Implementation of Nurse’s Listening Visits in Improving Emotionally Distressed Mothers in Neonatal Intensive Care Unit: A Scoping Review

1. Introduction

The degree of emotional distress experienced by mothers of infants in neonatal intensive care units (NICUs) is a significant concern for maternal and neonatal health. Recent studies have underlined the extent of this problem, with rates of depression and anxiety among NICU mothers far exceeding those in the general postpartum population (Asha et al., 2023; Kouri et al., 2023). Hawes et al. (2016) found that mothers of premature infants in the NICU face a much greater risk of developing postpartum depression, while Leahy-Warren et al. (2020) reported that up to 40% of these mothers exhibit depressive symptoms within the first year after discharge. NICU admission can be particularly stressful for mothers, impacting their mental health and quality of life (Asha et al., 2023). Interventions like listening visits (LVs) provided by NICU nurses have been explored to address this distress, with research indicating the potential for reducing maternal depression early on, especially in highly distressed women (Serge et al., 2023; Kouri et al., 2023). However, the effectiveness of LVs compared to usual care remains inconclusive. Maternal psychological distress in the NICU can also be influenced by factors such as intolerance to uncertainty and the availability of informal and formal support systems, emphasizing the importance of family-centered care approaches (Miri, 2022).

One of the new avenues of promise in meeting the emotional needs of mothers in the NICU is through nurse listening visits (Serge et al., 2024; Davila and Segre, 2018; Ahn and Kim, 2004). This intervention creates an atmosphere that harnesses compassionate care principles, where a trained nurse will offer focused and non-judgmental listening time to emotionally distraught mothers. Segre et al. (2024) explained that the visits were structured in such a way that psychosocial support needed to take the form of active listening, mood validation, and problem-solving, all collaboratively done by the nurse with the mother. Other than providing immediate emotional support, as indicated, through visits, it may significantly improve the self-esteem of mothers, enhance attachment of mother and infant, and bring improvement in postpartum depression symptoms. Indeed, recent adaptations, including telehealth listening visits, have done much to provide accessible support in the most challenging of circumstances, such as through the COVID-19 pandemic.

For various reasons, addressing emotional distress in a neonatal intensive care setting is very critical. Maternal mental health dramatically influences an infant's well-being and development. McGowan et al. (2017) found discharge readiness in neonatal ICU babies is strongly connected to maternal mental health, which suggests that an emotionally well-prepared mother is done with preparations for an infant's care after discharge. This might be the explanation for the long-term effects of unreceived emotional distress on both mother and child. Beck, 2003, emerges to underscore the cardinality of identification and intervention in case of postpartum depression in mothers with Neonatal ICU babies very early before poor outcomes set in. Furthermore, such emotional support during a neonatal intensive care unit stay can positively affect maternal self-esteem and family function, as Ahn and Kim showed in their 2004 research on home-visiting discharge education.

This scoping review synthesizes the literature from 2010 to 2024 on the implementation, effectiveness, and outcomes of nurse-led listening visits (NLVs) in the NICU to address maternal emotional distress (Davila & Segre, 2018; Segre et al., 2022). It explores various aspects of NLVs, including different models, their impact on maternal mental health, and their integration into standard NICU care. This review is timely, given the evolving landscape of neonatal care and the increasing recognition of maternal mental health's importance in holistic care (McCabe-Beane et al., 2018). Investigating the best practices, challenges, and future research directions, this review aims to inform clinical practice, policy development, and research efforts to ensure comprehensive emotional support for mothers in the NICU.

2. Methods

This scoping review was conducted following the methodological framework developed by  Arksey and O'Malley in 2005 and subsequently updated by Levac et al. in 2010. The authors (HSG and RTV) utilized this methodology to review the included articles. Moreover, The methodological strategy to develop the scoping review explicitly followed the standard reporting of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018), ensuring transparency and reproducibility (see Figure 1).

