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Concerns of mothers participating in the care of their children hospitalized for minor surgery in a day… Smith, Ethel Margaret 1970

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CONCERNS OP MOTHERS PARTICIPATING IN THE CARE OP THEIR CHILDREN HOSPITALIZED FOR MINOR SURGERY IN A DAY CARE UNIT by ETHEL MARGARET SMITH B.S.N., University of British Columbia, 1957 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Apri l , 1970 In presenting th i s thes i s in pa r t i a l f u l f i lment of the requirements fo r an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make i t f ree l y ava i l ab le for reference and study. I fur ther agree tha permission for extensive copying of th i s thes i s for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th i s thes i s f o r f i nanc ia l gain sha l l not be allowed without my wr i t ten permission. Department of NURSING  The Univers i ty of B r i t i s h Columbia Vancouver 8, Canada APR IL 20, 1970 ABSTRACT CONCERNS OF MOTHERS PARTICIPATING IN THE CARE OF THEIR CHILDREN HOSPITALIZED FOR MINOR SURGERY IN A DAY CARE UNIT ETHEL MARGARET SMITH At present very l i t t l e i s known of the various problems mothers experience when t h e i r children are admitted to a day care unit i n terms of the increased r e s p o n s i b i l i t y which i s placed upon them for the preparation of t h e i r children and t h e i r care at home following discharge. The purpose of t h i s study was to i d e n t i f y some of the major concerns expressed by mothers who pa r t i c i p a t e d i n a day care unit i n a children's h o s p i t a l In Vancouver. A sample of twenty mothers was selected and the kinds of nursing a c t i v i t i e s In which they p a r t i c i p a t e d i n the unit were assessed and rated by a p a r t i c i p a t i o n scale. The data were c o l l e c t e d by the researcher who took on the role of participant observer i n the day care unit. F i e l d notes were written on the mothers while they were In the unit and post h o s p i t a l interviews recorded approximately one week to ten days following discharge. The p a r t i c i p a t i o n scales, f i e l d notes and post h o s p i t a l interviews were analyzed and the frequency and percentages of the expressed concerns determined. Seventy per cent of the mothers i n the study group needed help i n a s s i s t i n g with the care of t h e i r children In the unit. Concerns expressed by the mothers were centered on the notion of time and a desire for information related to the child' s diagnosis, the anaesthetic, and operation performed. Postoperatively they expressed con-cerns re l a t e d to symptoms caused by the anaesthetic, operation or examination. They seemed p a r t i c u l a r l y apprehensive about the anaesthetic and i t s possible e f f e c t s on the children. Seventy-five per cent of the mothers had previous experience with the h o s p i t a l i z a t i o n of t h e i r children. This factor seemed most c h a r a c t e r i s t i c of the group and influenced t h e i r p a r t i c i -pation i n the day care a c t i v i t i e s . Only two mothers had p r i o r knowledge of the day care unit and they p a r t i c i p a t e d indepen-dently, requiring l i t t l e assistance from the nurse. Ninety per cent of the mothers were s a t i s f i e d with the day care experience. Two mothers were unhappy about the arrangements and would have preferred having t h e i r children i n h o s p i t a l for a few days post-operatively. These mothers would have benefited from a home v i s i t by a nurse. The remaining 9 0 per cent stated they did not f e e l they needed a v i s i t from a nurse postoperatively. A l l mothers appreciated a telephone c a l l from the hos p i t a l following surgery. The mothers contacted t h e i r doctors i f problems arose at home. They f e l t the instructions they received by mail p r i o r to admission were adequate. The success of s u r g i c a l day care units for children i s dependent upon the int e r e s t and support of parents. Mothers can prepare t h e i r children for surgery and cope with post h o s p i t a l care, i f they receive help and support from the nursing s t a f f . Mothers whose children have been treated i n a day care unit are most enthusiastic about t h i s type of ho s p i t a l care. 1^7 pages ACKNOWLEDGEMENTS I wish to express my sincere appreciation to the many people who made this study possible: to the Director of Nursing, her assistant, and the nurses i n the day care unit for their interest and cooperation; to the mothers in the study group who so graciously agreed to partleipate i n the study; and to the members of my committee, Mrs. J. Kurd and Miss K. Weber for their interest, and Miss E. Cawston for help with the designing and writing of the study. I especially wish to thank Miss A* Baumgart, the chairman of my committee, for introducing me to the subject of the study and for her time, interest and expert guidance. TABLE OP CONTENTS CHAPTER PAGE I. INTRODUCTION 1 Th© Problem 2 Limitations of the Study . . . . . 3 Definition of Terms Used 1 II. REVIEW OF THE LITERATURE 6 Literature on Separation Anxiety . . . . . . . . . 6 Literature on Parent Participation in Hospitals • 11 Literature on Day Care Units 17 III. THE RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY . . 20 Participant Observation 20 Theoretical Considerations . . . . 20 Personal Background . . . . . . . . . . . . . . 23 The Hospital Setting 23 The Research Role in the Day Care Unit . . . . . 23 Preparation for the Research Role in the Day Care Unit 25 The Data Collection 25 Selection of the Mothers . . . . . . . 26 Tools for Data Collection 27 The Post Hospital Interview 28 IV. METHOD OF ANALYSIS 31 V. INTERPRETATION OF FINDINGS 33 The Day Care Unit 33 The Study Population 36 Nursing Activities Carried Out by the Mothers in the Day Care Unit . . . . . . . . . . . . . . . 38 Nature of the Concerns Expressed by Mothers in the Study Group *I0 Concerns Related to Car© of Their Children Prior to Hospitalization 40 i v CHAPTER PAGE Concerns Related to the Mothers* Experiences In the Day Care Unit 40 Concerns Related to Care of the Children at Home 51 Factors That Influenced the Mothers' Activities and Expressed Concerns . . . . . 52 VI. SUMMARY, RECOMMENDATIONS AND AREAS FOR FURTHER INVESTIGATIONS 55 Recommendations . . . . . . 57 Areas for Further Investigations 58 BIBLIOGRAPHY * . 60 APPENDIXES 64 Hospital Forms • • • . « . . . . . . . • • * . . . . . 65 Case Histories 72 Participation Scale and Interview Guide . . . . . . . . 139 Tables • • 1*2 LIST OP TABLES TABLE PAGE I. Numbers and Percentages of the Types of Operations Perforated at the Pay Care Unit Between October 14 „ 1969 and January 14, 1970 143 II. Numbers and Percentages of the Age of the Twenty Children Included In the Study 144 XIX. Numbers and Percentages of the Types of Surgical Procedures Performed on the Twenty Children i n the Study Oroup 37 XV. Numbers and Percentages of the Place of Residence of the Twenty Mothers Included i n the Study . . . 145 V. Mothers' Participation In the Nursing Care Activities i n the Day Care Unit Expressed as to Frequency and Percentage . . . . . . . . . . . . 39 VI. Frequency and Percentages of Major Concerns Expressed by Mothers In the Study Oroup Related to Care of Children Prior to Hospitalization • . 41 VII, Previous Hospitalisation of the Children i n the Study Expressed as to Number, Frequency and Percentage . . . . . . . . 42 VXXX. Numbers and Percentages of Reasons Olven by the Twenty Mothers In the Study Oroup for the Previous Admissions of Their Children to Hospital . 44 XI. lumbers and Percentages of Children In the Families Selected for the Study . . . . . . . . . . . . . 46 X. Frequency and Percentages of the Nature of Concerns Expressed by Mothers In the Study Group Related to Their Experiences In the Day Care Unit . . . . 47 XX. Post Anaesthetic Symptoms Amongst the Children In the Study Oroup Expressed as to Frequency and Percentages . . . . . . . . . 49 V i TABLE PAGE XXI. Frequency and Percentages of Major Concerns Expressed by Mothers In the Study Group Related to Home Care of Their Children . . . . . . . . . . 51 XXIX. Typos of Complications Reported by the Twenty Mothers In the Study Group to the Researcher as to Frequency and Percentage 146 XXV. Frequency and Percentages of Complications Reported by 191 Mothers i n Response to Routine Follow-up Telephone Calls Mad® Between October 14, 1969 and January 14, 1970 W CHAPTER I INTRODUCTION A day care unit for children was recently opened In Vancouver and as It Is the f i r s t one in British Columbia, i t s success w i l l have a bearing on the establishment of similar units i n this province. At present very l i t t l e Is known about day care units for children. A child admitted to this type of unit should benefit from this experience compared to a child admitted to a more conventional hospital ward. He spends a few hours i n hospital following a general anaesthetic, compared to the usual one to two days. However, in accepting the idea of day care, nurses must also accept the fact that the responsibility for the preparation of the child and his care at home following surgery now rests with the parents. L i t t l e i s known of parental attitudes towards day care i n terms of their willingness to accept this additional responsibility. Therefore the present study was under-taken In an attempt to explore the kinds of concerns expressed by a selected group of mothers whose children were admitted to a day care unit and to observe how they participated in the nursing care a c t i v i t i e s . The Choice of the Problem At present very l i t t l e i s known of the various concerns mothers experience when their children are admitted to a day care unit i n terms of the increased responsibility which i s placed upon them for the preparation of the children and their care at home following discharge. Therefore the decision was made to design an exploratory study, whose purpose would be to generate theory as i t proceeded. The objective was a modest one, to achieve some indication of the kinds of concerns mothers ex-2 perienced while p a r t i c i p a t i n g i n such a program. Therefore, hypotheses were not formulated at the beginning of the study but evolved as an outcome of t h i s exploration. Glaser and Strauss stated: Generating a theory from data means that most hypotheses and concepts not only come from the data, but are systematically worked out i n r e l a t i o n to the data during the course of the research. Generating a theory involves a process  of researohTE Generating hypotheses requires evidence enough only to es t a b l i s h a suggestion — not an extensive p i l i n g up of evidence to es t a b l i s h a proof, and the consequent hindering of the generation of new hypotheses. 2 I. THE PROBLEM Statement of the problem. It was the purpose of t h i s study (1) to i d e n t i f y the kinds of nursing a c t i v i t i e s carried out by a selected group of mothers who pa r t i c i p a t e d i n the care of t h e i r children i n a day care s u r g i c a l u n i t , and (2) to i d e n t i f y concerns expressed by mothers i n ho s p i t a l and at home following discharge regarding care of t h e i r children p r i o r to, during and following h o s p i t a l i z a t i o n . Objectives of the study. The objectives of the study were to: 1. Identify the nature of the concerns expressed by these mothers as they pa r t i c i p a t e d i n the care i n ho s p i t a l and at home following discharge. 2. Identify the kinds of nursing a c t i v i t i e s c a r r i e d out by a selected group of mothers who pa r t i c i p a t e d i n the care of t h e i r children i n a day care s u r g i c a l unit. 3. Determine some of the factors that Influenced both Barney G. Glaser and Anselm L. Strauss, The Discovery  of Grounded Theory, (Chicago: Aldine Publishing Company, 1967; p. 6. 2 I b l d . , p. 40. 3 the kinds of acti v i t i e s in which they participated and the nature of the concerns which they expressed. XX. LIMITATIONS OP THE STUD! The study was limited by: (1) the size of the sample, (2) the setting i t s e l f , and (3) the time available to the re-searcher. Slse of the sample. The design of the study imposed certain limitations. As the methods selected for collecting data were participant observation and post hospital interviews, the sample of mothers was limited to twenty. Only a small group of mothers eould be Included due to the time available to the researcher to u t i l i z e these methods. The mothers were not selected at random, but according to a predetermined set of c r i t e r i a . The hospital setting. The hospital setting also Imposed certain limitations. The kinds of procedures which were per-mitted on a day care basis were predetermined. The number of children and the time of admission to the unit were arranged by the admitting department of the hospital. Time available to the researcher. The amount of time the researcher had available to spend In the unit was limited by other responsibilities which resulted from the fact that university courses were being attended at the same time. The mornings were selected as the most convenient times to be spent In the unit, leaving the afternoons free to v i s i t the mothers i n their homes. The study was limited to samples of the mothers9 behaviour as continuous observation would have been too time consuming. Follow-up interviews were generally held during the f i r s t week following discharge, but due to other commitments, some interviews had to be delayed u n t i l the second week. As the sample selected for this study was a select group of mothers, and not a random sample, caution must be used in 4 generalising the findings. The results are applicable only to the type of group studied. XIX. DEFINITION OF TERMS USED Day care surgical unit. This i s defined as a hospital f a c i l i t y for the performance of elective surgical procedures or operations on patients who are admitted and discharged from the unit en the day of surgery.^ i n this study the unit referred to i s separate from th® rest of the hospital and i s self con-tained* Elective surgical procedures performed on a day car®  basis. This term refers to minor operations which are performed on healthy, well-nourished children. The c r i t e r i a are that: (1) there must be nothing that can go wrong afterwards, (2) no special postoperative nursing i s needed, beyond a mother's loving care, (3) no drugs are needed or given, and (4) no restraint need be imposed except that of the child's own i n c l i -nation. The types of operations performed on this basis are quite well standardized from hospital to hospital. General anaesthesia. This refers to the administration of an anaesthetic gas which results i n unconsciousness. Xn this study, a l l children received this type of anaesthetic which was administered by mask or via an Intubation tube. Preparatory period. This refers to the pre-hospital period which began with th® notification to the mother regarding the date of admission up to the time of arr i v a l at the hospital. JChandrakant P* Shah and others, "A Study of the Need for Alternative Types of Health Care for Children in Hospital, 1 1  Pediatrics» XLXV (September, 1969)» p. 339. ^Rox L&wrle, "Operating on Children as Day-Cases," The  Lancet, XX (December, 1964), p. 1290. 5 Preoperative period. This refers to the period which began with the arr i v a l of the child in the day care unit u n t i l he went to the operating room. This was usually two and one-half hours i n length. Postoperative period. This refers to the period which began with the return of the child from the recovery room to the day care unit u n t i l he was discharged. It varied i n length from an hour to several hours. Many factors influenced the duration of the period. Participation by the mother. This refers to the willingness of the mother to share In the nursing care of her child, prior to, during, and up to ten days following discharge and her willingness to comfort and support him. Concerns. Concerns are defined as questions asked, and the kinds of worries and comments expressed by mothers which were deemed to be important to them. Overview of the Remainder of the Study The study Is organised i n the following way. Chapter II consists of a selected review of the literature on separation anxiety and Includes some of the significant research studies en parent participation i n hospitals, particularly those pertaining to day care units. Chapter i l l discusses the research design and development of the study. Chapter IV discusses the method of analysis, Chapter V the interpretation of findings, and Chapter VI, the Summary and conclusions. CHAPTER II REVIEW OP THE LITERATURE Much has been written on the effects of hospitalization on children. Literature which provided the necessary background knowledge for the present study i s included in this chapter. Three areas w i l l be considered: (1) separation anxiety s (2) parent participation i n hospitals, and (3) day care units. I. LITERATURE ON SEPARATION ANXIETY The subject of separation anxiety and i t s importance i n the nursing care of children admitted to hospital i s a very important issue and one that has received much emphasis during the past few years. Much of our present knowledge must be credited to the extensive research undertaken by experts i n the f i e l d of child behaviour. In the area of personality development during the pre-school years the work of Erikson has significance* He described the Eight Ages of Man and saw each stage as a c r i s i s that has i t s roots in the demands of society, which requires that certain tasks be mastered at a particular stage of development. There i s a c r i s i s when the child i s faoftd with these tasks and resolution of th® c r i s i s adds a new dimension to his personality. He stated the stages in the pre-school years as: (1) basio trust versus mistrust, which develops during the f i r s t year of l i f e , (2) auto-nomy versus shame and doubt, which develops during the second year of l i f e , and (3) i n i t i a t i v e versus g u i l t , which develops at 1 about ages four to fiv©. Spitz (19^5) described the effect of institutionalization of infants separated from their mothers and stated that impair-ment of the mother-child relation for more than a three month Interval during the f i r s t year of l i f e can cause irreparable Erik H. Erikson, "Eight Ages of Man," Readings i n Child  Behavior and Development, Celia Burns Stendler, editor (New York: Hareourt, Brace and World, Inc., 1964), 242-248. 7 damage to the Infant. Institutionalised children practically without exception developed subsequent psychiatric disturbances and became asocial, delinquent, feeble-minded, psychotic, or 2 problem children. This led to the widespread substitution of Institutional care by foster home care. In England during World War II, Burlingham and Preud studied the effects of separation anxiety on children who were separated from their parents as a result of the bombing of London. They discovered that separation of the young child from his parents was much more traumatic than leaving hira with his •a parents in the midst of the threat of air attacks. Much of the work during the 1950's was done In England by Robertson at the Tavistock Clinic. He identified three main phases of the "settling in" process of a young child's adjustment to hospital: (1) protest phase, (2) phase of despair, and (3) phase of denial.^ This i s similar to the interpretations of Bowlby who described this as a process of mourning for the mother. "The responses to be observed in young children on loss of the mother figure di f f e r in no material respect ... from those ob-ex served in adults on loss of a loved object. He feels that loss of the mother figure in the period between about six months and three or four years i s an event of high pathogenic potential.** McCreary states the age group of the child plays a large Rene A. Spita, "Hospitalism," The Psychoanalytic Study  of the Child, I (1945), p. 54. ^Dorothy Burlingham and Anna Freud, HYoung Children in Wartime: Traumatic Effects of Separation from Parents," Behavior  In Infancy and Early Childhood, Yvonne Brackbill and George C. Thompson, editors (New York: The Free Press, 1967), p. 484. *James Robertson, Young Children in Hospital, (London: Tavistock Publications Limited, 1958), p. 10. ^John Bowlby, "Grief and Mourning in Infancy and Early Childhood," The Psychoanalytic Study of the Child, XL (I960), p. 10. Ibid., p. 9. 8 part i n the nature of his reaction. The very tiny Infant shows few Immediate signs of damage i f his physical needs are met, but pediatric psychiatrists show more concern over this group than any other. They fear that the lack of a single Individual with whom the baby, with his limited powers of communication, can develop rapport, may cause more damage than hospitalization In-f l i c t s on any other age group. The two»to four age group i s affected more Immediately and most obviously ... Prom four years on, the effect of hospitalization diminishes and reaches a minimum after approximately eight years of age.7 The results of a study done i n Prance i n 1950 by Roudlnesco and Appall, demonstrated the differences between short-stay ohildren, aged one to three years and those of the same age who had since birth been i n a residential nursery. In the short-stay group, 71 per cent were within the normal range of development and 10 percent were severely retarded. In the institutional group, 13 per cent were within normal limits and 8 55 per cent were severely retarded. A report by Stler (1963) i n Germany showed that 53 per cent of small children i n German institutions were retarded in speech, restless and unsocialized. Studies such as these on the effects of maternal de-privation and separation anxiety are unanimous in finding re-tardation, especially that of language, and some indication of atypical emotional development such as lack of curiosity, and later indiscriminate shallow friendliness to adults. Dennis and Sayegh (1965) gave a small group of deprived infants an hour's 'J. P. Mccreary, "Current Trends in Hospitalization of Children," The Child and His Environment (British Columbia: Department of Health Services and Hospital Insurance, 1959), p. 3. ^Rosemary Dinnage and H. L. Kellmer Pringle, Residential  Child Care Pacts and Fallacies, (London: Longmans, Green and Company, Ltd., 1967), p. 7. Ibid. 9 extra attention a day for a fortnight with resulting gain in development.10 easier (1965) investigated separately g the effect of daily stroking on the babies and standardised verbal stimu-lation. Infants given extra handling did make greater develop-mental gains than their control who received standardised voc a l i s a t i o n . 1 1 The effect of separation on children up to seven months of age appears to be environmental. Sehaffer infers that this i s due to "perceptual deprivation," since the child has not yet related to the mother. These Infants frequently have somatic symptoms such as vomiting and sleep disturbances. Infants over 12 seven months show clear evidence of maternal deprivation. Branstetter states that the emotional distress seen in young children who are hospitalized, "originates from need deprivation — a lack of mothering care rather than from anxiety per se due to the loss of the mother as a special lrreplaeable object of love. J She questions the process described as grief and mourning and thinks i t could be described as stimulus de-privation or social deprivation due to a lack of mothering care, whether separation causes anxiety or deprivation or both of these, i t s effect on the young child i s marked. Deprivation does suggest the importance of body contact, perhaps a particular kind of sensory stimulation of the skin i s essential to physio-1 0 I b l d . , p. 10. n l b l d . 12 H. Rudolph Sehaffer, "Objective Observations of Personality Development i n Early Infancy," Behavior in Infancy  and Early Childhood. 626-638. ^Ellamae Branstetter, "The Young Child's Response to Hospitalization; Separation Anxiety or Lack of Mothering Care?" American Journal of Public Health. LXIX (January, 1969), p. 96. 10 logical functioning as well as to the development of psycho-id logical functioning. Older infants show a variety of disturbances associated with separation, such as marked anxiety towards strangers, desperate clinging to their mothers and vigorous crying on their departure. Research into the f i e l d of temporary separation of five year olds from home was undertaken by Klein and Ross, in the f i e l d of kindergarten entry. The children's reactions, as noted by parents, had some elements of the grief reaction. They noted increased stress and tension in the form of physical reactions, such as stomach upsets; regressive behaviour, such as bedwettlng and thumb sucking; and generalized "key-up" behaviour. Signs of Increased tension and growth went hand In hand. Parents were often surprised at the rapidity with which their children were u learning i n the presence of noticeable tension. ' Murphy studied pre-school children at a nursery school and added a valuable perspective to the concept of separation anxiety. She stated that new situations, such as hospitalization, need not be a frightening experience for a child, but can prove to be a challenging learning experience and made this comment on separation from mother at the time of hospitalization. ... It would seem that the opportunity to have the security giving contact with the mother i n strange or new situations or at times of a n t i c i -pated separation may be very Important in the child's a b i l i t y to handle the demands of the separation subsequently,16 Dorothy Johnson, "The Meaning of Maternal Deprivation and Separation Anxiety for Nursing Practice," Issues in Nursing, Bonnie Bullough and Vera Bullough, editors, (New York; Springer Publishing Company, Inc., 1966), p. 251. ^Donald C. Klein and Ann Ross, "Kindergarten Entry; A Study of Role Transition," Crises Intervention, Howard J. Parad, editor (Hew York: Family Service Association of America, 1965), 140-148. Lois Barclay Murphy, The Widening World of Childhood, (New York; Basic Books, Inc., 1963), p. 51. 