(1992) 8, 130-139
hlemiw and Cdkd Care Nursing @ Longman CroupUK Ltd 1992
The most important needs of parents of critically ill children: parents’ perceptions Michael F. Farrell and Charlotte Frost
Research studies have identified the needs of relatives when they have had an adult family member in the intensive care unit. However little similar work has been done within the paediatric setting. Therefore the aim of this study was to examine what parents considered to be their most important needs, when they have a child ill in the intensive care environment (PICU). A questionnaire was designed, and was distributed to parents of 30 children admitted into a PICU. The questionnaire identified needs items which may be important to parents of sick children. The parents were required to indicate how important each need was to them during the time of the child’s stay in the PICU. Results obtained indicate that parents have a strong need for information and relief of anxieties that they may have about their child’s condition. A conclusion reached in this study is that if the critical care staff can go some way to assess and meet the needs of parents of critically ill children, then these parents may be more able to become effective partners in care, which may have therapeutic effects upon the child’s health recovery.
INTRODUCTION It has now been well established that the involvement of parents in the care of their sick child has, in the majority of cases, positive therapeutic effects upon the health recovery of the child (Platt, 1959). Most paediatric health centres now recognise the potential adverse effects that any period of hospitalization can have upon a child and his/her family unit. These centres further recognise the unique contribution that parents
Michael F Farroll RGN, RSCN, ENB 160,999, Charlotte Frost RGN RSCN ENB 160, Cardiac intensive Care Unit, Hospital for Sick Children, Great Ormond Street, London, WC1 3JN (Requests for offprints to MF) M8nu8Cript Bccepted 22 February 1992
can have, when caring for a sick child, and have, therefore, adapted their caring practices so as to encourage maximum parental involvement. opportunities for parents of However, critically ill children to participate in the care of their child may be limited. Parents of critically ill children may find the paediatric intensive care unit (PICU) a very stressful environment. This environment may present adverse factors which may affect the parents’ ability to participate in their child’s care (Curley, 1988). The challenge for critical care nurses in their efforts to ensure the most optimal conditions to facilitate each child’s wellbeing, is to enable and support the parents through this crisis, so that the potential caring contribution that parents can make is realised. While the importance of parental involvement
INTENSIVE AND CRITICAL
in the care of each sick child is recognised, little emphasis has been placed upon the needs of the parents themselves. Where parental needs are not met, their ability to participate in the care of the sick child may be impaired to the detriment of parents, child and professional carers. A number of research studies have examined and identified what adult relatives consider to be their most important self needs, when they have a family member in an intensive care setting. These studies clearly identify that relatives have some needs which are more important than others. While some of these studies have included a small number of children, the sample is too small for the findings to be applied conclusively to paediatric critical care settings. There is limited available literature that specifically identifies the needs of parents of critically sick children. Therefore the purpose in this study is to: Identify what parents consider to be their most important needs when their child is admitted into a cardiac intensive care unit (CICU). Generate further questions for research.
THEORETICAL
FRAMEWORK
The theoretical framework for this study, as used by Kasper (1988), is based upon parental role theory/responsibility, and the crisis impact that can be generated when family members are admitted into a high care environment.
Parental
role theory
Parents are, in most cases, the best people to care for their children in sickness and health. Implicit in the parental role is the requirement to provide an environment that will be effective in facilitating the child’s development from a state of near total dependence to that state where at adolescence, with some support, the child is able to take responsibility for meeting his/her own needs. Until the children have reached a stage of cognitive and physical development which enables them to do this the parents will be
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required to act as primary caregivers. Within this role the parents may make many decisions that can affect the development of their child. If the child’s development is to be optimised then it is essential that the parents always make the most appropriate decision. Should any factors be present that adversely affect the relationship between the child and his/her parents then the potential for a profound disturbance to the child’s development and self-esteem of the parents will be evident (Bowlby, 1978).
Crisis theory Crisis is a very powerful and frequently used word. It is often used to describe the dramatic effects that may follow disaster situations e.g. famine, earthquakes, war. Such events or universal crises demand massive interventions if the adverse effects of these events are to be minimised (Wright, 1990). While the word crisis might be suggestive of international events it also has a much more personal meaning. Throughout the course of life individuals may have to face their own personal crisis, a situation/event that they find threatening, uncomforatble and unfamilar. This threatening event may demand unfamiliar actions and a change in perceived role and response if the consequences of the crisis are to be overcome (Caplan, 1964). In a health care environment the word crisis may relate to the impact that a health care deficit may have upon the individual and his/her significant others. This crisis may demand a response from the individual, significant others and the interventions of appropriate skilled professionals if the health care deficit is to be successfully resolved. Failure to mount a response to any crisis may overwhelm the individual and may result in significant health impairment. The admission of a child into a critical care environment is a crisis not only to the child but to the whole family unit. One of the major effects that the child’s admission to the PICU may have is that it may lead to a significant change in normal parental role. Instead of being a child’s primary caregivers, the parents, because they may not have all the required skills and know-
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ledge to assist the child, may have to relinquish their caring control to other more skilled/knowledgeable carers. This change in role can lead to the parents experiencing a sense of fear, frustration, low self-esteem and a lack of involvement/control in the child’s care (Rennick, 1986). If the parents are to be able to contribute in the care of their sick child, they will need to adapt and respond to the change in their own need requirements that their child’s admission demands. This adaptation will be facilitated when needs which may not previously have existed are identified and met. Failure to meet or resolve these needs may lead to increased parental anxiety and distress which can further compound their inability to contribute in the care of their sick child.