2.1 Five Stages of the Review Process

The review was conducted through five different stages. The first stage includes the formulation of research questions. The primary question to guide the review process in this review was: "What is the role of Nurse's listening visits in improving and supporting emotionally distressed mothers in NICU's?" developed using the Population, Concept, and Context framework.

The second stage was to do search recovery and retrieval and include the development of a comprehensive search strategy. The search included relevant key terms in conjunction with/without Medical Subject Headings from "NICU," "mothers," "emotional distress," "nurse's listening visits," and "psychosocial support." Searched databases included Embase, Science Direct, PubMed, Google Scholar, Scopus, and Web of Science. The search was conducted in studies published between January 2010 and March 2024.

The third stage includes study selection. Two reviewers independently screened the title, abstract, and full-text review of potentially relevant articles. Disagreements were solved by discussion or consultation with a third reviewer.

Moreover, the fourth stage was information organization, and the data extraction was carried out by filling out a standard form developed explicitly for this review. The forms elicited information on study characteristics, intervention characteristics, outcomes measured, and main findings.

The final stage of the review process was the recording of results. This includes synthesizing the findings, presenting them in a narrative form, and structuring them with thematic presentation, which answers the research question and the review's objectives.

Figure 1 Study flowchart

2.2. Sources of Information and Searches

We designed the nucleated search strategy to be broad and sensitive enough to retrieve all relevant literature. Our search included Boolean operators (AND, OR) and combinations of search terms and truncation symbols to pick up varieties in terminology (Villarino et al., 2022a). The initial search strategy was developed for PubMed and then translated into commands that suit others. This strategy was substantiated through hand-searching in the reference lists of all qualified inclusion studies and relevant reviews. ProQuest Dissertations & Theses Global and relevant conference proceedings were searched for gray literature.

2.3. Inclusion and Exclusion Criteria

2.3.1 Inclusion Criteria:

• Research relating to mothers of infants in the NICU
• Interventions including listening visits by a nurse or other psychosocial support delivered by a nurse
• Studies examining emotional distress, depressive or anxious state, or other similar psychological consequences.
• Individual studies comprising randomized controlled trials, quasi-experimental studies, cohort studies, case-control studies, and studies in a qualitative design.
• Published in the English Language during the Period from January 2010 through to March 2024
• Full-text articles

 2.3.2 Exclusion Criteria:

• Studies that focus on fathers only or other family members.
• Interventions do not involve nurses or do not specifically address emotional support.
• Studies do not report relevant outcomes linked to maternal emotional well-being.
• Review articles, editorials, or opinion pieces. Human studies published in or earlier than 2010 or after March 2024

 2.4. Selection of Relevant Studies:

A two-tier screening process was conducted. The first is the title and abstract screening, which includes two independent reviewers who screened through titles and abstracts of articles that pass the title and abstract screening processes. Articles that do not meet the level of criteria we will be working with here are excluded.

The second part of the screening process involves a full-text review, which constitutes the reviewers in the first screening, procuring the full texts of all potentially eligible articles and making independent assessments. Excluded studies at this stage documented reasons for exclusion. Differences between the two authors were resolved by discussion in cases of inconsistency, and a third reviewer was consulted if needed.

 2.5 Methodological quality

After determining the articles included in this review, the mixed methods appraisal tool (MMAT) was used to assess the methodological quality of the articles. The MMAT was developed by Pluye et al. (2009) and Hong et al. (2018) for appraising mixed methods research and primary studies, and it has been used in various contexts, including scoping reviews (Hong et al., 2018). Additionally, the MMAT provides a systematic and transparent approach to quality assessment, allowing researchers to evaluate the strengths and limitations of the included studies and make informed decisions about their inclusion in the review (Villarino et al., 2022b).

