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Iranian Journal of Pediatrics, Vol. 20, No. 2, Apri l-June, 2011, pp. 201-208 The Concept of Hospitalization of Children from the View Point of Parents and Children Kokab Bsiri-Moghaddam1, MSc; Mahdi Basiri-Moghaddam2, MSc; Leila Sadeghmoghaddam2, MSc; Fazlollah Ahmadi3, PhD
Received: Oct 16, 2009; Final Revision: Sep 03, 2010; Accepted: Oct 29, 2010 Code Number: pe11034 Abstract Objective: Disease and hospitalization can be the first crisis that a child encounters. The aim of this study is to reveal a clear picture of the meaning of hospitalization in children, to show the experience and behavior of hospitalized children and to discover the meaning and understanding of hospitalization in them. Key Words: Hospitalization; Children; Parents; Phenomenological Study Introduction Disease and hospitalization can be the first crisis that a child encounters. Due to the fact that tension causes a change in health condition and environmental routine, and that children have fewer compatibility mechanisms for elevating tensions, this age group is more vulnerable to crisis arising from disease and hospitalization. Children’s way of reacting to this crisis depends on the age at which the previous experience of disease and isolation took place, hospitalization, compatibility skills, gravity of the disease, and support systems present[1]. These days there is an increasing need for utilizing clear scientific proof in order to increase awareness and support in the process of policy making in the field of health. In view of this, guaranteeing the health of society is a complicated and debatable problem because working conditions and lifestyles are key aspects of people’s lives. Stress-causing conditions make people nervous and incompatible, are harmful to health and cause pre-matured death[2]. Holmes and Rahe have devised a scale that includes 41 stress-causing conditions, in order of importance. It is able to predict the relationship between the changes in life and mental health. Writers have considered a numerical value for each situation and have created a scale that evaluates the changes in life. In this scale, disease or getting injured is in sixth position and it has been given a value of 53[3]. Coyne’s research (2006) concluded that hospitalized children undergo a lot of stress and experience various fears and anxieties, especially, separation from parents, etc [4]. Halstorme and Elander clarify the conclusion of their research by stating that parents of hospitalized children are also in need of support and a feeling of security; and have explained the strategy of feeling of security in parents by using the Grounded Theory [5]. The percentage of children being hospitalized and their problems have undergone considerable change in the last two decades. Many of these children are sick newborns, injured children and children with current disabilities that have stayed alive because of the development of technology and have at present become incapacitated or have been suffering from a chronic illness and need long hospitalization periods. Research has shown that previous experience and familiarity with medical procedures do not reduce fear in children. In fact, a previous experience may be a cause of substituting a known or unknown fear. The state of the illness can cause an experience of invasive and traumatic procedures. These factors can cause adverse emotional effects on children resulting from hospitalization[6]. Considering the role and importance of stressors in hampering growth and in emergence of physical and mental disorders in children on the one hand, and the importance of disease and hospitalization as a cause of stress on the other, researchers have embarked on a study to identify the experiences that children and their parents undergo during hospitalization and understand the factors that cause dangers and consequently reveal the understanding and meaning of the concept of hospitalization in the mind of children. Thus, problems can be solved or decreased by identifying the experiences gained by people. The aim of this study is to reveal a clear picture of the meaning of hospitalization in children, to show the experience and behavior of hospitalized children and to discover the meaning and understanding of hospitalization in them. Subjects and Methods This study is a phenomenological study of qualitative research within the framework of Husserl Eidetic phenomenology through comprehensive interviewing. The objective group consisted of children 7–11 years old - and their parents - that were hospitalized in the children’s ward of 22 Bahman Hospital and the surgery ward of 15 Khordad Hospital during the the study (2008). Method of selection of participants was as follows: Having experience of hospitalization, having ability to answer the questions, and being volunteered. Sample size was detected by data saturation. In the method of sampling, an object group of 20 (12 children and 8 parents) were chosen and interviewed. In this study, hospitalized children and parents who were willing to discuss their experiences and feelings about hospitalization with the researchers were selected. A semi-structured interview style was used for collection of data. In order to begin the interview and to reach an overall understanding about the point of view of the participants regarding the phenomenon of hospitalization, the participants were asked to define their first days in hospital. For giving more depth, the questions that followed were asked on the basis of those initial definitions and by using the predictive technique. The following are a few samples of this kind of questions that were asked:
All the conversations were recorded on audio tape and then trans-scripted word to word on paper, and finally analyzed. Permission to record the interviews, aware approval, safeguarding anonymity, confidentiality of information, the right to withdraw at any desired time and moral commitments, were considered in all the interviews. Personal information, such as, age, gender and occupation, was also included along with the questions regarding hospitalization experiences. The interviews varied from thirty minutes to one hour and were continued until the needed objectivity, repetition and so to say, point of saturation of data was reached. The criteria for selection of number of samples in this qualitative research depended on data saturation, and reaching a point at which there was no additional information or topics worth extracting from new interviews. The research environment, an environment suitable for qualitative research, was a real and natural environment; and the interviews were done in a quiet room in the hospital. Reliability and validity of data criteria were used for evaluation of the research data. These criteria are as follows:
The Seven Colaizzi Stages used for analysis of data are as follows:
Findings The sample group for the object of this research consisted of 12 children (7 girls and 5 boys) with a range of 7–11 years, who were hospitalized in the surgery ward of the 15 Khordad Hospital and the children’s ward of the 22 Bahman Hospital, and 8 parents (5 mothers and 3 fathers) with an age range of 24–47 years. All the patients were interviewed between the 1st to 4th day of hospitalization and the reason of research was explained to them. All the participants were informed of the recording of the interview and their consent was taken. The interviews lasted 30–45min. If no further explanation or clarification was needed, after the interviewees had recounted their experiences the interview was considered to be finished. An extensive review of previous research was postponed till after the analysis of data stage. The interview was recorded on audio cassette and later transferred literally on paper and for further certainty of accuracy the audio scripts were again compared with the audio cassettes. Colaizzi’s method was used to analyze the data. For confirming the findings, the participants were re-interviewed the day after each interview for correction of any possible errors; moreover, they could confirm if the reflected explanations were in conformity with their experiences or not. An expert on Qualitative Research, who revised some of the notes and helped in the analysis of the data, was consulted in the process of this study. Furthermore, all three researchers reviewed the interviews and cited corrections wherever necessary. Continuous observation by comparing notes and analyses was also done. In addition, approximation and credibility of the findings was gotten by comparing the rough notes and drafts with the elicited and the formulized meaning. The analysis of the interviews and the written narrations of the participants led to the extraction of 6 inner themes consisting of sickness, environment, reciprocal relationship, parents’ personal problems, mental and emotional matters and a spiritual dimension; all of which define a specific aspect of the experience of hospital in children and parents. A. Disease: Disease included concerns related to the nature of disease, effects, diagnostic procedures and the individual’s knowledge regarding the disease. The nature of disease included physical and bodily signs in which most subjects experienced pain, and this was more evident especially during diagnostic procedures. Knowledge of disease had an effect on the anxiety of the participants of this research and the children with previous hospitalization experiences showed even stronger signs. A concern regarding the effects of the disease and recovery after leaving hospital was also present. Most were worried about the fact that whether they would return to a normal condition soon after leaving hospital or that the disease would leave some effect on them. Fright and anxiety from diagnostic procedures, like CT scan, radiography, sonography and repeated blood sampling were also part of the experience of the participants. Fear of pain caused by remedial procedures, especially from the injection needle, was common in all children. B. Environmental: Many of the participants in the research conveyed different degrees of dissatisfaction regarding the environment of the hospital in their experiences; and their accounts showed the same. They expressed concern regarding hospital noise, beds, clothes, equipment, as well as hospital food conditions, hospital rules, and visiting hours. In addition, unfamiliarity with the surroundings was also cited in the experiences of the participants. In fact the children were even worried about the state of beds and the lack of place of rest and sleep for their parents. That the parents had to sleep while seated on a chair and that they did not have a proper place to rest was a cause of concern for the children. In general, they were concerned or worried about the discomfort and troubles of their parents. Fear of the operation-theater and fear and anxiety of long green gowns and masks on the faces of personnel and the fear of the atmosphere of the operation room was a common experience among most of the children. Strange surroundings were seen as a major cause of disturbance in the experiences of all the participants. "The people in the operation room with their long green clothes and big masks, whose faces could not be seen at all, were really horrifying. I was frightened by them!" "I was frightened of the operation room with its strange equipment!" "Every night in the hospital is equal to ten years of my life; as if I’were in jail!" C. Mutual Relationship: One of the subjects that can