REVIEW OF THE LITERATURE A number of studies have identified that it is essential that parents, if they are to be able to influence and contribute in the recovery of their sick child, must be able to manage effectively the stressors and overcome the crisis that the child’s admission presents (Curly, 1988; Wolfe & Vistainer, 1975; Hymovich, 1976). However, there have been few studies that have specifically identified the important needs of parents when they have a child in the PICU. To date, the study by Kasper (1988) seems to be the only one that exclusively investigated the needs of parents of critically sick children. In this study parents were interviewed to identify what they considered to be their most important needs. It was concluded from this study that the most important needs were: to be with the child in the PICU; to be given accurate and truthful information; to have a place to sleep near the PICU; to participate in their child’s care; and to be assured that the child was receiving the most optima1 level of care. However due to the small sample size (15 parents were interviewed), again the findings cannot be taken as conclusive. Other studies, while not specifically identifying important parental needs, have proved useful in expanding the body of work available, to assess the impact of a child’s PICU admission
upon significant family members. A study by Miles and Carter (1982) is often used to identify the sources of parental stress when they have a child in the PICU. This study used findings obtained from observing parent responses when in the PICU, and conducting a series of interviews to identify that eight particular aspects of the PICU environment cause increased parental anxiety and distress. Such aspects included the sights and sound of the PICU environment, the child’s physical appearance and behaviours. The parents will have to work through dealing with the many stressors that may present during the time the child is in the PICU, if they are to be able to participate in care activities. Even though the PICU environment may be stressful for the parents, it is an environment to which they can adapt with help and support. Parents may utilise a number of coping mechanisms when they have a child in the PICU. Philichi (1989) suggests that critical care nurses can go some way to facilitate the successful use of such coping mechanisms by encouraging parents to use problem-solving approaches. She further considers that assistance should be given to parents which enables them to identify support resources to which they have access, and recommends implementing a process whereby individual parental needs are identified. While this work has been useful, further investigation is required if paediatric critical care nurses are to be able to identify and meet specific parental needs with a degree of sensitivity and accuracy.
METHODOLOGY The setting for this study was a major paediatric hospital situated in the southeastern region of England. Permission was gained from the Chief Nursing Officer to conduct the questionnairebased study. A pilot study was conducted to test the design of the questionnaire which tested well and only one question required adjustment in order to clarify particular information gained. The questionnaires were distributed and collected only by the authors. Parents gave their verbal consent to participate in the study. At
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distribution the parents were given the same information as to the purpose of the study, reassurance as to confidentiality of information given about themselves and their child, and the procedure for collection of their replies. Participants were, in order to maintain confidentiality, instructed not to put their name on the questionnaire and to put the completed questionnaire in a sealed envelope which was then to be deposited in a collection box. This box was situated outside the intensive care unit (ICU). The authors were not present during the completion of any questionnaires.
closed-ended questions the parents were asked to choose a statement that best described their feelings regarding how welcome they felt when entering the unit, how important they considered it to be involved in the care of their child, the degree and extent of any distress that may have been generated as a result of the child’s critical care admission, and the impact of the child’s admission open other family members. In the open-ended type questions, parents were invited to expand upon any other feelings that may have been generated by the child’s admission to the unit.
bstrument
Sampling
The design of this study was a questionnaire survey. This questionnaire consisted of a total of 55 questions of which 6 questions were of the open-ended type, 17 were of the closed-ended/ descriptive type, while the remaining 32 quesresponse to specific tions need sought statements. These need statements provided the main part of the questionnaire and were based on the work of Daley (1984) (which itself was based upon a pivotal work by Molter, 1979). Discussions were held with nursing and medical colleagues to determine the validity and content of the questionnaire. The professionals who contributed to (or reviewed) the design of the questionnaire included the hospital’s research nurse, a senior nurse tutor with research experience, the unit’s senior nurse manager and clinical nurse specialist, one of the unit’s medical directors and other members of the critical care team. In this questionnaire 32 statements of needs which have found to be important to relatives with a family member in the intensive care environment were adapted to reflect potential needs of parents whose child is admitted into a paediatric intensive care environment. The respondents were required to indicate how important they considered each of the needs to be. They could choose from three alternatives: 1) very important 2) important 3) not important. With regard to the closed-ended questions, parents were asked to give factual information i.e. age of child, nights spent in the ICU. In other
The questionnaire was distributed to parents of 30 children admitted into the Cardiac Intensive Care Unit (CICU) who met the following criteria: That their child had been admitted into the CICU and that this was the child’s first admission to a paediatric intensive care unit. The relative was the child’s parent, legal guardian and identified as the child’s significant carer. The child had been a patient in the ICU for a period of 24 h or more. The parents agreed to participate in the study. In all cases the questionnaire was distributed to parents whose child had a reasonable expectation of a good health outcome.
Description of the sample 27 questionnaires of the 30 distributed were returned (response rate 90%). 15 of the questionnaires were completed by a single parent while 12 questionnaires were completed by both parents. All but one of the single respondents identified themselves as the mother of the child. The age of the respondents ranged from less than 20 years to above 35 years. In 11 of the questionnaires the sex of the child was given as female, the other 16 as male. The age of the child ranged from 7 days - 6 years and
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Table 1 Diagnoses of children admitted to the CICU whore parents received questionnaires Condition Atrioventricular septal defect Tetralogy of fallot Ventricular septal defects Coarctation of the aorta Transposition of the great arteries Atrial septal defects Complex heart lesions Total anomolous pulmonary venous drainage Hypoplastic left heart Interrupted aortic arch. Myasthenia gravis Total
Number 8 6 3 3 2 2 2 1 1 1 1 30
11 months (mean (m) = 15 months). The length of stay for each child varied, the mean number of nights spent in the CICU was 4.96 (ranged 2- 15). In this study boys spent a longer period in the CICU (m = 6 nights), compared to girls (m = 3.45 nights). Table 1 shows the diagnoses of the children admitted to the CICU. Three of the questionnaires were returned by respondents ( 11%) who identified that they had
previous experience of a paediatric intensive care setting, with other child family members.
