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Hospitalisation
Hospitalisation of a child is a stressful experience that can threaten the stability of a family Heur (1993). For the child, hospitalisation is a crisis marked by stress, separation, discomfort, pain and an unfamiliar environment. Parents also suffer from psychological, social, financial, environmental and physical stress Smit (2000). Children do not have fully developed coping skills such as being able to problem solve or make decisions when placed in stressful situations Sheldon (1997).
Various studies were carried out during the 1980's detailing emotional problems that can occur in children as a result of hospitalisation.
Douglas (1975) carried out research that found that all children under 3 years and most under 5 years were emotionally disturbed by hospital admissions. However Rutter (1981) argued that a single hospital admission of less than one week was not associated with long term problems.
The majority of recent research was stimulated by Bowlby (1965) who stated that maternal deprevation could result from separation from the mother or main caregiver. He believed that maternal care was essential for the normal development and mental health of the child and that a prolonged period of deprevation could have serious effects on the child's mental health throughout his/her life.
Robertson (1970) corroborated this view by demonstrating that children, who had been in hospital alone displayed severe behaviour problems upon discharge. In 1953 he described separation anxiety as having 3 stages. Protest at having been left, despair when realising that protests were not working and denial resulting in depression and withdrawal.
Vernon et al (1965) studied the short term effects of hospitalisation on children's behaviour. It was found that in the week following discharge children were more nervous about separation, had difficulty sleeping and appeared more aggressive. Parental involvement was emphasised in the Platt Report (1959). The report suggested that the care of children in hospital should be shared by parents and nursing staff. There should be unrestricted visiting and adequate accommodation for parents especially for those children under 5, and school and recreational play provided. The report suggested that this would help reduce the effects of hospitalisation.
The Which? Campaign Report (1980) found that children were lonely and bored in hospital and that hospitals discouraged parents from staying and many children were still being treated in adult wards.
The Audit Commission (1993) investigated why the principles of The Platt Report were not being met and suggested ways to overcome barriers to achieve good practice.
Separation anxiety is the major source of stress caused by hospitalisation. There are 3 phases to separation anxiety. During the Protest phase Bowlby (1960), Robertson (1953) children cry or scream for their parent, avoid and reject strangers. These behaviours may last from a few hours to several days. During the phase of Despair the child stops crying. The child becomes sad and withdrawn and uncommunicative. The child may also regress in development such as bed wetting or want a bottle or dummy. Robertson (1953).
During the third phase known as Denial or Detachment the child shows an interest in their surroundings interacts with strangers and appears happy. Detachment only usually occurs after a prolonged period of separation from parent.
A major concern of hospitalised school age children is their fear of being told that something is wrong with them. Hart and Bossert (1994)
Although school age children are better able to cope with separation the stress of being in hospital may increase their need for parental support. However they may also react more to being separated from school and friends rather than absence of family. School age children often need more help and support from their family but may be unwilling to ask for it. School age children often strive for independence and are often vulnerable to events that may cause them to lose their sense of control and power. (Freud cited in Ball and Bindler 1999) believes that school age children places great importance on privacy and body understanding. Many hospital procedures can threaten a child's feeling of security, as they do not allow a child to make their own decisions. However when children are allowed some control over their situation they can respond well. (Kohlberg cited in Ball and Bindler 1999) believes that school age children are more able to see others point of view and are able to accept decisions. (Eriksson cited in Ball and Bindler 1999) also discusses how school age children learn to deal with demands or new situations, however failure to do so results in feelings of failure and inferiority. The child takes pride in accomplishment in school, sports and home Ball and Bindler (1999). Boredom often takes over and can lead to depression or frustration. The child's illness may also cause them to feel loss of control.
The school age child defines illness by a set of multiple concrete symptoms such as signs of a cold and views the case as primarily germs or bacteria Wong (2003). (Piaget cited in Ball and Bindler 1999) carried out research that showed children perceive illness as having an external cause but is inside them. Wolfer and Visintainer (1975) identified five areas that concern children when being admitted to hospital. These are physical harm which includes pain and death, separation which may block them from communicating with anyone else, fear of the unknown and uncertainty, the child is in an unknown environment and is often fearful until explanations are given. The last is loss of control. Children often suffer a loss of autonomy in hospital as decision making is placed in the hands of others.
Siblings often imagine that gruesome things happen in hospital Shepard and Mahon (2002). Many parents find it difficult to explain to other children in the family about their sibling's illness. Craft (1993) found that siblings often received little or no information regarding their brother or sister and that they thought that their parents treated them differently before their sibling's hospitalisation.