affect the understanding of hospitalized people regarding getting hospitalized is the social relationship that they have with other people in society. Most of the participants in the research emphasized the fact that getting hospitalized interferes with their social relationships, and counted this as a major issue in their experiences. One of the participants said: "Doctor does not speak to us at all. Very little. Only a couple of words to the nurses; and that too in whispers. He does not say anything to us; only writes something in the file and leaves." "When the nurses spoke to me, I felt a little relaxed. When they come to my child’s bedside, I feel relieved." A mutual relationship consists of school and friends, family and parents, hospital staff, especially doctors, nurses, security guards, etc. Anxiety and worry regarding schooling conditions was among the major concerns of both parents and children. Moreover, a disturbance in the relationship between friends and peers was also seen. Although anxiety arising from separation from parents should be less apparent among the school-going age group, all the children expressed a concern regarding separation from parents, and this worry was clearly evident in their experiences. In addition, missing the family and other relatives was also included in the experiences of the participants. The relationship with the doctor, the nurse, the security guard, the janitor, and the whole treatment staff had an effect on the experiences of the participants. "I expected the doctor to talk to me directly and tell me what medicine to purchase from outside. Why has he written in the file and not told me anything? The doctor just asks me a few questions and goes away." "I miss my brother and sister; I want to go home soon and play with my friends, go to school." D. Personal Problems of Parents: The problems of parents include change in their lifestyles, financial matters, job conditions, commuting, and the condition of the other members of the family. A change in lifestyle is a change that participants experience because of staying at their children’s bedside or because of hospitalization. These changes include a change in resting, place, daily schedule and lifestyle. A change in place and resting and physical environment consists of a place to sit and the noise of the hospital caused by the presence of room-mates or hospital staff. A change in daily routine and lifestyle comprises a change of daily work schedules and routines like bathing, sleeping and waking. The participants described their experiences as follows: "I have been wearing the same clothes for many days." "I have a bad feeling about the fact that I can’t take a shower here." "I’m worried about my job; I don’t know if they will give me more leave." "I am worried about my sheep and cattle. My farm produce will get spoilt. I don’t know what to do." E. Mental and Emotional Affairs: All participants showed some kind of mental excitement which differed in range from low to high. The themes considered in this cluster consisted of fear, anxiety, loneliness and homesickness, feeling of security, and sense of duty and conscientiousness for caring. The participants described these emotions in different ways. Fear related to pain arising from remedial and diagnostic procedures was recounted as an experience by all children. Their anxiety was related to separation from parents, school and studies, anxiety from unknown surroundings, medical procedures of diagnosis, and anxiety from losing a part of the body or even death. E. Spiritual Aspect and Relationship with God: Spiritual aspect was described by most of the participants among the other experience. Entrusting in God, saying prayers and reading supplications of prayers (du’a) in the hospital were among the experiences of most parents. "When my daughter had gone into the operation room, I was reading supplications all the time; I put my trust in God." "My mother recites supplications whenever she is free. She goes to the prayer room and says prayers and supplications." People remember God more when they are in distress. It is such also when they are in hospital. Discussion The findings of this research have shown that hospitalization of children can bring about negative changes and mental and spiritual pressure on children and their parents, and can endanger their health. Concerns regarding the gravity of the illness of the child, hospital environment, mutual relationship, personal problems of the parents and emotional matters were the common themes included - either typically or under different headings - in other researches. The results of a research in England by Emelda Coyne showed that the anxiety caused by the disease or by diagnosis and cure, anxiety regarding the effects of the illness and loss of life or the ability to care for oneself, were among the main experiences related by participants [4]. In addition, Terri Carney [10] and also Chitra Kumar and Marie Fitzgerald [11] have introduced these anxieties as one of the three main themes of their findings. Diaz [12] and colleagues and Polkki et al [13] have stated in a research that all the children showed a fear of medical procedures, especially of the injection needle. These researches are compatible with the present research. Only that in this research the children and parents did not express a worry about loss of life. It is possible that this point is related to the state of illness of the children and that none of the children in this research had a chronic disease. Clark and Fugarti [15], Carr and Dadley [16] in America and Darbyshire [17] have confirmed the existence of these themes. They have considered active and dynamic relationships as one of their main themes of their research. Moreover, they have found change in daily