The MMAT was chosen for the quality assessment of these 42 articles due to its versatility in evaluating diverse study designs within a single review. This scoping review includes qualitative, quantitative, and mixed methods studies, making the MMAT an ideal tool for comprehensive quality appraisal. The MMAT allows for a consistent approach to quality assessment across different methodologies, enabling a more holistic understanding of the methodological rigor of the included studies. Its use in this context aligns with best practices in scoping review methodology, as Tricco et al. (2018) outlined in the PRISMA-ScR guidelines.

3. Results

3.1 Study Design and Mixed Methods Appraisal Tool (MMAT) Assessment

Table 1 provides a comprehensive overview of the included studies (n=38) examining the implementation and impact of nurse-led listening visits on emotionally distressed mothers in neonatal intensive care units (NICUs), assessed using the Mixed Methods Appraisal Tool (MMAT). The studies encompass a variety of research designs, including cross-sectional, randomized controlled trials (RCTs), qualitative, systematic reviews, cohort studies, case studies/pilot studies, mixed methods, literature reviews/perspective pieces, and quasi-experimental studies. For each study, the table outlines the critical MMAT criteria relevant to its design, aiding in assessing methodological quality and rigor. This overview facilitates a vital appraisal of the evidence-based nurse-led listening visits. It identifies areas for future research to enhance the support of mothers in the NICU context.

 Table 1. Study Design with the corresponding MMAT checklist areas.

The diverse methodologies in Table 1 reflect the multifaceted nature of evaluating the implementation of nurse’s listening visits in the NICU. While some studies, such as RCTs like Shaw et al. (2013), directly assess the effectiveness of listening visits on maternal mental health outcomes, others, such as qualitative studies like Bry & Wigert (2019), offer valuable insights into the lived experiences of mothers and nurses, enriching our understanding of the intervention's implementation and impact. Including systematic reviews further strengthens the evidence base by synthesizing findings from multiple studies.

Furthermore, the variability of the MMAT assessment highlights the importance of critical appraisal when interpreting the findings and considering the implications for practice. Although the evidence for the effectiveness of listening visits is promising, some studies have limitations, such as small sample sizes and potential biases, warranting further investigation. The MMAT assessment also highlights the need for more research examining the long-term effects of listening visits and the mechanisms through which they influence maternal well-being.

3.2 Methodological Quality

Table 2 (see attached Table 2 file)  presents a comprehensive Mixed Methods Appraisal Tool (MMAT) assessment of the 38 studies investigating the implementation and impact of Nurse’s Listening Visits (NLV) on emotionally distressed mothers in neonatal intensive care units (NICUs). The assessment evaluates the methodological rigor of these studies across various research designs, including qualitative, randomized controlled trials (RCTs), systematic reviews, and mixed methods. The table highlights the strengths and weaknesses of each study, guiding future research and clinical practice by identifying areas for improvement in the study of this intervention.

The scoring system includes two screening questions (S1 and S2) and specific criteria for different study types:

1. Qualitative studies (1.1-1.5) aim to understand participants' subjective experiences and perceptions. Criteria include the research question, data collection, analysis, credibility, and transferability.
2. Quantitative randomized controlled trials (2.1-2.5): RCTs are experimental studies that compare the effects of two or more interventions. Criteria include the research question, randomization, allocation, blinding, outcomes, and analysis.
3. Quantitative non-randomized studies (3.1-3.5): Non-randomized studies do not use random assignment to compare groups. Criteria include the research question, data collection, analysis, confounding factors, and generalizability.
4. Quantitative descriptive studies (4.1-4.5): Descriptive studies describe the characteristics of a population or sample. Criteria include the research question, sampling, data collection, analysis, and validity.
5. Mixed methods studies (5.1-5.5): Mixed methods studies combine quantitative and qualitative research methods. Criteria include the research question, sampling, data collection, analysis, and methods integration.

Each criterion is scored as 'Yes,' 'No,' or 'Can't Tell.' The overall quality of a study is determined by the number of 'Yes' responses.