Some siblings develop behaviour problems. Young children may become irritable and withdrawn whereas older children may become disruptive. Wong (2003) found that other problems may include headaches, bed wetting, sleep problems and severe separation anxiety.
Research has shown that successful psychological management of the ill child is influenced by the effectiveness of the parents coping with the illness (Wolfer and Visintainer 1975). If families can manage their own personal stress then they can provide support for their child.
Carnevale (1982) found that families reported unsatisfied needs regarding information given to them about their child. If parents are informed and prepared they experience less stress and anxiety and less psychological effects.
Young (1991) carried out a study that indicated that adopted children were more likely than biological children to have chronic conditions and hospital admissions. The adoptive family may be vulnerable to the stress that having a child in hospital brings. Adoptive families may have little or no information regarding the child's medical background. They may feel embarrassed or inadequate as parents if they are unable to answer any questions relating to their child Rosenberg and Groze (1997).
Parental participation now has become an accepted feature in the care of children in hospital. The costs that parents face receive little to low income families, or no attention Callery (1997).
Financial costs include loss of earnings and travel costs. Shelley (1992) states although travel expenses can be a substantial burden only limited assistance is available and social workers can offer very little help or advice to parents. For some parents the cost of time spent in hospital has used up their annual holiday entitlement. Food and drink is another cost incurred by parents especially those parents who are resident. Financial costs also continue after discharge from hospital when children continue to need the close attention of a parent at home Callery (1997). Leader et al (2002) concluded that out of pocket expenses and missed work continued during the month following discharge.
Social costs such as the care of other children in the family have to be met. This is of particular importance to single parent families, as they may not have anyone else available to help. This may result in having to make a difficult decision as to stay in hospital with their ill child or leave their child in hospital in order to look after their other children. Other social costs may include loss of privacy. Parents also incur personal costs. Parents may become distressed when their child is in pain or undergoing unpleasant procedures. Resident parents may also feel isolated and unable to receive adequate support Callery (1997). Noyes (1998) highlighted the effect of the environment on parents. Many parents also become distressed at seeing so many ill children and families. There are clearly many advantages in having parents present and participating in the care of their child in hospital. The emotional stress of the child is reduced and feels more secure Palmer (1993). There has also been evidence to show that cross infection is reduced and there is also a decrease in post-operative complications when parents are resident Brain and Mackay (1968).
There are many services and organisations at a major paediatric hospital in Scotland that aim to reduce the effects of hospitalisation on children and their families.
Article 31 of the UN Convention on the Rights of the Child Newell (1991) states that every child should have the right to engage in play. Play Leaders operate on every ward in the hospital. The play service aims to promote normal child development and help children regain skills lost through regression and the effects of hospitalisation. They ensure that the play environment is safe, stimulating and well maintained. Play leaders offer emotional support to children and families. The play leaders also engage in distraction techniques. Distraction techniques involve play that is targeted to the child's developmental age and encourages coping strategies between the child, family and staff. The child's favourite games and toys are used to help the child cope with stress. Nurses can use therapeutic play to help the child deal with stress. School age children enjoy books, computers and crafts that provide an outlet for aggression and increase self esteem. The play should also promote a sense of achievement as (Eriksson cited in Bell and Bindler 1999) believed that school age children place great importance on achievement and accomplishment.
Freud (cited in Bell and Bindler 1999) believed that children place importance on privacy, which therefore, should prompt the nurse to respect the child's privacy and explain all treatment and procedures especially those involving examinations of the genital area. The nurse should also provide gowns, covers and underwear for the child if they do not have their own.
The hospital operates a named nurse policy. The Patients Charter (1991) states that Named Nurses are responsible for co-ordinating care for patients. Part of their role is to keep families informed of their child's progress. The named nurse will also arrange for families to see the doctors responsible for their child's care and will be available to answer any concerns or queries that the child and family may have. The named nurse should always try to prevent separation especially in the under 5's. This can be done by encouraging parents to stay in with their child and by having unrestricted visiting which is one of the recommendations in The Platt Report (1959). The nurse should also be aware of the child's separation anxiety and any behaviour that may be displayed because of it.
The hospital has a Family Support and Information Service, which offers families emotional and practical support. They can listen to parents in private, assist and accompany at hospital meetings and provide contact with other organisations. They also offer information about medical conditions and health, a wide range of leaflets and books, child friendly health information, contact with self help and support groups and information on local amenities and services. The family support service may be of great benefit to parents who are resident in the hospital and may be feeling isolated and lonely Callery (1997) highlighted that parents face personal, social and financial problems, which the family support service may also be able to help with.