routine lifestyles and the change of living space as one of the experiences among the parents; and they have considered it under the heading of transfer themes. On the whole it can be said that stress-causing events can be a source of fear when children fall sick or get hurt. These include new environment, adapting with separation, coming in contact with different medical and surgical procedures and equipment, a change in routine activities, seeing distressed children and unknown hospital staff[14-17]. Relieving emotional stress in children and their families is one of the important elements of caring for the disease. Giving emotional and psychological support is difficult, but it is an important aspect needed to help the child adapt better to the disease and hospitalization. Although children at school-going age can adapt better to separation, the stress forced upon them by the disease or hospitalization can increase the need of security and guidance from their parents. School-goers (at middle- and senior-school age) show a greater reaction to separation from their current activities as well as social activities rather than to separation from parents; whereas children at an early school-age reveal a greater anxiety arising from separation from parents. The same has also been identified in the experiences of the participants of the present research. High levels of mental and physical activities mostly cause a shortage of suitable outlets in the hospital environment. Even those of them who detest school are aware of this case. A feeling of loneliness, separation, depression and vexation is common. It is important to distinguish whether these reactions are caused by separation than from disease or cure or the hospital conditions. School-aged children may feel a need or tendency for the guidance of their parents or the support of other people and may not be able to or may not want to express this fact. Because of the fact that gaining independence is very important to them, they refrain from taking any direct help and they imagine that they will get named, e.g. sissy, mama’s boy or weak. The fear of harm to one’s body or getting dismembered is also common at this age. Moreover, losing one’s status in the group of peers, disability, losing control, unconsciousness, surgery, the seriousness of the disease and death, are also some of the fears. One of the reasons why children get frightened is a fear of the unknown. While there is a difference of opinion regarding the fact that whether it is positive or negative to get the child ready enough for hospitalization, it has been proven that getting the child ready for near-future medical procedures and other events help reduce of anxiety. Preparation helps the child feel as if he has gained a control over the situation. Fear gets stronger when the child does not know or cannot understand what is happening and why it is happening. In the present research, the experience of the participants clearly indicates that unawareness causes anxiety and fear in children. In cases when the hospital stay is lengthy, it is necessary that school programs of the children be followed up in the hospital. It must be emphasized that following up on the studies of that group of children who stay in hospital for longer periods is of utmost importance. For avoidance of the feeling of loneliness and homesickness in children, hospitals must plan programs for their recreation and entertainment. Usage of characters, such as, “Khānoom-e Mas’ool-e Bāzi” (literally: Madam Games-In Charge), who entertains and keeps the children pre-occupied in hospital and raise their moral, is still very uncommon in our remedial system. In addition, paying attention to the needs of the parents and to their mental-emotional reactions is among the important points of caring. Callery (1997) has noted that caring for parents of hospitalized children is an aspect that is hidden out of sight of the nursing staff. The parents need help and guidance, too, in order to be able to execute and to shoulder the responsibility of looking after their children[16]. Conclusion The experience of hospitalization in children can be considered as a process of effort for returning to health and, on the whole, the regaining of the individual’s status in the world. Nurses can ease this process by showing the importance of experience and feelings of individuals at the time of hospitalization and help people to adapt themselves to their new surroundings. This matter can enable the nurses to utilize methods of helping in the adaptation of individuals and thus guide the unique powers present in every individual to ease and quicken recovery. A point and theme which was reached in this research, from the experience of the participants that was different from those of other researches, was a spiritual aspect and an entrustment in God. The other researchers did not find this theme in the experiences recorded in their research, whereas in this research most parents cited a spiritual aspect, with an entrustment in God and a calm which they felt afterwards. This is a very positive and interesting point; and nurses can soothe people by taking their religious beliefs into account, especially, in critical times, by encouraging them to pray and put their trust in God as it is said: “only with the name of God do the hearts become calm”. Acknowledgment Permission for human studies from Researches Committee of the University and Ethics Committee was duly taken. This study was supported by the grant of Gonabad University of Medical Sciences. We wish to thank children and parents who collaborated in this study. Conflict of Interest: There are no conflicts of interest. References
Copyright 2011 - Iran Journal of Pediatrics |
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