Commentary on Hopia H, Tomlinson PS, Paavilainen E & Åstedt-Kurki P (2005) Child in hospital: family experiences and expectations of how nurses can promote family health. Journal of Clinical Nursing 14, 212–222

Authors

  • Linda Shields PhD, FRCNA,

  • Imelda Coyne PhD, RN


Linda Shields, Professor, Faculty of Health and Social Care, University of Hull, Hull, UK. Telephone: + 44 1482 463326; E-mail: linda.shields@uq.edu.au

The care of children in hospital has been a topic of research since the 1940s (Spitz 1945, Levy 1945a,b, Powers 1948, Prugh et al. 1953), most influentially in the UK (Bowlby 1944a,b, 1952, Robertson, 1953, 1958). Government policy (Platt 1959) followed consumer (parent) led lobby groups which, using research findings about psychological damage to young children who were left unaccompanied in hospital wards, advocated effectively for parents to stay (Hales-Tooke 1973; Association for the Welfare of Children in Hospital 1974; Haris et al. 1983). As nurses entered the research field, many turned their attention to this topic and paediatric models of care were devised, including care-by-parent (Goodband & Jennings 1992), partnership-in-care (Casey 1995), and family-centred care (Shelton et al. 1989). However, these models, while ideals, are difficult to implement (Darbyshire 1994, Callery 1995, Shields 1999, Coyne 2003).

It is given that while a child is hospitalized the whole family is affected, and Hopia et al. are correct when they point out that research about hospitalized children, while substantial, is usually about persons within the family, for example the individual child (Shields 2001), parents (Kristjánsdóttir 1995, Shields et al. 2003), mothers (Melnyk et al. 2004), fathers (McNeill 2004), and to a lesser degree, siblings (Fleitas 2000), and grandparents (Hall 2004). The aim of their paper is to provide evidence about the process of family health promotion during a child's hospitalization, and it does this. However, because it involves only parents, it falls into the trap which the authors disparage in others. This research would have been more valuable if admitted children, their siblings, grandparents, and other family members had been included. The authors have explained how nurses are well placed to support parents, and we would strongly recommend that they, or others, repeat the research with other family members.

It was said that the results gave insight into family health promotion and the interpretation highlighted important areas for practice during a child's hospitalization. One of the most significant observations (though we are unsure if this was a direct finding of the research or a comment by the authors) surrounds the guilt which a parent feels when a child is hospitalized. Some research exists which examines the guilt which accompanies family functioning (Aber et al. 1999), particularly at times of crisis (Trollvik & Severinsson 2004). Parents express anecdotally the guilt that seems to be an inherent part of parenthood, and this (a) could provide a fertile field for paediatric nurses to investigate, as it is particularly cogent during a child's admission to a health service, and (b) needs articulating so practice can develop ways of helping parents through such affections, particularly during emotionally hazardous times such as illness and hospitalization. On the other hand, parents may express feelings of guilt, but these feelings may be caused or contributed to by health professionals’ behaviour and attitudes, which may intimate that a ‘good’ parent should be there for their child, and should stay, regardless of circumstances and other pressures on them at the time. The concept of parental guilt requires further exploration to determine if feeling guilty is a normal parenting attribute that is exacerbated by hospitalization and health professionals’ actions.

During a child's admission, parents experience a parenting role deficit (Brown & Ritchie 1990), but is this an assumption rather than reality? Does this parenting deficit apply to all parents irrespective of their circumstances, or could it be pertinent only to parents of babies and young children rather than parents of adolescents? Another finding in the paper surrounds the interchange of roles which occur between nurses and parents during a child's hospitalization. On page 8, Hopia et al. state that ‘the most important thing is what nurses do with families, not how much time they spend with them’. We disagree, as we have found that parents describe the value and importance of nurses being there as a ‘caring presence’ rather than doing set tasks at odd times in the day (Coyne 2003).

Parents may be unsure of expectations placed on them and nurses may not be aware of how much the parents know or perceive about expectations of their roles while their child is hospitalized. An interesting comment, ‘Nursing staff may be inclined to think that passive and quiet parents are always happy and satisfied’ is reminiscent of times pre-Bowlby and Robertson and resultant changes to exclusionist policies in paediatric hospitals, which arose from their work (Alsop-Shields & Mohay 2001). Until that time, hospitalized children were thought to have ‘settled in’ when they became quiet and withdrawn, and sat in their cots playing by themselves. Bowlby and Robertson unequivocally demonstrated that this was when psychological damage occurred, caused by exclusion of parents (Shields & Nixon 1998). Hopia et al.'s research evinces that we must question whether we are making the same mistakes 40 years on. Recent research has found that when parents were expected to perform much of their child's care, they resented being in this position but at the same time concealed their anxieties and pretended to cope in order to be seen as ‘good’ parents (Coyne 2003). Superficially, the quiet parent may comply passively with nurses’ expectations while in reality be hiding their anxieties and possible resentment. Good research not only provides evidence to guide practice, it also affords opportunities to question what we do, even if, or particularly if, such questioning makes us uncomfortable.

Early in the development of parental involvement in care, some asseverated that this might not always be in the family's best interests (Meadow 1964, 1969, 1972). In the rush to empower parents to implement their right to be involved, such comments were ignored. The circle now is turning. Darbyshire (1994) and Coyne (2003) found that parents resent having to do what they perceive to be nurses’ work. Scant attention has been paid to parents in developing countries where there is no social welfare, who place their employment at risk by taking time off to stay with hospitalized children (Shields & King 2001a,b). Hospitals and nurses now are placing too many demands on parents, who often feel that they have no choice but to stay with their child, despite other demands on their time. They feel that they are having to perform tasks which are nursing skills, for which they have neither the education, nor training nor sometimes the inclination (Coyne 2003). Nurses view their roles as facilitators rather than actors. Parents are expected to be present, co-operative, helpful, follow all instructions, and become actively involved in care delivery. Parents were generally reluctant to execute technical nursing care and described feeling stressed and anxious about performing such care in case their inexperience or lack of knowledge about medicine and nursing could harm their children. Moreover, they were reluctant to administer care that could cause pain, harm, or discomfort to their children as inflicting pain on one's child is inimical to the natural, inherently protective drive of parenthood.

To conclude, we make an important general comment on all research such as that of Hopia et al. and which all those who embark on research about parental involvement in care need to consider. Society is constantly changing, and nursing in particular has changed dramatically in the last two decades. Commensurate changes are occurring in concepts surrounding parental involvement in care. There is a need to acknowledge these societal changes and to find ways of supporting and strengthening the family social world. While all recognize that children need their parents during hospitalization, and that every consideration must be made to ensure that this is possible, it must equally be acknowledged that parents may not be able to accompany their children to hospital, or be involved in care, and they should not be coerced into doing so. Expecting parents to be present and responsible for care may threaten stability of the family unit and consequently be detrimental to family functioning. There is much worth in recognizing the family as the unit of care and directing our energies towards finding ways to promote family health when a child is hospitalized.

A caution about Hopia et al.'s research must be sounded, as it includes only nurses. Other health professionals probably hold similar attitudes towards parents. If this research could be continued and include medical and allied health colleagues, it would provide evidence to improve practice for all those who care for children and families. It is pleasing to see research leading the way to legitimately question contemporary practice. Hopia et al. have initiated work which will provide opportunities to examine their ideas in more detail. It would be beneficial if this research could be continued with the whole family and with a range of paediatric health professions.

Ancillary