Parent-inclusive Pediatric Units: A Survey of Policies and Practices CAROL B. HARDGROVE, MA, AND ROSANNE KERMOIAN, MA
Abstract: A nation-wide survey of Parent-Inclusive Pediatric Units identified innovations and restrictions in policies and practices. Questionnaires mailed to Directors of Nursing Service at 84 general hospitals which encourage parental "living-in" indicated that parents are provided with a place to sleep but infrequently are offered additional facilities, serv-
ices, and guidance necessary to optimize their presence on the Parent-Inclusive Pediatric Unit. Restrictions on parents remaining with their children are common during highly stressful procedures. Results indicate a gap between research on the importance of parental presence and current hospital practice. (Am. J. Public Health 68:847-850, 1978.)
Over two million children under the age of six are hospitalized in the United States each year.' For many of these children, abrupt separation from their parents heightens the potentially traumatic aspects of the hospitalization experience.2' 3 In the last 12 years, many physicians have recognized the importance of a familiar adult to the physical and social well-being of the young hospitalized patient.4 As a result, the number of pediatric units providing rooming-in facilities has dramatically increased. However, variations in staff reception to parental presence in hospitals which allow "living-in" ranges widely from mere toleration to active inclusion of parents as an integral part of hospital functioning.5-7 Although the serious consequences of a young child's separation from its parents (attachment figures) has been frequently documented in the past 25 years,2 3 8.9 more recent studies have focused specifically on the effect of parental presence as compared with parental absence on the hospitalized child. Brain and MacClay reported a significantly lower incidence of emotional problems and infections in infants whose mothers remained with them during hospitalizations.'I Branstetter similarly reported less withdrawn and aggressive behavior, less crying, and more positive social interactions in children between 14 and 36 months of age
whose mothers or surrogates were present as compared with children who receive normal care on the unit without the company of a trusted adult." Prugh, in an older study, had found that none of the practices designed to counteract anxiety were effective with children under four years of age who did not have a parent with them during hospitalization.'2 Parental presence alone, however, without a parent-education procedure, does not result in optimal patient recovery. Children of parents who receive well-timed and adequate information about the nature of their illness and specific guidance about the parental role recovered more quickly with fewer post-hospital complications than children of parents prepared in a less systematic manner.'3 14 Although the number of Parent-Inclusive Units has grown rapidly and the concept of family-centered pediatric care has become widely accepted as good practice, there have been few attempts to investigate the way in which these units function. The purpose of this study was to identify policies and procedures that are in use by hospitals with "livingin" programs. Two classes of variables were investigatedservices offered to parents, and ways in which parents are systematically involved in the care and nurturance of their children.
Method Address reprint requests to Carol B. Hardgrove, Associate Clinical Professor, Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA 94143. Ms. Kermoian is a PhD Candidate, Child Development/Early Education, Boys Town Center, Stanford University, Stanford, CA. This paper, submitted to the Journal January 9, 1978, was revised and accepted for publication April 13, 1978.
AJPH September, 1978, Vol. 68, No. 9
The sample was selected from 1,498 of the 2,656 general hospitals in the 1974 American Hospital Association listing which had responded to a previous questionnaire designed to locate Parent-Inclusive Pediatric Units. For the present study, a subsample of 84 hospitals was chosen from 267 hos847
HARDGROVE AND KERMOIAN TABLE 1 -Percentage of Affirmative Responses to Facilities and Support Services Checklist
ITEM
Free sleep space for parents Sleep space available at patient bedside Gathering facilities for parents (other than those used by patients) Bathing facilities (other than those used by patients) Kitchen facilities Parent advocate or staff person to facilitate parent inclusion Parent "rap groups" Parent relief (hospital volunteers) Child care for well siblings Parent education prior to hospitalization Parent education after hospitalization
Per Cent of Affirmative Responses*
63 69 21 34 7 8 11 24 3 28 39
*N = 63
pitals meeting the following criteria: 1) they supplied beds or cots for parents of hospitalized children between the ages of six months and five years; 2) they considered their facilities adequate in quantity and/or quality; 3) they systematically informed parents about their living-in programs; and 4) they self-rated their staff as encouraging parent-inclusion. A stratified random sampling procedure was used to insure equal representation of hospitals from different categories: 1) locations in the United States-west, midwest, south, east; 2) affiliation-teaching or non-teaching hospitals; and 3) size of unit-12 beds or less, over 12 beds. Data from a previous study6 and discussions with directors of parent-inclusive programs led the investigators to expect significant dif-
ferences in policies and procedures within each of the three categories. Questionnaires designed to gather data on the way in which hospitals conduct their Parent-Inclusive Programs were sent to Directors of Nursing Service in 1976. Forty questions addressed the following concerns: 1. Who is responsible for the "living-in" program and what training have they received? 2. What services are available to parents and how are they informed of these services? 3. How are families encouraged to nurture their hospitalized children physically and psychologically? 4. What guidelines exist to promote optimal effectiveness of parents and staff members interacting with the patient?