Results For analysis of the results each of the need statements was assigned to a category as identified and used by Dafey (1984) (Table 2 shows the allocation of the need statements to the various categories used). Scores were obtained for each of the need statements, the scores were then ranked in order of score - from the highest to lowest (Table 3 shows the needs in rank order of importance). The rank scores for the 32 need statements were then divided into 4 levels each containing 8 need statements. Level 1 contained the 8 highest scored needs whereas level 4 contained the lowest level scored needs. Each level was examined to identify if needs from one category were seen more frequently in one level than another. These scores were obtained and then placed in Chi square cells. The score of the two highest scoring categories, the need for information and the need for relief of anxiety were combined against the combined score of
Table 2 The needs items in each category are ranked in order of importance as identified by the respondents Parental Need Categories The need far relief of anxiety To know what may be the expected outcome To know what treatment my child is receiving To know if the nurses are giving the best care possible To be told there is hope To have someone explain the equipment being used with my child To be informed when my child is to be transferred ahead of time To participate in my child’s care
The need for support To have a nurse with me at the bedside To be assured that my child is doing alright To be accepted by the staff To be assured that it is alright to leave the hospital for a while To talk to someone about my feelings To have other family members nearby To talk to the same nurse each day To talk to other parents/guardians whose children are also in the CICU To have the hospital chaplain visit
The need for informution To know what is wrong with my child To be informed of changes in my child’s condition To have my questions answered honestly To have explanations in understandable terms To talk to the doctor To talk to the nurse To be allowed to call the unit and ask about my child at any time To know the qualifications of the staff members that are caring for my child To have several people answer my questions
Personal needs To have a place to rest while I am staying there To have a place to take care of personal needs To have a telephone nearby To have a bathroom nearby that I can use To have refreshments available To be alone To have help with financial concerns
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Table3 Parental need statements rankd in order of importance to respondents (n = 27)
Very Needs
important
Important
To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To
% 96 96 96 93 89 89 81 78 78 78 78 74 74 74 63 63 60 59 56 48 48 48 44 41 33 33 30 30 22 22 19 11
% 4 4 4 7 11 11 19 22 22 18 18 18 11 26 33 30 33 41 33 45 33 33 37 18 37 33 40 40 44 18 22 33
know what is wrong with my child be informed of any changes in my child’s condition have my questions answered honestly know what may be the expected outcome have explanations in understandable terms know what treatment my child is receiving talk with the doctor talk with the nurse know if the nurses are giving the best care possible have a nurse with me at my bedside be allowed to call the unit and ask about my child at any time be assured that my child is doing alright be told there is hope have someone explain the equipment being used with my child have a place to rest while I am staying there be informed when my child is to be transferred ahead of time be accepted by the staff participate in my child’s care be assured that it is alright to leave the hospital for a while have e place to take care of personal needs talk to someone about my feelings have a telephone nearby have other family members nearby talk to the same nurse each day talk to other parents/guardians whose children are also in the CICU know the qualifications of the staff members that are caring for my child have a bathroom nearby that I can use have refreshments available have several people answer my questions have help with financial concerns be alone have the hospital chaplain visit
the lowest scoring categories, the need for support and personal needs. A two sample Chi square test was conducted using ‘Stat Mode 2’ computer statistic package. A Chi square value of 2 1.1923 was seen giving an associated probability score of P < O*OOOl(DF = 3). No significant difference was found between the most important need categories of those parents who completed the questionnaire singly (56%) and those parents who completed the questionnaire jointly (44%) (Tables 4 & 5). Similarly there was no difference between the most important need categories for those parents whose children spent a shorter stay in the CICU (number(n) = 13, m = 2.3 nights) against those parents whose children spent a longer stay in the CICU (n = 13, m = 7.69nights). Although there
Not important % -
4 4 7 15 4 7 7 11 7 19 19 19 41 30 33 30 30 34 60 59 56
was no difference between need categories, the rank order of importance of individual needs was different for groups of single as compared to joint respondents, and those parents whose children spent a longer period in CICU. In this study the doctor achieved the highest score as being the best person to prepare the parents for the time to be spent in the ITU (89%), the nurse from the CICU scored 8 1% and the nurse from the referring ward scored 41%. The majority of respondents (96%) considered that they and their child had been sufficiently prepared for their CICU admission. 74% of respondents identified that they had experienced a degree of distress as a direct result of their child’s admission to the CICU. The respondents were asked to indicate, from a
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Table 4 Parental need statements ranked in order of importance to respondents (15)
Very Needs To be informed of any changes in my child’s condition To know what is wrong with my child To know what treatment my child is receiving To know what may be the expected outcome To have questions answered honestly To know if the nurses are giving the best care possible To have explanations in understandable terms To be allowed to call the unit and ask about my child at any time To have someone explain the equipment being used with my child To talk with the doctor To have a nurse with me at the bedside To talk with the nurse To participate in my child’s care To be informed when my child is to be transferred ahead of time
important
important
Not important
%
%
%
100 100 100
-
:: 87 87 87 80 80 80 80 73 73
7 7 13 13 13 20 20 20 13 27 20
-
7 7
Table 5 Parental need statements ranked in order of importance to parents who responded as a couple (12 couples) Very Needs To To To To To To To To To To To To To To
have my questions answered honestly know what may be the expected outcome know what is wrong with my child’s condition be informed of any changes in my child’s condition have explanations in understandable terms talk with the doctor be assured that my child is doing alright talk with the nurse be told there is hope know what treatment my child is receiving have a nurse with me at the bedside have someone explain the equipment being used with my child know if the nurses are giving the best care possible be allowed to call the unit and ask about my child at any time
choice of statements,
important
Important
% 100 92 92 92 92 83 83 83 83 75 75 67 67 67
% 8 8 8 8 17 17 17 25 25 33 33 33
Not important % -
17 -
the level of distress that
the child’s admission to the CICU, was identified
they experienced during the time of their child’s admission - the most frequently given level was
as the grandparents (59%). Three respondents (11%) identified other siblings as being the other
‘a little degree of distress’ (37%).
family during
respondents
considered
However 48%,
that they experienced
a
higher level of distress on a range from ‘moderate’ to ‘large’.
In the follow-up
question,
the
parents were asked to indicate how often they experienced this level of distress the most frequent response, from a list of alternatives was ‘some of the time’ (59%). The other most significant family member identified as experiencing distress, as a result of
members who experienced distress the time of the child’s admission to the
CICU. The majority of respondents
felt that parents
should be able to visit their child all the time when in the intensive care unit (70%), although a number of responses (30%) felt that parents should only visit for most of the time. For some parents (33%) a number of factors prevented them visiting their child as often as they wished.
INTENSIVE
These factors included work commitments, distance of travel, feelings of family members, other children and the parents not wishing to disturb the nurses. The amount of time that parents spent visiting their child per day ranged from 5min - 16h (m = 8.3 h). Most parents believed that they should be involved in the care of their sick child (85%). In this study, most respondents (96%) identified that they were able and encouraged, by the critical care staff, to participate in their child’s care. The most frequently cited caring activities in which parents participated were performing mouth and eye care, assisting in bathing the child, comforting the child during medical/nursing procedures and performing nappy care.