11 Her comments on physical examination; When a child has raarked fears of body intrusion or pain, even the presence of the mother did not prevent anxiety in a situation where these fears were aroused. In view of this* i t Is easy to see the probable role of fears about possible body damage in separation anxiety. In the face of unknown physical danger* the small child feels the need of his mother as protector. 17 Robertson, who stayed with her four-year-old daughter i n hospital suggested that even in the presence of the ©other, the child, when faced with bodily injury, may develop ambivalent feelings towards the mother, viewing her as a proteetor and also as the person responsible for delivering him to danger. There i s general agreement amongst authors i n the f i e l d that the young child suffers considerable anxiety and behavioural ehanges when separated from his mother as a result of hospitali-sation. II. LITERATURE OK PARENT PARTICIPATION IN HOSPITALS The research studies on separation anxiety led to changes In pediatric practice which permitted increased participation by parents in the care of their hospitalised children. Some of these changes were rooming-in, l i b e r a l v i s i t i n g hours, home-care programs and day care units. The literature contains some very Interesting studies on this subject. Meadow studied 400 mothers with sick children under the age of five and asked them the following question; *If your child had to be admitted to hospital today or tomorrow, would you like to and be able to stay there, provided a room is free?** The replies of the mothers were noted, together with the ages of the AMbld., p. 52. Joyce Robertson, "A Mother's Observation on the Tonsillectomy of Her Four-Year Old Daughter," The Psychoanalytic  Study of the Child. XI (1956), 410-433. children, the social class, and the family commitments. He found that nearly half of the mothers would liked to have stayed with their children, and this proportion seemed to he regardless of social class. Factors that reduced to a third, those mothers who were able to go Into hospital with their children included, the number of other children at home, the mother's Job and per-haps the attitude of their doctor. 1^ Following this i n i t i a l study, he conducted a survey over a 2 1/2 year period to find out what mothers f e l t about their stay in hospital when they roomed-in with their children. The strongest impression gained from informal interviews with the mothers was that of their exquisite boredom during their stay in hospital. The normalrelationship i s altered when suddenly th© mother Is thrust into the sole company of her child i n a strange uncomfortable hospital with nothing to do and surrounded by bland staff who treat the situation as i f i t i s the most natural thing i n th© world. Most mothers are desperately bored and look forward to discharge from hospital as i f to the end of a long prison sentence.20 The mothers did worry less. At home they would have been worrying about what was happening, however, sora© worries occurred because they were in the hospital, such as those related to investigations their child had, operations performed, and a lack of explanation about the©. A l l except six mothers out of 130 oaid they had too l i t t l e information. Most mothers pointed out that "when you are alone in a room with your 111 child, there i s no such thing as enough information.'* About twenty-five per cent of the mothers really f e l t they had been poorly informed. They wanted to know the result of the operation and more definite Information about the date of discharge. Meadow *^S. R. Keadow, "The Captive Mother," Archives of Diseases of Childhood, XLIV (I960), p. 362. j°lbid., p. 363. stated the mothers did not know why they did not ask the staff for information. He f e l t much of this d i f f i c u l t y lay i n the power and authoritarian structure of hospitals. Th® majority of th© mothers would have liked more definite information about ways to help. They were uncertain of their role. The nurses who worked with the mothers stated their nursing care was not as rewarding and more than half of them said mothers on the ward created more work. Meadow postulated that "the system i s faulty — perhaps in the training of nurses, perhaps In ward admlni-21 stration, most likely in both." In spit© of these d i f f i c u l t i e s , ninety-six of the mothers said they would want to come in again with a sick child. Many f«slt they had gained from the experience and mentioned such things a3 confidence in looking after an i l l c hild, pride in having put up with something unpleasant for the sake of their children and the absence of upset when they got home compared with previous unaccompanied v i s i t s to hospital. Brain and Maclay studied a group of children admitted to hospital for tonsillectomy. Th© experimental group was admitted with their mothers, the control group was unaccompanied. The experimental group demonstrated a significantly lower incidence of emotional and infective complications. At the and of the experiment the nursing staff were unanimous in their opinion that they preferred the children to be admitted on their own, though they conceded that the mother's presence was often a great comfort to a very young child. The reasons given for not wanting the mothers were: (1) It was easier to carry out nursing procedures when the child was alone, (2) the nursing staff were able to make more personal contact, with children admitted un-accompanied, and (3) si few of the mothers were " d i f f i c u l t " and upset both their own children and other mothers in the ward. The results indicated that mothers are often the best judges of Ibid., p. 366. whether or net their children need thera i n hospital. Admission to hospital appeared to eause further distress to children already maladjusted, whether or not they were accompanied by their mothers* About eighty-five per sent of the mothers who were admitted with their children were satisfied with the 22 arrangement and were prepared to repeat the experience* The results of this study are very similar to the study conducted by Fagln. She studied sixty ohildren between the ages of one and one-half to three years of age* There were thirty children i n the experimental group, where the mothers were per-mitted to remain with their children during the total period of hospitalisation and an equal number of ohildren i n the control group, where mothers were permitted to v i s i t dally for a re-stricted period of time* Pre and post hospital interviews were held* She concluded that ohildren who were attended by the mother did not show significant regression i n their behaviour one week or one month after hospitalisation* The control group shewed significant regression one week and one month after hos-pitalization. Those results east doubt en two popular theories held i n medical and nursing circles that some mothers would do mere nana than good i f they remained with their children during hospital!sation and mothers who remain wish unconsciously to keep their children dependent* Miarslng personnel should under-stand that the attendance of the aether ie necessary for the mental health ef the child. Net only should mothers be per-mitted to remain with their children, they should be encouraged to do so* This implies changes i n attitudes as well as i n the reles which nurses and doctors f u l f i l l * Encouraging the mother to bosoms a participant i n the hospital experience implies D* J* Brain and Xnga Maelay, "Controlled Study ©f Mothers and Children i n Hospital," British Medieal Journal, X (3 February, 1963), 278-280. 15 accepting and seeking to understand her feelings as well as those of the child. This also means planning with and assisting the parent in order to maximize her participation in caring for the c h i l d . 2 3 A preliminary report based on two-years' experience with hospitalization of children In the Care-By-Parent Unit at the University of Kentucky showed that a surprising number of mothers could, with supervision, take complete care of their i l l children. The plan lessened the emotional trauma of hospitalisation to the child and greatly improved the learning experience for mothers who were Interested In their child's illness and i t s management at home. It was thought that hospitalisation in this manner was 2k economical and that patients received superior care. An experimental study by Skipper and Leonard at the Child Study Centre, Yale University, was concerned with the reduction of some of the effects of hospitalisation and surgery in young children admitted for a tonsillectomy. Experimental data i n * dicated that social interaction between a mother and a nurse, who provides information and emotional support, may reduce th* mother's stress which In turn may reduce the child's stress and have a profound effect on his social, psychological and physio-logical responses to hospitalization. The data suggest that some of the after-effects of hospitalisation and surgery i n young children ... may be alleviated through a relatively simple and inexpensive social process. An authori-tative figure, by establishing an expressive relationship with the mother of a child, and pro-viding her with information, may reduce the mother's stress and allow her to make a more rational J C l a i r e M. Fagln, The Effects of Maternal Attendance During Hospitalization on the Post Hospital Behavior of Young  Children: A Comparative Survey, (Philadelphia; T. A. Davis Company, 19^6), p. 64. 2k Vernon L. James and Warren E. Wheeler. "The Care-By-Parent Unit," Pediatrics, XLIII (April, 1969), 488-494. 16 adaptation to the child's problems and take a more motive role i n aiding h i m . 2 5 Hoy In California, studied thirty mothers of hospitalised children i n terms of the mothers' a b i l i t y to relate to their children before and after the introduction of cues designed to help thorn* The findings suggested that the mothers' levels of adequacy In relating to their hospitalised children were raised by the nurse's introduction of helpful cues. A study to locate and relate the social and attltudinal determinants of participation and non-participation In discussion courses on child-rearing was undertaken by Cullen at the Uni-versity of Sydney. When ninety-sis mothers of babies between six and twelve months of age were invited to a course of dis-cussions on child-rearing, only twenty-three showed keen interest, and only fcwolv© subsequently attended. When this group was compared with the uninterested mothers i t was found that only those mothers with high educational and/or occupational status, combined with an Interest i n child behaviour, were li k e l y to to© attracted to such a course. 2^ I f mothers are to be encouraged to participate In the car® of their children i n hospital, i t Is Important to discover more about their attitudes and motivations. A theory of nursing practice cannot bo developed without this knowledge. 'James E. Skipper and Robert C. Leonard, "Children, Stress, and Hospitalization; A Field Experiment," Journal of Health and Social Behavior. IX (December, If68), 2 7 5 - 2 8 7 . Slater Mary Ca l l l s t a Roy, "Role Cues and Mothers ©f Hospitalised Children," Nursing Research. XVI (Spring, 1967)* 178-182. 'James 3 * Cullen, "Determinants of Participation In Parent Education Courses, n Journal of Health and Human Behavior. VII (Winter, 1966), 3 0 2 - 3 0 8 . 17 III. LITERATURE OH DAY CARE UNITS There are very few reported studies on day oare surgical programs for children. Only three w i l l he discussed in this chapter. The Evelina Children's Hospital in London, England has been performing surgery on a day-care basis since 1949 and although i t was originally planned to help prevent post operative infection i t soon became apparent that i t was advantageous to both the child and his parents. As a result of Its early success, the hospital soon adopted day-ease operations as routine procedures• Lawrle states that very few parents have ignored instructions to bring the child to hospital fasting, and vomiting during induction has not been a problem. After the operation the child recovers in the ward, no special area being set aside for this type of case. The parents c a l l for the child and take him home In the afternoon. The only follow up appears to be a v i s i t at the outpatient c l i n i c on the f i f t h postoperative day. In the five year period from 1959 to 1963, 734 operations were performed on a day oare basis. "The policy has been welcomed by parents and children, and has led to no untoward results." The Children's Hospital of Winnipeg has performed sur-gery on a day-care basis for many years, but f e l t there were gaps in the care the child received. There was no assessment of the home situation, no knowledge of the parents' understanding of the surgical procedure, no guarantee that preoperative In-structions had been given and understood, and no information regarding the current health status of the child. The laok of Rex Lawrif, "Operating on Children as Day Cases," The  Lancet. II (December 12, 1964), p. 1290. 18 parental Instruction was f e l t to be a factor i n th® cancellation each month of 15 per cent of the children scheduled for day care surgery. 7 Therefore in May„ 1969, a program of pre-operative and postoperative v i s i t s by a public health nurse to selected children was started. A six month follow-up evalu-ation indicated that "since the i n i t i a t i o n of home v i s i t s , the hospital i s offering improved care to children and better u t i l i -sation of hospital f a c i l i t i e s . A study conducted by the Department of Pediatrics, University of British Columbia attempted to investigate parental attitudes towards proposed day care units and conventional hospitalization. The results indicated that in a population of hospitalised children, MS per cent of the 611 parents whose children qualified for day care stated they would have preferred day care i f such an alternative had been available at the time and i f the choice of type of care had been l e f t to them. Factors which seemed to be related to the parents* choice of care were the child's age, the distance from home to hospital, the parents' education, the parents' perception of the degree of safety afforded by hospitali-sation and the a b i l i t y to make the necessary arrangements to care for the child at home following day care. The higher the edu-cational level attained by either of the parents, the greater their preference for day care. It is probable that the parents with higher education were more aware of the possible psychological trauma of hospitalisation. yThe Children's Hospital of Winnipeg Proposed Program  for Home Vi s i t s by V.O.N, (document submitted to the Manitoba Hospital Commission and to the Victorian Order of Nurses, March 3, 1969) 3 Evaluation of the N.F.A. Program of Home V i s i t s . (document prepared by the Children's Hospital of Winnipeg, November, 1969) 19 The parents of younger children were more In favour of day eare probably because of the greater parental ooncern about being separated from young children. No relationship was found between parental choice of care and such variables as the sex of the child, number of employed family members, occupational class and family Income. The Implications of this study appear to be that short-stay day-care arrangements are on© answer to a number of medical and economic problems presently associated with hospitali-sation.^ 1 Parents must be shown that day oare i s a safe alternative to hospitalization. The most effective means of achieving this objective w i l l be Involvement of the parents i n medical and surgical day-care experiences, provision of home v i s i t s by nurses after day surgery and assurance to the parents of th® immediate availability of any required safety. Even on a limited basis i n each community, such p a r t i c i -pation i n successful day-care programs could result in more widespread acceptance of, or even i n a demand for, such services.32 SUMMARY Although much has been written on the effects of separation anxiety on young children admitted to hospital, very l i t t l e i s known of parental reactions to hospitalisation. Interest i n short-stay hospitalization for children, particularly day eare units, has led to increased participation by parents, especially mothers, In the preparation of children for hospitalization and increased responsibility for their care at home following discharge. The purpose of this study was to explore concerns expressed by a group of mothers who participated i n the eare of their children admitted to a day care unit. JAChandrakant P. Shah and others, TIA Study of the Need for Alternative Types of Health Care for Children In Hospital," Pediatrics, XLIV (September, 1969), 338-347. : ^ b i d . , p. 347 CHAPTER III THE RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY The decision to collect data using the combined methods of participant observation and post hospital interview was based upon these considerations. F i r s t , given the nature of the problem i t seemed important that direct observation of act i v i t i e s of mothers be included to obtain a measure of parti-cipation and the kinds of concerns at the moment of impact. Second, a retrospective account would throw light on the total process. Because of theoretical considerations, the researcher's personal experience, and the nature of the hospital setting, the decision was reached to use participant rather than non-partici-pant observation. I, PARTICIPANT OBSERVATION A. Theoretical Considerations The decision was made to conduct the research at the day care unit by using participant observation as the means of col-lecting data on the concerns of the mothers and the ways in which they participated i n the nursing care. The theoretical background was provided by reading an excellent book by Bruyn, which described the methodology of participant observation. He identified three principles which are inherent in this approach. 1. The participant observer shares in the l i f e a c t i - v i t i e s and sentiments of people i n face-to-face relationships. The role of the participant observer requires both detachment and personal involvement. In seeking to share something of the experience of the observed the researcher must acquire a role which can function within the culture of the observed. 2. The participant observer i s a normal part of the  culture and the l i f e of the people under observation. It i s not the intent to create roles which are "forced" on or considered a r t i f i c i a l to the ways of the people under study. The sc i e n t i f i c rolo of the participant observer i s interdependent with his social role. In his sc i e n t i f i c or observer role he i s interested i n people as they are and not as he thinks they ought to be. This coincides i n many ways with his social role as a participant. The personal lives of the people studied often become of special Importance i n the fulfillment of both the sc i e n t i f i c rol® and the social role. Without this primary Interest i n the subjects as persons the data would become liable to distortion. 3. The role of the participant observer reflects the  social process of l i v i n g i n society. The researcher participates i n a social process which has meaning for people i n groups out-side the group he studies since the processes of liv i n g in any society are similar for people every-where. He sees people i n the concrete rea l i t y in which they present themselves.1 The extent to which the participant observer becomes Involved i n the situation must be examined carefully, however both Involvement and detachment are fundamental to this role i n research. The participant observer Is partly involved and partly detached. The research data with which the participant observer works consists basically of human meanings interpreted through the observer's communication with his subjects. The I n i t i a l and perhaps most fundamental assumption underlying the Severyn T. Bruyn. The Human Perspective i n Sociology, (Englewood C l i f f s , New Jersey, Prentice-Hall Inc., 1966), 13-22. work of the participant observer i s that "the participant can communicate a message to another participant and have i t under-stood as he intended i t . The assumption i s that people can arouse i n others that which i s aroused in themselves." The participant observer seeks to locate particular meanings which people share through communication. He i s con-cerned with whether what he identifies and describes as existing meanings really exist. This can usually be achieved by mutual verification between the researcher and the subject. Bruyn identified two steps to be taken in preparing for the role of participant observer: (1) defining the social role which should be friendly, direct, and honest, and (2) recording, assembling, classifying and interpreting data. This should be done according to a clearly stated system of procedures. This involves noting the frequency with which subjective interpre-tations are mad©, the varying circumstances under which they are expressed, and the collective character of the expressed •a meanings, that i s , the extent to which they were shared« How-ever, for accurate generalizations to be made, the participant observer must see his subjects in their normal as well as i n their abnormal environment, before he can derive reliable conclusions about his own special contacts with them. This formed the basis for the decision to v i s i t the mothers at home following discharge. Byerly 9 who studied a nursing unit in a hospital using participant observation, stated there were three dilemmas in this role. These are the question of: (1) objectivity versus subjectivity, (2) soientiflc integrity of the study versus pro-tection of the rights of individuals who are the subjects of research, and (3) nonintervention into the act i v i t i e s of the study group versus intervention which risks changing the course 2 I b i d . , p. 161. 3 I b l d . . 202-204. *Ibld.. p. 212. 23 of th® fladings. B. Personal Background The researcher was basically a c l i n i c a l practitioner, therefor© the methods selected reflected this experience of working directly with people as a means of gaining valuable information about them. Last year a course Psychology of Childhood was taken, which led to the decision to study i n depth the subject of separation anxiety and maternal deprivation. Field work experiences Included an observational period at a children's hospital with th® purpose of studying the effects of separation anxiety on four young children admitted for surgical treatment, and experience studying th® play ac t i v i t i e s of normal pre-sohool children. These experiences Involved conversations with mothers and led to the convictions that the role of p a r t i c i -pant observer was an excellent one i n terms of finding out certain kinds of Information about a group of people and that mothers were an invaluable source of Information and w i l l freely discuss their thoughts and concerns with an Interested profes-sional person who Is a complete stranger. The role of p a r t i c i -pant observer was a natural and comfortable one. C. The Hospital Setting The day ear© unit was small and Intimate. It lent i t s e l f well to participant observation. It would have been d i f f i c u l t to have structured a completely observational role. This would have been moat conspicuous. D. The Research Role In the Day Care Unit The research role taken was one of a nurse functioning ^Elizabeth Lee Byerly, "Th® Nurse Researcher as P a r t i c i -pant-Observer i n a Nursing Setting," Nursing Research. XVIII (May-June, 1969), p. 232. 