Results Eighty per cent of the questionnaires were returned after two mailings. The 63 cases used for analysis proportionately reflected the stratified sample; three hospitals which no longer had a "living-in" unit were excluded. Questionnaires were returned from 81 per cent of hospitals located in the west, 71 per cent in the midwest, 72 per cent in the south, 848
and 76 per cent in the east, 75 per cent of the teaching hospitals and 73 per cent of the non-teaching hospitals with over 12 beds, and 68 per cent of the hospitals with 12 beds or under. Approximately one-half (44 per cent) of the units had been operating parent "living-in" programs for over six years. As can be seen from Table 1, 63 per cent of the hospitals in the study offered free sleep space and 69 per cent offered sleep space located in patients' rooms. Some units had additional facilities solely for the use of parents. These included gathering places (21 per cent), bathing facilities (34 per cent), and kitchen facilities (7 per cent). Responses to support services indicated that 8 per cent of the hospitals had a parent advocate; 11 per cent offered "rap groups"; 24 per cent had volunteers to stay with children whose parents could not remain or who needed relief; 3 per cent had child care for well siblings. In addition, parent-education programs either prior to hospitalization (28 per cent) or after hospitalization (39 per cent) were conducted by approximately one-fourth of these units. Responses indicated that there were more hospitals that had a systematic way of sharing information with parents about their child's state of health (45 per cent) than had guidelines specifying appropriate parental behavior on the unit (36 per cent) or that had special routines developed to make best use of parental presence (24 per cent). Seventy-seven per cent of the hospitals surveyed depended on parents to give psychological support to their children and to perform parenting activities. Other family members, such as well siblings, were allowed to visit the patient in one-half of the hospitals surveyed. The degree of familial involvement usually was controlled, however, in that most hospitals (65 per cent) placed restrictions on parents cooking for their children either at home or in the hospital, staying with their child during tests and treatments, (71 per cent), staying with their child during induction into anesthesia (89 per cent), or staying with their child in the recovery room (81 per cent). Chi square analyses were computed between dichotomous responses from teaching and non-teaching hospitals with over 12 beds, and between pediatric units with 12 or fewer beds and 13 or more beds. The results showed no significant differences in responses to most questions. However, both teaching hospitals and larger pediatric units had a higher probability of having bathing facilities solely for the use of parents (X2(l), p < .025), and allowed well siblings to visit the patient more frequently (X2(1), p < .005). Teaching hospitals also tended to offer parent "rap groups" (X2(1), p < .005) more frequently than non-teaching hospitals, and were more likely to have a staff trained in working with parents (X2(1), p < .01). Chi square analyses showed no significant differences between questionnaire responses of parent-inclusive pediatric programs in operation under three years, those in operation three to six years, or over six years. In order to determine how closely five questions that theoretically should discriminate between hospitals could predict hospital response across the total questionnaire, a linear regression was computed. Each hospital was assigned AJPH September, 1978, Vol. 68, No. 9
PARENT-INCLUSIVE PEDIATRIC UNITS
a composite score by summing positive responses to the following questions: 1) Is cooking for children by parents generally against your policy? 2) Are parents allowed to stay with their child in the recovery room? 3) Is there a procedure by which well siblings are allowed to visit the patient? 4) Is parent education provided after the child is hospitalized? 5) Is there a systematic way of sharing information about the patient's state of health with parents? The summary scores became the independent variable and the number of positive responses across the total questionnaire became the dependent variable in a linear regression. The results showed that R2 = 56, thus 56 per cent of the variance in hospital response along the restrictive-supportive dimension was predicted from five out of a total of 40 questions.
