30

Fatherhood

Today, cultural notions of quality in paternity implies that the father should be involved and have a close father-child relationship27,32,34; however, historically, there is no doubt that mothers have had the primary responsibility for childrearing. Therefore, men need to prove that they are just as capable as mothers and many fathers expressed concerns about their own ability.46 Traditionally, fathers have perceived their own father as a role model. As the fathering role has changed, fathers do not want to have their own fathers as role models, at least not to the same degree as they did previously.27,28,47

The findings in our study indicated the change in the fathering role as the fathers wished to play an active part in the infants' care, to be the stronger partners, to provide support, and to remove any worries, stress, and frustration from their partners' shoulders. Furthermore, they expressed a wish for a network of fathers where they could receive social support.

Although not wanting to expose themselves to the staff, fathers expressed a need to talk about their worries. They needed to have a time-out from the NICU instead of showing their vulnerability and “feeling insane” as expressed by one interviewed father. This emotional challenge could reflect their wish to be perceived as traditional “men in control” who could take care of themselves. Our findings is in accordance with the traditional gender roles in which boys are brought up not to cry. Studies find that men have a need to act and manage any critical situation, because if they collapse, it is perceived as embarrassing.27,28,31

Transferability

In other Western countries, observations of fathers' needs have been published, and interestingly, there seem to be widespread similarities. In accordance with the findings from the present Danish study, previous studies report that fathers want to be present, take responsibility, and be involved in childcare, and by being involved in childcare, they establish a closer father-child relationship.1,48–51 In a Canadian study, researchers found that fathers' involvement was the main theme by which fathers establish a father-infant relationship.10

Studies from France, Canada, Sweden, and Australia found that fathers need to be in control and require to be directly informed by the staff.1,2,5,6,48,50,52–54 Furthermore, a study from England found that fathers hide their own worries and have difficulties talking about feelings and request parent-support networks in the NICU.2,55 Fathers are afraid of hurting their infants and feel that their main role is to support the mothers. However, in a French study, fathers prefer to stand back and not have physical contact with their infants.56 By discussing fathers' needs within a theoretical frame on masculinity, we found that the Danish fathers in our study have to balance cultural and social norms and expectations of being breadwinners with their wishes to be equal coparents.

Our findings indicate that the healthcare professionals must be aware of the cultural expectations of men and fathers and how these norms affect the fathering role when supporting fathers. This awareness is likely to be relevant both for higher-level NICUs in Denmark and in other countries. However, in this process, one has to take into consideration the cultural differences and similarities that apply in the different countries.

Limitations

The study was conducted with a relatively small sample that could limit the generalization of the results. Although the researchers were flexible and the interviews were scheduled at a time and locations of the fathers' choices, it was challenging to make appointments with them because of their busy schedules. If the time of the project had been extended, more fathers could have been enrolled; however, this was not possible in the context of this project. Although the small sample size implies a limitation to the study's reliability, the validity was strengthened by incorporating multiple sequential interviews and a strategic sample of fathers. Subsequently, the themes that evolved during the initial data analysis were validated in a group discussion with fathers.42 Moreover, the data were obtained across time and context and the fathers' experiences were studied as closely as possible. What was learned in one context was further explored in more details in a new context. Through this iterative data collection, saturation was reached and the process yielded in-depth data with multiple approaches supporting the general validity of the data. Furthermore, to document results and demonstrate validity, quotes from most of the participants were included.

Previous research has shown that men might perceive interviews as intimidating for their masculinity and self-control57; to avoid this, we included both formal interviews and informal conversations. The trust and confidentiality between the fathers and B.N. was strengthened by ongoing conversations during the data collection period. These informal conversations provided the opportunity to gain a more nuanced and fuller story of the fathers' experiences and needs during the hospitalization because the stories were told while they occurred.41 By following the fathers over time, the “impatience” theme surfaced. This theme may not have been expressed if we had interviewed the fathers only once.

A critical reflection on the gender of the interviewer and the gender of the analytic team is important. The primary interviewer and project lead, B.N., was of advanced years, which could have prompted the fathers to speak more freely and voluntarily: Talking to a female interviewer who was the same age as their own mothers and who could be considered “grandmotherly” may have made them feel that they did not have to be in control or appear to be a strong man.27

Both genders were equally represented in the research team and the ongoing discussions of data between the authors strengthened the coding and data reliability.58,59

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PROFESSIONAL DEVELOPMENT

This study investigated the needs of Danish fathers when their infants were admitted to a Danish NICU and it contributed to a better understanding of fathers' needs in this context. By discussing fathers' needs within a theoretical frame of masculinity, traditional and cultural norms of men as fathers were elucidated. These norms and expectations affect fathers' potential of enacting fathering roles. Fathers want to be involved and responsible in childcare but have to balance cultural and social norms and expectations of being breadwinners with their wishes to be equal coparents. Healthcare professionals in NICUs must be aware of fathers' needs and desires to be equal coparents. Nurses should play a key role in this regard by, for example, telling fathers that they are as important to their infants as are the mothers, helping them become involved in childcare, and ensuring that they are directly informed about their infants' progress. The knowledge gained broadens the basis for a family-centered healthcare practice, where healthcare professionals met the needs of both fathers and mothers. Further research in other cultural settings and at other levels of NICUs would contribute to knowledge regarding fatherhood and the role of fathers in childcare, and likewise research in how paternal involvement will affect the father-infant relation after discharge may provide valuable information on the topic.

Summary of Recommendations for Practice and Research

What we know:	Fathers want to participate in the care of their infants. Fathers are torn between being with the mother and the newborns at the hospital, at work, or at home with older siblings. Fathers want to support their wives and be the stronger partner. Fathers experience stress and their needs for support are not addressed.
What needs to be studied:	How different cultural expectations affect fathers' potential to assume fathering roles. How staff can allocate time to support both fathers and mothers, while also caring for the child. Interventions that address the needs of fathers and, therefore, reduce parental stress.
What we can do today:	Recognize that fathers are competent and important caregivers as are mothers. Support fathers in achieving a sense of control while family members are hospitalized. Involve fathers in childcare. Make sure that fathers are informed by staff about their infants' health and treatment. Organize networks of fathers for sharing experiences. Be conscious of cultural norms and expectations regarding men and fathers.