24 as a participant observer. It involved participation in the normal nursing ac t i v i t i e s i n the unit. The degree of involve-ment was determined by the activity i n the unit and i t tended to fluctuate between observation and participation. The role was not a static on® but a pattern began to emerge after the f i r s t week or so. The nursing role involved supporting the mothers, attempting to answer their questions and offering explanations regarding th® preoperative, operative and postoperative pro-cedures. Cursing care was given to the children and i t was explained to the mothers, who were encouraged to assist. A l l of these ac t i v i t i e s were shared with the regular staff and nothing new was introduced. Mothers were informally interviewed during the hospitali-sation period, usually while the child was in the operating room, or while asleep and at this time the request was made to v i s i t them at home. The research role was revealed at this point and the reason for the home v i s i t explained. The role was essentially a comfortable one and was aided by the interest and acceptance of the nursing staff. As Whyte stated "people did not expect me to be just like them." I n i t i a l l y they were protective and very helpful, not certain of the degree to which they would be assisted, but later, as the researcher's participation increased, a good working relation-ship developed and with this, confidence and trust. Whyte pointed outt There i s a strain to doing such f i e l d work, the strain i s greatest when you arc a stranger and are constantly wondering whether people are going to accept you. But, much as you enjoy your work, as long as you are observing and interviewing, you have a role to play, and you are not completely relaxed.7 William Foote Whyte, Street Corner Society, (Chicago: University of Chicago Press, 1955), p. 304, Ibid., p. 297. E. Preparation for the Research Role In the Unit The data oolleotion phase of the study commenced on January 9, 1970, and was completed by February 20, 1970. It was preceded by a preparatory period which was conducted in two stages: (1) the planning stage, and (2) the orientation to the unit. The planning stage. This involved two v i s i t s to the hospital i n the Autumn of 1969 to introduce the subject of the study to the Director of Nursing and her assistant and to acquire their approval. A copy of the research proposal was submitted to them. Final plans were completed i n December. Orientation to the unit. A brief orientation to the unit was given by the supervisor i n late December about one week prior to the commencement of the study. The researcher then spent two mornings i n the unit becoming familiar with the routines, policies and normal a c t i v i t i e s . This was mainly an observational period during which notes were written on some of the mothers and their a c t i v i t i e s . The various ac t i v i t i e s in which the mothers could participate were noted. The nurses in the unit were extremely helpful i n providing essential Infor-mation on the operation of the unit* Based upon the information received from this orientation period, the decision was made to spend three mornings a week in the unit, leaving the afternoons free to Interview the mothers i n their homes. A participation scale was also designed to be used for rating the mothers' participation i n the unit. II. THE DATA COLLECTION Time spent In the unit. The mornings were selected as the most appropriate times for collecting data on the mothers. The researcher spent Tuesday, Wednesday and Friday mornings in the unit and stayed for approximately four hours. The number of children admitted each day varied so i t was necessary to 26 assess the situation each morning on arrival* A total of forty hours was spent in the unit. A. Seleotion of the Mothers The methodology chosen for the study, participant obser-vation and follow-up interviews in the home, both required that the researcher spend a certain amount of time with each mother to adequately collect the required data. As Bruyn stated: .*. the more time an individual spends with a group the more lik e l y i t i s that he w i l l obtain an accurate interpretation of the social meanings i t s members liv e by. 8 Bruyn added: ... the greater degree of intimacy the observer achieves with his subjects, the more accurate his Interpreta-tions . 9 Therefore, the number of mothers included i n the study was esta-blished at twenty. Cri t e r i a for selection. The mothers were not selected at random, but according to the following predetermined set of c r i t e r i a . 1. The mother's willingness to stay with the child for at least part of the hospitalisation period. 2. Her a b i l i t y to speak English clearly. This was required because of the taping of the post hospital interview. 3. The age of the child. Since hospitalization has a more serious effect on younger children, the mother of a younger child was selected i n preference to the mother of an older child. 8 Severyn T. Bruyn, The Human Perspective i n Sociology. p. 181. 9 I b i d . , p. 182. 4. Attempts were made to include a variety of surgical procedures. 5. The mother's Intelligence and her interest in her child and In the unit as revealed by her acti v i t i e s * 6. The mother's willingness to be visited to home. The procedure for selection. The researcher had no knowledge of the mothers and children prior to their arrival In the unit. Before the mothers were selected, the researcher ob-served the mother's a c t i v i t i e s , participated i n the care of the children and conversed briefly with them. This was required to evaluate c r i t e r i a numbers 1, 2 and 5 as li s t e d previously. The patient's chart revealed sufficient information to f u l f i l l c r i t e r i a numbers 3 and 4. If the f i r s t five c r i t e r i a were met, the mother was approached, the study explained to her and a request made to v i s i t her at home within ten days following dis-charge. In the early stages of the study the selection was comparatively eas>y, but as the study progressed more discrimi-nation was required. Towards the end of the study, an alter-native day was selected to avoid including too many children with urological problems. Ho more than three mothers were selected on any one day. This was the maximum number of people who oould be observed at one time. Since the research role included participation, sufficient time had to be made available so that the researcher was free to talk with the mothers, par-ticipate In the oare of each of their children, and have time to record the data. B. Tools for Data Collection Two tools were used to record the activ i t i e s of the mothers and the concerns they expressed while i n the unit: (1) f i e l d notes, and (2) a participation scale. Th® f i e l d notes. Essential background information on the mothers and children was collected from the charts and transferred to cards. The Information recorded i s Illustrated i n Appendix 1, pages c73 to 3^ 8 which contains the ease histories @t each of the mothers included i n the study. Information describing the mothers' acti v i t i e s and expressed concerns were either recorded at the time or as soon as possible. Participation scale. A participation scale was designed and completed en each mother Included i n the study. Each mother was rated as to whether she: (1) participated independently, ( 2 ) participated with help, or ( 3 ) did net participate i n the following a c t i v i t i e s . 1. Stayed with ohlld 2 . Assisted nurse with care 3 . Comforted child 4. Played with child 5 * Made arrangements for discharge Please see Appendix C , page 140 for more details. As a reminder, continuous observation was not possible so only samples of the mothers* ac t i v i t i e s were assessed. Th® researcher spent approxi-mately the same period of time with each mother, at the same time each day, and a l l were involved i n similar ac t i v i t i e s i n the unit. Therefore, a f a i r l y consistent observational period was established i n terras of time and a c t i v i t i e s . XXX. THE POST HOSPITAL INTERVIEW The second method selected for collecting data was the use of a post hospital interview. If the success of the unit depended te a great extent upon the opinions of th® mothers, then their opinions should be u t i l i s e d as the major source of information. The decision was made to use a partially struc-tured or focused interview, which because of i t s f l e x i b i l i t y , would achieve i t s purpose of e l i c i t i n g the spontaneous responses of the mothers to the experience i n the day care unit. These 29 responses would be speeifle and personal. S e l l t i a substantiated this by stating: In the focused Interview, the main function of the interviewer i s to focus upon a given experience and i t s effects. Ke knows in advanee what topics, or what aspects of a question, he wishes to cover. This l i s t of topics or aspects i s derived from his formu-lation of the research problem. This l i s t constitutes a framework of topics to be covered, but the manner In which questions are asked and their timing are l e f t largely to the interviewer's discretion. He has freedom to explore reasons and motives, to probe further in directions that were un-anticipated.^ Where possible the researcher asked the mothers questions during the Interview to c l a r i f y certain observed behaviour or comments made during the hospital experience. This was more successfully achieved towards the end of the study due to the researcher's increasing knowledge of the day oare experience and awareness of the pattern of some of the mothers' concerns. Some unexpected concerns were revealed quite accidently during the home v i s i t s . The mothers were interviewed i n their homes approximately one week to ten days following discharge. A l l of the mothers were telephoned within two to three days following discharge and a convenient time arranged for the home v i s i t . A l l but three of the Interviews were taped. Those not taped were written up as soon as possible. The interviews lasted for about thirty minutes and were generally followed by short informal conver-sations with the mothers. The interview guide i s illustrated i n Appendix C, page 141. SUMMARY Participant observation in the day eare unit provided the following: (1) essential background information on the Claire S e l l t i a , and others, Research Methods in Social  Relations, (New York: Holt, Rlnehart and Winston, 1959), p. 26*1. 30 mothers and children, (2) a sampling of the kinds of aetlvities in whleh the mothers participated, (3) data on the concerns ex-pressed by the mothers while they were participating i n the care of their children, and (4) an opportunity to establish rapport with the mothers, which permitted the researcher to make a home v i s i t . This was necessary preparation prior to probing more deeply into the various observed acti v i t i e s and expressed con-cerns. The post hospital interviews provided: (1) elaboration and c l a r i f i c a t i o n of the information collected in the unit, and (2) data on the post hospital period. The data from the f i e l d notes, participation scales and post hospital Interviews were analyzed and the major concerns identified as to their frequency and percentages. CHAPTER IV METHOD OF ANALYSIS Due to the exploratory nature of the study, the analysis of the data consisted of examining as much data as possible to learn more about a certain group of mothers who participated i n a day care unit. The reader w i l l need to remember this was net a random sampling of time or mothers. The analysis of the data collected by means of the participation scales, f i e l d notes and post hospital interviews was conducted i n three stages: (1} establishment of a p a r t i c i -pation score, (2) identification of the nature of the concerns expressed by mothers, and (3) Identification of factors that influenced both the mothers1 participation and concerns• I. MOTHERS' PARTICIPATION IN THE NURSING ACTIVITIES IN THE UNIT For each mother the major categories on the scale were analysed and the frequency and percentages determined. A pattern of ac t i v i t i e s for eaeh mother was obtained. The scale provided a rough estimate of the frequency with which mothers engaged in certain types of a c t i v i t i e s . II. IDENTIFICATION, CATEGORIZATION AND DETERMINATION OF THE NATURE OF THE CONCERNS EXPRESSED BY THE MOTHERS The nature of the expressed concerns was identified from the f i e l d notes and interview reports in order to determine their frequency and to develop a classification. The analysis proceeded i n the following way: a. Summary of f i e l d notes, editing of interviews and typing of f i n a l interview reports. b. Tentative Identification of the concerns expressed. Each incident, that i s , each summary and interview, was studied and as many categories as possible were noted. c. The Incidents were compared with each other, and as the various categories were compared, certain similarities appeared, so that some categories became integrated into larger more Inclusive ones. d. Final organization of major categories. The f i n a l organization of major categories was made under the three time periods previously identified as the period prior to, during, and following hospitalization. Verification of the data was achieved by means of con-sensus, which Bruyn defines as "some form of verbal assent or confirmation that the meanings Interpreted by the observer are correct."1 III. IDENTIFICATION OP FACTORS THAT INFLUENCED BOTH THE MOTHERS * PARTICIPATION AND CONCERNS Factors that Influenced both the kinds of act i v i t i e s In which the mothers participated and the concerns which they ex-pressed were identified from the f i e l d notes and interview reports. An analysis of the data revealed certain similarities amongst the mothers themselves. A l l that could be Identified was the existence of certain trends that seemed to be descrip-tive of the mothers who participated i n the study. Severyn T. Bruyn, The Human Perspective In Sociology, (Englewood C l i f f s , New Jersey: Prentice Hall, Inc., 1966), p. 183. CHAPTER V INTERPRETATION OP FINDINGS Before discussing the findings i t w i l l be necessary to introduce the reader to: (1) the day eare unit in which the participant observation took place, and (2) the population participating In this study* This information i s necessary background to understanding the concerns expressed by the mothers. The Day Care Unit The day care unit opened on October 14, 1969* A re-search project on day oare for selected surgical patients had been i n progress for eighteen months prior to the opening of the unit. The children in this study were admitted to regular wards* With the opening of the day oare unit, a l l children scheduled for day oare, Including those i n the research group, were admitted directly to the unit. The children i n the research group were classified as Study E on the admission and operating room forms* These children were excluded from the present study. The unit I t s e l f consisted of one large, brightly decorated room with accommodation for eight children. There was a bright orange carpet on the floor, shelves containing numerous toys and colourful drapes on the window. Special oare had been taken to make the room look home-like. It was located on the ground floor of the hospital adjacent to the admitting department. The unit was completely separate from the rest of the hospital. The nursing units and operating rooms were located on the floor above. It was self contained, having i t s own bathroom and medication room. A nurse's desk was located at the front of the room. Each patient's unit consisted of a stretcher and a chair. Curtains could be drawn between the units i f privacy was desired. The unit operated from Monday to Friday, and was closed on the weekends. Selection of patients. The patients were selected by their doctors and dentists. During the f i r s t three months twenty-eight doctors and seventeen dentists admitted patients to the unit* The operations that were performed on a day care basis had been approved prior to the opening of the unit. Table I illustrates the number and types of operations per-formed between October 14, 1969 and January 14, 1970. Please see Appendix D, page 143. The nursing staff. The five nurses i n the admitting department rotated through the day care unit. Saoh nurse spent two weeks out of five i n the unit. Two nurses were assigned to the unit each day. One nurse came on at 7*00 a.m. and the ether at 12:30 p.m. There was no coverage in the unit after 9:00 p.m., so I f a child was not ready to go home by this time, he was transferred to one of the wards and kept i n hospital overnight. Admission policies and routines. The arrangements for admission were initiated by the various doctors and dentists who admitted children as day care patients. Upon receiving the name of the child, the hospital mailed out a letter to the parents and enclosed a sheet of instructions and information. This information i s shown i n Appendix A, page 67* The date and time of admission were confirmed the day prior to admission. The children were scheduled to arrive at the hospital two and one-half hours prior to the operating time. The majority of the children were required to be i n hospital between seven and eight o'clock* Most of the operations were scheduled In the morning. When the children arrived i n the hospital, the usual types of forms were completed by mothers. The children were weighed and a hemoglobin was done. I f young children appeared apprehensive, the hemoglobin was done i n the operating room. The children were then brought to the day eare unit by the admitting nurse. The mothers and children were greeted and the mothers asked to complete a history form which was required by the anaesthetist. A copy of this form i s shown in Appendix A, page 63. The nursing staff expected the mothers to stay with their children In the unit and they were encouraged:.to participate In the admission procedures. Since some mothers did not stay with their children, a l l mothers were given a sheet, at the time of admission, which outlined the routine care of children following a general anaesthetic* A copy of this sheet Is illustrated In Appendix A, page 69. If a mother could not stay, arrangements were made with her regarding the method of notifying her of the child's discharge time. Preoperative routines. Once the children were admitted to the unit, the anaesthetist was notified* He examined the children, asked the mothers a few questions and then ordered the premedication. Once the premedication was administered, the children were put to bed. They were taken to the operating room i n their beds and the mothers were encouraged to accompany them* If the mother was planning to wait for her child, she returned to the unit and was offered a cup of coffee while she waited. Postoperative routines. The children remained i n the recovery room u n t i l they were awake and then were transferred to the day oare unit. Mothers were not permitted In the recovery room. The usual postoperative observations were made by the nurses. The children were usually quite sleepy so were encouraged to sleep* The mothers generally sat beside their beds. Once the children were awake and s i t t i n g up, they were given small amounts of water or juice to drink and the mothers were instructed to offer the children sips of clear f l u i d as desired. The children were given toys to play with to amuse them during the postoperative period. The anaesthetists were frequently i n the unit so would discharge the children when they f e l t It was safe to do so. The nurses reviewed home care with the mothers prior to discharge and answered their questions. The hospital rules stated that two adults were te be present when the child was going home by ear; one to drive, the ether to attend to the child. Some mothers found i t more convenient to take a taxi. Follow-up procedures. The only follow-up procedure Initiated by the hospital was a telephone c a l l to the mothers the day following surgery. A questionnaire had been designed for this purpose. It was part of the research study referred to ear l i e r , and was completed on a l l children, including those en the Study E program. A copy of this form Is shown i n Appendix A, page 70. The nurses then made a note i n the o f f i e l a l record book regarding the presence or absence of com-plications as reported by the mothers* The Study Population As was previously mentioned, the sample of twenty mothers was hot selected at random, but according to a pre-determined set of cr i t e r i a * The children. There were twelve boys and eight g i r l s In the sample and their ages ranged from seven months to fourteen years. For additional information please refer to Table I I , Appendix D, page 144. Sixty percent of the children had been hospitalised previously. Table III shows the numbers and types of surgical procedures performed on the children i n the: study group. 37 TABLE III NUMBERS AMD PERCENTAGES OP THE TYPES OP SURGICAL PROCEDURES PERFORMED ON THE TWENTY CHILDREN IN THE STUDY GROUP Type of surgical Number of procedure ohildren Percentage of children Dental work 6 30.0 Cystoscopy and pyelogram 5 25.0 Myringotomy 3 15.0 Plastic surgery 3 15.0 Eye examination 1 5.0 Cautery of nose 1 5.0 Umbilical hernia repair 1 5.0 Total 20 100.0 The mothers' personal background. Seventy-five percent of the mothers had previous experience with the hospitalisation of one or more of their children. Eighty-five percent were married, the remaining 15 percent were separated or divorced. Ninety percent lived i n houses, the remaining 10 percent in apartments. Table IV, Appendix D, page 145 shows the place of residence of the mothers In the study group. Eighty percent lived i n the greater Vancouver area. Records were available on th® education of 60 percent of the mothers, and 80 percent had at least twelve years of education. I. NURSING ACTIVITIES CARRIED OUT BY THE MOTHERS IN THE DAY CARE UNIT The mothers' activities were observed and rated on the participation scale. Table V shows the frequency and percen-tages of the mothers' participation rated as to whether they participated independently, participated with help, or did not participate. Again It must be remembered that the re-searcher did not observe the mothers' total stay in the unit. This data represents only a given time interval* Assisted with Nursing Care Twenty-five percent of the mothers helped the nurse without being asked, 70 percent required help and only one mother did not participate. Sixty-five percent gave fluids, 35 percent took their children to the bathroom, 20 percent helped administer the premedication, 10 percent took the child' temperature and only one mother helped take a blood pressure. TABLE V MOTHERS' PARTICIPATION IN THE NURSING CARE ACTIVITIES IN THE DAY CARE UNIT EXPRESSED AS TO FREQUENCY AND PERCENTAGE Participation i n Independently With Help Did not participate Nursing Activities frequency percentage frequency percentage frequency percentage Stayed with child 12 60.0 1 10.0 6 30.0 Assisted nurse with care 5 25.0 14 70.0 1 5.0 Comforted child 17 85.0 3 15.0 -Played with child 19 95.0 - - 1 5.0 Made arrangements for discharge 17 85.0 3 15.0 40 Comforted and played with child The mothers participated very actively in these areas and needed only minimal assistance from the nurse. Three mothers needed direction i n picking up their young children when they started to cry. Only one mother brought toys from home, the other 95 per cent did not. The unit was well supplied with toys and 50 per cent of the mothers gave their children toys independently, 45 per cent did when It was suggested to them, and one mother did not participate In this activity. Made arrangements for discharge Eighty-five per cent of the mothers made their own arrangements regarding transportation home, which according to the hospital policy, required two adults i f a oar was to be used. Three mothers required advice from the nursing staff i n making the necessary arrangement. Two mothers were advised to find another person to assist them as they planned to take the children home alone. One mother Mrs. R. was experiencing per-sonal problems and needed help i n making plans for the discharge of her young daughter. As i t turned out, the mother had di f f i c u l t y coping with the care at home and may have been helped by having the child stay i n hospital overnight. II. MATURE OF THE CONCERNS EXPRESSED BY MOTHERS IN THE STUDY GROUP A. Concerns Related to Care of Their Children  Prior to Hospitalization The mothers' concerns related to the care of their children prior to hospitalization were identified and categorized into: (1) concerns directly related to the preparation of the 41 child, and (2) concerns related to arrangements the mother needed to make to stay with her child. The preparatory period was previously identified as the period i n i t i a t e d by notifying the mother of the date of admis-sion, u n t i l she arrived i n the unit. The nature of these con-cerns i s presented in Table VI. Approximately 70 per eent of the concerns were related to the mother's preparation of the child. Over 50 per eent of these were related to the mother's concern with the child's fear of needles, his past experiences with hospitalisation and his fears of being hurt. Preparation of the Child TABLE VI FREQUENCY AND PERCENTAGES OF MAJOR CONCERNS EXPRESSED BY MOTHERS IN THE STUDY GROUP RELATED TO CARE OF CHILDREN PRIOR TO HOSPITALIZATION Concerns expressed by mothers Frequency Percentage Preparation of child Child's fear of needles or hospital D i f f i c u l t y obtaining urine specimen Lack of instruction 13 6 4 18.2 12.1 39.4 Hospital policy Early admission time 10 30.3 Total 33 100,0 42 Fear of needles. Twenty per eent of the mothers worried about the idea of the child receiving a preoperative injection. Ten per eent expressed a fear of injeotlons themselves and stated that perhaps they had transmitted this fear to their children. F i f t y per cent of the children who feared needles, received them, the other f i f t y per cent did not. Effect of previous hospitalisation. Sixty per oent of the ohildren had been previously admitted to hospital. The number of times these children had been hospitalized i s shown i n Table VII. TABLE VII PREVIOUS HOSPITALIZATION OF THE CHILDREN IN THE STUDY EXPRESSED AS TO NUMBER, FREQUENCY AND PERCENTAGE Number of Frequency of previous Percentage of children hospitalization of children children 7 1 58 .5 3 2 25*0 2 2 16 .5 Total 12 100.0 Table VIII shows the reasons given by the mothers for these admissions. The number of children exceeds twelve when they are classified according to the reasons for admission. This i s due to the fact that some mothers gave more than on® reason for the admission. Thirty per cent of the children had been hospitalized for a tonsillectomy. The mothers whose children had been hospitalized previously were concerned regarding how th© children would accept being i n hospital again. One mother whose two year old child had been hospitalized three times be-fore, did not t e l l him he was being admitted. This fear related to previous hospitalisation was most acute when the experience had been an unpleasant one for both the child and mother. Fifteen per cent of the mothers worried about the possibility of permanent damage resulting from these separations. One mother was worried because her eight year old daughter had been upset a week prior to admission and had arrived home from school crying. She was afraid of the dentist's d r i l l and being hurt. TABLE VIII NUMBERS AND PERCENTAGES OP REASONS GIVEN BY THE TWENTY MOTHERS IN THE STUDY GROUP FOR THE PREVIOUS ADMISSIONS OP THEIR CHILDREN TO HOSPITAL Reasons given Number of children Percentage of by mothers admitted for this children admitted for admission reason for this reason Tonsillectomy 5 29.4 Appendix