Discussion This survey has identified a gap between research-based rationale for encouraging parents to stay with their hospitalized child and the current manner of implementation of "living-in" programs. Although questionnaire return was high (80 per cent), and hospitals differing in size, affiliation, and length of operation of parent programs showed few significant differences in responses, caution must be taken in generalization of these findings to all Parent-Inclusion Units. This sample was biased toward hospitals which had willingly participated in a previous survey which may have resulted in oversampling of pediatric units with more established and/or liberal policies and procedures than the actual population of "living-in" units in the United States. Results showed that institutional support of parental presence, for the most part, is limited to providing beds. Accommodations that would make parents more comfortable and relaxed-reserved bathing, kitchen, and meeting areas-were uncommon. Psychological and familial support-such as parent advocates, parent "rap groups", volunteer substitute parents, and child care for well siblingswere infrequently provided by pediatric units. Parent surrogates were seldom provided for children whose parents did not remain with their child, although such substitute parents have been found to be effective in minimizing distress caused by separation. Hospitals in England and the United States that have used "Ward Grannies", Foster Grandparents, or student volunteers on a one-to-one basis as companions for infants and children whose parents do not live-in find that the children are less distressed and regressed than children who must cope with the separation and hospitalization on their own.'1' 15 Another recurrent problem that interferes with parental support is the lack of a facility where parents may leave their well children while visiting the patient. Whereas many hospitals prominently display signs stating that children younger than 12 or 14 years are not allowed on the pediatric floor, few hospitals offer an alternative. Hospitals in Sweden and Denmark provide drop-in supervised play space in hospital lobbies to encourage hospital visiting of sick children. Results from this study showed that hospitals infrequently impart to parents expectations of acceptable behavAJPH September, 1978, Vol. 68, No. 9
ior on the unit and seldom have special routines to include them in their child's stay. When parents are allowed to remain, but are ignored, they may feel demeaned and stripped of their power, hence behave in a manner that is unfamiliar and confusing to their child. Wolfer and Visintainer's studies'4 show the benefits of preparing parents as well as children for the hospital experience, especially regarding expectations for performance. Children recuperate faster, parents express greater satisfaction with hospital and medical care, and both children and parents are more cooperative when adequately prepared. The following quotation from one hospital's preparation for parent participation in the recovery room illustrates the kind of definitive instruction that reduces anxiety for parents, staff, and as a result, anxiety for patients: "We would like to emphasize that you are called to the recovery room to provide support for your child. We request that you stay at your child's bedside. Do not walk around the room, and do not inquire about other children in the room. Chairs will be provided and when physically possible,
you may hold your child as he or she awakens."'6
Although the presence of a familiar adult can help a child cope with the stress of hospitalization, parents are usually barred from procedures that are the most stressfultests and treatments, induction and recovery from anesthesia. Yet for more than 30 years, Children's Hospital National Medical Center in Washington, D.C. has practiced inducing anesthesia with the child on the parent's lap, in her arms, or holding her hand. Parents can have a normalizing affect on the environment but they are often limited in their freedom to support their child in a natural way. For example, most hospitals in this study had rules against home-cooked food being allowed in the hospital although this might make a difference in how well a child eats. Similarly, although sibling visits might be reassuring to the hospitalized child, approximately one-half of the units surveyed did not allow such visits. The American Academy of Pediatrics, in its recommendations for the care of children in hospital, has this to say on the subject of visiting by siblings: "The hospital should provide facilities and attitudes to promote the well-being of both the parents and the child. The pediatric patient needs continuing contact with his parents, and visiting privileges should be generous. "Traditionally, hospitals caring for children have excluded siblings and other children on the rationale that children would be more likely to carry infection to patients than would adults. However, the scientific basis for this assumption is questionable. Experience now indicates that visiting by children and siblings is as safe as visiting by adults, if those with obvious infection or known exposure to contagion are excluded. The psychological importahce to the hospitalized child of seeing his friends and siblings is so significant, and the danger of introduction of infection so small, that liberalization of visiting procedures is recommended."'5
The findings that Parent-Inclusive Units in operation for over six years do not differ significantly in policies and practices from more recently established programs are not surprising. Absence of in-service training in methods of working with parents, and lack of systematic staff and parent evalua849
HARDGROVE AND KERMOIAN
tion of the "'living-in" program, indicate that after a "'livingin" program is implemented, little is done to improve program quality. This study indicates that despite a growing concern for the psychosocial needs of pediatric patients, most "livingin" programs do not optimize parental presence. TITLE 22 of the California Administrative Code requires hospitals to adhere to standards of the American Academy of Pediatrics, recommendations which favor comprehensive forms of parent-inclusion.4 17 Since the hospitals in this sample, specifically chosen for their support of parental presence, only minimally meet those standards, it is unlikely that most pediatric units are in compliance. This finding indicates a strong need for education of health care professionals to the special problems of the hospitalized child and his family. Likewise, greater effort is required for implementation of programs involving parents and research on the effects of these programs.
