University of Huddersfield

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(No Transcript)
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University of Huddersfield
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Tokenism or true partnership to what extent is
parental involvement in the childs acute pain
care facilitated by nurses within a culture of
family centred care in general childrens wards?
Jackie Vasey
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Historical perspective- the early years

• Dr George Armstrong 1717-1789- instigated
  ambulatory care, and believed in families caring
  for their children at home. He stated that to
  separate a child from their families would break
  their hearts immediately. (Miles, 1986 p 83)
• But that is exactly what happened when childrens
  hospitals/wards began to open, with very limited
  or no parental visiting. In 1951, 150 hospitals
  completely banned visiting for parents
  (Robertson, 1989)
• Nurse felt that parental presence was detrimental
  to the child settling in and a hindrance to the
  nurse! (Glasper and Richardson, 2006 Jolley,
  2008)

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Who would dare to argue with this matron?
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Historical perspective- late 1900s

• Bowlby and Ainsworth (Betherton, 1992)
• Robertson- stages of separation anxiety
  (Robertson, 1970)
• Platt Report (Committee of the Central Health
  Services Council, 1959)
• NAWCH/ASC (ASC, 2002)

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Stages of separation anxiety during maternal
deprivation

• Protest
• Despair
• Denial/ detachment
• (Robertson, 1970)

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The 2 year old who went to hospital Parental
involvement in this era- parents were still
trying to get through the door!
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Historical perspective- late 1900s

• Concept of family centred care emerged from the
  1950s following the work of Bowlby and Robertson
  (Bowlby, 1953 Robertson, 1989 Smith et al,
  2002)
• The Platt report resulted in slow adoption of
  open visiting (Committee of the Central Health
  Services Council, 1959)
• Other reports followed- Court report (Department
  of Health and Social Security, 1976), Welfare of
  children and young people in hospital (DH, 1991),
  Audit Commission Report (1993), The Patients
  Charter (DH, 1996)
• Some reluctance by nurses who felt parental
  presence was not a positive move.
• Questions were raised about this cherished
  policy of involvement. FCC has been argued to be
  ill-defined (Franck Callery, 2004).
• Darbyshire identified inconsistencies in how the
  meaning of family involvement is interpreted,
  resulting in parental involvement occurring more
  at the level of professional ideology that in
  everyday practice (Darbyshire, 1994)
  
  
  
  
• Callery described it as ad hoc and
  unpredictable and highlighted the financial,
  social and personal costs to parents (Callery,
  1997)
• Shields et al (2008) argues that its
  effectiveness has not been measured.

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Started to let mums in
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And dads too!
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Even both parents at the same time!
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Family centred care continuum
Family centred care is an approach to the
planning, delivery and evaluation of healthcare
that is governed by mutually beneficial
partnerships between healthcare providers,
patients and families (Shields et al 2006, p.
1318)
No Involvement Involvement Participation Partnership Parent-led
Nurse-led Nurse-led Nurse-led Equal status Parent-led
Smith et al (2002)
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Current perspectives regarding pain care-

• Abundance of literature regarding childrens pain
  management emerged in the 1990s (Helgadottir,
  2000 Cunliffe Roberts, 2004 Gold et al, 2006
  Johnstone et al, 2007 Reaney, 2007)
• However, few studies explicitly explored parental
  involvement and the most recent appears to be in
  2002. (Woodgate Kristjanson, 1996 Simons et
  al, 2001 Simons Roberson, 2002)
• RCN/RCPCH developed guidelines that advocate the
  involvement of parents (Royal College of
  Paediatrics and Child Health, 2004 Royal College
  of Nursing, 2009)
• NSFs standards 4.28-4.33- whilst this document
  sets standards in response to the Kennedy report
  and attributes the lack of partnership with
  parents as a contributory factor in the events at
  Bristol- it does not specifically include
  parental involvement in a childs pain care in
  the pain management section (DH, 2003).
• However, the parent version states you should be
  able to discuss with the staff what more they
  could do to help with your child if he or she is
  in pain (DH, 2003 p 15).
• Also, whilst the Care Quality Commission looked
  at how the standards had been met in relation to
  aspects of pain management it did not
  specifically audit parental involvement- perhaps
  this reflects the relative importance placed on
  this
• Clayton (2000) states that the culture in child
  nursing, is one where nurses would not
  contemplate using an approach to care that did
  not involve families.

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How may parents be involved in pain care?

• Provide a pain history
• Assist with the assessment of the childs pain
• Assist in the selection of the most appropriate
  pain control methods
• Administer pharmacological and non-
  pharmacological pain relief
• Alert the nurse to any adverse effects of the
  treatment
• Evaluate its effectiveness
• Continue pain care at home