Infection or other infections 3 17.6 Eye surgery 2 11.7 Appendectomy 1 5.9 Asthma 1 5.9 Circumcision 1 5.9 Failure to thrive 1 5.9 Hematoma 1 5.9 Myringotomy 1 5.9 Observation 1 5.9 No reason given 2 Total 19 100.0 Difficulty obtaining a urine specimen. Fifteen per cent of the mothers were unable to obtain a urine specimen from their children and were worried that they had not compiled with the hospital's instructions. One mother telephoned the hospital for directions on how to collect a specimen from a seven month eld baby, Lack of instructions. Twenty per cent ©f the mothers did not receive any instructions i n the mail regarding the day care unit and the required preparation of their children for admission. A l l of the children were physically prepared* and no cancellations were required. One mother In the study group was worried about the effects of the eye drops en her children. She was instructed to i n s t i l l them at home before leaving and wondered If they would be able to see. Another mother did net know what to t e l l her six year eld bey about the operation as she did not understand what the doctor was planning to do. Arrangements Heeded to Stay with Child The arrangements the mothers needed to make to stay with their children were dependent upon: (1) the admission time, and (2) ether ohildren at home. Admission time. The hospital had established certain policies regarding notifying parents of admission, the mailing of instructions and the time the ohildren were to arrive i n th© unit. As was mentioned previously the children were scheduled to arrive two and one-half hours prior to the operating time, with the exception of children scheduled for the operating roora between eight and nine o'clock. These children a l l arrived at seven o'clock. Thirty percent of the concerns expressed by mothers regarding the preparatory period were directed towards the early hour they were expected at the hospital. Thirty per eent of the mothers i n the study group mentioned this as being one of their biggest problems. Eighty per cent of the children k6 i a the study group were admitted between seven and eight o'clock i n the morning. Other children at home* Twenty-five per cent of the mothers expressed d i f f i c u l t i e s i n making arrangements for other children at home. Two mothers solved this problem by bringing younger children with them. Table IX Illustrates the number and percentages of children i n the families selected for the study. TABLE IX NUMBERS AMD PERCENTAGES OF CHILDREN IH THE FAMILIES SELECTED FOR THE STUDY Number of children Number of Percentage of In the family families families 1 5 25.0 2 11 55*0 3 3 15.0 k 1 5.0 Total 20 100.0 B. Concerns Related to the Mothers' Experiences in the Day Care Unit The mothers' concerns related to their actual experiences in the day oare unit were mainly focused on the anaesthetic and the operation that was performed. Table X shows the nature of these concerns i n frequency and percentages. The concerns were identified by studying the types of questions asked by the mothers. Sixty per cent of their concerns were requests for information regarding the child's diagnosis, the anaesthetic and the operation or examination performed. TABLE X FREQUENCY AND PERCENTAGES OF THE NATURE OF CONCERNS EXPRESSED BY MOTHERS IH THE STUDY GROUP RELATED TO THEIR EXPERIENCES IN THE DAY CARE UNIT Concerns expressed Frequency by mothers Percentage Heed for information about the diagnosis, anaesthetic and operation 35 61.4 The long preoperative waiting period 9 15.8 Concerns about other children i n unit 6 10.5 Unexpected bruises, needle marks or sutures 4 7.0 Worry over other children at home 3 5.3 Total 57 100.0 48 Need for Information about the Diagnosis ? Anaesthetic and Operation The concerns included i n this category included those concerns related to the preoperative waiting period, the pre-medication, the method of administering the anaesthetic, i t s effect en the child, and the need for information about the re-suits of the operation or examination. The preoperative waiting period. Thirty-five per cent of the mothers expressed ooncern over the long preoperative waiting period. This was of particular concern to the mothers of pre-school children. Seventy per eent of the mothers who mentioned this as a major concern, were admitted with preschool children. As Table X, page *S7 showa, 16 per eent of the concerns related to the hospital experience were related to this factor. Seme of the mothers did not understand the reason for the long preopera-tive period. One mother stated she would not arrive so seen next time and another mother stated that one hour was a l l the time the nurses needed in order to prepare the child. The mothers seemed most concerned over keeping the children happy and were afraid they would get bored. The premedication. Twenty per cent of the mothers were concerned about the effects which the premedication had on their children. Following the administration ef the drug, four children became overactive and d i f f i c u l t to manage. The mothers appeared mainly concerned about their a b i l i t y to handle the children and found the preoperative experience a very trying one. One child who was very upset, was given a rectal sedative which immediately put her to sleep. Another mother stated she wished her two year old son had been put te sleep right away, as the preoperative period was so upsetting for him. Ten per cent of the siothers misunderstood the purpose of the premedication and thought i t was the anaesthetic. They were concerned because their ohildren were awake when they went to the operating room and wondered i f they were also awake during the surgery. Concerns related to the premedication were mainly revealed during the follow-up interviews. Due to incomplete data on this subject, the degree to which mothers shared the miscon-ceptions could not be determined. Method of administering the anaesthetic. Two mothers asked questions related to the actual method of administering the anaesthetic. Misunderstandings regarding this matter were revealed only towards the end of the study, so the degree to which this was shared by the mothers was not determined. The post anaesthetic period. The mothers asked many questions while they were In the unit regarding the length of time their children would be in the recovery room and when they would be discharged. This notion of time was of major concern to the mothers. They were frequently surprised at the speed with which the children recovered from the anaesthetic. A l -though they were worried about possible consequences from the anaesthetic, sixty-five per cent of the mothers reported that their children had suffered no i l l effects from the anaesthetic. Table XI shows the symptoms displayed by the remaining 35 per cent of the children. TABLE XI POST ANAESTHETIC SYMPTOMS AMONGST THE CHILDREN IN THE STUDY GROUP EXPRESSED AS TO FREQUENCY AND PERCENTAGES Symptom Frequency Percentage Vomiting 4 20.0 Di f f i c u l t y with balance 3 15.0 Croupy cough 2 10.0 No symptoms 11 55*0 Total 20 100.0 Only three symptoms developed, vomiting, d i f f i c u l t y with balance and a croupy cough. Vomiting accounted for almost 50 per cent of the symptoms. Desire for Information about the operation and diagnosis. The majority of the mothers expressed concern over the operation and wanted information regarding what the doctor was preparing to do, what had actually been performed i n the operating room and Information about the child's diagnosis. Only two doctors came to see the children and their mothers in th® unit. Some of the mothers waited outside th® operating room hoping to eateh the doctor, but most telephoned him at home. Unexpected marks and sutures Twenty per cent of the mothers were concerned about unexpected needle marks, bruises or sutures. Concerns regarding these matters were expressed at home. Only one of the mothers noticed a needle mark in hospital, and was given an explanation at the time. The three remaining mothers did not notice the marks un t i l they were home. They did not receive an explanation u n t i l the time of the home v i s i t when they asked the researcher about them. Worry over other children at home Although worry over other children constituted a major concern during the preparatory period, i t was not a major source of worry during the time the mother was in the unit. Two mothers were unable to make satisfactory baby s i t t i n g arrange-ments for their children and had to leave and return later* This category accounted for Just over 5 per cent of the total concerns expressed by mothers during the hospitalization period. 51 C. Concerns Related to Cay® of Children at Home The major concerns expressed by mothers which were related to the care of the children at home were grouped into four main categories: (1) postoperative complications, (2) effects of the anaesthetic, (3) child's activity, and (4) child's diet. Table XZZ shews the frequency with which these concerns were expressed and their percentages. TABLE XIX FREQUENCY AND PERCENTAGES OF MAJOR CONCERNS EXPRESSED BY MOTHERS IH THE STUDY GROUP RELATED TO HOME CARE OF THEIR CHILDREN Concerns expressed Frequency Percentage by mothers Postoperative complications 17 51.5 Effects of the anaesthetic 7 21.2 Child's activity 5 15.2 Child's diet 4 12.1 Total 33 100.0 Postoperative complications Over f i f t y per eent of the concerns related to the home care of the children from the time of discharge, up to ten days postoperatively, were focused on the postoperative discomforts experienced by the ohildren. A l l of the ohildren who had a ur©logical examination suffered from some degree of dysuria. Eighty per cent of the (mothers were able to cope with this problem. One mother, Mrs. J. became very upset over son's dy-suria and f e l t he would have received more prompt treatment in hospital. More details are given in Appendix B., page 104. 52 A l l of the children who had a myringotomy had some discharge from their ears. Two of the children required medical treatment from their doctors th® day following surgery* Two-thirds of the children who had dental work, had some discomfort at home, but none severe enough to require more than the administration of an aspirin by the mother. Table XIII, Appendix D, page 146 shows the types of complications which were reported to the researcher by the mothers at the time of tho home v i s i t . They are divided into two categories: (1) postoperative complications, and (2) post anaesthetic complications. The post anaesthetic complications referred to i n Table XIII are those whioh developed after the children were dis-charged from the unit. The mothers had to deal with these on their own. Activity and Diet Twenty-seven per cent of the mothers* concerns related to home care were problems associated with placing restrictions on the child's activity and diet. The children were hungry and thirsty and the mothers did not know how much they should give them to eat. They were also quite l i v e l y and wanted to play. Thirty per cent of the mothers of preschool children stated the restriction of ac t i v i t i e s was one of their most d i f f i c u l t tasks. While outside the objectives of the study, It i s interest-ing to note that the complications whioh were reported by the mothers i n the study group varied somewhat from those which were reported by the 191 mothers whose children were admitted to the unit during the f i r s t three months of i t s operation. Table XIV, Appendix D, page 147 shows the frequenoy of complications re-ported by these mothers. IV. FACTORS THAT INFLUENCED THE MOTHERS' ACTIVITIES AND EXPRESSED CONCERNS There appeared to be a certain homogeneity to the 53 twenty mothers In the group. If a profile were drawn of the mothers, they would appear to share the following: (1) past experiences with hospitalization of children, (2) motivation and interest in the welfare of their children, and (3) a b i l i t y te cope independently with the preparation of their children and their care at home following discharge. Past Experiences with Hospitalisation Seventy-five per cent of the mothers had experience with the hospitalisation of at least one of their children. They expressed dissatisfaction with the hospitalisation and were c r i t i c a l of the arrangements for v i s i t i n g their children and of the attitude of the nursing staff towards mothers. These particular mothers were the most vocal in their acceptance of the day care program. Motivation and Interest i n the Welfare of Their Children The motivation of the mothers was assessed by their desire to participate i n the day care program and i n the study group* Eighty per cent of the mothers had to get up at 6 a.m. or earlier to arrive at the unit by 7 or 8 o'clock, depending upon the distance they had to travel. Seventy-five per eent of the mothers agreed to come to the day care unit without any prior knowledge of i t s existence, other than the fact that their doctors stated i t would be more desirable for their children. In talking with the toothers, they a l l discussed topics which were related to some aspect of child behaviour. Mothers of preschool children were very interested i n this subject and asked the researcher questions related to various subjects such as, t o i l e t training and sibling r i v a l r y . Ninety-five per cent of the mothers were aware of the effects of hospitalisation on children. The one mother who did not discuss this subject was having d i f f i c u l t y coping with personal problems at the time and would have preferred It If her child had stayed i n hospital for a few days. A l l of the mothers expressed an interest in the day care program* Ability to Cope with Home Care Ninety per cent of the mothers were able to accept responsibility for the horn© care of their children. Thirty per cont of the mothers contacted their doctors, and a l l stated they would contact their doctors i f problems developed at home. Only one mother telephoned the hospital for advice. She had been unable to contact her doctor. A l l of the mothers f e l t a telephone c a l l the evening of surgery or the next day was a good idea. Only one mother f e l t a v i s i t from a nurse would have been helpful. The mothers who received the printed information In the mail prior to hospitalisation (80 per cent) f e l t the infor-mation was adequate and that they did not require a v i s i t from a nurse preoperative^. The mothers who did not receive the Information (20 per cent) f e l t a v i s i t preoperatively was a good idea. Two mothers f e l t their children should have remained in hospital for a few days post operatively. More information on Mrs. J'a and Mrs. R's comments are in Appendix B, pages 104 to 105 and 130 to 131* Xn summary, the interpretation of the findings indicated that the mothers were mainly concerned with the notion of time, the child's diagnosis, the operation performed and the possi-b i l i t y of post anaesthetic and post operative complications. The mothers appeared particularly apprehensive about the anaesthetic * CHAPTER VI SUMMARY, RECOMMENDATIONS AND AREAS FOR FURTHER INVESTIGATION At present very l i t t l e i s known of the various problems mothers experience when their ohlldren are admitted to a day eare unit In terms of the increased responsibility which i s plaoed upon them for the preparation of their children and their care at home following discharge. The purpose of this study was to Identify some of the major concerns expressed by mothers who participated i n a day care unit i n a children's hospital i n Vancouver* A ©ample of twenty mothers was selected and the kind® of nursing activities i n which they participated in the unit were assessed and rated by a participation scale. The data were collected by the researcher who took on th© role of participant observer i n the day eare unit. Field notes were written on the mothers while they were i n the unit and post hospital Interviews recorded approximately one week to ten days following discharge. The participation scales, f i e l d notes and post hospital interviews were analysed and the frequency and percentages of the expressed concerns determined. Seventy per cent of the mothers in the study group needed help In assisting with the oare of their children in the unit. Concerns expressed by the mothers were centered on the notion of time and a desire for information related to the child's diagnosis, the anaesthetic, and operation performed. Postoperatively they expressed con-cerns related to symptoms caused by th® anaesthetic, operation or examination. They seemed particularly apprehensive about the anaesthetic and Its possible effects on the children. Soventy-fiv© per cent of the mothers had previous experience with th® hospitalisation of their children. This factor seemed most characteristic of the group and Influenced their p a r t i c i -pation In the day care a c t i v i t i e s . Only two mothers had prior 56 knowledge of the day care unit and they participated Independently, requiring l i t t l e assistance from the nurse. Ninety per cent of the mothers were satisfied with the day oare experience. Two mothers were unhappy about the arrangements and would have pre-ferred having their children i n hospital for a few days post-operatively. These mothers would have benefited from a home v i s i t by a nurse. The remaining 90 per cent stated they did not feel they needed a v i s i t from a nurse postoperatively. A l l mothers appreciated a telephone c a l l from the hospital following surgery. The mothers contacted their doctors i f problems arose at home. They f e l t the instructions they received by mall prior to admission were adequate. Findings from this study are similar to those reported in the literature which Indicate that mothers can and w i l l participate i n the care of their children in hospital i f given direction and encouragement. The introduction of role cues and their importance i n helping mothers participate in the care of their children in hospital was studied by Roy whose findings suggested that, "the mother's level of adequacy in relating to her hospitalized child i s raised by the nurse's introduction of helpful cues". 1 Mahaffy stated: Allowing a mother to bring her child to an environment which i s supportive, compassionate, and understanding, and where she i s assisted and encouraged to participate In caring for her child i s , ... an approach which may provide ohildren with a less distressful experience in the hospital, a more rapid recovery from the operation, and less symptoms of anxiety on returning home.2 Meadow reported that 88 per cent of the mothers i n his study group who stayed with their children in hospital would have liked more definite information about ways to help. The Sister Mary Cal l i s t a Roy, "Role Cues and Mothers of Hospitalized Children," Nursing Research, XVI (Spring, 1967), p. 182. 2Perry R. Mahaffy, "The Effects of Hospitalization on Children Admitted for Tonsillectomy and Adenoldectomy," Nursing  Research, XIV (Winter, 1965), p. 19. 57 mothers were uncertain of their role: "of what child care, ward work, and helping they are meant to be doing or even allowed to do".3 The majority of the mothers had a desire for information about the child's diagnosis, the anaesthetic and the operation. This type of concern was also reported by Meadow who stated: Many of the minor worries were related to investigations their child had and lack of ex-planation about them. The mothers long for definite news of the operation, for the surgeon or anyone to come along grandly and say, "I circumcised him, everything went according to plan." Even i f the operation i s for the removal of a birthmark under local anaes-thetic, they s t i l l hope a member of the surgical staff w i l l come and t e l l them of the success of the operation. What usually happens i s that the staff automatically assume that a l l routine pro-cedures go according to plan, and i t i s only when things have gone wrong that the operation is dis-cussed with the mother.4 Although the idea of day care was well accepted by the mothers i n this study some areas w i l l require further research. AREAS FOR FURTHER INVESTIGATION Hypotheses were not formulated at the beginning of the study, but three did evolve as the study progressed. These w i l l require further investigation. 1. Mothers who receive information about the day care unit and the preoperative routines can participate more successfully i n the nursing care act i v i t i e s than mothers who do not receive this information. «S. R. Meadow, "The Captive Mother," Archives of Diseases  of Childhood. XLIV3 (1969), p. 364. Ibid., 363-364 58 2 . Mothers who receive s p e c i f i c instructions regarding the anaesthetic, operation and post operative care, experience fewer problems at home than mothers who do not receive t h i s information. 3. Misconceptions and lack of knowledge about the anaesthetic are a major source of worry to mothers who p a r t i c i p a t e i n day care. RECOMMENDATIONS The r e s u l t s of t h i s study would Indicate: 1. That there i s a need f o r more explanation to mothers p r i o r to admission regarding the purpose of the day care unit and Its operation. 2 . That children not be admitted before 8 a.m. due to problems such as arranging f o r the care of other children at home. 3. That the preoperative waiting period i n the unit be reduced to one and one-half hours from two and one-h a l f hours. This i s an adequate amount of time to give the children the necessary preoperative care and should prevent young children from becoming bored. 4. That mothers be given more information about the anaesthetic: i t s purpose, method of administration, and expected reactions. 5 . That mothers be given more information about the operation, the complications that may occur and s p e c i f i c nursing care required by the c h i l d at home. 6. That attempts be made to reach a consensus regarding whether an o r a l or Intramuscular premedication i s to be administered to the children. 7. That mothers are telephoned the evening of surgery 59 and i f any problems arise that a nurse make a home v i s i t to assess the situation. 8. That a waiting room be made available for parents adjacent to the day care unit while they wait for the children to return from the operating room. 9. That nurses try to make mothers feel at home i n hospital by encouraging them to help care for their children, by answering their questions and by pro-viding them with information about the child's condition. 10. That mothers be given a clearer Idea of time in relation to the planned activities for the child. The success of surgical day care units for children i s dependent upon the interest and support of parents. Mothers can prepare their ohildren for surgery and cope with post hospital care, i f they receive help and support from the nursing staff. Nurses should recognize the importance of the mothers' presence in comforting the children and preventing post hospital upsets due to separation at the time of hospitalization. Mothers whose children have been treated in a day care unit are most enthusiastic about this type of hospital care. BIBLIOGRAPHY A* BOOKS Adams, Richard N, and Preiss, Jaok J. (ad.). Human Organization Research. Homewood, I l l i n o i s : The Dorsey Press, Ino., 19W. Becker, Howard (ed.). Modern Sociological Theory. Hew York: Holt, Rlnehart and Winston, 1966. Burlingham, Dorothy and Freud, Anna. "Young Children in Wartime: Traumatic Effects of Separation from Parents,11 Behaviour  in Infancy and Early Childhood, Yvonne Braekbill and George C. Thompson, editors. Hew York: The Free Press, 1967. Bruyn, Severyn T. The Human Perspective i n Sociology. Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1966. Davenport, Harold T. Pediatric Anaesthesia. London: William Heinemann Medical Books Ltd., 1967. Dlnnage, Rosemary and Pringle, H. L. Kellmer. Residential Child  Care Facts and Fallacies* London: London: Longmans, Green and Co. Ltd., 1967. Erickson, Erik H. "Eight Ages of Man," Readings i n Child Behavior and Development. Celia Burns Stendler, editor. New York: Haroourt, Brace and World, Inc., 1964. Fagin, Claire M.. The Effects of Maternal Attendance During Hospitalisation on the Post Hospital Behavior of Young  Children: A Comparative Survey. Philadelphia: F. A. Davis Company, 1966. Glaser, Barney and Strauss, Anaelm L. The Discovery of Grounded  Theory. Chicago: Aldlne Publishing Company, 1967. Heinleke, Christoph and Westhelmer, Use J . Brief Separations. New York: International Universities Press, Inc., 196$. Hoffman, Martin and Hoffman, Lois Waldls. Review of Child Development Research. New York: Russell Sage Foundation, 1964. 61 Johnson, Dorothy. "The Meaning of Maternal Deprivation and Separation Anxiety f o r Nursing Practise," Issues i n Nursing. Bonnie Bullough and Vern Bullough, ed i t o r s . New York: Springer Publishing Company, Inc., 1966. K l e i n , Donald C. and Ross, Ann. "Kindergarten Entry: A Study of Role T r a n s i t i o n , " Crises Intervention, Howard J . Parad, ed i t o r . New York: Family Service Association of America, 1965. McCreary, J . F, "Current Trends i n H o s p i t a l i z a t i o n of Children," The Child and His Environment. V i c t o r i a : B r i t i s h Columbia Department of Health Services and Hospital Insurance, 19159. Murphy, Lois Barclay. The Widening World of Childhood. New York: Basic Books, Inc., 1963. Robertson, James. Young Children i n Hospital. London: Tavistock PubIIcations Limited, 1958. Sehaffer, H. Rudolph. "Objective Observations of Personality Development i n Early Infancy," Behavior i n Infaney and  Early Childhood, Yvonne B r a c k b i l l and George C. Thompson, editors. New York: Th® Free Press, 1967. Schwartz, Doris, Henley, Barbara and Z e i t z , Leonard. The Elde r l y  Ambulatory Patient. New York: The Macmillan Company, 1 9 6 4 . S e l l t l z , C l a i r e , and others. Research Methods i n S o c i a l Relations. New York: Holt, Rlnehart and Winston, 1962. Whyte, William Foote. Street Corner Society. Chicago. University of Chicago Press, 1943. B. PERIODICALS Bowlby, John. "Grief and Mourning i n Infancy and Early Childhood," The Psychoanalytic Study of the C h i l d , XV (1966)fl 9-52. Brain, D. J . and Maclay, Inga. "Controlled Study of Mothers and Children i n Hospital," B r i t i s h Medical Journal, I (3 February, 1968)» 278-280. Branstetter, Ellaraae. "The Young Child's Response to H o s p i t a l i -zation: Separation Anxiety or Lack of Mothering Care?" American Journal of Public Health, LXIX (January, 1969), 92-97. 