REFERENCES 1. National Center for Health Statistics. Utilization of Short-Stay Hospitals: Annual Survey for the United States, 1975. Vital Health Statistics Series 13, No. 31. Health Resources Administration, p. 24, 1977. 2. Bowlby J: Attachment and Loss. Vols. I and II. Basic Books, 1969, 1973. 3. Freud A and Burlingham D: War and Children. Medical War Books, 1943. 4. American Academy of Pediatrics: Care of Children in Hospitals, 1971, pp. 4, 11-14. 5. Hardgrove C: Living-in accommodations and practices for parents in hospital pediatric units: An update, Journal of the Association for the Care of Children in Hospitals, 4(l):24-26, xxxx.
I
6. Fagin C: The case for rooming-in when young children are hospitalized, Nursing Science, 2:324-333, 1964. 7. Mahaffy P: Nurse-patient relationships in living-in situations, Nursing Forum, 111(2):53-64, 1964. 8. Edelston H: Separation anxiety in young children: A study of hospital cases, Genetic Psychology Monographs, 28(1): 1943. 9. Robertson J: Young Children in Hospital, 2nd edition. New York: Burst & Noble, 1970. 10. Brain DJ and MacClay J: Controlled study of mothers and children in the hospital. British Medical Journal, 1:278, 1968. 11. Branstetter EM: The young child's response to hospitalization: Separation anxiety or lack of mothering care. Am J Public Health, 59:92-97, 1969. 12. Prugh DG, Staub EM, Sands HH, et. al: A study of the emotional reactions of children and families to hospitalization and illness, Am J of Orthopsychiatry, 23:20, 1953. 13. Skipper JK and Leonard RC: Children, stress and hospitalization: A field experiment, Journal of Health and Social Behavior. 9(4):275-287, 1968. 14. Wolfer J and Visintainer M: Pediatric surgical patients' and parents' stress responses and adjustment, Nursing Research, 24(4):244-255, July/August, 1975. 15. Jolly J: Children in hospital: The ward granny scheme. Nursing Times, April 11, 1974. (reprint) 16. Guidelines for Parents Visiting in the Pediatric Recovery Room. University Hospitals of Cleveland, University Circle, Cleveland, OH 44106. 17. California Administrative Code, Title 22, Section 705 37 (a).
ACKNOWLEDGMENTS This investigation was supported in part by Biomedical Research Support Grant RR 05604 from the Biomedical Research Support Branch, Division of Research Facilities and Resources, National Institutes of Health. Parts of this paper were presented to the International Symposium of the International College of Pediatrics, Helsinki, Finland, June 1978.
Physician's Fees
Fhe English physician, Thomas Dimsdale, probably established a record (fee-for-service) for all time when he received fifty thousand dollars cash, an annual pension of ten thousand dollars, and a Russian baronetcy, allfor vaccinating Catherine the Great and her son. Shryock R.H. Public Relations of the Medical Profession in Great Britain and the United States: 1600-1870. Ann. Med. Hist. 2:308-339, 1930.