DISCUSSION The small sample size and the potential for misinterpreting the questions posed in the questionnaire may limit the generalisation of the results found in this study. Although the results found will be useful to indicate the important needs of parents of critically ill children, a larger sample, which takes into account the broader social and cultural influences that may affect parents when they have a critically ill child, is required to test whether these results can be replicated. Other studies which have been conducted in paediatric high care environments, which are different in their medical/surgical orientation from the environment in which this study was conducted, will be useful to identify the generalisability of these findings. A more refined research instrument, which is also able to identify the needs of parents of children who do not survive their critical care admission, will be essential to establish conclusive findings. The major need as identified by parents in this study is to obtain as much information as they can about their child’s condition and to have access to those strategies that lessens their anxiety about their child’s admission. Parents, in order to respond to and control the crisis that their child’s CICU admission presents, consider highly the need to know what is happening to the child, why it is happening and what the likely
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course of events are to be during the time of the child’s admission. Although the information they may receive may at times be very distressing and traumatic, it is the parents overwhelming need to know that the information that they are receiving is both informed and honest. The parents expressed a strong need to talk to the medical and nursing staff. Obviously the parents view these staff members as the main information givers. Sharing information is one of the first steps to be taken to allow participation in any decision making process. When parents are involved in the decision making process, they may feel a sense of control over the situation in which they find themselves, and may feel more able to participate in the care of their sick children. Nearly all the parents in this study considered it important to be able to be with their sick child. Some parents spent very long periods visiting their sick child whereas some other parents could only manage very short periods. Many parents give an indication as to why they visited their child for the amount of time that they did. One parent, who because her son’s condition distressed her, could at times, manage spending no more than 5min visiting her sick child. She wrote: ‘sometimes 5min was all I could manage because he looked so thin and pathetic’. whereas a parent so because:
who spent up to 8 h visiting did
‘we were very worried and concerned about our baby’s condition; she had a major operation. We just felt we had to be with her to satisfy ourselves that she was comfortable and that everything possible was being done for her.’ Parents in this study indicated the need to ensure that their child is receiving the most appropriate and highest level of care possible. This anxiety may be generated from the fact that the parents may have had to surrender some of their caring responsibility. Although this does cause the parents some anxiety, this may be lessened if they have confidence that their child is receiving the most comprehensive standard of
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AND CRITICAL
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care from committed and considerate health care professionals. Some parents indicated in their remarks that they could not comprehend any suggestion that the level of care their child was receiving was anything less than appropriate. If parents believe that their child is receiving less than adequate care then this may lead to the parents experiencing feelings of guilt and low esteem, because in this study many parents will have allowed and participated in the hospital admission culminating in the child’s critical care admission. The parents have to believe that they have brought their child to the best environment possible where the most appropriate caring practices are being implemented. In this study personal and support needs ranked of low importance. A number of reasons may be offered for such a ranking. Firstly many parents may not have wished to indicate that their own personal needs are of much importance because they fear the implication that this may somehow be viewed by the caring professionals as being selfish. Secondly, it may be that, due to the child’s crisis, the parents cannot comprehend that they may have a personal need which can, in any way, equal any of the needs of their sick child, and therefore consequently rate their needs to be of low importance. Individual needs, between the various groups compared, did vary slightly in level of rank importance. This was probably more due to the individual circumstances of the parents, rather than an accurate reflection of the needs of a particular group of parents. However it is interesting to note that parents of children who spent the longer period in the CICU rated the need to participate in their child’s care as being very important (77%), whereas only 46% of parents whose child spent a shorter time in the ICU rated this need to be of equal significant importance. This result might suggest that it is only as parents adapt to the critical care environment, which occurs over a period of time, are they able and desire to participate in their child’s care. Further research is required to investigate this finding.
Implications Clearly parents
for nursing of critically ill children
have their
own needs too. Therefore, the critical care nurse, when caring for the sick child, has to consider the significance of these needs to the wellbeing of the parents. Each high care environment should implement some assessment of need technique whereby individual parental needs are clearly identified. When these needs are identified appropriate actions should be then implemented to ensure that these needs are met. Critical care staff must also fully understand the importance of trust that parents of critically ill children place in the professional carers. In our words and actions we must reciprocate this trust. Parents trust the carers to share even the most insignificant aspect of information with them. Such a need will require the carers to be ever considerate and sensitive in their information sharing process.
CONCLUSION The main finding of this study is that parents of critically ill children whether jointly or singly, short stay or long stay, consider their most important needs to be for accurate and comprehensive information and relief of the anxieties that they have about their child’s admission. Their major anxieties are to receive comprehensive information about their child, to be with their sick child and to be assured that their child is receiving the most appropriate level of care possible. These results would be in line with those as identified by Kasper (1988). The critical care staff can and must ensure that individual parental needs are assessed and that the measures are taken to ensure that these needs are met. The critical care environment may generate difficulties which affects the parents ability to function as effective partners in care. However, if the critical care staff ensure that parental needs are identified and met, then these difficulties can be overcome. Resolving such difficulties will enhance the ability of the parents to participate in their child’s care. The sick child’s admission does not have to be the incapacitating event for the parents and the family unit that it can easily become. Rather, it
INTENSIVE AND CRITICAL CARE NURSING
can be a positive and developing experience, where parents experience the support and involvement of highly skilled and committed professionals. Although the critical care staff will, by necessity, have a major role to fulfil in the care of the critically ill child, they can greatly reassure the parents by focussing upon the uniqueness of the parental role and by confirming that the parental role will always be of prime importance in facilitating the recovery of the critically sick child.
Acknowledgements The authors would like to thank Mrs M. Swanick, Tutor, Charles West School of Nursing and Professor K Swanick, University of London for their assistance in this study.
References Bowlby J 1978 Attachment and Loss. Penguin Books, Harmondsworth, p 14 Caplan 1964 Principles of intervention in psychiatry. Basic Books, New York (Cited in Wright, 1990)
1%
Curly M A 1988 Effects of the nursing mutual participation model of care on parental stress in the pediatric intensive care units. Heart and Lung 17 (6): 683 Daley L 1984 The perceived immediate needs of families with relatives in the intensive care setting. Heart and Lung 13 (3): 232-237 Hymovich D P 1976 Parents of sick children: their needs and tasks. Pediatric Nursing Sept/Oct: 9-13 Kasper J W 1988 parents of children in the pediatric intensive care unit. What are their needs? Heart and
Lung 17 (5): 574-581 Miles M S, Carter M C 1982 Sources of parental stress in the ITU. ACCH Journal 1 I (2): 65-69 Molter N C 1979 Needs of relatives of critically ill patients; a descriptive study. Heart and Lung 8: 322 Platt H (Sir) 1959 The welfare of children in hospital (Report of the committee). Ministry of Health Commissioned Renort. Central Health Service Council Phihchi L M 1989 Family adaptation during a pediatric intensive care hospitalisation. Journal of Pediatric Nursing 4 (4): 268-275 Rennick J 1986 Re-establishing the parental role in a pediatric ICU. Journal of Pediatric Nursing 2: 40-44 Wolfe J A, Vistainer M A 1975 Pediatric surgical patients and parents stress response and adjustment as a function of pyschological preparation and stress point nursing care. Nursing Research 24: 244-355 Wright R 1990 Crisis intervention skills. Churchill Livingstone, Edinburgh
hlemiw and Cdkd Care Nursing @ Longman CroupUK Ltd 1992
The most important needs of parents of critically ill children: parents’ perceptions Michael F. Farrell and Charlotte Frost
Research studies have identified the needs of relatives when they have had an adult family member in the intensive care unit. However little similar work has been done within the paediatric setting. Therefore the aim of this study was to examine what parents considered to be their most important needs, when they have a child ill in the intensive care environment (PICU). A questionnaire was designed, and was distributed to parents of 30 children admitted into a PICU. The questionnaire identified needs items which may be important to parents of sick children. The parents were required to indicate how important each need was to them during the time of the child’s stay in the PICU. Results obtained indicate that parents have a strong need for information and relief of anxieties that they may have about their child’s condition. A conclusion reached in this study is that if the critical care staff can go some way to assess and meet the needs of parents of critically ill children, then these parents may be more able to become effective partners in care, which may have therapeutic effects upon the child’s health recovery.