62 Byerly, Elizabeth Lee. "The Nurse Researcher as P a r t i c i p a n t -Observer i n a Nursing Setting," Nursing Research» XVIII (May-June, 1969), 230-236. Cullen, James S. "Determinants of P a r t i c i p a t i o n i n Parent Education Courses." Journal of Health and Human Behavior, VII (Winter, 1956), 302-3o8. James, Vernon L. and Wheeler, Warren E. "The Care-By-Parent Unit," P e d i a t r i c s , XLIII ( A p r i l , 1 9 6 9 ) , 488-494. Lawrle, Rex. "Operating on Children as Day-Cases," The Lancet. II (December 1 2 , 1964), 1289-1291. MaoDonald, E. Mae. "Parents Par t i c i p a t e i n Care of the Hospi-t a l i z e d C h i l d / ' The Canadian Nurse, LXXV (December, 1969), 37-39. Mahaffy, Perry R. "The E f f e c t s of H o s p i t a l i z a t i o n on Children Admitted f o r Tonsillectomy and Adenoidectomy," Nursing  Research, XIV (Winter, 1965), 12-19. Meadow, S. R. "The Captive Mother," Archives of Diseases of  Childhood, XLIV (1969), 362-367T , "No, thanks; I'd Rather Stay at Home," B r i t i s h Medical Journal, II ( 2 6 September, 1964), 813-814. Miles, Margaret Shandor. "Body Integrity Pears i n a Toddler," Nursing C l i n i c s of North America, IV (March, I 9 6 9 ) , 39-51. P e a r s a l l , Marion. "Participant Observation as Role and Method i n Behavioral Research," Nursing Research, XIV (Winter, 1965), 37-42. Robertson, Joyce A. "A Mother's Observation on the T o n s i l l e c -tomy of Her Four-Year Old Daughter," The Psychoanalytic  Study of the C h i l d , XI (1956), 410-431^ Roy, S i s t e r Mary C a l l l s t a . "Role Cues and Mothers of Hospitalized Children," Nursing Research, XVI (Spring, 1967), 178-182. S c o f l e l d , Cheryl. "Parents In the H o s p i t a l / Nursing C l i n i c s of  North America, IV (March, 1969), 59-67. Shah, Chandrakant and others. "A Study of the Need f o r A l t e r -native Types of Health Care f o r Children i n Hospital: Parental Attitudes Towards Day Care," P e d i a t r i c s , XLIV (September, 1969), 338-347. Skipper, J&raes K., and Leonard, Robert C. "Children, Stress, and Hospitalization: A Field Experiment," Journal of Health and Social Behavior, IX (December, 1968), 2 7 5 - 2 8 7 . Spitz, Rene A. "Hospitalism," The Psychoanalytic Study of the Child, I (1945), 53-74. C. UNPUBLISHED MATERIALS The Children's Hospital of Winnipeg Proposed Program for Home  Vi s i t s by y.Q.NT A Document Submitted to the Manitoba Hospital Commission and to the Victorian Order of Nurses, March 3, 1969. Evaluation of the N.F.A. Program of Home V i s i t s . A Document Prepared by the Children's Hospital of Winnipeg, November, 1969. APPENDIXES APPENDIX A HOSPITAL FORMS APPENDIX A Dear Parent's Dr? has arranged for your child to have his/her surgery done at this hospital as a Day Care Patient 0 The date and time of surgery will be confirmed with you by the hospital staff on the day prior to the surgery, We enclose instructions and suggestions for your child's safety and well-being. Please read them carefully and do a3 they advise, If you have any questions regarding the Day Care program please call the Admitting Department of this hospital,. 67 INSTRUCTIONS AND INFORMATION FOR PARENTS  WHO ARE BRINGING THEIR CHILDREN. TO HOSPITAL FOR DAY CARE SURGERY 1. It is very important, that your child have nothing to eat or drink for eight hours before going to the Operating Room. This rule is for your child's safety and is very important. Please be completely honest and report i f you suspect that your child has had anything by mouth. 2. When your child gets up on the morning you are to bring him to hospital, please obtain a urine.specimen arid bring i t to the hospital in a clean container. Some children find these specimens difficult to produce on request at the hospital. After arriving at the hospital, this specimen . will be tested and a drop of blood from Ma. linger will also be taken and tested. 3. Please report any. diarrhoea, colds, sniffles, sore throat, spots and skin rashes on this child or any other member of the family. 4. Please report i f this child or any other member of the family has ever _had any problems with.an .anaesthetic or an allergy* 5. Please report i f this child has any loose teeth. 6. Be completely honest with your child. It helps him to trust you and the hospital staff, i f he is told.only the truth. This trust will reduce his fear of the unknown. Try to avoid having him told unnecessary or lurid stories of hospitals by his family or playmates. 7. Bathe your child the night before his surgery. It will help him to have a good night's sleep as well as ensuring his cleanliness before ._ admission to hospital. Fingernails and hair should also be clean. 8. The hospital staff will be happy to let you stay with your child until he goes to surgery and to have you available to greet him again on his return to the ward. 9. The attending doctor in consultation with the Anaesthetist will decide what time your child is ready to go home. 10. It is important that the parent looking after the child on the journey home should have someone else drive the car. 68 JHILIREN'S HOSPITAL 'Chile's Name SURGICAL HISTORY FORM Date „niRTE HISTORY OF THIS CHILD Was the pregnancy abnormal YES NO Was the d e l i v e r y complicated YES NO B i r t h weight Was h i s / h e r c o n d i t i o n at b i r t h abnormal YES NO V Was h i s / h e r development abnormal during infancy YES NO C- Any behaviour problems with your c h i l d YES NO PAST ILLNESSES Repeated ear i n f e c t i o n s YES NO -' Repeated t o n s i l l i t i s YES NO Frequent chest colds YES NO Wheezing YES NO B r o n c h i t i s ' YES NO " Br o n c h i a l asthma YES NO Repeated pneumonia YES NO Any heart c o n d i t i o n YES NO <v Convulsions YES NO Bleeding tendency ,. . . YES NO Measles YES NO ' German measles •. YES NO - Mumps . , YES NO Chicken pox YES NO • Whooping cough YES NO Any recent i l l n e s s (please s p e c i f y ) YES NO HAS THIS CHILD HAD: any previous h o s p i t a l i z a t i o n YES NO (Where?) (Why?) any previous surgery YES NO (Why?) any a n e s t h e t i c complications YES NO (What type?) Is t h i s c h i l d on any medication .... YES NO (What?) Is he/she a l l e r g i c to any medication YES NO (What?) - to any other substance YES NO (What?) Has he/she had a blood t r a n s f u s i o n ..YES NO Does any blood r e l a t i o n of t h i s c h i l d have any of the f o l l o w i n g ? : (please s p e c i f y ) A l l e r g y .YES NO Bleeding tendency YES NO Diabetes YES NO Other i l l n e s s e s : IMMUNIZATION Whooping cough) Tetanus ) D.P.T. three-in-one YES NO Di p h t h e r i a ) SIGNATURE Form #133 RELATIONSHIP TO PATIENT CHILDRENCS HOSPITAL  SUGGESTIONS FOR THE CARE OF CHILDREN FOLLOWING GENERAL ANAESTHESIA The evening you take your child home from hospital the child will be sleepy, thirsty and possibly a l i t t l e nauseated. Give only clear fluids to drink, a mouthful at a time, until you feel the child can keep the fluid down. Solid food should be started slowly in the same way. Toast, a plain cookie or a light, sandwich seems the most acceptable. Diet the next day should be light and given as tolerated - do not force the child to eat, but offer the type of food to which he is accustomed. Fluids in any form form should be encouraged;* The day following an anaesthetic should be a quiet day as the child will be tired. There should be no running around.or climbing„ Bathroom rputine should follow the child?s normal habit. Deep breathing should be encouraged - three deep breaths before each meal is a good plan 0 In a day or two please call your doctor's office for a check appointment. IF YOU ARE WORRIED IN ANY WAY ABOUT YOUR CHILD'S CONDITION, PLEASE PHONE YOUR DOCTOR OR THE ANAESTHETIST AT CHILDREN'S HOSPITAL. o Form # 54 DAY CARE UNIT 70 Follow-up Questionnaire NAME: Phone No. Date RESPONDENT: Mother (or mother figure) 1 Father (or father figure) 2 Reliable Other relative 3 Unreliable Other k Please make up a form for each patient using the D.C.U. If no follow-up contact is made state the reason - e.g. language barrier, patient admitted to hospital, study patient, unable to contact, or out of town patient. QUESTIONNAIRE: Completed 1 • Not completed 2 Reason, i f incomplete Using the following definitions please note the degree to which the items listed below were a problem during the fir s t 2k hours at home. (0) No problem - self explanatory (1) Mild - the problem was present or complained of but no action or intervention was required. (2) Moderate - the problem was severe enough to require some action -that is some medication or treatment was given. "At Children's Hospital, we are interested in finding out i f you have had any problems in looking after your child since you brought him/her home after his/her operation. " I. Since taking your child home has he (or she) had any NO PROBLEM MILD MODERATE (a) Nausea 0 1 2 3k 0>) Vomiting 0 1 2 35 (c) Sore throat 0 1 2 36 (d) Hoarseness 0 1 2 37 (e) Cough 0 1 2 38 (f) Difficulty voiding 0 1 2 39 (g) Irritability 0 1 2 ko (h) Pain at site of operation 0 1 2 kl 1 2 • 32 Please ask each of the following questions as i t is written and circle the appropriate answer. Please give the parent a choice of answer i.e. YES, NO, NO OPINION. • • YES NO NO OPINION II. Are you restricting his (or her) activity today? (Or is he/she less active than usual?) 1 2 3 III. Did you need the help of a doctor for the management of your child? 1 2 3 If yes, give details: IV. Did you have any other problems in caring for your child at home? 1 2 3 If yes, specify: V. Do you think your child would have been more comfortable in the hospital after the operation? VI. .Do you think your child would have been safer in hospital the night following the operation? VII. Was your child happy to be with the family after the operation rather than spending a night in hospital? VIII. Do you feel that a home visit by a nurse after you took your child home would have been of any value? If yes or no, please state the reasons: IX. If you had to do i t again would you prefer your child to go home as he did on the evening after his surgery? If not, why? EDUCATION OF PARENTS: YEARS OF SCHOOLING COMPLETED UNIVERSITY (less than 12) HIGH SCHOOL DEGREE Father (or father figure) 1 2 3 Mother (or mother figure) 1 2 3 APPENDIX B CASE HISTORIES APPENDIX B RESPONDENT #1 I. Background; Name of the mother; Mrs. A. Marital status: married Name of the child: Michael Age: 5 years Education; No record available Number of children: 2 Diagnosis: Meatal stenosis Operation performed; Cystoscopy, pyelogram and meatotomy Length of anaesthetic; 15 min. Length of hospitalisation: 4 hours Previous hospitalization: Michael had been hospitalized twice. 1. eye surgery 2. circumcision Mrs. A. worked as a children's nurse i n England before she was married. She frequently looked after f©stern children who were waiting for adoption and seemed to enjoy doing this. She was expeotlng her third child In about a month. II. Mother's participation i n day care unit: A. Participation scale: participated with help B. Precis of f i e l d notes: Mr. A. brought Michael into hospital at 7 o'clock and stayed with him unt i l he went to the operating room. Mr. and Mrs. A. both came i n postoperatively. Mrs. A. was eager to help care for Michael and needed only a suggestion. C. Summary of concerns expressed while in unit: 1. Michael's diet postoperatively. 74 INTERVIEW WITH MRS. A, Key: M •» mother R • researcher M: He's had enough as far as hospitals go and that's how we f e l t too. He's been more upset this time than before because he's had so much of i t . He's had nightmares and cried i n his sleep before going to the hospital this time. The f i r s t two times he was really good but this time we found he was more upset because he knew about the needles. He has had so many needles, they were the problem. R: Did he have a needle this time? M: Yes. R: He appeared quite well adjusted to being i n hospital. M: That's the only thing, I think, the needles, because when my husband took him i n that morning he really pulled the place apart as he knew he'd be getting a needle. We explained to him exactly what was going to happen. R: When he was hospitalised for his eye surgery, did you notice any after effects? Ms No, there was no problem with him when he came home or when he was i n there, he was really cheerful. He liked i t very much, a l l the ice-cream and popsioles. R: Your husband brought Michael into hospital on his way to work? M: I would have gone with him myself but my l i t t l e g i r l had to go to school and I wasn't too sure how long I was going to be. Michael wasn't upset because I couldn't come with him, as long as I could come and take him home. R: Did Michael have any problems when he got home? M: None except when he passed his urine. It hurt him for the f i r s t couple of days. He was thirsty but other than that we couldn't keep him down. He was out playing that same day. That's what worried ma mere than anything else. I wondered i f he should be out there. He had a good night's sleep. The next day i t hurt him when he urinated, that was the only thing. 75 Ri I don't think we told him that I t might hurt. He knew he was having an examination? Mt Oh, yes. R: When he woke up he pulled down his covers to look at his penis to see i f It was a l l right, asfd when he discovered that It was he didn't worry about i t after that. M: He may have been relating i t to his circumcision. R: How old was he when he had the circumcision? H: It was 18 months ago. He's had so much hospitalisation In the past 2 years. I think he has done very well considering what he's been through. Rs I t was his fear of having another needle that was worrying him this time? Mt Yea, definitely. R; Perhaps i f we had known we could have arranged to have had him receive a liquid medication. The fact that he couldn't have breakfast didn't worry him? Mt Ho, It was too early i n the morning. He didn't have time to think about I t . R: Was there anything we could have done that would have helped you? Ht Ho, not really. It worked out wfill, except for the fact I couldn't take him i n . It was so early in the morning. My husband solved It by saying he would take Michael. 76 RESPONDENT §2 I. Background: Nam© of the mother: Mrs* B. Marital status: married Name of th® child: Kenneth Age: 6 years Education: Grade 12 Number of children: 3 Diagnosis: Bilateral Secretory Oti t i s Media Operation performed: Bilateral Partial Tympanotomies with tubes Length of anaesthetic: 15 min. Length of hospitalisation: 5 hours Previous hospitalisation: Kenneth had been hospitalised twice. 1. failure to thrive, tonsillectomy, and myringotomy 2* myringotomy Mrs. B. was a laboratory technician* She had p a r t i c i -pated i n the nursing care of two of her children who had been hospitalised. Kenneth had been one of the Research Study children on his last admission so Mrs* B. was familiar with the idea of day care. II . Mother's participation i n day care unit: A. Participation scale; participated Independently B. Precis of f i e l d notest Mrs. B. stayed with Kenneth and participated actively in his nursing care. She needed some help i n arranging transportation home. Her husband had taken the day off work to look after the other children. C. Summary of concerns expressed while i n unit: 1. The early morning scheduling of the admission time. 2* Wanted to see the doctor to ask him about Kenneth's operation, 3* The small bandage on Kenneth's foot. 77 INTERVIEW WITH MRS. B. The interview was not taped because of mechanical d i f f i c u l t i e s with the tape recorder. I asked her for her impressions of Kenneth's hospitali-zation i n the day care unit as she had mentioned last week how well he had accepted being i n hospital this time. She said she thought i t was because he was just i n for the day. She then told me about Kenneth's previous experience i n hospital when he was three. He had failed to thrive and was admitted for 3 weeks and underwent "every test in the book - had to swallow chalk, have X-rays, blood tests - the works. He was only three.$ She said she went to see him every day but couldn't stay because her youngest son, Keven was in another hospital at the same time, having fallen from his crib and broken both his legs. She f e l t Kenneth had developed a fear of hospitals and f e l t her family doctor should not have admitted him for so long a time when he was just 3 years old. He cried most of the time and developed "deep hollows under his eyes." She said "I don't know what hap-pened when w® weren't there but I know he was very unhappy. He lost weight because he had so many tests scheduled and was not permitted to eat." Before he was discharged, the doctor decided to do a tonsillectomy and myringotomy which meant he had to spend an extra week i n hospital. I asked her what she told Kenneth this time when she found out he had to come into hospital. She said "I told him about a week before that he would have to have his ears drained again, but I don't think he really understood. Dr. P. had also told him that he was going to have to do some surgery on his ears but that he would not have to stay i n hospital overnight." She f e l t Kenneth responded so well because he knew he was not going to stay i n overnight* She said she f e l t the Day Care Unit was a wonderful idea and i f Kenneth ever had to come i n again she would in s i s t i t be on a Day Care basis. When asked why she f e l t the mother's presence was so im-portant, she said "Children are usually afraid of white uniforms 78 and feel much more confident when the mother Is present." She mentioned several times the fact that she worried about Kenneth's long separation when he was only three. „ I mentioned to her the fact that I had observed her p a r t i -cipating- quite actively i n Kenneth's care and she replied that she f e l t the child would accept the care more easily from the mother. I asked her If she f e l t she could have done more for him and she said she didn't think so. "I'm not sure If there was anything else I could have done." The only thing she had not been prepared for was the Intravenous. When she saw his foot with the bandage on i t she wondered what had happened. She did ask Or. P. and he told her essentially the same thing I had told her at the time. She said she thought the Day Care Unit was very nice — bright and cheerful. Kenneth exclaimed "Oh, fab!" when he saw the orange carpet on the floor. She f e l t the colourful room added to his acceptance of the unit. I asked her about any complications Kenneth developed* The only one was that his ears began to drain 2 days following and she immediately phoned Dr. P. who put him on antibiotics. She mentioned that last time she had a v i s i t the evening of surgery by th® research nurse, but didn't feel It was necessary. "There was nothing really that she could do. I don't see the point in having her v i s i t * " I asked her what she would think of a pre-operatlve v i s i t the day before, particularly for those mothors who had not had any previous experience. She said she thought a v i s i t beforehand was a good idea. She said Dr. P. phoned her twice, the day of surgery to check on Kenneth - once in the afternoon and again in the evening. I asked her If she f e l t a phone c a l l from a nurse the evening of surgery would be a good idea. She said "fas, i t would be reassuring to the mother." 79 RESPONDENT #3 Background: Name of the mother: Mrs. C. Name of the c h i l d : B i l l Education; Grade 12 Diagnosis: Anterior Epistaxis Operation performed: B i l a t e r a l Length of anaesthetic; 2 0 m l n -Previous h o s p i t a l i z a t i o n : Once Marital status: married Age: 14 years Number of children: 2 e l e c t r i c cautery Length of h o s p i t a l i s a t i o n : 5 I / 2 before f o r a tonsillectomy B i l l and his 2 year old brother David were both admitted to the day care unit at the same time. David was kept i n ho s p i t a l overnight because he had an adenoldectomy and did-not return to the un i t . Mrs. C. stayed with B i l l and would not go up to see David even when asked to see him. She said she thought i t would upset him as he had been upset pre-o p e r a t i v e ^ . Mother's p a r t i c i p a t i o n i n day care unit: A. P a r t i c i p a t i o n scale; did not pa r t i c i p a t e B. Precis of f i e l d notes: Mrs. C. did not a s s i s t the nurses with B i l l ' s care. She talked with him and kept him company during the entir e period except when she l e f t to pick up a r e l a t i v e to help take B i l l home. C. Summary of concerns expressed while i n u n i t : 1. The preoperative needles that had been given to the children as her doctor had t o l d her they would not be receiving any. 2. The side e f f e c t s of the preoperative medication, 3. The side e f f e c t s of the anaesthetic. 4. Wanted to see the dootor regarding the operation* 80 INTERVIEW WITH MRS. C. Key: M « mother R « researcher M: B i l l had terrible effects from the anaesthetic but other than that i t was a tremendous set-up. The one thing that threw me was having to f i l l out the history sheet at the hospital. It would be much better i f i t could be f i l l e d out at home as I forgot to put down some things that were important. It was d i f f i c u l t because David wanted to hang onto me. He was good u n t i l he took that medicine and then he was unbelievable. He had never carried on like that before. It had to be the medicine. He was just like a wild man. R: The medicine i s supposed to sedate them but sometimes i t seems to over-excite them and has a stimulating effect. M: B i l l was rather apprehensive u n t i l Dr. B. explained to him what he was going to do and told him "no needles, 8111." R: You were not prepared for that, were you? M: No, B i l l said that Dr. B told him a f i b . Dr. B. told me he preferred hospital because they did not use needles so we were surprised when both boys were given needles. That was a j o l t . When we went to get David the next day he was crying. The nurses said he was very good. R: I was wondering i f you could explain what your thoughts were when the nurse asked you to go up and see David and you said you would rather not at that time. M: I was worrying about upsetting him. I thought he should be quiet and didn't know how he would react. It was only for the one night. If he had been in longer I definitely would have gone to see him. I think this i s a carry-over from our own doctor because when B i l l had his tonsils out, they definitely wouldn't let you go and see him. The doctor said that he usually suggested that the parents not v i s i t when the child was i n only overnight as i t usually upsets the child. R: This approach Is changing now and parents are being encouraged to v i s i t even If the child i s i n for a short period. Mi My niece has been i n hospital several times and i t i s Just murder getting out of there. She really earries on u n t i l she knows we have gone. Rj You didn't want that to happen? Ms No I didn't. R: Parents often need help in this situation. Children usually express their feelings when they see their parents. It i s a release for them and young children w i l l cry when they see them. Did you feel the instructions you received were adequate and did you have any problems preparing the children? Ms No, not at a l l . The only thing was f i l l i n g out the form. You try to be as helpful as possible In trying to remember but there were too many things going on at the time and I wasn't thinking clearly. R: How did you feel about your participation in the unit? Would you have liked to have done more for B i l l ? M: No, he was fine. He was older so was more on his own. I held David for a while but he wouldn't settle down so I walked out and said to the nurse "maybe you can do more with him." The poor nurse was running a l l over the place getting toys for him and X said to myself "Just pow hits one." Finally she Just shook her head and said to come back because he wasn't going to settle down. He wouldn't go to sleep. Someone suggested I go up to the operating room with him to quieten him down but there wasn't any point because he would s t i l l have gone up fighting. I am sure i t was the effect of the medicine. R: It was probably the effect of the medicine and everything else. How did B i l l manage when he got home? He was feeling quite faint Just before he l e f t . M: He went straight to bed and then he was sick to his stomach. He must have been sick five or six times. He was tired the next morning but was able to eat* The doctor said he could go back to school but he was feeling too tired. R: You were wise i n not sending him. Did he have any bleeding from his nose? 82 Ms Ho. We went back to see Dr. B. and he was extremely pleased. R: Do you feel a v i s i t from a nurse during the week prior to hospitalisation would be helpful i n any way? M: No, not really. We received a letter i n the mall explaining the preparation. The nurses were efficient and relaxed and put the parents at ease. I would much rather be busy than be si t t i n g In the h a l l wondering what was going on. The nurse was relaxed with David. If she hadn't been I would have been very upset. It helped me relax which helped David. There i s nothing that gets to a child faster than his parents reactions. It was a good idea putting both B i l l and David in together. It worked out tremendously. It relaxed David more. They are very elose. R: Yes. I am sure i t helped both of them* Do you think a phone c a l l from a nurse the evening of surgery i s a good idea? Would i t have been of any help to you? Ms N o t r r e a l l y . The instructions said to be prepared for vomiting. I don't think i t would have been of any benefit. If anything had happened I would have phoned the hospital or the doctor. 