850
AJPH September, 1978, Vol. 68, No. 9
Abstract: A nation-wide survey of Parent-Inclusive Pediatric Units identified innovations and restrictions in policies and practices. Questionnaires mailed to Directors of Nursing Service at 84 general hospitals which encourage parental "living-in" indicated that parents are provided with a place to sleep but infrequently are offered additional facilities, serv-
ices, and guidance necessary to optimize their presence on the Parent-Inclusive Pediatric Unit. Restrictions on parents remaining with their children are common during highly stressful procedures. Results indicate a gap between research on the importance of parental presence and current hospital practice. (Am. J. Public Health 68:847-850, 1978.)
Over two million children under the age of six are hospitalized in the United States each year.' For many of these children, abrupt separation from their parents heightens the potentially traumatic aspects of the hospitalization experience.2' 3 In the last 12 years, many physicians have recognized the importance of a familiar adult to the physical and social well-being of the young hospitalized patient.4 As a result, the number of pediatric units providing rooming-in facilities has dramatically increased. However, variations in staff reception to parental presence in hospitals which allow "living-in" ranges widely from mere toleration to active inclusion of parents as an integral part of hospital functioning.5-7 Although the serious consequences of a young child's separation from its parents (attachment figures) has been frequently documented in the past 25 years,2 3 8.9 more recent studies have focused specifically on the effect of parental presence as compared with parental absence on the hospitalized child. Brain and MacClay reported a significantly lower incidence of emotional problems and infections in infants whose mothers remained with them during hospitalizations.'I Branstetter similarly reported less withdrawn and aggressive behavior, less crying, and more positive social interactions in children between 14 and 36 months of age
whose mothers or surrogates were present as compared with children who receive normal care on the unit without the company of a trusted adult." Prugh, in an older study, had found that none of the practices designed to counteract anxiety were effective with children under four years of age who did not have a parent with them during hospitalization.'2 Parental presence alone, however, without a parent-education procedure, does not result in optimal patient recovery. Children of parents who receive well-timed and adequate information about the nature of their illness and specific guidance about the parental role recovered more quickly with fewer post-hospital complications than children of parents prepared in a less systematic manner.'3 14 Although the number of Parent-Inclusive Units has grown rapidly and the concept of family-centered pediatric care has become widely accepted as good practice, there have been few attempts to investigate the way in which these units function. The purpose of this study was to identify policies and procedures that are in use by hospitals with "livingin" programs. Two classes of variables were investigatedservices offered to parents, and ways in which parents are systematically involved in the care and nurturance of their children.
Method Address reprint requests to Carol B. Hardgrove, Associate Clinical Professor, Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA 94143. Ms. Kermoian is a PhD Candidate, Child Development/Early Education, Boys Town Center, Stanford University, Stanford, CA. This paper, submitted to the Journal January 9, 1978, was revised and accepted for publication April 13, 1978.
AJPH September, 1978, Vol. 68, No. 9
The sample was selected from 1,498 of the 2,656 general hospitals in the 1974 American Hospital Association listing which had responded to a previous questionnaire designed to locate Parent-Inclusive Pediatric Units. For the present study, a subsample of 84 hospitals was chosen from 267 hos847
HARDGROVE AND KERMOIAN TABLE 1 -Percentage of Affirmative Responses to Facilities and Support Services Checklist
ITEM
Free sleep space for parents Sleep space available at patient bedside Gathering facilities for parents (other than those used by patients) Bathing facilities (other than those used by patients) Kitchen facilities Parent advocate or staff person to facilitate parent inclusion Parent "rap groups" Parent relief (hospital volunteers) Child care for well siblings Parent education prior to hospitalization Parent education after hospitalization
Per Cent of Affirmative Responses*
63 69 21 34 7 8 11 24 3 28 39
*N = 63
pitals meeting the following criteria: 1) they supplied beds or cots for parents of hospitalized children between the ages of six months and five years; 2) they considered their facilities adequate in quantity and/or quality; 3) they systematically informed parents about their living-in programs; and 4) they self-rated their staff as encouraging parent-inclusion. A stratified random sampling procedure was used to insure equal representation of hospitals from different categories: 1) locations in the United States-west, midwest, south, east; 2) affiliation-teaching or non-teaching hospitals; and 3) size of unit-12 beds or less, over 12 beds. Data from a previous study6 and discussions with directors of parent-inclusive programs led the investigators to expect significant dif-
ferences in policies and procedures within each of the three categories. Questionnaires designed to gather data on the way in which hospitals conduct their Parent-Inclusive Programs were sent to Directors of Nursing Service in 1976. Forty questions addressed the following concerns: 1. Who is responsible for the "living-in" program and what training have they received? 2. What services are available to parents and how are they informed of these services? 3. How are families encouraged to nurture their hospitalized children physically and psychologically? 4. What guidelines exist to promote optimal effectiveness of parents and staff members interacting with the patient?