Most studies (28 out of 38) demonstrated methodological robust quality, meeting most or all of the MMAT criteria for their respective study designs. This robust body of evidence indicates that NLV is a well-researched intervention with a strong foundation of evidence. For instance, Shaw et al. (2013) and Welch et al. (2016) conducted randomized controlled trials (RCTs) that met most MMAT criteria, providing experimental evidence for the efficacy of NLV.

Secondly, the reviewed studies encompass various methodologies, including qualitative studies, RCTs, systematic reviews, cohort studies, cross-sectional studies, and mixed methods approaches. This diversity strengthens the evidence base by providing multiple perspectives and data types on NLV. For example, Bry & Wigert (2019), Heidari et al. (2013), and Feeley et al. (2016) conducted qualitative studies that consistently met all MMAT criteria, suggesting a strong foundation for understanding the lived experiences of NICU mothers and nurses implementing NLV.

Thirdly, systematic reviews, such as Asha et al. (2023), Cano Giménez & Sánchez-Luna (2023), and Dol et al. (2019), all met all MMAT criteria, providing high-quality syntheses of existing evidence on NLV and related interventions. This highlights the importance of systematic reviews in comprehensively understanding the evidence base.

Fourthly, cross-sectional studies and cohort studies, such as Hawes et al. (2016), McCabe-Beane et al. (2018), Golfenshtein et al. (2021), and Holditch-Davis et al. (2014), demonstrated methodological solid quality, offering valuable quantitative data on the impacts of NLV.

However, some studies, particularly literature reviews and mixed methods studies, showed moderate quality, often due to unclear ethical considerations or integration of processes. This suggests areas where future research could strengthen methodological rigor. For example, Beck (2003), Davila & Segre (2018), and Barr (2022) demonstrated moderate quality, often due to unclear ethical considerations or integration of methods.

Ethical considerations were also a concern in several studies, especially literature reviews. This highlights an area for improvement in future research on NLV in NICU settings. Researchers should ensure that ethical considerations are reported to maintain the integrity and reliability of the study’s findings (Villarino et al., 2023a).

The range of study designs and consistently high methodological quality suggest that the evidence base for NLV is comprehensive, covering various aspects from implementation to effectiveness and lived experiences. This extensive coverage provides a robust foundation for understanding the intervention's impact and potential applications. Finally, while many studies provided strong evidence, there appears to be a need for long-term follow-up studies to understand the sustained effects of NLV beyond the immediate NICU stay.

3.3. Distress of mothers who Experience NICU.

The following table presents a thematic analysis of the 38 included studies focusing on the distress experienced by mothers in the Neonatal Intensive Care Unit (NICU). This analysis aims to identify common themes across the literature and provide insights into the various aspects of maternal distress in the NICU setting.

Table 3. Thematic Analysis of Maternal Distress in NICU Settings.

The thematic analysis of the 38 included studies reveals several key aspects of maternal distress in the NICU setting. These themes highlight the complex and multifaceted nature of mothers' emotional challenges during this critical period.

