"to save them we have to hurt so many other parts of them": Clinician perceptions of stress in infants undergoing cardiac surgery

Stressful encounters within the neonatal or early infant period are harmful both acutely and longitudinally. Prior research on stress exposure in hospitalised infants excludes infants with CHD, limiting our understanding of stress exposure in this uniquely vulnerable population. This study aimed to identify and describe sources of stress, stress cues, stress responses, and clinical implications in neonates and infants undergoing cardiac surgery. Conducted at tertiary cardiac centres, 17 expert clinicians in nursing, anaesthesia, surgery, and intensive care medicine were included. Participants represented two care areas (cardiac intensive care unit, operating room) and three phases of care (preoperative, operative, postoperative). Using individual semi-structured interviews informed by Selye's General Adaptation Syndrome, clinicians were asked about their perceptions of sources of infant stress within each phase of care and signs or cues of overwhelming stress or of stress tolerance. Utilising semantic content analysis, responses were analysed thematically and by frequency. Seven themes were identified involving sources of infant stress (Clinical Environment, Operative Stress, Disrupted Bonding, Cardiac Physiology), and clinician recognition and response to infant stress (Cognitive Integration, Infant Protection, Balance of Care). Perceived sources of infant stress were identified and together describe infant stress burden related to cardiac surgery. This study highlights the concept of infant stress specific to cardiac surgical intervention and offers a foundation to recognise and address infant stress as part of comprehensive cardiac care. The results may inform future research evaluating stress exposure and determining whether stress reduction strategies can improve outcomes in this high-risk population.