Results Eighty per cent of the questionnaires were returned after two mailings. The 63 cases used for analysis proportionately reflected the stratified sample; three hospitals which no longer had a "living-in" unit were excluded. Questionnaires were returned from 81 per cent of hospitals located in the west, 71 per cent in the midwest, 72 per cent in the south, 848
and 76 per cent in the east, 75 per cent of the teaching hospitals and 73 per cent of the non-teaching hospitals with over 12 beds, and 68 per cent of the hospitals with 12 beds or under. Approximately one-half (44 per cent) of the units had been operating parent "living-in" programs for over six years. As can be seen from Table 1, 63 per cent of the hospitals in the study offered free sleep space and 69 per cent offered sleep space located in patients' rooms. Some units had additional facilities solely for the use of parents. These included gathering places (21 per cent), bathing facilities (34 per cent), and kitchen facilities (7 per cent). Responses to support services indicated that 8 per cent of the hospitals had a parent advocate; 11 per cent offered "rap groups"; 24 per cent had volunteers to stay with children whose parents could not remain or who needed relief; 3 per cent had child care for well siblings. In addition, parent-education programs either prior to hospitalization (28 per cent) or after hospitalization (39 per cent) were conducted by approximately one-fourth of these units. Responses indicated that there were more hospitals that had a systematic way of sharing information with parents about their child's state of health (45 per cent) than had guidelines specifying appropriate parental behavior on the unit (36 per cent) or that had special routines developed to make best use of parental presence (24 per cent). Seventy-seven per cent of the hospitals surveyed depended on parents to give psychological support to their children and to perform parenting activities. Other family members, such as well siblings, were allowed to visit the patient in one-half of the hospitals surveyed. The degree of familial involvement usually was controlled, however, in that most hospitals (65 per cent) placed restrictions on parents cooking for their children either at home or in the hospital, staying with their child during tests and treatments, (71 per cent), staying with their child during induction into anesthesia (89 per cent), or staying with their child in the recovery room (81 per cent). Chi square analyses were computed between dichotomous responses from teaching and non-teaching hospitals with over 12 beds, and between pediatric units with 12 or fewer beds and 13 or more beds. The results showed no significant differences in responses to most questions. However, both teaching hospitals and larger pediatric units had a higher probability of having bathing facilities solely for the use of parents (X2(l), p < .025), and allowed well siblings to visit the patient more frequently (X2(1), p < .005). Teaching hospitals also tended to offer parent "rap groups" (X2(1), p < .005) more frequently than non-teaching hospitals, and were more likely to have a staff trained in working with parents (X2(1), p < .01). Chi square analyses showed no significant differences between questionnaire responses of parent-inclusive pediatric programs in operation under three years, those in operation three to six years, or over six years. In order to determine how closely five questions that theoretically should discriminate between hospitals could predict hospital response across the total questionnaire, a linear regression was computed. Each hospital was assigned AJPH September, 1978, Vol. 68, No. 9
PARENT-INCLUSIVE PEDIATRIC UNITS
a composite score by summing positive responses to the following questions: 1) Is cooking for children by parents generally against your policy? 2) Are parents allowed to stay with their child in the recovery room? 3) Is there a procedure by which well siblings are allowed to visit the patient? 4) Is parent education provided after the child is hospitalized? 5) Is there a systematic way of sharing information about the patient's state of health with parents? The summary scores became the independent variable and the number of positive responses across the total questionnaire became the dependent variable in a linear regression. The results showed that R2 = 56, thus 56 per cent of the variance in hospital response along the restrictive-supportive dimension was predicted from five out of a total of 40 questions.