1. Anxiety and uncertainty emerge as predominant themes across multiple studies. Hawes et al. (2016) found that social-emotional factors significantly increase the risk of postpartum depression in mothers of preterm infants. This anxiety is often rooted in the unpredictable nature of the NICU experience, as highlighted by Jubinville et al. (2012), who observed symptoms of acute stress disorder in mothers of premature infants.
2. The challenge of separation and bonding is another crucial aspect of maternal distress. Fleck (2019) emphasized the importance of connecting mothers and infants in the NICU, recognizing the potential long-term impacts on attachment. Holditch-Davis et al. (2014) further explored this theme, examining the effects of maternally administered interventions on maternal psychological distress and mother-infant relationships.
3. Postpartum depression emerges as a significant concern for NICU mothers. McCabe-Beane et al. (2018) highlighted the importance of anxiety screening during the assessment of emotional distress in mothers of hospitalized newborns. Segre et al. (2018) explored depression management by NICU nurses, emphasizing the critical role of healthcare providers in addressing maternal mental health.
4. The traumatic nature of the NICU experience is evident in several studies. Shaw et al. (2013) conducted a randomized controlled trial on preventing traumatic stress in mothers with preterm infants, underlining the need for early interventions. Feeley et al. (2011) found that post-traumatic stress persisted among mothers of deficient birth weight infants even six months after discharge from the NICU.
5. Role alteration and loss of control are significant contributors to maternal distress. Heidari et al. (2013) explored parents' experiences with infants in the NICU, highlighting the challenges in adapting to new parental roles. Franck et al. (2017) examined the perinatal-neonatal care journey for parents of preterm infants, identifying areas for improvement in supporting parental involvement and control.
6. Social isolation and lack of support are recurring themes in the literature. Leahy-Warren et al. (2020) investigated the experiences of mothers with preterm infants within the first year post-discharge from NICU, emphasizing the importance of social support in mitigating depressive symptoms. Kouri et al. (2023) further explored the relationship between depression and loneliness among parents of premature infants admitted to the NICU.

These themes emphasize the need for comprehensive, multifaceted interventions to support NICU mothers. The studies collectively point to the importance of early screening, ongoing psychological support, and interventions that address not only the immediate emotional needs of mothers but also the long-term implications for maternal-infant bonding and family well-being. Future research and clinical practice should focus on developing and implementing interventions that address these various aspects of maternal distress in the NICU setting.

 3.4. Nurse’s listening visits

Table 4 presents the themes highlighting nurse's listening visits in the NICU setting. The analysis identifies common themes across the included studies (n=38) and briefly discusses the corresponding theme about nurse's listening visits. This thematic breakdown offers insights into the various aspects of this intervention and its impact on emotionally distressed mothers in the NICU.

 Table 4. Thematic Analysis of Nurse's Listening Visits in NICU Studies.

The included studies reveal several critical insights into nurse's listening visits in the NICU setting:

1. Implementation and Effectiveness: Studies by Segre et al. (2024, 2022, 2018) and Chuffo Siewert et al. (2015) provide valuable insights into the practical aspects of implementing nurse listening visits. These studies highlight the importance of proper training for nurses and the need for a structured approach to these interventions.
2. The effectiveness of these visits in reducing maternal distress is well-documented in randomized controlled trials (Shaw et al., 2013; Welch et al., 2016; Samra et al., 2018; Labib et al., 2021), providing strong evidence for their positive impact on maternal mental health.
3. Maternal Experiences: Qualitative studies (Bry & Wigert, 2019; Heidari et al., 2013; Feeley et al., 2016) offer rich, contextual data on mothers' experiences with nurse listening visits. These studies consistently report themes of feeling heard, validated, and supported, underscoring the psychological value of these interventions beyond measurable mental health outcomes.
4. Mother-Infant Bonding: Research by Holditch-Davis et al. (2014), Golfenshtein et al. (2021), and Ahn & Kim (2004) demonstrate that nurse listening visits can positively influence mother-infant bonding. By addressing maternal distress, these interventions appear to enhance mothers' capacity to connect with and care for their infants, potentially improving long-term outcomes for both mother and child.
5. Cultural Adaptations: Studies by Valizadeh et al. (2012), Kouri et al. (2023), and Papadopoulou et al. (2020) highlight the importance of cultural sensitivity in implementing nurse listening visits. These findings suggest that while the core principles of emotional support are universal, delivering such support may need to be tailored to different cultural contexts to maximize effectiveness.
6. Long-term Outcomes: Longitudinal studies (Leahy-Warren et al., 2020; Feeley et al., 2011; McGowan et al., 2017) provide valuable insights into the lasting effects of nurse's listening visits. These studies suggest that early emotional support in the NICU can have enduring benefits for maternal mental health and potentially for child development. However, more research is needed in this area.
7. Integration with Other Interventions: Research by Franck et al. (2017), Kestler-Peleg (2022), and Dol et al. (2019) explores how nurse listening visits can be integrated with other NICU interventions. These studies emphasize the importance of a holistic approach to supporting NICU families, suggesting that emotional support should be considered a key component of comprehensive NICU care.