1 sort of expected that .he would be sick. R: Was there anything that we could have done that would have helped you? Ms No, everything ran beautifully. I would never hesitate to take them ba&k. Rs Did you have any trouble arranging transportation? Ms No, not really. It worked out fine. 83 RESPONDENT §H I. Background; Name of the mother: Mrs. D. Marital status: married Name of the child: Cindy Age: 8 years Education: No record available Number of children: 1 Diagnosis; Dental carles Operation performed: Dental restoration Length of anaesthetic: 55 minutes Length of hospitalization: 5 hours Previous hospitalization: none Cindy was a foster child and had lived with Mr. and Mrs. D. since she was three years of age. She had cerebral palsy and her movements were quite spastic but she spoke clearly and was bright. Mrs. D. was extremely fond of her and was hoping to adopt her. II. Mother's participation In day care unit: A. Participation scale; participated Independently B. Precis of f i e l d notes: Mrs. D. sat beside Cindy's bed preoperatively and held her hand. She f e l t she should be with her as she understood her. She stayed for the entire period, C. Summary of concerns expressed while In unit; 1. The long preoperative waiting period in the unit. 2. The length of the operation. 3. The length of time Cindy would be the unit post-operatively. 84 INTERVIEW WITH MRS. D. Key: M • mother R » researcher R: When I last saw you In the day oare unit you were waiting for Cindy to come back. How did you manage? M; I just sat and waited. I walked around the plaee and watched the babies. When I got back the nurse said she'd Just come back. She was awake. The doctor came in and said she could go home so I phoned my husband,he came down and got us. I made up blankets on the chesterfield for her. She was feeling very sorry for herself, and wanted a lot of nursing. When I put her to bed she didn't settle down very well, she said her teeth hurt. The next day she had some soup for lunch. She wasn't sick at a l l . She sat on the chesterfield i n the after-noon and had a l i t t l e sleep. She went to school the next day. H: So the only d i f f i c u l t y Cindy had was that her mouth was sore? M: The discomfort went by the next day. R: Did you give her anything for i t ? M: No, I didn't have anything. R: How did you feel about the day care unit? Did you find you had things to do to help Cindy? Hi Yes, I went with the idea of being determined to stay. I was going to put up a fight. She needed someone with her. R; How did you find out about the unit? Mi From the dentist. Someone phoned me from the hospital and asked me If I wanted to leave her in overnight or bring her in the morning and take her home at night. They told me what time to bring her i n . I took her to her own doctor the day before for a physical examination to see i f she could take the anaesthetic. Day Care i s a good idea* Rl.i Do^you feel you could have received more explanations regarding day care? 85 MJ Ho, I don't think so but I would have liked to have seen the dentist. R: You never did get a ohanoe to see him? Ui No, I thought he might have come i n to see her. R: You would have liked to have asked him about Cindy's teeth? M: Yes. I think i t might be a good idea i f they warned you beforehand about needing two people to bring the child home. R: You didn't know? m No, X didn't. Ri Did you not receive the instructions in the mall? M: No, Just what X received when X was there. X overheard some of the other ladles talking about i t . X had no idea. Rt That was very unfortunate. Mi The forms may have gone to th© Children's Aid. Noon© thought to t e l l me about i t * The nurse could have mentioned i t when she phoned me the day before. R: What did you t e l l Cindy about coming into the hospital? Mi X told her she was going to have her teeth looked at and that they'd give her something to put her to sleep. I don't be-lieve in hiding things, sometimes i t comes as a shock. R: How did she respond? M; She didn't worry except for the fact that she couldn't have anything to eat. Cindy had a big bruise on her foot when she got home and what looked like a needle prick. R: Sometimes the doctor gives the children something intra-venously. That was probably what It was. M: Yes, X remember now. The l i t t l e boy in the next bed had the same thing. X heard his mother mention i t . R: How helpful were the instructions you received? M: They were fine. Xt only requires common sense. 86 RESPONDENT #5 I. Backgrounds Name of the mother: Mrs. E. Marital status: divorced Name of th© child: Rita Age: 3 years Education: no record available Number of children: 4 Diagnosis: Dental caries Operation performed: Dental restoration Length of anaesthetic: 7 0 min. Length of hospitalization:6 nr. Previous hospitalization: none The family lived i n New Westminster and Mrs. E. brought Rita by bus as she did not have a car. She was on social welfare. She planned to take Rita home on the bus but was advised to try to make other arrangements. She did arrange to have a friend pick them up as she did not have money for a taxi. Three of her children had been hospitalized. II. Mother's participation in day care unit: A. Participation scale: participated independently B. Preels of f i e l d notes: Mrs. E. participated independently In a l l the categories on the scale except for making arrangements for discharge. She needed help in this area. Rita became very upset following the premedication and fi n a l l y had to be given a rectal medication which quickly put her to sleep. Mrs. E. stayed for th© entire hospitali-zation period. C. Summary of concerns expressed while i n unit: 1. The effect of the premedication on Rita, who was crying and refused to take off her clothes. 2. Problem in arranging transportation home. 3. The early hour she had to get up. U, The long wait preoperatively. 5. Anxiety over her older daughter who might have rheumatic fever. 6. Upset over a comment made by one of the nurses that Rita was spoiled. 7. The length of time Rita would be in the operating room. Asked for Information about dental care. 88 INTERVIEW WITH MRS. E. Keys M * mother R « researcher M: Rita was fine. She Just kept drinking. I was afraid she would be sick on the way home. I would insist next time that she be put to sleep right away because of the reverse effect on the premedication. R: That period was the most upsetting one for you. M; The nurses thought she was having a tantrum but i t was the medicine. I had prepared her. R: What did you t e l l her? Ms I told her she was going into hospital and would be sleeping i n someone else's crib for the day and that the dentist would put her to sleep and f i x her teeth, because she s t i l l remembers a year ago when she was at Dr. T's and she had a bad experience. I told her that when she woke up and got dressed, we would bring her home. She knew I would be with her when she went to sleep and when she woke up. I had no trouble preparing her. She was looking forward to i t . I had no trouble waking her up at 6:15. R: She didn't want anything to eat or drink? M: No, mind you I only got her up 20 minutes before we l e f t , only time to get her dressed. She didn't have time to think about i t . I got the specimen. R: How did she respond when she got home? M: She was very pleased about her new teeth. She didn't appear to remember the experience. R: She appeared most upset about having to get undressed. Do you know what was i n her mind at that time? M: I think having strangers t e l l i n g her to take off her clothes gave her the impression they were going to take her away and keep her in bed. She saw a l i t t l e boy and g i r l come in, be put to bed, and then go out, without taking their parents with them and I think she was afraid she was going to be taken 89 away too. R: How was she when she same back to the unit? M: She was fine. She knew she would be going home. She seemed to remember what I had told her. R: You did have some d i f f i c u l t y arranging transportation that day. M: I thought I would take her home on the bus. I didn't think she would be sick and f e l t I could manage her which I did. I didn't realize they meant she had to go home by car. R: You received the instructions? Mi I didn't receive any Instructions. They were sent to the wrong address, so I didn't have a clue. The nurse phoned a couple of days before to ask me some questions and I told her I had not received the instructions. R: The nurse told you how to prepare her? M. No, nothing, except that I was not to give her anything after midnight, but I knew that. R: It was very fortunate that you were able to be with Rita. M: They sent me out for a few minutes but the nurse called me baek in because she couldn't handle her. She thought she would settle down but she didn't. R: I guess Rita thought you were leaving her? M: Yes, I had told her I would be staying. I told the nurse that but she said that sometimes they settle down without the parents, but she soon realized what I meant. R; How much did you do for Rita when she came back? Mi I gave her the drinks and completely took over, because she Is a l i t t l e wary of nurses. She i s going through a stage where she w i l l only take things from me. R: So i f you had not been there she would not have accepted any-thing from them? M: Ho, she wouldn't have taken the premedication either. R: Do you feel a v i s i t the day before by a nurse would be helpful to a mother? M: Yes, for a mother who had not had any experience but i t should be made at least a week before, In order to give some time to prepare the child. R: How did you manage when Rita got home? Ui Fine. She had a bowl of soup and some juice and went to bed. I got up In the night a couple of times to see i f she was alright. The night before she was keyed-up and didn't go to sleep for a long time. R: Do you feel a v i s i t the day following would be helpful to a mother? Ms Not for me because I have had so much experience with hospitals but for someone who had not had a child in hospital before, i t would be a good Idea. The phone c a l l from the hospital the next morning is a good idea. Some mother might be having a rough time and not know who to contact. Dootors often aren't in their offices u n t i l the afternoon. R: You found the waiting period quite long, didn't you? Ms I didn't realise we would have such a long wait. We arrived at 8 o'clock and were told she wasn't going to the operating room u n t i l 1 0 s 3 0 . I f e l t i t was too long a wait for a l i t t l e child, especially when she had nothing to eat. If they had told me 1 0 : 3 0 you wouldn't have seen me un t i l 9 : 3 0 . I had 111/2 hours with nothing to do, trying to keep her amused. I wouldn't do i t again. I thought the nurses did a wonderful job. I was real pleased. It was just that one hour of frustration. 91 RESPONDENT §B I. Background; Name of the mother: Mrs. F. Marital status: married Name of the child: Jeoffrey Age: 7 years Education: No record available Diagnosis; Bilateral Secretory O t i t i s Media Operation performed: Bilateral Myringotomy with tubes Length of anaesthetic: 10 minutes Length of hospitalization: 5 hours Previous hospitalization: Jeoffrey had been hospitalized twice. 1. tonsillectomy, myringotomy and tubes 2. adenomectomy, myringotomy and tubes II. Mother's participation In day care unit: A. Participation scale: participated independently B. Precis of f i e l d notes: Mrs. F. achieved the highest rating on the scale. She brought a big bag of toys for Jeoffrey and something for herself to do while she was waiting for him to come back. She stayed for the entire period and sat beside his bed, playing with him and ex-plaining what was happening. C. Summary of concerns expressed while i n unit: 1. Worried about the operation. It was the third such operation in three years. 2. Wanted to know when Jeoffrey was going to the operating room so she could plan when to go to lunch. She wanted to be present when he went up. 92 INTERVIEW WITH MRS. P. Key: M » mother R » researcher Rs You mentioned last week the fact that there was quite a difference between the new unit and the f a c i l i t i e s for day care last year when Jeoffrey was in . What do you see as the advantages of the new unit? M: It i s a lot easier on the kids. There i s a difference i n the colour of the room, the floor, the beds. It Is a much happier atmosphere. R: Did Jeoffrey remember his last experience in hospital? M: He remembers going into hospital, but not afterwards. A l l he remembered was that he couldn't eat and that he was sick. R: Was he sick this time? Mi No, not at a l l . He came home and ate, Rs Jeoffrey has been in hospital twice before. Is there anything about i t that frightens him? M: No, A l l he worried about was not being able to eat and then he remembered being sick. Rs How did you prepare him? M: I don't believe in t e l l i n g him too much in advance. I told him the night before at supper time he was going in to have his ears fixed. R: How did you manage when you brought him home? Ms He was tired and went to bed early. He got up the next morning and was fine. He wanted to know why his ears were wet, but i t was just a l i t t l e b i t of blood. R: When did he go back to school? M: I sent him back i n the afternoon, R: Was there anything we could have done that would have helped you? M: No, I don't think so. I probably had more questions last time. Everything worked out very well. 93 RESPONDENT #7 I. Background: Name of the mother: Mrs. 0. Marital status: married Name of the child: Rlchy Age: 6 years Education; No record available Number of children: 2 Diagnosis: Possible Urethral Obstruction Operation performed: Cystoscopy, Fyelogram and Meatotomy Length of anaesthetic: 5 minutes Length of hospitalization: 3 1/2 hours Previous hospitalization: Rlchy had been hospitalized for a tonsillectomy. Mrs. 0. had been hospitalized herself a few times so had some idea of hospitals In terms of her own experience, particularly injections, whioh she feared. Rlchy had a history of urgency and frequently wet the bed at night. This was beginning to upset him, particularly when he had an acci-dent at school, which had happened a few times* II. Mother's participation in day oare unit: A. Participation scale: participated with help B. Precis of f i e l d notes: Mrs. Q. stayed with Rlchy for the entire period. She participated i n some of the nursing activ i t i e s but was more of an observer. C. Summary of concerns expressed while In unit: 1. Was Rlchy going to have a needle? 2. Wanted to know how long he would be i n the unit post-operatively . 3. Wanted to know what the doctor was planning to do. 4. Was worried about Rlchy's bladder problem. 5. Wanted to know i f he would have any d i f f i c u l t y voiding at home. 94 INTERVIEW WITH MRS. 0. Key: M =» mother R « researcher R: Richy asked about getting a needle. Has he had one before? Ms He had a hypo when he had his tonsils out and complained that his behind was sore, and kept saying the needle was s t i l l there. R: When did he have his tonsils out? M: When he was three or four. Rs Did he remember anything else about the hospital? Ms He wanted to know i f he was going to get ice cream and j e l l y . What worried him most was that he would get another needle. He probably gets i t from me, as I am petrified of needles. Rs I am very pleased that he did not receive one in the unit. Did he know what the doctor was going to do? Ms I told hisa they had to put him to sleep and find out i f there was a problem up there. I didn't want to t e l l him too much and scare him. I f e l t i n a spot as X didn't know exactly how much to t e l l hint and wasn't exactly too sure of what he planned to do. As far as I knew they were going to put a light up Into the kidney and take a boo around. (An explanation of the C and P procedure was given) Ms Rlchy has had only one accident since he came home, but that was because he wasn't feeling well and I didn't wake hira up and take him to the bathroom. I hope the operation did the trick. The Doetor said the opening was narrow. He had a stitch on the end of his penis. R: I guess the doetor dilated the opening, and just put a stitch i n the area* Did he have any pain at all ? Ms A l i t t l e discomfort. It hurt him when he passed his water. I was mean the f i r s t time and ran water so he just had to go. He held i t for quite a while because i t stung each time he tried. 95 R: If he had experienced d i f f i c u l t y going, what would you have done? Ms I would have f i n a l l y put him in a tub of warm water* R: Yes, that i s a very good idea* We w i l l have to make a point of letting the mothers know about It* Dr. J. suggests this i f the mothers phon® him for advice. It should be included i n the teaching. Were the instructions you received quit® clear? M: I had been In hospital several times myself. I had no d i f f i -culties. R: How did you find out about day care? M: Prom Dr. J. The only thing I specified was that I didn't want to take him home u n t i l he had passed his water without d i f f i -culty. I hadn't had any sleep the night before. I was so tired that day. I figured Rlchy would be tired and would sleep when he got horn®. R; I bet that didn't happen* He was so wide awake and active. Mj He lay on the chesterfield but chatted constantly so I couldn't sleep. He was quite keyed-up. M: You f e l t quite comfortable about bringing him home as long as he could void. M*. Yes. There is nothing worse than bringing a child home from hospital figuring everything i s fine then finding out you have a very sick youngster on your hands. You're not a nurse and not sure of what to do. It makes you feel sick. When you phone the doctor a l l he says i s to give the child a couple of aspirins. R; If anything had happened you would have preferred It i f Rlchy had stayed In overnight? M: Yes, but I think i t i s a wonderful idea. R; Did you have any d i f f i c u l t y arranging transportation? M: I got a taxi home. I thought I was going to be there a lot longer than I was. My husband was going to pick us up but I decided we might just as well come home. R: Would you have f e l t more comfortable i f you knew someone from the hospital was going to phone you the evening of surgery to see i f everything was alright? 96 Ms Yes, I think i t would he a good idea, either someone from the hospital or the doctor himself, to find out i f there were any problems. This ahould be done around supper time because the drug stores are s t i l l open i f a prescription i s needed, and i t i s not too late for someone to come to the house. A nurse could advise the mother or phone the doetor. R: You had a question "regarding whether or not you could put Richy i n the bath because he had a stitch and a nurse could have advised you. Ms Richy was quite taken with the stitch. He thought i t was a hair and tried to p u l l i t off. That was the f i r s t I knew of It . Rs I didn't realize i t either. I guess we didn't prepare him for that. Ms Richy i s very modest. When I told him i t was a stitch he said, "how about that!" 97 RESPONDENT 8& X. Background: Nam* of the mother: Mrs. II. Marital status: married Name of the child: Corey Age: 7 months Education: Grade 12 Number of children; 2 Diagnosis: Query congenital cataracts Operation performed: Eye examination under anaesthetic Length of anaesthetic: 15 minutes Length of hospitalization; 4 hours Previous hospitalization: none Mr. and Mrs. H. brought both of their children Into the unit for an eye examination. Mrs. H. looked after Corey and Mr. H. looked after 2 1/2 year old Darren. Mrs. H. had previous experience with hospitalized children. She had participated actively i n looking after Darren when he was hospitalized the year before for failure to thrive. IX. Mother's participation in day care unit: A. Participation scale: participated independently B. Precis of f i e l d notes: Mrs. H. held Corey preoperatively and helped the nurs© give him his preoperative injection. Postoperatively she did everything for him such as, holding, feeding and changing him. C. Summary of concerns expressed while In unit: 1. Wanted to know how long Corey would be in the operating room. 2. Anxiety over the results of the examination. 3. Wanted to see the doctor regarding the examination. 4. Found the preoperative period very confusing* 98 INTERVIEW WITH MRS. H. Keys M « mother R «• researcher R: Did your husband arrange to have the day off work ao he eould help you with the two children? Hi He doaided to take the day off because we didn't know what to expect. We didn't know I f they would be able to see after X put the drops In their eyes, se he deeided to core® and help me. R: How did you find out about the day care unit? Mi I had read about i t in the paper, but i t was the doctor who arranged i t . Hi Did you have any problems with their eyes when you got them home? Ms Darren had d i f f i c u l t y with his balance and they were both bothered by the light because their eyes were s t i l l dilated* R? You put drops i n their eyes before they went to the hospital? Mt Yes, I started the night before and in the morning. It didn't take that long but I didn't know what i t would be like* R: That was very wlae, deciding that both of you would take the children i n . M: Yes, i t would have been a handful. We had Darren i n hospital before. I eouldn't see leaving them and coming baek later. R: Darren was i n hospital before? Ms He was i n for three weeks when he was 16 months old, for failure to thrive. He was a very small baby. A l l they con-cluded was that he had gotten so active that he was not eating enough and that was why he was losing weight. Rs How did he respond to this separation from you? M: We had to leave him crying the f i r s t time* After a couple of days when we l e f t him he knew we would be coming baek the next day. Mind you, I spent a l l day at the hospital. Rs You helped with his care? Hi I pretty well looked after him. Most of his tei t s were In the aomlng. R: I am sure that made a lot of difference. When he came home did you notice any d i f f i c u l t y with his eating or sleeping? M: Ho, but he came home exhausted. He was on dally weight and the night staff woke him at six each morning to weigh him. He wasn't used to waking up un t i l 9 o'clock, and then he Just had one nap after lunch and then was up again at 1:30. When he got home he was so tired for the f i r s t week, I phoned the doctor. R: You appeared very much at home in the day care unit. I wondered i f you had previous experience in hospital. Ui I think day care i s ideal. I did wonder about the anaesthetic, and how they would be following the examination. R: Did you find the instructions you received In th® mail satis-factory? M: I phoned in . I had one question and that was how to get a urine specimen from an 8 month old baby. She told me not to worry about It . R: You asked at one point how long the children would be upstairs. Were you thinking of leaving and coming back later? M: At no time did we really consider leaving unless they were going to be in the unit unti l supper time. We certainly wanted to be there when they came back. 100 RESPONDENT #9 I. Background: Name of the mother: Mrs. I. Marital status; married Name of the c h i l d : John Age 2 years Education: 12 years In school Number of children: 2 Diagnosis: B i l a t e r a l Secretory O t i t i s Media Operation performed: B i l a t e r a l Myringotomy with tubes Length of anaesthetio: 10 minutes Length of h o s p i t a l i z a t i o n : 4 hours Previous h o s p i t a l i z a t i o n : John had been hospitalised three times. 1. ear i n f e c t i o n 2. ear i n f e c t i o n and possible meningitis 3. asthma Mrs. I. was a very quiet woman. She mentioned John had developed some fear of hospitals and nurses and had been spoiled when he was In hosp i t a l l a s t time. I I . Mother's p a r t i c i p a t i o n In day care u n i t : A. P a r t i c i p a t i o n scale; p a r t i c i p a t e d with help B. Precis of f i e l d notes: Mrs. I. stayed with John f o r the entire period. She needed help In a s s i s t i n g with his care but with d i r e c t i o n coped quite well. C. Summary of concerns expressed while In un i t : 1. Wanted to know i f John's ears would oontlnue to drain postoperatively. 2. Worried that John would develop an ear ache. 3. Worried about John's recurring ear problems. 4. Worried that John's younger brother would not l e t him rest when he got home. 5. John's di e t postoperatively. 101 INTERVIEW WITH MRS. I. Key: M » mother R » researcher R; How did you manage with John? M: I had to c a l l the doctor. His l e f t ear is s t i l l draining. The doctor said there was some i r r i t a t i o n there. I've been putting some drops in i t . R: How i s his hearing? M: I think his hearing i s better. R: How did you find the day care unit? MJ It's really nice. When John was In hospital before I didn't know what was happening and he couldn't t e l l me. R: When John was In hospital before s how did he respond when he got home? M: When John went in the f i r s t time, the nurses had carried him around a lot and when we got him home he was hard to handle. The next time he was in he was in Isolation and the nurses l e f t him alone. The last time he had asthma and when we got him home he was just terrible, hitting his brother and Just being a brat. They really spoiled him. He wouldn't sleep in the afternoon anymore. R: Yes, I remember, you mentioned that last week. Did you have any d i f f i c u l t i e s preparing him this time? You received the instructions in the mall? M: I didn't get any. I didn't t e l l John he was coming i n . He knew when we arrived and I started taking off his clothes. R: You knew what to do as far as preparation was concerned, such as nothing to eat? M: Yes. R: You did you feel about being i n the unit with John? M: It was nice being right there with him. How did you manage when you got home? M: He wouldn't sleep. He wanted to eat so I gave him some soup. He was very tired but he wouldn't sleep. 