Discussion This survey has identified a gap between research-based rationale for encouraging parents to stay with their hospitalized child and the current manner of implementation of "living-in" programs. Although questionnaire return was high (80 per cent), and hospitals differing in size, affiliation, and length of operation of parent programs showed few significant differences in responses, caution must be taken in generalization of these findings to all Parent-Inclusion Units. This sample was biased toward hospitals which had willingly participated in a previous survey which may have resulted in oversampling of pediatric units with more established and/or liberal policies and procedures than the actual population of "living-in" units in the United States. Results showed that institutional support of parental presence, for the most part, is limited to providing beds. Accommodations that would make parents more comfortable and relaxed-reserved bathing, kitchen, and meeting areas-were uncommon. Psychological and familial support-such as parent advocates, parent "rap groups", volunteer substitute parents, and child care for well siblingswere infrequently provided by pediatric units. Parent surrogates were seldom provided for children whose parents did not remain with their child, although such substitute parents have been found to be effective in minimizing distress caused by separation. Hospitals in England and the United States that have used "Ward Grannies", Foster Grandparents, or student volunteers on a one-to-one basis as companions for infants and children whose parents do not live-in find that the children are less distressed and regressed than children who must cope with the separation and hospitalization on their own.'1' 15 Another recurrent problem that interferes with parental support is the lack of a facility where parents may leave their well children while visiting the patient. Whereas many hospitals prominently display signs stating that children younger than 12 or 14 years are not allowed on the pediatric floor, few hospitals offer an alternative. Hospitals in Sweden and Denmark provide drop-in supervised play space in hospital lobbies to encourage hospital visiting of sick children. Results from this study showed that hospitals infrequently impart to parents expectations of acceptable behavAJPH September, 1978, Vol. 68, No. 9
ior on the unit and seldom have special routines to include them in their child's stay. When parents are allowed to remain, but are ignored, they may feel demeaned and stripped of their power, hence behave in a manner that is unfamiliar and confusing to their child. Wolfer and Visintainer's studies'4 show the benefits of preparing parents as well as children for the hospital experience, especially regarding expectations for performance. Children recuperate faster, parents express greater satisfaction with hospital and medical care, and both children and parents are more cooperative when adequately prepared. The following quotation from one hospital's preparation for parent participation in the recovery room illustrates the kind of definitive instruction that reduces anxiety for parents, staff, and as a result, anxiety for patients: "We would like to emphasize that you are called to the recovery room to provide support for your child. We request that you stay at your child's bedside. Do not walk around the room, and do not inquire about other children in the room. Chairs will be provided and when physically possible,
you may hold your child as he or she awakens."'6
Although the presence of a familiar adult can help a child cope with the stress of hospitalization, parents are usually barred from procedures that are the most stressfultests and treatments, induction and recovery from anesthesia. Yet for more than 30 years, Children's Hospital National Medical Center in Washington, D.C. has practiced inducing anesthesia with the child on the parent's lap, in her arms, or holding her hand. Parents can have a normalizing affect on the environment but they are often limited in their freedom to support their child in a natural way. For example, most hospitals in this study had rules against home-cooked food being allowed in the hospital although this might make a difference in how well a child eats. Similarly, although sibling visits might be reassuring to the hospitalized child, approximately one-half of the units surveyed did not allow such visits. The American Academy of Pediatrics, in its recommendations for the care of children in hospital, has this to say on the subject of visiting by siblings: "The hospital should provide facilities and attitudes to promote the well-being of both the parents and the child. The pediatric patient needs continuing contact with his parents, and visiting privileges should be generous. "Traditionally, hospitals caring for children have excluded siblings and other children on the rationale that children would be more likely to carry infection to patients than would adults. However, the scientific basis for this assumption is questionable. Experience now indicates that visiting by children and siblings is as safe as visiting by adults, if those with obvious infection or known exposure to contagion are excluded. The psychological importahce to the hospitalized child of seeing his friends and siblings is so significant, and the danger of introduction of infection so small, that liberalization of visiting procedures is recommended."'5
The findings that Parent-Inclusive Units in operation for over six years do not differ significantly in policies and practices from more recently established programs are not surprising. Absence of in-service training in methods of working with parents, and lack of systematic staff and parent evalua849
HARDGROVE AND KERMOIAN
tion of the "'living-in" program, indicate that after a "'livingin" program is implemented, little is done to improve program quality. This study indicates that despite a growing concern for the psychosocial needs of pediatric patients, most "livingin" programs do not optimize parental presence. TITLE 22 of the California Administrative Code requires hospitals to adhere to standards of the American Academy of Pediatrics, recommendations which favor comprehensive forms of parent-inclusion.4 17 Since the hospitals in this sample, specifically chosen for their support of parental presence, only minimally meet those standards, it is unlikely that most pediatric units are in compliance. This finding indicates a strong need for education of health care professionals to the special problems of the hospitalized child and his family. Likewise, greater effort is required for implementation of programs involving parents and research on the effects of these programs.