INTRODUCTION It has now been well established that the involvement of parents in the care of their sick child has, in the majority of cases, positive therapeutic effects upon the health recovery of the child (Platt, 1959). Most paediatric health centres now recognise the potential adverse effects that any period of hospitalization can have upon a child and his/her family unit. These centres further recognise the unique contribution that parents
Michael F Farroll RGN, RSCN, ENB 160,999, Charlotte Frost RGN RSCN ENB 160, Cardiac intensive Care Unit, Hospital for Sick Children, Great Ormond Street, London, WC1 3JN (Requests for offprints to MF) M8nu8Cript Bccepted 22 February 1992
can have, when caring for a sick child, and have, therefore, adapted their caring practices so as to encourage maximum parental involvement. opportunities for parents of However, critically ill children to participate in the care of their child may be limited. Parents of critically ill children may find the paediatric intensive care unit (PICU) a very stressful environment. This environment may present adverse factors which may affect the parents’ ability to participate in their child’s care (Curley, 1988). The challenge for critical care nurses in their efforts to ensure the most optimal conditions to facilitate each child’s wellbeing, is to enable and support the parents through this crisis, so that the potential caring contribution that parents can make is realised. While the importance of parental involvement
INTENSIVE AND CRITICAL
in the care of each sick child is recognised, little emphasis has been placed upon the needs of the parents themselves. Where parental needs are not met, their ability to participate in the care of the sick child may be impaired to the detriment of parents, child and professional carers. A number of research studies have examined and identified what adult relatives consider to be their most important self needs, when they have a family member in an intensive care setting. These studies clearly identify that relatives have some needs which are more important than others. While some of these studies have included a small number of children, the sample is too small for the findings to be applied conclusively to paediatric critical care settings. There is limited available literature that specifically identifies the needs of parents of critically sick children. Therefore the purpose in this study is to: Identify what parents consider to be their most important needs when their child is admitted into a cardiac intensive care unit (CICU). Generate further questions for research.
THEORETICAL
FRAMEWORK
The theoretical framework for this study, as used by Kasper (1988), is based upon parental role theory/responsibility, and the crisis impact that can be generated when family members are admitted into a high care environment.
Parental
role theory
Parents are, in most cases, the best people to care for their children in sickness and health. Implicit in the parental role is the requirement to provide an environment that will be effective in facilitating the child’s development from a state of near total dependence to that state where at adolescence, with some support, the child is able to take responsibility for meeting his/her own needs. Until the children have reached a stage of cognitive and physical development which enables them to do this the parents will be
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required to act as primary caregivers. Within this role the parents may make many decisions that can affect the development of their child. If the child’s development is to be optimised then it is essential that the parents always make the most appropriate decision. Should any factors be present that adversely affect the relationship between the child and his/her parents then the potential for a profound disturbance to the child’s development and self-esteem of the parents will be evident (Bowlby, 1978).
Crisis theory Crisis is a very powerful and frequently used word. It is often used to describe the dramatic effects that may follow disaster situations e.g. famine, earthquakes, war. Such events or universal crises demand massive interventions if the adverse effects of these events are to be minimised (Wright, 1990). While the word crisis might be suggestive of international events it also has a much more personal meaning. Throughout the course of life individuals may have to face their own personal crisis, a situation/event that they find threatening, uncomforatble and unfamilar. This threatening event may demand unfamiliar actions and a change in perceived role and response if the consequences of the crisis are to be overcome (Caplan, 1964). In a health care environment the word crisis may relate to the impact that a health care deficit may have upon the individual and his/her significant others. This crisis may demand a response from the individual, significant others and the interventions of appropriate skilled professionals if the health care deficit is to be successfully resolved. Failure to mount a response to any crisis may overwhelm the individual and may result in significant health impairment. The admission of a child into a critical care environment is a crisis not only to the child but to the whole family unit. One of the major effects that the child’s admission to the PICU may have is that it may lead to a significant change in normal parental role. Instead of being a child’s primary caregivers, the parents, because they may not have all the required skills and know-
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ledge to assist the child, may have to relinquish their caring control to other more skilled/knowledgeable carers. This change in role can lead to the parents experiencing a sense of fear, frustration, low self-esteem and a lack of involvement/control in the child’s care (Rennick, 1986). If the parents are to be able to contribute in the care of their sick child, they will need to adapt and respond to the change in their own need requirements that their child’s admission demands. This adaptation will be facilitated when needs which may not previously have existed are identified and met. Failure to meet or resolve these needs may lead to increased parental anxiety and distress which can further compound their inability to contribute in the care of their sick child.