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Positive and less positive aspects of FCC for the
parents/child
Positive aspects of FCC for the parents/child Less positive aspects of FCC for the parents/child
Child has security of a consistent and stable parent present who assists with their needs- as normal (Hutchfield, 1999). Greater parental understanding of and participation in decisions regarding their childs care (MacKean et al, 2005) More control over what happens to their child (Clayton, 2000) Mutual respect between nurses/parents (Hutchfield, 1999 Smith Coleman, 2010). More prepared to care for the child at home on discharge (Smith Coleman, 2010) Minimises effects of hospitalisation (Hutchfield, 1999). Gate control theory- parental presence reduces anxiety for the child (Twycross et al, 1998) Parents may pick up on their childs pain behavioural cues, as they know them best (Simons et al, 2001 Gimbler-Berglund et al, 2008) Child more likely to tell parent if they have pain (Simons et al, 2001) Parents are a true advocate for the child (MacKean et al, 2005) Empowerment may increase parent confidence in themselves as care-givers (MacKean et al, 2005) Increasing anxiety and stress for parents (Shields et al, 2008). Captive mothers (Meadow, 1969) Parent trap- parents prisoners by expectation (Darbyshire, 1994) Nurses are in control of their involvement (Callery Smith, 1991 Clayton, 2000) Parents have to learn in minutes/hours what nurses take years to learn (Valentine, 1998) Information overload or lack of information for parents (Hutchfield, 1999 Shields et al, 2008) Parents may find it a financial, social and/or emotional burden (Callery, 1997) Is fully informed, fully burdened? (Callery, 1997) Parents may have conflicting demands- for example work/siblings/marriages (Callery, 1997 Clayton, 2000)) If parents indicate they want to be involved- they may feel it becomes an expectation. Feel unable to take a break (Smith et al, 2002). Nurses hold power and select which roles to involve parents in (Nethercott, 1993) Guilt- bad parents if they are not involved (Nethercott, 1993) Parenting in public- Human Rights Act (DH, 1998) the right to respect for private family life. Older children/young people may not want their parents to be involved (Franck Callery, 2004)
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Captive mother caught in the parent trap?
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Positive and less positive aspects of FCC for
the nurse
Positive aspects for the nurse Less positive aspects for the nurse
Can work with parents to minimise the negative effects of hospitalisation (DH, 2003) Increased job satisfaction (Smith et al, 2002) Encourages communication with families (MacKean, 2005) Childrens nurses taught FCC and pain care from pre-registration- so not unexpected (Nethercott, 1993 Twycross, 2000). Lack of clarity about the concept and implementation of FCC (Callery, 1997 MacKean, 2005) Blanket approach- assuming parents are willing to be involved (Callery, 1997 Shield et al, 2006). Perceived increase in workload- teaching parents nursing skills (Simons et al, 2001) Shorter hospital stays result in limited time to assess desired parental level of involvement (Darbyshire, 1994 Corlett Twycross, 2006) May feel threatened by expert parents (Simons Roberson, 2002) Nurses may feel they have failed if parents are unable/unwilling to be involved (Smith et al, 2002) Lack of knowledge and skills regarding pain management may make nurses feel vulnerable/less likely to involve parents (Manworran, 2007, Zisk et al, 2007) Lack of understanding of FCC between nurses and other nurses and other professionals (Clayton, 2000) Concerns about accountability if tasks are delegated to parents (Smith Coleman, 2010) Nurses may feel de-skilled. Anecdotally our students report that they cant get near children to develop their skills when parents present Requires the nurse to be able to judge when to initiate parent involvement (Lee, 1999 Lee, 2004 Smith et al, 2002)

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Safeguarding parents
Nurses must be trained in how to share care with
a resident mother and how to use her as an
efficient and willing source of labour (Meadow,
1969, p 366)
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These are the questions I hope to answer.

• Are parents involved in their childs acute pain
  care?
• If so, to what extent is parental involvement
  implemented effectively?
• What influences involvement?
• Should they be involved?
• If so, how can this be better facilitated?

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So how do I intend going about it?

• Approach- Ethnography
• Method- Non-participant observation with
  potential follow up semi-structured interviews
  with nurses, parents and children
• Data analysis- possibly content analysis

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References

• ASC (2002) Online. Available at
  http//www.action forsickchildren.org/about_histor
  y.html.
• Audit Commission (1993) Children first A study
  of Hospital Services. HMSO London
• Bowlby J. (1953) Child Care and the Growth of
  Love. Penguin Harmondsworth
• Bretherton,I. (1992) The origins of attachment
  theory John Bowlby and Mary Ainsworth.
  Developmental Pscyhology. 28, pp. 759-775
• Callery P. Smith L. (1991) A Study of the Role
  Negotiation Between Nurses and Parents of
  Hospitalised Children. Journal of Advanced
  Nursing. 16, 772-781
• Callery, P. (1997) Paying to participate
  financial, social and personal costs to parents
  of involvement in their childs care in hospital.
  Journal of Advanced Nursing. 25, pp. 746-752
• Clayton, M. (2000) Health and social policy
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• Committee of the Central Health Services Council
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• Corlett, J., Twycross, A., (2006) Negotiation
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• Cunliffe, M., Roberts, A,S. (2004) Pain
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• Darbyshire, P. (1994) Living with a sick child in
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  children. London Chapman Hall.
• DEPARTMENT OF HEALTH (1996) The Patients
  Charter- Services for children and young people.
  London HMSO
• Human Rights Act (1988) London HMSO
• DEPARTMENT OF HEALTH (1991) Welfare of Children
  and Young People in Hospital. HMSO London
• DEPARTMENT OF HEALTH. (2003) The National Service
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• DEPARTMENT OF HEALTH AND SOCIAL SECURITY. (1976)
  Fit for the Future (The Court Report)
  LondonHMSO.
• Franck, L.S., Callery, P., (2004) Re-thinking
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References

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• Glasper, A and Richardson, J (2006) A Textbook of
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