The themes demonstrate that nurse listening visits are a promising intervention for supporting emotionally distressed mothers in the NICU. The evidence suggests that these visits can effectively reduce maternal distress, improve mother-infant bonding, and potentially have long-lasting positive effects. Future research should focus on refining implementation strategies, exploring cultural adaptations, and investigating long-term outcomes for mothers and infants. Additionally, more studies are needed on integrating nurse's listening visits with other NICU interventions to develop comprehensive, family-centered care models.

 3.5 Improving Emotionally Distressed Mothers in Neonatal Intensive Care Unit

The following table presents evidence-based recommendations for improving the emotional well-being of distressed mothers in the Neonatal Intensive Care Unit (NICU) using nurse's listening visits. These recommendations are derived from a thematic analysis of 38 included studies, which revealed key aspects of maternal distress and the potential benefits of nurse's listening visits in the NICU setting.

Table 5. Evidence-Based Recommendations for Nurse's Listening Visits to Support Emotionally Distressed Mothers in the NICU.

The recommendations presented in Table 5 are grounded in the comprehensive findings from the included studies and address the multifaceted nature of maternal distress in the NICU setting.

Addressing Anxiety and Uncertainty: Nurse's listening visits can play a crucial role in mitigating anxiety and uncertainty, which Hawes et al. (2016) identified as significant risk factors for postpartum depression in NICU mothers. By providing regular, scheduled visits, nurses can offer consistent support and information, helping to alleviate the acute stress symptoms observed by Jubinville et al. (2012). The recommendation to teach anxiety management techniques during these visits is supported by the work of Shaw et al. (2013), who demonstrated the effectiveness of early interventions in preventing traumatic stress.

Enhancing Mother-Infant Bonding: The challenge of separation and bonding, highlighted by Fleck (2019) and Holditch-Davis et al. (2014), can be addressed through nurse-listening visits that facilitate skin-to-skin contact and encourage maternal participation in infant care. This approach aligns with the findings of Golfenshtein et al. (2021) and Ahn & Kim (2004), who demonstrated the positive impact of such interventions on mother-infant relationships.

Addressing Postpartum Depression: The integration of depression screening into regular listening visits, as recommended, is supported by the work of McCabe-Beane et al. (2018) and Segre et al. (2018). This proactive approach allows for early identification and intervention, potentially mitigating the long-term impacts of postpartum depression observed by Leahy-Warren et al. (2020).

Trauma-Informed Care: The recommendation to use trauma-informed care principles during listening visits is based on the findings of Shaw et al. (2013) and Feeley et al. (2011), who highlighted the traumatic nature of the NICU experience and its lasting effects. By providing a safe space for mothers to process their experiences, nurses can help prevent the development of post-traumatic stress symptoms.

Empowerment and Control: Addressing role alteration and loss of control through empowerment and involvement in decision-making is supported by the work of Heidari et al. (2013) and Franck et al. (2017). This approach can help mothers adapt to new roles and regain control in the NICU environment.

Social Support: The recommendation to facilitate peer support connections and provide information about community resources addresses the themes of social isolation identified by Leahy-Warren et al. (2020) and Kouri et al. (2023). This approach recognizes the importance of social support in mitigating depressive symptoms and enhancing maternal well-being.

These evidence-based recommendations provide a comprehensive framework for implementing nurse's listening visits in the NICU. By addressing the key themes of maternal distress identified in the literature, these interventions can significantly improve the emotional well-being of NICU mothers, potentially leading to better outcomes for both mothers and infants.