REVIEW OF THE LITERATURE A number of studies have identified that it is essential that parents, if they are to be able to influence and contribute in the recovery of their sick child, must be able to manage effectively the stressors and overcome the crisis that the child’s admission presents (Curly, 1988; Wolfe & Vistainer, 1975; Hymovich, 1976). However, there have been few studies that have specifically identified the important needs of parents when they have a child in the PICU. To date, the study by Kasper (1988) seems to be the only one that exclusively investigated the needs of parents of critically sick children. In this study parents were interviewed to identify what they considered to be their most important needs. It was concluded from this study that the most important needs were: to be with the child in the PICU; to be given accurate and truthful information; to have a place to sleep near the PICU; to participate in their child’s care; and to be assured that the child was receiving the most optima1 level of care. However due to the small sample size (15 parents were interviewed), again the findings cannot be taken as conclusive. Other studies, while not specifically identifying important parental needs, have proved useful in expanding the body of work available, to assess the impact of a child’s PICU admission
upon significant family members. A study by Miles and Carter (1982) is often used to identify the sources of parental stress when they have a child in the PICU. This study used findings obtained from observing parent responses when in the PICU, and conducting a series of interviews to identify that eight particular aspects of the PICU environment cause increased parental anxiety and distress. Such aspects included the sights and sound of the PICU environment, the child’s physical appearance and behaviours. The parents will have to work through dealing with the many stressors that may present during the time the child is in the PICU, if they are to be able to participate in care activities. Even though the PICU environment may be stressful for the parents, it is an environment to which they can adapt with help and support. Parents may utilise a number of coping mechanisms when they have a child in the PICU. Philichi (1989) suggests that critical care nurses can go some way to facilitate the successful use of such coping mechanisms by encouraging parents to use problem-solving approaches. She further considers that assistance should be given to parents which enables them to identify support resources to which they have access, and recommends implementing a process whereby individual parental needs are identified. While this work has been useful, further investigation is required if paediatric critical care nurses are to be able to identify and meet specific parental needs with a degree of sensitivity and accuracy.
METHODOLOGY The setting for this study was a major paediatric hospital situated in the southeastern region of England. Permission was gained from the Chief Nursing Officer to conduct the questionnairebased study. A pilot study was conducted to test the design of the questionnaire which tested well and only one question required adjustment in order to clarify particular information gained. The questionnaires were distributed and collected only by the authors. Parents gave their verbal consent to participate in the study. At
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distribution the parents were given the same information as to the purpose of the study, reassurance as to confidentiality of information given about themselves and their child, and the procedure for collection of their replies. Participants were, in order to maintain confidentiality, instructed not to put their name on the questionnaire and to put the completed questionnaire in a sealed envelope which was then to be deposited in a collection box. This box was situated outside the intensive care unit (ICU). The authors were not present during the completion of any questionnaires.
closed-ended questions the parents were asked to choose a statement that best described their feelings regarding how welcome they felt when entering the unit, how important they considered it to be involved in the care of their child, the degree and extent of any distress that may have been generated as a result of the child’s critical care admission, and the impact of the child’s admission open other family members. In the open-ended type questions, parents were invited to expand upon any other feelings that may have been generated by the child’s admission to the unit.
bstrument
Sampling
The design of this study was a questionnaire survey. This questionnaire consisted of a total of 55 questions of which 6 questions were of the open-ended type, 17 were of the closed-ended/ descriptive type, while the remaining 32 quesresponse to specific tions need sought statements. These need statements provided the main part of the questionnaire and were based on the work of Daley (1984) (which itself was based upon a pivotal work by Molter, 1979). Discussions were held with nursing and medical colleagues to determine the validity and content of the questionnaire. The professionals who contributed to (or reviewed) the design of the questionnaire included the hospital’s research nurse, a senior nurse tutor with research experience, the unit’s senior nurse manager and clinical nurse specialist, one of the unit’s medical directors and other members of the critical care team. In this questionnaire 32 statements of needs which have found to be important to relatives with a family member in the intensive care environment were adapted to reflect potential needs of parents whose child is admitted into a paediatric intensive care environment. The respondents were required to indicate how important they considered each of the needs to be. They could choose from three alternatives: 1) very important 2) important 3) not important. With regard to the closed-ended questions, parents were asked to give factual information i.e. age of child, nights spent in the ICU. In other
The questionnaire was distributed to parents of 30 children admitted into the Cardiac Intensive Care Unit (CICU) who met the following criteria: That their child had been admitted into the CICU and that this was the child’s first admission to a paediatric intensive care unit. The relative was the child’s parent, legal guardian and identified as the child’s significant carer. The child had been a patient in the ICU for a period of 24 h or more. The parents agreed to participate in the study. In all cases the questionnaire was distributed to parents whose child had a reasonable expectation of a good health outcome.
Description of the sample 27 questionnaires of the 30 distributed were returned (response rate 90%). 15 of the questionnaires were completed by a single parent while 12 questionnaires were completed by both parents. All but one of the single respondents identified themselves as the mother of the child. The age of the respondents ranged from less than 20 years to above 35 years. In 11 of the questionnaires the sex of the child was given as female, the other 16 as male. The age of the child ranged from 7 days - 6 years and
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Table 1 Diagnoses of children admitted to the CICU whore parents received questionnaires Condition Atrioventricular septal defect Tetralogy of fallot Ventricular septal defects Coarctation of the aorta Transposition of the great arteries Atrial septal defects Complex heart lesions Total anomolous pulmonary venous drainage Hypoplastic left heart Interrupted aortic arch. Myasthenia gravis Total
Number 8 6 3 3 2 2 2 1 1 1 1 30
11 months (mean (m) = 15 months). The length of stay for each child varied, the mean number of nights spent in the CICU was 4.96 (ranged 2- 15). In this study boys spent a longer period in the CICU (m = 6 nights), compared to girls (m = 3.45 nights). Table 1 shows the diagnoses of the children admitted to the CICU. Three of the questionnaires were returned by respondents ( 11%) who identified that they had
previous experience of a paediatric intensive care setting, with other child family members.