102 R: You were worried about ear pain, because John was holding his ear. Did he have an ear ache? Ms No, he was fine. I did give him a couple aspirins. R: When did you phone the doctor? Ui The next day as his ear was running quite heavily and he said to bring him In to see him. X was to clean It with peroxide. He said i t was quite natural for i t to drain. R: He must have had quite a lot of pressure in his ear before surgery. M: It used to break about once a week. The doctor said that was why he wanted to put the tubes i n . Last October his ear was running and he developed a high fever. I took him to the hospital and they thought he had meningitis. He was i n iso-lation for a week. Rs That must have been very hard on him. Do you feel a v i s i t by a nurse from th© day eare unit a week or so before surgery would be beneficial? She could explain the routines to you. Ms I think s*©. When the nurse phoned the day before and I asked her If I should stay or leave him. She said to leave hlra and they would phone. I didn't know about the unit so didn't know X could stay. Rs So when you arrived you were not prepared to stay? M: Ho. R: It was fortunate you were able to stay because your mother was here to look after Jason. Since John had been in hospital so much he would be so much more comfortable having you with him. Would you have f e l t more comfortable i f you had known someone from the hospital was going to phone you that evening to ask you about John? Mt Yes. The phone c a l l the next day was a good idea. R: If you hadn't been able to reach the doctor would you have phoned the hospital? Mt Yes, I would have. If he had been sick I would have phoned. I don't think the nurses would have known what to do about his ear. The doctor knows more about i t and the pattern i t takes. Rs You would prefer to phone the doctor? Mt Yes. 103 RESPONDENT #10 I. Background s Nam© of the mother: Mrs. J. Marital status: married Name of the child: Jim Age: 6 years Education: No record available Number of children: 2 Diagnosis; Urethral Stenosis Operation performed: Cystoscopy and Pyelogram Length of anaesthetic: 10 minutes Length of hospitalization: 3 hours Previous hospitalization; Jim had been hospitalized once before. Reasons unknown. II. Mother's participation in day care unit: A . Participation scale: participated with help B. Precis of f i e l d notes: Mrs. J. appeared at home i n the unit and appeared interested i n i t . Once she was shown what to do and It was explained to her, she participated well. She sat beside Jim's bed and played with him. While he was up in the O.R. she spoke with the other mothers. C. Summary of concerns expressed while in unit: 1. Wanted to know how long Jim would be i n the operating room. 2. Concerned about his voiding postoperatively, 3. Jim's postoperative diet. 104 INTERVIEW WITH MRS. J. Key: M « mother R « researcher M: I thought having the mothers participate was excellent, but sending the child home after an examination like that i s not too good. I think they should stay in for 24 to 48 hours to make sure they are fine because of what happened to Jiia. I understand most of them are fine, Is that right? R: Some of the boys have had some pain on voiding but your Jim had more than the normal degree of d i f f i c u l t y . M: He had very severe pain. He did go the f i r s t day, three times but after that he refused to void. It meant another t r i p to the hospital to be catheterized and then the next day we went through the same performance but we did get him to go f i n a l l y in the evening, but each time i t was a 24 hour span, Just the limit. It Is so painful for him he just screeches. It's Just awful. Rj Is i t any better today? Ms Slightly, but i t Is s t i l l painful. Today Is the f i r s t time he's gone before 7 o'clock. Rs You put him in the bath? Ms I watch him. He doubles over and I know i t i s time to try. I Just pick him up and put him in the warm bath. You almost need two people, one to get the water ready and one to manage him as he's so against i t at the time. He refuses to co-operate. So I feel he would have been better in hospital for 2 days, although It would have upset him more. He would have had less discomfort as we didn't know what to do at the time. We couldn't cope with i t . It meant calls to the doctor, bothering him. Rs So each day i t Just got worse? Ms Yes. We thought each day i t would get better. R: You phoned Dr. J. when a l l this d i f f i c u l t y started? M: Yes, but we couldn't reach him. I couldn't get anyone, so we phoned the hospital as a last resort and they said to bring him in immediately and they would look at him. The next day I got Dr. J. and he told us what to do. Mot being able to reach the doctor was upsetting. If Jim had been in hospital they would have known what to do. It was really frustrating, R: I am sure you were quite upset, not knowing what to do. Ms The idea behind day care la good but they are going to have to limit itfhat they do. R; You mentioned on the phone yesterday something about your family doctor's feeling about the experience. Ms He's never been enthusiastic about It because he feels the procedure Is quit© uncomfortable and It doesn't hurt to have the children under observation for awhile, for 2 days at least. R; When you took him back to the hospital would you have preferred i t If he had stayed in? Ms Yes, but at th® time I thought It would get better. They sort of indicated i t would but how would you know, they didn't. He was so happy at the time and glad to be home. Rs Jim i s the f i r s t child who has experienced this degree of d i f f i c u l t y since the unit opened last October, but we w i l l have to look out for i t . Ms I would never consent to i t being done on day care again. He would have to be admitted. R: Would a v i s i t from a nurse the day following the examination have helped you? Ms Yes, I couldn't roach anyone and she could probably have contacted a doctor. The hospital didn't phone u n t i l Monday. 106 RESPONDENT #11 I. Background: Nam© of th© mother* Mrs, K. Marital statue: married Hase of the child: Christine Ager a years Educations II© reeord available Number of ohildren t 1 Diagnosis: Urethal Stenosis Operation performed i Cystoscopy and Pyelogram Length of anaesthetic; 15 minutes Length of hospitalisation: 3 hours Previous hospitalisation: none Mrs. K. was expecting a baby nest month. She had worked so Christine was used to being l e f t with a baby s i t t e r . IX. Mother's participation in day ©are unit. A. Participation scales participated with help B. Precis of f i e l d notes? Mrs. K. stayed with Christine for the entire period. She helped look after her by playing with her, holding her on her knee and by taking her t© the bathroom. She participated well with direction• C. Summary ©f concerns expressed while i n unit* 1. Wanted to know how long Christine would be i n the operating room. 2. Christine's diet postoperatively. 107 INTERVIEW WITH MRS. K. Key: M « mother R « researcher R: Could you give me your Impression of the day eare unit? M: I thought i t was very nioe. I was surprised, as I thought i t would be Just like a regular hospital* They have so much there for th® kids, just like a nursery school. Christine didn't Bdnd i t at a l l . R: How would you have f e l t I f you had had to leave her In hospital? M: I wouldn't have liked having to leave her* She probably would have been alright but kids often get frightened of the hospital. R: Did you have any d i f f i c u l t y preparing her? M: Ho. We just got up and got ready to go, then woke her up and took her* She didn't ask for breakfast which i s unusual, but i t was dark outside. R: You received the instructions i n the mall and were prepared to stay? M: Yes, but I didn't think we would be home so fast. We were only there a couple of hours. I was very pleased with i t . I thought i t would be more unpleasant for her than It was. The environ-ment was so nice. R: Was she asleep when she went up to the operating room? M: She was drowsy. I went up with her to the door of the operating room and she looked In the door ana I Just walked away. She didn't cry. R: She has been separated from you before? M: I worked for a few months so she i s used to being away from me. She has never been away overnight. The thought did cross my mind that she might have to stay i n hospital overnight for some reason and then with the baby arriving soon, I did worry a l i t t l e . She would just get home and then I would be going away. R: You had a l i t t l e d i f f i c u l t y with her voiding when she got home? 108 Ms That day and again the nest morning she didn't want to go but when ah® did go she said, "that didn't hurt," She was afraid It would hurt. R: You mentioned on the phone you had put her hands i n water to help her go. Ms That was my husband's Idea. We tried i t the evening of th® surgery. She played with the bowl of water and we sat her on her potty. She couldn't hold It back so she went. That was the only way X think we could have got her to go. R: How did you manage with her diet? n: She wanted to eat right away and she was fine. X didn't want to give her too much but sho was hungry* She at© like a horse and the next day was back to normal, R; She was very wide awake when she came back to the unit. M: The only effect she seemed to have was that her legs were a bit shaky. R: You were able to arrange transportation? M: X had no d i f f i c u l t y with that. R: Would you have been reassured i f you had known someone was going to phone you the evening of surgery? Ms No, X wasn't worried at a l l . Rt If she had experienced d i f f i c u l t y in voiding who would you have called? Mt X don't know, probably Dr. J. or the hospital. Rs Do you have any suggestions for improvement i n the unit? Ms Ho. X had planned on being there for the whole day. Dr. J's nurse had phoned me and said X would be there for the whole day so X was surprised to be home so early. 109 RESPONDENT #12 I. Background; Nam® of the mother: Mrs. L. Marital status: married Name of the child: Nancy Age: 8 years Education: No record available Number of children: 3 Diagnosis: Dental Carlos Operation performed: Tooth Extraction and F i l l i n g s Length of anaesthetic: 2 hours Length of hospitalization: 8 hours Previous hospitalization: none Mrs. L. was Italian and needed some help in f i l l i n g out the various forms. Nancy was very unhappy when she arrived i n the unit and started to cry. She thought the dentist was going to hurt her. Mrs. L. tried to reassure her that she would be asleep and not feel anything. II. Mother's participation in day care units A. Participation scales participated with help B. Precis of f i e l d notess Mrs. L. stayed with Nancy for about an hour preoperatlvely but as the schools had closed that morning unexpectedly, she had to go home and arrange for someone to look after her children. She planned to come back as soon as possible. While she was there she com-forted Nancy and sat beside her bed trying to amuse her. She appeared worried about leaving her alone. C. Summary of concerns expressed while In units 1. Worried about the children at home. 2. Wanted to know when Nancy would be going to the operating room. 3. The long preoperative waiting period. 4. Wanted to know when Nancy would be ready to go home. 110 INTERVIEW WITH MRS. L. Key: M « mother R *» researcher R: When Nancy arrived in the hospital she seemed quite upset. Ms She came home from school the day before crying. She i s afraid of the dentist. R: She had not been in hospital before? M: No, never. She was so upset at the dentist's when she went for a check-up that he decided to bring her in and f i x them a l l at once. R: Once she was settled in the unit she was fine. Ms I went back to see her at 4:30 p.m. and she was s t i l l half-asleep. She wanted.to rest a l i t t l e more. She was sick a couple of times. R: Was she sick when she got home? M: No, she had something to drink and slept right through the night. R: Did she t e l l you anything about i t ? Was It as bad as she had thought i t wa3 going to be? M: She was really surprised when she woke up and found a l l her teeth were fixed. She said she didn't feel anything. R: After you l e f t she was very good. She didn't cry any more. Ms She wasn't frightened then? R: No. She was very good. She Just needed to get used to what was happening. Was she afraid of the d r i l l ? Ms Yes, i t was the d r i l l . She didn't like i t , but she was really happy to have her teeth fixed, R: Did she have any pain? Ms Yes, for about a week, but she didn't complain about i t too much. Rs You had some d i f f i c u l t y making arrangements for the children that day, didn't you? Ms Yes. The next door neighbour iboked after them for me. I phoned my husband and asked him to come and pick us up on his I l l way home from work, but when he came she wasn't ready so he came home and had supper with the children, then came back to get us. R: You stayed with her. M: Yes. She kept saying she wanted to go home. R: Did you have any questions regarding her preparation? M: No*v There wasn't anything I was wondering about. The only thing was that she was so scared. 112 RESPONDENT #13 I. Background; Name of the mother: Mrs. M. Marital status: married Name of the child: Mark Age: 9 years Education: 12 years Number of children: 2 Diagnosis: Meatal Stenosis Operation performed: Cystoscopy. Pyelogram and Meatotomy Length of anaesthetic: 15 minutes Length of hospitalization: 4 hours Previous hospitalization: Mark had been hospitalized twice. Reasons unknown. Mrs. M. had a full-time job. She had arranged to take the day off so she could come in with Mark. Mr. M. accompanied her and decided to stay when he found out Mark would not be i n hospital very long. XX. Mother's participation In day care unit: A. Participation scale: participated with help B. Precis of f i e l d notes: Mrs. M. assisted the nurses i n caring for Mark. She needed to be given cues. She sat beside his bed but did not entertain him. At one point she was going to join her husband who was s i t t i n g just outside the unit, but Mark asked her to stay with him. When he went to the bathroom he said the meatus was bleeding but when i t was cheeked, It just looked red. This was explained to Mark and Mrs. L. He seemed to understand. C. Summary of concerns expressed while In unit: 1. Wanted to see the doctor regarding the operation* 2* Wanted to know i f Mark could play soocer the next day. 3* Wanted to know when Mark could go home* 4. Worried about the redness around the meatus* 5. Worried about Mark's dysuria postoperatively. 113 INTERVIEW WITH MRS. M. Key: M « mother R » researcher R: How did you find out about the day care unit? Mj Through Dr. J. Did he explain i t to you? M: No. he didn't t e l l me anything. I had never heard of i t . R: Did you find the Instructions you received in the mail clear? Hi They were very clear. R; You had to arrange to have the day off work? Ms Yes, but everything was Just straight forward. R: How did you prepare Mark? Ms We told him he was going in and that he would be home the same afternoon, but a l l he was worried about was missing "hot dog day at school" and his favourite cartoon on TV. R: Did you find the time long at a l l while you were there? Ms We went out and had a cup of coffee and when we came back Mark had returned so we didn't s i t there very long. It isn't too comfortable a place to s i t for long. R: Mark wanted you to be with him, didn't he? M: He wanted to have us there. It's a big thing i n their lives. They don't very often have an operation. R: Did Mark have any d i f f i c u l t y voiding? Ms The same day he complained but after that i t didn't hurt anymore. What he honestly did think was that i t wasn't the same one. He thought he had a new one transplanted there. He asked sue i f i t was his old one. Rs He thought he had a new penis? Ms He thought i t was a different end at least. It was a transplant. R: I thought he understood but you never can be sure what children are thinking. Ms He was quite serious about i t . R; He had been voiding fine since then? His stream i s normal? Ms Yes, everything Is fine. Rs He was very eager to go home. Did you have any d i f f i c u l t y keeping him quiet? Mi He stayed In the house but he played around. I told him no climbing, etc., but he wouldn't have If I hadn't seared him a l i t t l e . R: I remember he was so eager to play soccer th® next day. It was fortunate the game was cancelled. Ms Before we knew It was cancelled I had told him he wouldn't be able to play and he was almost in tears. I spoke to the doctor the next day and he said no sports for a couple of days. Then Mark accepted i t . 115 RESPONDENT #14 I. Background; Name of the mother: Mrs. N. Marital status: married Name of the child: Sharon Age: 5 years Education: 12 years Number of children: 2 Diagnosis: Dental carles Operation performed: Dental Restoration Length of anaesthetic: 2 hours Length of hospitalisation: 11 hours Previous hospitalisation; Sharon had been hospitalised once before for an "appendix" infection. Mr. and Mrs. K. brought Sharon into hospital, with Casey who was 2 1/2 years of age. It was too early i n the morning to leave hiro with a neighbour. When Sharon's O.R. time was delayed, they decided to go home as they had been up at 6 o'clock and did not have time for breakfast. They drove i n from Surrey. Mr. N. was not feeling well and wanted to go home to bed. II. Mother's participation In day care unit: A. Participation scale: participated with help B. Precis of f i e l d notes: Mrs. N. stayed with Sharon post-operatively. She assisted with her care and responded well to suggestions. Sharon became rather talkative and active following her premedication and kept Mrs. N. busy finding toys for her. Mrs. N. sat beside her bed and read to her. Mrs. N. stayed with her u n t i l 10?30 and Sharon f i n a l l y went to the operating room at 11:30, 4 1/2 hours after being admitted to the unit. C. Summary of concerns expressed In unit: 1. The long preoperative waiting period In the unit. 2. Worried about Casey who was with them and who hadn't had any breakfast. 3. Concerned about not being able to obtain a urine specimen from Sharon at home. Worried about ber husband who was not feeling well. 117 INTERVIEW WITH MRS. N. Key: M » mother R » researcher R: How has Sharon been? The last time I saw her she was s t i l l waiting to go up. M: She was fine. She was sick in the car on the way home. She played when she got home and was fine the next day. I kept her home from kindergarten. R: She must have been quite thirsty as she hadn't had anything to drink for a long time. M: I just gave her a l i t t l e b i t at a time and she kept i t down. R: How did she sleep that night? Ms Fine. She did have a tooth ache before we l e f t and I thought perhaps i t might bother her again, but i t didn't. I was really impressed with the day care unit, th© way i t was decorated. Sharon was so Impressed too, a l l the toys. It helped t© take her mind off I t . R: How did you prepare her? Ms I told her everything. I told her about having her finger pricked which she didn't have done, but i t was on the sheet. She didn't have a needle. They aren't using them any more? R: She had the oral medication which i s being used more now. Ms What did they give her upstairs? (An explanation of the anaesthetic procedure was given) Ms She had a l i t t l e prick on her heel. Sharon thought they had given her a needle there* Rs They may have taken some blood for a hemoglobin while she was asleep. It was good that you had explained i t t© her. Has she been i n hospital before? Ms She was i n for 3 nights for an infection around her appendix. She didn't like i t , she complained about i t the whole time. She was in just before Christmas. She was in — - — — hospital. It was so different from the day care unit* We weren't allowed near the cribs without a smock on. It didn't have the 118 decor. The only toys they had were the ones you brought for them. They were not allowed out of the crib or to stand on their feet* A l l the time w® were there i t was a session of s i t down* s i t down* R: You mentioned something about the toys last week. Ms In the other hospital X asked i f X could bring i n some toys and they said i t was my responsibility. X didn't mind i f they got l o s t . It was just their attitude about i t * If X asked them a question i t was as i f X was questioning them* That was my f i r s t experience with having my children i n hospital. Th© nurses In the day eare untl didn't seem to mind what werwere saying. X talked to them a l l the time X was i n there. X wish they had something like that out here. The only thing Sharon was worried about was that she might have to stay i n overnight. Rs Your husband wasn't feeling very well that day* Ms Mo, he lay down in the afternoon. We weren't quite sure when to come back. X phoned a couple of times and we f i n a l l y l e f t here at five. Rs You didn't know about the unit then u n t i l you arrived? Ms Ho, X didn't know i t was a speelal unit. Rs Was there anything that would have made i t easier for you? Ms X don't understand why we had to be there so early. We were supposed to be there at 7:30 and she wasn't to have her medicine u n t i l 9s00. Everything they had to do they did In about 15 minutes. She was getting so tired waiting to go up. We just sat there after we f i l l e d out the forms. We had to wait when we arrived back because the doctor who had to sign her out was having dinner, but that was okay. (An explanation of the reason for the ear|ry a r r i v a l time was given) Ms The time was fine, X Just couldn't understand why we had to s i t there so long. An hour ahead would have been fine. I was afraid she would get bored. 119 RESPONDENT #15 Background; Name of the mother: Mrs. 0. Marital status: married Name of the c h i l d : Michael Age: 2 years Education: 12 years Number of children: 1 Diagnosis: Dental Carles Operation performed: Dental Restoration Length of anaesthetic; 1 hour Length of h o s p i t a l i z a t i o n : 1 hour Previous h o s p i t a l i z a t i o n : none Mother's p a r t i c i p a t i o n i n day care unit: A. P a r t i c i p a t i o n scale; participated with help B. Precis of f i e l d notes: Mrs. 0. stayed f o r the entir e time. She stayed with Michael and helped care f o r him. She managed very well with help. He reacted to the premedi-cation and became quite over-active and d i f f i c u l t to manage. He wanted to be car r i e d around but was too heavy f o r Mrs. 0. She went to the operating room with him and asked I f she could stay with him but the nurse said i t would be better i f she didn't. While she was waiting f o r him to come back, she talked with the other mothers. Postoperatively she looked aft e r him. C. Summary of oonoerns expressed while i n u n i t : 1. Wanted to know what would happen i f Michael wasn't asleep when he went up to the operating room. 2. Wanted to know how long he would be upstairs. 3. Concerned about Michael's teeth. 4. Conoerned about his t o i l e t t r a i n i n g . 120 INTERVIEW WITH MRS. 0. Key: M » mother R = researcher R: How did you feel about Michael's experience in the day care unit? M: It wasn't an upsetting experience, except for the period before he went up. R: He seemed to become upset following the medication. I was wondering i f he was having visual problems. M: He was fine u n t i l he took i t . It seemd to take hold of him and he began to lose his balance. He couldn't figure out what was happening to hiia. He had a scratch on his head where he hit i t on the side of the bed. That was the only thing that bothered him. It wasn't an upsetting experience for him, he enjoyed i t . R: Even holding him didn't help. M: He Just couldn't understand, R: At any time did you feel you were having d i f f i c u l t y handling him? M: I was almost wishing the anaesthetic had knocked him out immediately. It seemed to drag on. He was fine after and when he came home he had a b a l l . R: Did you have any d i f f i c u l t y keeping him quiet? M: He played, I didn't restrict him. He f e l t fine. R: You mentioned on the phone that he had developed some hoarseness. M; I noticed i t In the afternoon and then during the night i t got worse. He had quite a cough. R: It could have been caused by the intubation tube that was used to administer the anaesthetic. (an explanation of the administration of the anaesthetic was given) R: He's eating well/? Ms Yes, he's been fine. I thought the day oare unit was wonderful. I didn't know about i t . (An explanation of day oare followed) 121 M; I think It i s wonderful especially for children up to the age 4 or 5. When they get to be four or five you oan start ex-plaining things to them. I wouldn't have Michael stay over-night. I would have found some way to have his teeth fixed. It would have really upset him to stay in a strange place overnight. At this age the thought of someone going i n and never coming back really bothers them. R: Did you have any d i f f i c u l t y preparing Michael? Ms It was a bit early. I couldn't believe we had to be there so early. We came from West Vancouver. I had a rest that after-noon. The nurses were a l l very nice. They were so different from some of the ones in th® doctors' offices. 122 RESPONDENT #16 I. Background; Maine of the mother; Mrs. P. Marital status: married Name of the c h i l d : Donald Age: $ years Education: 16 years Number of children: 2 Diagnosis: Old Crush Injury - t i p r i g h t middle finger Operation performed: Change of Dressing r i g h t middle finge r Length of anaesthetic; 10 minutes Length of h o s p i t a l i z a t i o n ; 4 1/2 hour© Previous h o s p i t a l i z a t i o n : Donald had three h o s p i t a l i z a t i o n s . 