 Discussion

The scoping review on the implementation of nurse's listening visits in improving emotionally distressed mothers in Neonatal Intensive Care Units (NICUs) reveals several consistent themes across the literature and some unique or contradictory findings.

Similar Themes:

1. Effectiveness of Nurse's Listening Visits:

A consistent finding across multiple studies (e.g., Segre et al., 2024, 2022; Shaw et al., 2013; Welch et al., 2016) is the effectiveness of nurse listening visits in reducing maternal distress in the NICU setting. These interventions consistently show positive impacts on maternal mental health, particularly in reducing symptoms of anxiety and depression.

2. Importance of Early Intervention:

Studies such as Shaw et al. (2013) and McCabe-Beane et al. (2018) emphasize the critical nature of early intervention. Early implementation of nurse listening visits appears to be more effective in preventing the development of severe emotional distress and post-traumatic stress symptoms.

3. Mother-Infant Bonding:

Multiple studies (e.g., Holditch-Davis et al., 2014; Fleck, 2019; Golfenshtein et al., 2021) highlight the positive impact of nurse listening visits on mother-infant bonding. These interventions seem to enhance mothers' capacity to connect with their infants, potentially improving long-term outcomes for both.

4. Need for Cultural Adaptations:

Research by Valizadeh et al. (2012), Kouri et al. (2023), and Papadopoulou et al. (2020) consistently emphasize the importance of cultural sensitivity in implementing nurse's listening visits, suggesting that while the core principles are universal, the delivery may need cultural tailoring.

Differences and Contradictory Findings:

1. Long-term Effects:

While some longitudinal studies (e.g., Leahy-Warren et al., 2020; Feeley et al., 2011) suggest lasting benefits of nurse listening visits, others indicate that the effects may diminish over time. This discrepancy highlights the need for more long-term follow-up studies.

2. Optimal Frequency and Duration:

There is variability in the literature regarding the ideal frequency and duration of nurse's listening visits. Some studies advocate for intensive, short-term interventions, while others suggest a more prolonged, less frequent approach.

3. Integration with Other Interventions:

While some research (e.g., Franck et al., 2017; Kestler-Peleg, 2022) strongly supports integrating nurse's listening visits with other NICU interventions, other studies suggest that these visits are most effective when provided as a standalone intervention.

4. Role of Technology:

Newer studies (Dol et al., 2019; (Villarino et al., 2023b) explore the potential of eHealth interventions, including virtual nurse listening visits. However, there is disagreement about the effectiveness of technology-mediated interventions compared to traditional face-to-face visits.

Significant Implications:

1. Clinical Practice:

This scoping review underscores the importance of incorporating nurse listening visits as a standard component of NICU care. It suggests that healthcare systems should prioritize training nurses in this intervention and allocating resources for its implementation.

2. Policy Development:

The findings support the development of policies that mandate emotional support interventions for NICU mothers, potentially including nurse's listening visits as a required element of care.

3. Education and Training:

The review highlights the need for enhanced education and training programs for NICU nurses, focusing on emotional support techniques and the implementation of listening visits.

4. Research Directions:

This review identifies several areas for future research, including the need for more long-term follow-up studies, investigations into the optimal delivery of nurse's listening visits, and exploration of culturally adapted interventions.

Limitations of the Scoping Review:

1. Heterogeneity of Studies:

The included studies varied widely in their methodologies, making direct comparisons challenging and limiting the ability to draw definitive conclusions.

2. Geographic Bias:

Many of the included studies were conducted in Western countries, potentially limiting the generalizability of findings to other cultural contexts.

3. Publication Bias:

As with many reviews, there is a risk of publication bias, where studies with positive results are more likely to be published and included.

4. Focus on Maternal Outcomes:

While this review focused on maternal outcomes, it may have overlooked potential impacts on infant outcomes or family dynamics.