Results For analysis of the results each of the need statements was assigned to a category as identified and used by Dafey (1984) (Table 2 shows the allocation of the need statements to the various categories used). Scores were obtained for each of the need statements, the scores were then ranked in order of score - from the highest to lowest (Table 3 shows the needs in rank order of importance). The rank scores for the 32 need statements were then divided into 4 levels each containing 8 need statements. Level 1 contained the 8 highest scored needs whereas level 4 contained the lowest level scored needs. Each level was examined to identify if needs from one category were seen more frequently in one level than another. These scores were obtained and then placed in Chi square cells. The score of the two highest scoring categories, the need for information and the need for relief of anxiety were combined against the combined score of
Table 2 The needs items in each category are ranked in order of importance as identified by the respondents Parental Need Categories The need far relief of anxiety To know what may be the expected outcome To know what treatment my child is receiving To know if the nurses are giving the best care possible To be told there is hope To have someone explain the equipment being used with my child To be informed when my child is to be transferred ahead of time To participate in my child’s care
The need for support To have a nurse with me at the bedside To be assured that my child is doing alright To be accepted by the staff To be assured that it is alright to leave the hospital for a while To talk to someone about my feelings To have other family members nearby To talk to the same nurse each day To talk to other parents/guardians whose children are also in the CICU To have the hospital chaplain visit
The need for informution To know what is wrong with my child To be informed of changes in my child’s condition To have my questions answered honestly To have explanations in understandable terms To talk to the doctor To talk to the nurse To be allowed to call the unit and ask about my child at any time To know the qualifications of the staff members that are caring for my child To have several people answer my questions
Personal needs To have a place to rest while I am staying there To have a place to take care of personal needs To have a telephone nearby To have a bathroom nearby that I can use To have refreshments available To be alone To have help with financial concerns
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Table3 Parental need statements rankd in order of importance to respondents (n = 27)
Very Needs
important
Important
To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To To
% 96 96 96 93 89 89 81 78 78 78 78 74 74 74 63 63 60 59 56 48 48 48 44 41 33 33 30 30 22 22 19 11
% 4 4 4 7 11 11 19 22 22 18 18 18 11 26 33 30 33 41 33 45 33 33 37 18 37 33 40 40 44 18 22 33
know what is wrong with my child be informed of any changes in my child’s condition have my questions answered honestly know what may be the expected outcome have explanations in understandable terms know what treatment my child is receiving talk with the doctor talk with the nurse know if the nurses are giving the best care possible have a nurse with me at my bedside be allowed to call the unit and ask about my child at any time be assured that my child is doing alright be told there is hope have someone explain the equipment being used with my child have a place to rest while I am staying there be informed when my child is to be transferred ahead of time be accepted by the staff participate in my child’s care be assured that it is alright to leave the hospital for a while have e place to take care of personal needs talk to someone about my feelings have a telephone nearby have other family members nearby talk to the same nurse each day talk to other parents/guardians whose children are also in the CICU know the qualifications of the staff members that are caring for my child have a bathroom nearby that I can use have refreshments available have several people answer my questions have help with financial concerns be alone have the hospital chaplain visit
the lowest scoring categories, the need for support and personal needs. A two sample Chi square test was conducted using ‘Stat Mode 2’ computer statistic package. A Chi square value of 2 1.1923 was seen giving an associated probability score of P < O*OOOl(DF = 3). No significant difference was found between the most important need categories of those parents who completed the questionnaire singly (56%) and those parents who completed the questionnaire jointly (44%) (Tables 4 & 5). Similarly there was no difference between the most important need categories for those parents whose children spent a shorter stay in the CICU (number(n) = 13, m = 2.3 nights) against those parents whose children spent a longer stay in the CICU (n = 13, m = 7.69nights). Although there
Not important % -
4 4 7 15 4 7 7 11 7 19 19 19 41 30 33 30 30 34 60 59 56
was no difference between need categories, the rank order of importance of individual needs was different for groups of single as compared to joint respondents, and those parents whose children spent a longer period in CICU. In this study the doctor achieved the highest score as being the best person to prepare the parents for the time to be spent in the ITU (89%), the nurse from the CICU scored 8 1% and the nurse from the referring ward scored 41%. The majority of respondents (96%) considered that they and their child had been sufficiently prepared for their CICU admission. 74% of respondents identified that they had experienced a degree of distress as a direct result of their child’s admission to the CICU. The respondents were asked to indicate, from a
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Table 4 Parental need statements ranked in order of importance to respondents (15)
Very Needs To be informed of any changes in my child’s condition To know what is wrong with my child To know what treatment my child is receiving To know what may be the expected outcome To have questions answered honestly To know if the nurses are giving the best care possible To have explanations in understandable terms To be allowed to call the unit and ask about my child at any time To have someone explain the equipment being used with my child To talk with the doctor To have a nurse with me at the bedside To talk with the nurse To participate in my child’s care To be informed when my child is to be transferred ahead of time
important
important
Not important
%
%
%
100 100 100
-
:: 87 87 87 80 80 80 80 73 73
7 7 13 13 13 20 20 20 13 27 20
-
7 7
Table 5 Parental need statements ranked in order of importance to parents who responded as a couple (12 couples) Very Needs To To To To To To To To To To To To To To
have my questions answered honestly know what may be the expected outcome know what is wrong with my child’s condition be informed of any changes in my child’s condition have explanations in understandable terms talk with the doctor be assured that my child is doing alright talk with the nurse be told there is hope know what treatment my child is receiving have a nurse with me at the bedside have someone explain the equipment being used with my child know if the nurses are giving the best care possible be allowed to call the unit and ask about my child at any time
choice of statements,
important
Important
% 100 92 92 92 92 83 83 83 83 75 75 67 67 67
% 8 8 8 8 17 17 17 25 25 33 33 33
Not important % -
17 -
the level of distress that
the child’s admission to the CICU, was identified
they experienced during the time of their child’s admission - the most frequently given level was
as the grandparents (59%). Three respondents (11%) identified other siblings as being the other
‘a little degree of distress’ (37%).
family during
respondents
considered
However 48%,
that they experienced
a
higher level of distress on a range from ‘moderate’ to ‘large’.
In the follow-up
question,
the
parents were asked to indicate how often they experienced this level of distress the most frequent response, from a list of alternatives was ‘some of the time’ (59%). The other most significant family member identified as experiencing distress, as a result of
members who experienced distress the time of the child’s admission to the
CICU. The majority of respondents
felt that parents
should be able to visit their child all the time when in the intensive care unit (70%), although a number of responses (30%) felt that parents should only visit for most of the time. For some parents (33%) a number of factors prevented them visiting their child as often as they wished.
INTENSIVE
These factors included work commitments, distance of travel, feelings of family members, other children and the parents not wishing to disturb the nurses. The amount of time that parents spent visiting their child per day ranged from 5min - 16h (m = 8.3 h). Most parents believed that they should be involved in the care of their sick child (85%). In this study, most respondents (96%) identified that they were able and encouraged, by the critical care staff, to participate in their child’s care. The most frequently cited caring activities in which parents participated were performing mouth and eye care, assisting in bathing the child, comforting the child during medical/nursing procedures and performing nappy care.