In order to prepare children for admission to hospital, the hospital offers a pre-admission programme. The programme aims to prepare children of all ages and their families for a stay in hospital, to describe what happens during a stay in hospital, to show the child around a hospital ward and give them an opportunity to meet staff, to give parents and children the opportunity to ask questions and voice any special needs that they may have, to minimise anxiety and enable the child to recover more quickly, to make a child's stay in hospital an experience to be anticipated with interest and not fear Wong (1997).
Following the recommendations of The Platt Report (1959) the hospital offers accommodation, which is available for parents and close relatives of in-patients to stay in. The rooms are issued on a first come basis and there is a strict criteria that staff must adhere to when referring parents to stay there. The accommodation is of great benefit to parents who stay a considerable distance away from the hospital as it allows them to be closer to their child. The hospital also has several cubicles on each ward for parents to room in with their child.
Kloosterhouse and Ames (2002) found that the hospitalization of a child is stressful for a family, and turning to religion or spirituality is a potential coping mechanism. In the study the majority of families believed that religion and spirituality was important in helping them cope and that their beliefs and practices influenced their choice to use religion and spirituality as a resource. The hospital has a family chaplaincy service and chapel for families of all faiths to use. Representatives from all faiths are available in the hospital for families to confide in and seek support from.
In 1959 The Platt Report made several recommendations to improve children's hospital facilities, the most important being parental involvement.
The report also suggested that the care of the ill child be shared by parents and hospital staff and that parents should be encouraged to stay with their child whenever possible.
However through personal experience the author feels that nurses today find it difficult to share the care of children with parents. Ayer (1978) suggested several reasons for this including staff shortages. Ayer (1978) also suggested that a lack of adequate facilities for parents and the inability of parents to provide appropriate care also contributes to the problem. Meadow (1969) found that the majority of nurses believed that they were better at looking after the child than the mother.
Dunn (1979) found that attitudes among nurses towards parental participation were age related. The staff who had the most problems accepting parents were under 25 or over 38 years of age.
Merrow and Johnson (1968) found that there are often discrepancies between the expectations of mothers and nurses to the activities that each should perform for the child. However Sheldon (1997) suggests that the involvement of parents in the care of their sick child in hospital has positive therapeutic effects on the child's recovery. Parents are under a great deal of stress concerning their child and nurses need to understand this better. Noyes (1999) stated that nurses need to be competent in assessing the psychological needs of mothers and be aware that they might be in shock.
The author also feels through personal experience on clinical placements, nurses can find it difficult to build up trust with young patients, especially if there stay is short term. Bricher (1999) stated that developing trust with a child is a process that cannot be hurried, and once established it must be honoured. Getting to know a child as a person rather than a patient is another aspect of developing this trusting relationship. Genuine liking and respect for children provides a starting point for this communication to occur Bricher (1999). The nurse-child relationship however may be blocked by parents who, in trying to protect their child keep nurses at arms length Bricher (1999). Their may also be a lack of parental understanding, in which parents may threaten their child with a nurse in order to make them behave appropriately. Bricher (1999) concluded that distressed parents may get in the way of trusting relationships because their distress undermines the child's confidence. Nurses also have to build up a trusting relationship with the child's parents and family. Miles (2003) found that parents of hospitalized, critically ill children have rated nursing support as an important influence on their experiences. For future nursing practice the author understands the importance of communication and information giving. Parents often need help understanding the information they are given about their child's condition and treatment Miles (2003). Through learning about the various theories of child development nurses can have a better understanding of how the child perceives their illness and how they are able to cope with it. This makes nurses better able to advise parents why their child may be experiencing certain behaviours, for example separation anxiety Bowlby (1965).
Nurses also need to be able to offer parents emotional support and raise parent's confidence levels. Nurses need to convey that they are concerned about how the parents are coping with the child's illness and the impact its having on their lives Miles (2003). Nurses can help boost parents self esteem by encouraging them to participate in care, and involving them in decision making. Nurses can also encourage parents to seek support and help from clergy, support groups and from friends and family.
Although the hospitalisation of a child is generally a stressful experience for the child and family, it can also be beneficial. The main benefit is recovery from illness but hospitalisation can also allow the child to face a stressful situation and develop adequate coping skills. Hospitalisation also provides opportunities for parents to learn about their child's growth and development Ball and Bindler (1999).
The hospital can provide children and their families with a chance to socialise and make new friends who are undergoing a similar experience as themselves.
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