REFERENCES 1. National Center for Health Statistics. Utilization of Short-Stay Hospitals: Annual Survey for the United States, 1975. Vital Health Statistics Series 13, No. 31. Health Resources Administration, p. 24, 1977. 2. Bowlby J: Attachment and Loss. Vols. I and II. Basic Books, 1969, 1973. 3. Freud A and Burlingham D: War and Children. Medical War Books, 1943. 4. American Academy of Pediatrics: Care of Children in Hospitals, 1971, pp. 4, 11-14. 5. Hardgrove C: Living-in accommodations and practices for parents in hospital pediatric units: An update, Journal of the Association for the Care of Children in Hospitals, 4(l):24-26, xxxx.
I
6. Fagin C: The case for rooming-in when young children are hospitalized, Nursing Science, 2:324-333, 1964. 7. Mahaffy P: Nurse-patient relationships in living-in situations, Nursing Forum, 111(2):53-64, 1964. 8. Edelston H: Separation anxiety in young children: A study of hospital cases, Genetic Psychology Monographs, 28(1): 1943. 9. Robertson J: Young Children in Hospital, 2nd edition. New York: Burst & Noble, 1970. 10. Brain DJ and MacClay J: Controlled study of mothers and children in the hospital. British Medical Journal, 1:278, 1968. 11. Branstetter EM: The young child's response to hospitalization: Separation anxiety or lack of mothering care. Am J Public Health, 59:92-97, 1969. 12. Prugh DG, Staub EM, Sands HH, et. al: A study of the emotional reactions of children and families to hospitalization and illness, Am J of Orthopsychiatry, 23:20, 1953. 13. Skipper JK and Leonard RC: Children, stress and hospitalization: A field experiment, Journal of Health and Social Behavior. 9(4):275-287, 1968. 14. Wolfer J and Visintainer M: Pediatric surgical patients' and parents' stress responses and adjustment, Nursing Research, 24(4):244-255, July/August, 1975. 15. Jolly J: Children in hospital: The ward granny scheme. Nursing Times, April 11, 1974. (reprint) 16. Guidelines for Parents Visiting in the Pediatric Recovery Room. University Hospitals of Cleveland, University Circle, Cleveland, OH 44106. 17. California Administrative Code, Title 22, Section 705 37 (a).
ACKNOWLEDGMENTS This investigation was supported in part by Biomedical Research Support Grant RR 05604 from the Biomedical Research Support Branch, Division of Research Facilities and Resources, National Institutes of Health. Parts of this paper were presented to the International Symposium of the International College of Pediatrics, Helsinki, Finland, June 1978.
Physician's Fees
Fhe English physician, Thomas Dimsdale, probably established a record (fee-for-service) for all time when he received fifty thousand dollars cash, an annual pension of ten thousand dollars, and a Russian baronetcy, allfor vaccinating Catherine the Great and her son. Shryock R.H. Public Relations of the Medical Profession in Great Britain and the United States: 1600-1870. Ann. Med. Hist. 2:308-339, 1930.
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