DISCUSSION The small sample size and the potential for misinterpreting the questions posed in the questionnaire may limit the generalisation of the results found in this study. Although the results found will be useful to indicate the important needs of parents of critically ill children, a larger sample, which takes into account the broader social and cultural influences that may affect parents when they have a critically ill child, is required to test whether these results can be replicated. Other studies which have been conducted in paediatric high care environments, which are different in their medical/surgical orientation from the environment in which this study was conducted, will be useful to identify the generalisability of these findings. A more refined research instrument, which is also able to identify the needs of parents of children who do not survive their critical care admission, will be essential to establish conclusive findings. The major need as identified by parents in this study is to obtain as much information as they can about their child’s condition and to have access to those strategies that lessens their anxiety about their child’s admission. Parents, in order to respond to and control the crisis that their child’s CICU admission presents, consider highly the need to know what is happening to the child, why it is happening and what the likely
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course of events are to be during the time of the child’s admission. Although the information they may receive may at times be very distressing and traumatic, it is the parents overwhelming need to know that the information that they are receiving is both informed and honest. The parents expressed a strong need to talk to the medical and nursing staff. Obviously the parents view these staff members as the main information givers. Sharing information is one of the first steps to be taken to allow participation in any decision making process. When parents are involved in the decision making process, they may feel a sense of control over the situation in which they find themselves, and may feel more able to participate in the care of their sick children. Nearly all the parents in this study considered it important to be able to be with their sick child. Some parents spent very long periods visiting their sick child whereas some other parents could only manage very short periods. Many parents give an indication as to why they visited their child for the amount of time that they did. One parent, who because her son’s condition distressed her, could at times, manage spending no more than 5min visiting her sick child. She wrote: ‘sometimes 5min was all I could manage because he looked so thin and pathetic’. whereas a parent so because:
who spent up to 8 h visiting did
‘we were very worried and concerned about our baby’s condition; she had a major operation. We just felt we had to be with her to satisfy ourselves that she was comfortable and that everything possible was being done for her.’ Parents in this study indicated the need to ensure that their child is receiving the most appropriate and highest level of care possible. This anxiety may be generated from the fact that the parents may have had to surrender some of their caring responsibility. Although this does cause the parents some anxiety, this may be lessened if they have confidence that their child is receiving the most comprehensive standard of
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care from committed and considerate health care professionals. Some parents indicated in their remarks that they could not comprehend any suggestion that the level of care their child was receiving was anything less than appropriate. If parents believe that their child is receiving less than adequate care then this may lead to the parents experiencing feelings of guilt and low esteem, because in this study many parents will have allowed and participated in the hospital admission culminating in the child’s critical care admission. The parents have to believe that they have brought their child to the best environment possible where the most appropriate caring practices are being implemented. In this study personal and support needs ranked of low importance. A number of reasons may be offered for such a ranking. Firstly many parents may not have wished to indicate that their own personal needs are of much importance because they fear the implication that this may somehow be viewed by the caring professionals as being selfish. Secondly, it may be that, due to the child’s crisis, the parents cannot comprehend that they may have a personal need which can, in any way, equal any of the needs of their sick child, and therefore consequently rate their needs to be of low importance. Individual needs, between the various groups compared, did vary slightly in level of rank importance. This was probably more due to the individual circumstances of the parents, rather than an accurate reflection of the needs of a particular group of parents. However it is interesting to note that parents of children who spent the longer period in the CICU rated the need to participate in their child’s care as being very important (77%), whereas only 46% of parents whose child spent a shorter time in the ICU rated this need to be of equal significant importance. This result might suggest that it is only as parents adapt to the critical care environment, which occurs over a period of time, are they able and desire to participate in their child’s care. Further research is required to investigate this finding.
Implications Clearly parents
for nursing of critically ill children
have their
own needs too. Therefore, the critical care nurse, when caring for the sick child, has to consider the significance of these needs to the wellbeing of the parents. Each high care environment should implement some assessment of need technique whereby individual parental needs are clearly identified. When these needs are identified appropriate actions should be then implemented to ensure that these needs are met. Critical care staff must also fully understand the importance of trust that parents of critically ill children place in the professional carers. In our words and actions we must reciprocate this trust. Parents trust the carers to share even the most insignificant aspect of information with them. Such a need will require the carers to be ever considerate and sensitive in their information sharing process.
CONCLUSION The main finding of this study is that parents of critically ill children whether jointly or singly, short stay or long stay, consider their most important needs to be for accurate and comprehensive information and relief of the anxieties that they have about their child’s admission. Their major anxieties are to receive comprehensive information about their child, to be with their sick child and to be assured that their child is receiving the most appropriate level of care possible. These results would be in line with those as identified by Kasper (1988). The critical care staff can and must ensure that individual parental needs are assessed and that the measures are taken to ensure that these needs are met. The critical care environment may generate difficulties which affects the parents ability to function as effective partners in care. However, if the critical care staff ensure that parental needs are identified and met, then these difficulties can be overcome. Resolving such difficulties will enhance the ability of the parents to participate in their child’s care. The sick child’s admission does not have to be the incapacitating event for the parents and the family unit that it can easily become. Rather, it
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can be a positive and developing experience, where parents experience the support and involvement of highly skilled and committed professionals. Although the critical care staff will, by necessity, have a major role to fulfil in the care of the critically ill child, they can greatly reassure the parents by focussing upon the uniqueness of the parental role and by confirming that the parental role will always be of prime importance in facilitating the recovery of the critically sick child.
Acknowledgements The authors would like to thank Mrs M. Swanick, Tutor, Charles West School of Nursing and Professor K Swanick, University of London for their assistance in this study.
References Bowlby J 1978 Attachment and Loss. Penguin Books, Harmondsworth, p 14 Caplan 1964 Principles of intervention in psychiatry. Basic Books, New York (Cited in Wright, 1990)
1%
Curly M A 1988 Effects of the nursing mutual participation model of care on parental stress in the pediatric intensive care units. Heart and Lung 17 (6): 683 Daley L 1984 The perceived immediate needs of families with relatives in the intensive care setting. Heart and Lung 13 (3): 232-237 Hymovich D P 1976 Parents of sick children: their needs and tasks. Pediatric Nursing Sept/Oct: 9-13 Kasper J W 1988 parents of children in the pediatric intensive care unit. What are their needs? Heart and
Lung 17 (5): 574-581 Miles M S, Carter M C 1982 Sources of parental stress in the ITU. ACCH Journal 1 I (2): 65-69 Molter N C 1979 Needs of relatives of critically ill patients; a descriptive study. Heart and Lung 8: 322 Platt H (Sir) 1959 The welfare of children in hospital (Report of the committee). Ministry of Health Commissioned Renort. Central Health Service Council Phihchi L M 1989 Family adaptation during a pediatric intensive care hospitalisation. Journal of Pediatric Nursing 4 (4): 268-275 Rennick J 1986 Re-establishing the parental role in a pediatric ICU. Journal of Pediatric Nursing 2: 40-44 Wolfe J A, Vistainer M A 1975 Pediatric surgical patients and parents stress response and adjustment as a function of pyschological preparation and stress point nursing care. Nursing Research 24: 244-355 Wright R 1990 Crisis intervention skills. Churchill Livingstone, Edinburgh