5. Lack of Economic Evaluation:

The review did not include studies evaluating the cost-effectiveness of nurse's listening visits, which is essential for implementation.

**This scoping review provides substantial evidence supporting the implementation of nurse listening visits in NICUs to improve the emotional well-being of mothers. However, it also highlights the need for further research to address inconsistencies in the literature and to explore the long-term impacts and optimal delivery of these interventions.

 Conclusions

This scoping review on the implementation of nurse's listening visits in improving emotionally distressed mothers in Neonatal Intensive Care Units (NICUs) synthesizes evidence from various studies, providing a comprehensive overview of the current knowledge in this field. The review consistently demonstrates that nurse listening visits are an effective intervention for addressing maternal emotional distress in the NICU setting. These visits have shown positive impacts on reducing symptoms of anxiety, depression, and post-traumatic stress while also enhancing mother-infant bonding and maternal self-efficacy. This scoping review highlights the significant potential of nurses' listening visits as a critical component of comprehensive NICU care. It provides a strong foundation for the further development and implementation of these interventions while also highlighting areas that require additional research and consideration.

6. Recommendations

Based on the findings of this scoping review, the following recommendations are proposed:

1. Clinical Practice:

   - Implement nurse's listening visits as a standard component of NICU care.

   - Initiate listening visits early in the NICU stay to prevent the escalation of emotional distress.

   - Tailor the frequency and duration of visits to individual maternal needs and cultural contexts.

   - Integrate listening visits with other NICU interventions for a holistic approach to care.

2. Policy Development:

   - Develop policies that mandate emotional support interventions, including nurse listening visits, as part of standard NICU care.

   - Allocate resources for the training and implementing nurse listening visits in NICUs.

   - Establish guidelines for integrating listening visits with other NICU care practices.

3. Education and Training:

   - Enhance nursing education programs to include training on emotional support techniques and implementing listening visits.

   - Provide ongoing professional development for NICU nurses to improve their skills in conducting listening visits.

   - Develop cultural competency training to ensure culturally sensitive and appropriate listening visits.

4. Research:

   - Conduct more long-term follow-up studies to assess the enduring effects of nurse's listening visits.

   - Investigate the optimal frequency, duration, and format of listening visits for maximum effectiveness.

   - Explore the potential of technology-mediated listening visits, mainly in contexts where in-person visits may be challenging.

   - Research the cost-effectiveness of implementing nurse's listening visits in various healthcare settings.

   - Investigate the impact of nurse's listening visits on infant outcomes and overall family well-being.

5. Cultural Adaptation:

   - Develop and evaluate culturally adapted versions of nurse's listening visits for diverse populations.

   - Conduct cross-cultural studies to understand how the effectiveness of listening visits may vary across different cultural contexts.

6. Interdisciplinary Collaboration:

   - Foster collaboration between nurses, mental health professionals, and other healthcare providers to enhance the effectiveness of listening visits.

   - Explore the potential for involving other family members, such as fathers or partners, in listening visit interventions.

Implementing these recommendations can help healthcare systems work towards improving mothers' emotional well-being in the NICU, potentially leading to better outcomes for both mothers and infants. However, it is crucial to continue monitoring and evaluating these interventions to ensure their ongoing effectiveness and relevance in diverse healthcare contexts.

Author contributions: Hawraa Hussein Ghafel: Writing – original draft, Supervision, methodology, Project administration, Investigation, Funding acquisition, Data curation, Conceptualization. Resti Tito H. Villarino: Writing – review & editing, Resources, Formal analysis, Data curation.

Funding : the author(s) declare that no financial support was received for the research , authorship and/or publication of this article.

Acknowledgment: We appreciate the efforts and dedication of Dr.Sadeq AL-Fayyadh, Dr.Qahtan Qassem Mohammed, and Dr.Adraa Hussein Shawq, and Dr.Fatimah fadel  (faculty members at College of Nursing, University of Baghdad) for their help.

Declaration of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.