1. Observation 2. Tonsillectomy 3. Appendectomy Mr. and Mrs. P. accompanied Donald. They o r i g i n a l l y planned to stay only u n t i l he went to the operating room. Mrs. P. seemed torn between wanting to stay with Donald and going home with her husband. Mrs. P. had been a school teacher. I I . Mother's p a r t i c i p a t i o n i n day care u n i t : A. P a r t i c i p a t i o n scale: p a r t i c i p a t e d with help B. Precis of f i e l d notes: Mrs. P. decided to stay for the entire period as the dootor had said he would see her following surgery. She stated she was pleased she had as Donald recovered quickly from the anaesthetic. Mr. P. went home. Dr. M. did come and see her. She seemed more relaxed once she decided to stay. She sat beside Donald's bed, kept him company, and gave him f l u i d s to drink. C. Summary of concerns expressed while In unit: 1. Wanted to know how long Donald would be i n the operating room. 2. Anxious to see the doctor. 3. Concerned about keeping Donald's dressing clean at home. 123 INTERVIEW WITH MRS. P. Key: M => mother R « researcher R: Donald has been in hospital before? M: He had bis tonsils out when he was six and was in when he was a baby for observation. He was one of these children who hold their breath when they hurt themselves. I really think he fainted. He never did i t out of anger but only when he was hurt. When he's i l l he's prone to faint. I've been like that a l l of my l i f e . A lot of people have this problem. He had a ruptured appendix in Venice last year. That was an experience. Donny's one of these children. He broke two bones In his hand last spring. He's very quick in his move-ments, just like this business where he hurt his hand. He went out the door and the next thing we knew his finger had been l e f t behind in the door. It's Just his quickness. He doesn't stop and think before he does something. R: What did he think about going into the day care unit to have his dressing changed? M: He didn't say too much. He was glad to be able to come home the same day. He wasn't very concerned when I told him he was going to be admitted to hospital. He asked i f he was going to be staying in overnight. He knew why he was going i n and said he would much rather be asleep when the bandage came off, so he was quite happy to be going. R: There was some confusion last week as to whether you would be staying or going home, wasn't there? M: We had thought Donny would be an hour or so up in the recovery room so we thought we would come home and have a cup of coffee and then go back, but as i t happened I'm glad we didn't as Denny was only 1/2 hour up there and I did see the dootor as soon as he came out of the operating room. If i t ' s going to be a long procedure I can't see any point in waiting i f there i s something else that can he done at home. My husband thought he would go home and phone the office and see i f there was anything special. Rt It was very d i f f i c u l t to predict how long i t would take as we Weren't certain of what was going to be done. You mentioned that Dr. M. might do a graft and that of course, would have taken longer. M: We were surprised as B i l l got into the car and went a l l the way back to the office after we had seen the doctor only to find out I wanted him right back again to take Donny home. We thought i t would be 3 or 4 o'clock i n the afternoon before we could take him home. R: Did someone say i t would be about that time? M: Yes. Some of the children seemed to be much sleepier than oth-srs. Sonny was older and he was more interested i n looking at things around him and this may have been the difference. I wondered about the parents who came in and l e f t their l i t t l e g i r l alone. She was so upset. They brought her and went away. Perhaps they had to go to work, I don't know what these people do. I know some people feel the children w i l l settle without their parents. When Donny was in with tonsils, I stayed part of the time with him. They don't encourage I t . Sometimes, for some children, i t ' s better that they get over the I n i t i a l crying stage, get accustomed to where they are and to the people around them and then the parents can come back and get them. It seems to calm them down rather than mothers and fathers going in and out a l l of the time and children screaming when they leave. R: Some parents need help In how to deal with this situation, such as how to leave the child. Mt In the majority of cases, especially for something like t h i s , i t i s better to have the parents with them. It was wonderfully quiet and pleasant really. Imagine what i t would have been like i f a l l those parents had l e f t . It would have been fan-tas t i c , and a l l the work for the nurses. Do any of the other hospitals have units like this one? (An explanation of day care units was given) 125 Another thing too, I'm a l l In favour of saving the taxpayer's money. It saves time and effort and i t Is much more pleasant for the child and parents. The child could get upset and harm himself. I think i t ' s a super idea. I'm a l l in favour. 126 RESPONDENT #17 I. Background: Name of th© mother: Mrs. Q. Marital status: married Name of the child: Lisa Age: 4 years Education: 10 years Number of children: 2 Diagnosis: Dental Caries Operation performed: Dental Restoration Length of anaesthetic: 2 hours Length of hospitalisation; 7 hours Previous hospitalization: Lisa had been hospitalized once before for a squint repair and stayed i n for only one night. I I . Mother's participation in day care unit: A. Participation scale: participated with help B. Precis of f i e l d notes: Mr. and Mrs. Q. stayed with Lisa. It was Mr. Q's day off and they brought Jeoffrey, their 18 month old son along as they did not know how long they would be staying* While Lisa was in the operating room, they went out for breakfast and did some shopping. Lisa developed a eroupy cough postoperatively so had to remain in the unit an extra hour for observation. She vomited Just before she went home, which further delayed her discharge time. Mrs. Q. sat beside her bed and held her hand. She appeared apprehensive when Lisa developed the cough, and seemed relieved that she would be staying a while longer. C. Summary of concerns expressed while in unit: 1. Wanted to know how long Lisa would be in the unit postoperatively. 2. Worried about the cause of Lisa's cough. 3* Worried about the effects of the anaesthetic. 127 INTERVIEW WITH MRS. Q. Keys M » mother R * researcher R; Lisa was in hospital before for an eye operation? M: She just want in for the one night. She didn't make a fuss at a l l . She was on the eye ward. R: When you had her i n last week was there any time at a l l that you found frustrating? M: No, not really. With Joeffrey having to wait i t was a bit hard. I liked the idea of bringing her home right away and not having to leave her i n . Rs When I last saw Lisa she had just vomited and was s i t t i n g on your knee. M: She went to sleep after that and when she woke up she f e l t ...Jfre.tty good, so we brought her home. She started to come to l i f e around 4 o'clock. She stayed awake for a long time. M: Did her mouth hurt her at al l ? Ms Yes. She said i t hurt her when we brought her home so I gave her an aspirin. Of course, she wanted to eat so we gave her anything she wanted and she was fine. She didn't have any more vomiting. R: It must have been quite confusing for you when Dr. D. said she could go home and you got her dressed and then he decided she should stay. Ms When she started to oough like that I thought "Oh, am I going to get her home?" Rs I thought you appeared apprehensive at that point. She did have a 2 hour anaesthetic and perhaps did need a longer period to recover, M: When she had her eye operation we went up to get her about 6 o'clock at night and she was s t i l l sleeping. We got her awake and dressed and brought her home but she was s t i l l awfully sleepy. I wondered i f that was a good idea. She got over i t a l l right. 128 R: I am sure you would be concerned following a long anaesthetic, wondering i f she would be a l l right. Ms It didn't really bother me. Once she was sick and had a sleep, she f e l t good. I knew I could phone to the doctor i f I had to. Rs Your husband was good with Lisa and seemed very understanding. Ms Dr. 3. had said we would be bringing her home the same day. I think i t bothers me more than her If I have to leaverher In. I liked i t . Rs If i t hadn't been your husband's day off would he have been able to make arrangements to be off? Ui I think he could have changed his day off. Rs Did you have any d i f f i c u l t i e s getting everyone ready in the morning? M: That was the hard part, trying to get there on time. We were late. I had to get the baby ready and then get Lisa up and dressed and she wouldn't go to the bathroom so I couldn't get a specimen. She was quite cranky. Once we got them dressed i t wasn't too bad. The only thing was they wanted us there at 7 o'clock and i t was so hard, Rs What did you t e l l Lisa about coming in? Ms W® told her she was going into the hospital to have her teeth fixed, and that she would be asleep. We've always told her the truth. I was surprised when she cried. She was so good the f i r s t time. R: Perhaps she wasn't too sure of what was going to happen but the fact that you were with her certainly helped. Was there anything we could have done that would have helped you? Ms Ho, everything was very good. 129 RESPONDENT #18 I. Background: Name of the mother: Mrs. R. Marital status: separated Name of the child: Linda Age: 2 years Education 9 years Number of children: 1 Diagnosis: Rectal Bleeding and Fusion of Labia Operation performed: Sigmoidoscopy and Repair of Labia Length of anaesthetic: 15 minutes Length of hospitalisation: 9 hours Previous hospitalization: none Mrs. R. was recently separated from her husband and was liv i n g with Linda in a couple of rooms in a house, but was not happy there. She was on social welfare and appeared tense and worried. II. Mother's participation in day care unit: A. Participation scale; participated with help B. Precis of f i e l d notes: Mrs. R. stayed with Linda pre-operatively. Sh® was up early and did not have any breakfast. She helped the nurse give Linda her pre-operative medication, which made her overactive and d i f f i c u l t to manage. Mrs. R. needed help In looking after her. Linda was carried to the operating room as she would not l i e down on the bed. Mrs. R. was rather tense and said she could not stay in the unit as she had an appointment with the social worker to pick up her cheque. As she was rather upset, no attempts were made to ask her to wait for Linda. G. Summary of concerns expressed while In unit: 1. Wanted to know when Linda would be ready to go home. 2. Concerned about the effect of the premedication. 3. Upset over personal problems. 130 INTERVIEW WITH MRS. R. The Interview was not taped due to the fact that Mr. R. was present. Mrs. Armstrong stated she would have preferred having Linda spend the f i r s t night i n hospital. She f e l t she would have received better care by "professionals". She sfefited she was afraid of th© effects of the anaesthetic. Later in the interview she mentioned she was allergic to many things and was afraid Linda might "react to" the anaesthetic. She stated she was concerned that Linda was s t i l l awake when she went to the operating room and thought the oral premedication was the anaesthetic and that she would be awake during the operation. When she went past the operating room door she saw the staff holding Linda down and she was s t i l l crying. I explained the anaesthetic to her. She said she would have appreciated knowing about the anaesthetic at the time. She mentioned the long wait — 2 1/2 hours, before Linda went to the OR and wondered why It was so long, "th© children get bordd". She said she was afraid she might not be able to amuse Linda and that she would become d i f f i c u l t to manage. She then asked me i f Linda had a "bad effect" from the premedication (she had become overactive). I explained the expected reaction and tried to explain the effect It had on Linda, She did have problems i n the application of the ointment which was prescribed by the doctor postoperatively. There was a discrepancy between the instructions she had received from the nurse In the unit and what the doctor explained to her a couple of days later. She found the ointment very d i f f i c u l t to apply and said i t took 2-3 people to do i t as Linda cried and struggled. She f e l t the doctor's method was much simpler. She stated she would have stayed with Linda and would have liked to have been present when she returned from the O.R. but had been told by the nurse i n the doctor's office that Linda would not be back into the unit u n t i l 3-4 o'clock and not be ready to go home un t i l 6-7 p,», at night. (She returned to th© unit by 131 11:30 a,sn, and would have been ready to go home by about 2 p.m.) Based upon the information she had received she had made other plans for the afternoon. She mentioned other problems she was experiencing with Linda, .,. her poor appetite and frequency with voiding. She stated the surgery had not improved the problem with frequency and the cause of the rectal bleeding had not been determined. She f e l t something was "bothering Linda" as she was not sleeping or eating well. Due to the fact that her husband was present, i t was not possible to discuss the effect the separation might be having on Linda, i n terms of i t s effect on her behaviour. 132 RESPONDENT #19 I. Background: Nam© of the mother: Mrs. S. Mar i t a l status: married Name of the c h i l d : Diane Age: 1 year Education 12 years Number of children: 1 Diagnosis: Vaginal Fusion Operation performed: Repair of Vagina Length of anaesthetic: 15 minutes Length of h o s p i t a l i s a t i o n : k hours Previous h o s p i t a l i z a t i o n : none Mrs. S. had done volunteer work at a children's h o s p i t a l when she was attending high school. She had also been a nursery school teacher and enjoyed i t very much. She was a b a l l e t dancer and s t i l l danced professionally a couple of times a week. Diane was l e f t with a neighbour on these occasions. She was very aware of current trends In c h i l d behaviour. II. Mother's p a r t i c i p a t i o n i n day eare unit: A. P a r t i c i p a t i o n scale: p a r t i c i p a t e d with help B. Precis of f i e l d notes: Mrs. S. stayed tfith Diane u n t i l she went up to the operating room. She helped the nurse give the premedication, played with her and changed her diaper. Diane stood up and cr i e d when being wheeled out of the room, so Mrs. S. was asked to accompany her to the operating room. She held her hand and spoke q u i e t l y to her. Diane stopped struggling and s e t t l e d down. Mrs. S. said she had some errands to do so would return i n about 1 1/2 hours. C. Summary of concerns expressed while In unit; 1. Wanted to know how long Diane would be i n the operating room. 2. Wanted to know when she would be ready to go home. 133 INTERVIEW WITH MRS. S. Key: M « mother R ° researcher R; How did you find out about the day care unit? M: My niece was i n about three weeks ago for the same thing. I didn't go to the hospital knowing about the day care unit, I only knew that Diane had to go i n . My niece vomited at home and had to go back in, so I didn't know what to expect with Diane. I thought maybe she would have trouble. That after-noon she didn't even sleep, she was up playing. R: You were concerned then about the affects of the anaesthetic? M: Yes, I wondered, because of my niece. I also wondered i f Diane had been put under because she had no reaction to i t . She was a l i t t l e wobbly for about an hour. R: She had a short anaesthetic. M: Did they put the gas mask on her? (An explanation of the anaesthetic procedure was given) M: My husband wasn't too happy about her going i n , but we knew i t was necessary. He asked me i f they had put her out. He s t i l l wondered. When I spoke to the doctor the other day he said they had put her out. The day care unit It s e l f i s fabulous. I thought i t was very well organized and the nurses were very helpful, no problem at a l l . The whole concept of this type of hospitalization for children Is good. Having the mother there relieves both the child of worries and helps the nurses too. They don't have rto worry about each child, i f i t ' s Just a minor thing. R: Diane was very good. The only time, she cried was when she went to the operating room and then stopped when you went along with her. M: She has been very attached to me but has been going to a baby s i t t e r , which has helped her, R: She was very good when she came back. She did ask for you but didn't cry. One of the nurses picked her up and fed her. 134 M: I'm very glad, because I was worried about her attachment to me. My husband couldn't even hold her u n t i l she was about 9 months. (An explanation of Infant attachment was given) M: The whole day was very nice. The room i t s e l f was so nice, with the bright carpet. R: Would you repeat the experience again i f i t was necessary? Ms Yes, I think I would ask for i t . How long has It been open? (An explanation of the day care &nit was given) M» One of the nurses mentioned they took turns in the unit. I was thinking after, that i t might be easier i f people were there definitely for that purpose. R: Yes, a regular nursing staff i s a good Idea. What kind of instructions did you receive about bringing Diane into the unit? M: The doctor didn't t e l l me anything. I thought she would be in u n t i l suppertime. I was prepared for the whole day. The hospital phoned the day before and said she was to come in the next day. That's the thing my husband didn't l i k e . She was a l l ready in bed by the time I knew she was to have a urine specimen. I know they have to wait u n t i l the last minute to make sure they have enough beds. He f e l t we could have been told a l i t t l e earlier. R; You didn't receive any printed Instructions in the mall? MJ NO. I'm the kind of person who doesn't get upset, I Just wait to see what happens. It's quite interesting. They phoned my husband at work because I was out and told him what to do. But i t was really fun, I enjoyed i t . R: Diane was fine when she got home? Mi Yes. She slept in the car going home, ate supper and went to bed. She was fine. R: Did you receive any instructions about treating the area? Mt I phoned the doctor's office the next day and the nurse said there was nothing to do. When I took her into the office a few days later, he said to put vaseline on her. R: She didn't complain of any pain? Mi It didn't bother her at a l l . R: Everything worked out well then? Boy, they've got my 100 per cent. 136 RESPONDENT #20 I. Background; Name of the mother: Mrs. T. Name of the child: Andrew Education: Grade 12 Marital status: divorced Age: 2 1/2 years Number of children: 2 - twins Diagnosis: Umbilical Hernia Operation performed: Repair of Umbilical Hernia Length of anaesthetic: 20 minutes Length of hospitalization: 6 hours Previous hospitalization: Andrew had been hospitalized once before when he f e l l and developed a hematoma. Andrew was a twin. His sister had just recently been hospitalized after f a l l i n g out a second storey window, suffering a ruptured spleen. She was very i l l and had developed a fear of hospitals, nurses and doctors. Both children were on tranquilizers. Although Andrew was basi-cally a quiet child, he became very excitable when around his sister. Mrs. T. lived in an apartment in a low rental housing development In Vancouver. II. Mother's participation In day care unit: A. Participation scale: participated with help B. Precis of f i e l d notes; Mrs. T. stayed with Andrew u n t i l he went to the operating room. She played with him In the room u n t i l he was given his premedication. Following this, he was put to bed. Mrs. T. tended to over-excite him as she entertained him, however, he was very happy and experienced no untoward effects from the premedi-cation. She l e f t as soon as he went to the operating room, as she was having babysitting problems. She planned to return around 3 o'clock. C. Summary of concerns expressed while In unit; 137 Wanted to know the kind of bandage Andrew would have on his abdomen. Concerned about the number of times her ohildren had been In hospital during the past few months. 138 INTERVIEW WITH MRS. T. The interview was not taped. Mrs. Simmons said she had no d i f f i c u l t i e s In preparing Andrew for the hospital. The instructions she received were adequate. She was concerned about bringing him home so soon. (He was discharged at 2;30 p.m.) as she had been requested to keep him quiet but found that Impossible because of the presence of his twin sister. She f e l t he was too overactive in the afternoon. She said she would have f e l t better If she had been able to bring him home after supper. This would have been better for Andrew as he would have had a quieter environment in the hospital. She said she f e l t apprehensive in the car on the way home and suddenly wondered what she would do i f "something went wrong". In response to the question, "What did you think might happen?" she said, "I don't really know." She then explained Melanie's hospitalization in another hospital and said that twice she was to have brought her home, and both times a complication developed. Melanie was hospitalised for 30 days and when she came home she was no longer t o i l e t trained and Ignored her when she talked to her — She frequently says "I can't!" when asked to do something. She expected things to be done for her. Andrew had been hospitalized for a hematoma about 6 months ago and was in for 3 days. I asked her how she had prepared Andrew and she said she told him "the truth". Everything she told him was correct except for the bandage. She told him he would have one but he didn't and this disappointed him. She liked the idea of day care. She also discussed the problem of l i v i n g i n a small apartment with 2 children, the d i f f i c u l t i e s she was experiencing i n disciplining them and the fact that she had been advised by the public health nurs© to consider going to work. She really didn't want to right now, but was considering taking a Laboratory Technician's course in a ©ouple of years' time. She said she wanted to talk about this with someone — a stranger. APPENDIX C PARTICIPATION SCALE AND INTERVIEW GUIDE APPENDIX C PARTICIPATION SCALE NAME Indepen-dently With Help Did Not Stayed with c h i l d Assisted nurse with care taking temperature taking B.P. giving medication giving f l u i d s taking c h i l d to bathroom Comfort measures held c h i l d ' s hand held c h i l d on lap brought favourite object from home washed ch i l d ' s face Played with c h i l d brought toys from home gave c h i l d toys from room Undressed & dressed c h i l d D i s c i p l i n e d c h i l d Made arrangements for discharge 141 The Interview Guide The interviews with the mothers included the gathering of data on the following topics. 1. The mother's perception of the day care unit. 2. The reaction of the child to the experience and comparison with previous hospital experiences* 3* The preparation period at home and any d i f f i c u l t i e s this may have created. 4. The condition of the child at home following surgery. This included any problems the child experienced, what actions the mother took and who she called for help. 5. The mother's knowledge of the day care unit and i t s purpose. 6. Her opinion as to the need for a pre and post hos-p i t a l v i s i t by a nurse and to the Idea of a telephone c a l l from the hospital the evening of surgery. 7* Confirmation of the opinion gained by observing the mother and child in the unit. 8. Any suggestions the mother had which would have made the experience easier for her. Time was provided for the mother to ask questions. APPENDIX D TABLES I II IV XIII XIV APPENDIX D TABLES TABLE I NUMBERS AND PERCENTAGES OP THE TYPES OP OPERATIONS PERFORMED AT THE DAY CARE UNIT BETWEEN OCTOBER 14, 1969 AND JANUARY 14, 1970 Type of operation Number of children Percentage of performed operated upon children operated upon Dental work 88 46.1 Myringotomy 25 13.1 P l a s t i c surgery 17 9.0 Cystoscopy & pyelograra 14 7.3 Examinations 8 4.2 Circumcision x 7 3.6 Hernia re p a i r 7 3.6 Nasal surgery 7 3.6 Change of cast 6 3.2 Squint 4 2,1 Minor ©ye surgery 2 1.0 Miscellaneous 6 3,2 Total 191 100.0 TABLE II NUMBERS AMD PERCENTAGES OF THE AGE OF THE TWENTY CHILDREN INCLUDED IN THE STUDY 8Age Number of children Percentage of children 1 and under 2 10.0 2 5 25.0 3 1 5.0 it 1 5.0 5 2 10.0 6 3 15.0 7 1 5.0 3 2 10.0 9 2 10.0 14 1 5.0 Total 20 100.0 9 rounded to the nearest year 145 TABLE IV NUMBERS AND PERCENTAGES OP THE PLACE OP RESIDENCE OF THE TWENTY MOTHERS INCLUDED IN THE STUDY City or Municipality Number of mothers Percentage of mothers Vancouver 13 65.0 North Vancouver 1 5.0 Burnaby 2 10.0 Coquitlam 1 5.0 Hew Westminster 1 5.0 Richmond 1 5.0 Surrey 1 5.0 Total 20 100.0 146 TABLE XIII TYPES OP COMPLICATIONS REPORTED BY THE TWENTY MOTHERS IN THE STUDY GROUP TO THE RESEARCHER EXPRESSED AS TO FREQUENCY AND PERCENTAGE Complication Frequency Percentage Postoperative complication 37.8 Dysuria 5 Sore mouth 4 22.2 Draining ears 3 16.7 Post anaesthetic complication 16.7 D i f f i c u l t y with balance 3 Vomiting 2 11.1 Croupy cough 1 5.5 T o t a l 18 100.0 147 TABLE XIV FREQUENCY AND PERCENTAGES OF COMPLICATIONS REPORTED BY 191 MOTHERS IN RESPONSE TO ROUTINE FOLLOW-UP TELEPHONE CALLS MADE BETWEEN OCTOBER 14, 1969 AND JANUARY 14, 1970 Complication Frequency Percentage Nausea and vomiting 16 69.5 Croupy cough 3 13.1 Bleeding 3 13.1 Voiding problem 1 4.3 Total 23 100.0 

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