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Effect of parental presence on the behaviour of the postoperative preschool age child in the pediatric… Brunke, Margaret Laurel 1989

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EFFECT OF PARENTAL PRESENCE ON THE BEHAVIOUR OF THE POSTOPERATIVE PRESCHOOL AGE CHILD IN THE PEDIATRIC RECOVERY ROOM By MARGARET LAUREL BRUNKE B.Sc.N., The University of Ottawa, 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1989 (c) Margaret Laurel Brunke, 1989 In presenting t h i s thesis i n p a r t i a l f u l f i l l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I further agree that permission f o r extensive copying of t h i s t h e s i s for scholarly purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Nursing The University of B r i t i s h Columbia Vancouver, Canada Date A p r i l 22. 1989 ABSTRACT EFFECT OF PARENTAL PRESENCE ON THE BEHAVIOUR OF THE POSTOPERATIVE PRESCHOOL AGE CHILD IN THE PEDIATRIC RECOVERY ROOM T h i s s t u d y e x a m i n e d t h e e f f e c t o f p a r e n t a l p r e s e n c e on t h e b e h a v i o u r o f t h e p o s t o p e r a t i v e p r e s c h o o l age c h i l d i n t h e p e d i a t r i c r e c o v e r y room. The i m m e d i a t e p o s t o p e r a t i v e p e r i o d has b e e n i d e n t i f i e d a s one o f t h e t h r e e most s t r e s s f u l p e r i o d s i n a c h i l d ' s h o s p i t a l i z a t i o n . A l t h o u g h i t h a s b e e n s u g g e s t e d t h a t p a r e n t a l p r e s e n c e d u r i n g p a i n f u l and s t r e s s f u l p r o c e d u r e s c a n r e d u c e a n x i e t y a n d i n f l u e n c e p a i n p e r c e p t i o n , r e v i e w o f t h e l i t e r a t u r e d e m o n s t r a t e d a s c a r c i t y o f r e s e a r c h t h a t d e s c r i b e s t h e e f f e c t s o f p a r e n t a l p r e s e n c e on c h i l d r e n ' s b e h a v i o u r i n a r e a s s u c h a s t h e r e c o v e r y room. T h i s s t u d y t h e r e f o r e c o n t r i b u t e s t o a c u r r e n t l y i n a d e q u a t e r e s e a r c h b a s e , and t h e r e b y e n h a n c e s t h e a b i l i t y o f h e a l t h c a r e p r o f e s s i o n a l s t o make o b j e c t i v e d e c i s i o n s r e g a r d i n g p a r e n t a l p r e s e n c e i n t h e p e d i a t r i c r e c o v e r y room. A q u a s i - e x p e r i m e n t a l d e s i g n was u s e d t o s t u d y two g r o u p s o f t e n c h i l d r e n b e t w e e n t h e a g e s o f t h r e e a n d s i x y e a r s i m m e d i a t e l y f o l l o w i n g s t r a b i s m u s r e p a i r . The b e h a v i o u r o f t e n c h i l d r e n a c c o m p a n i e d by p a r e n t s and t e n c h i l d r e n u n a c c o m p a n i e d by p a r e n t s i n t h e R e c o v e r y Room was r e c o r d e d on v i d e o t a p e w h i c h was t h e n a n a l y z e d f o r d u r a t i o n and f r e q u e n c y o f 2 6 i t e m s on a b e h a v i o u r a l c h e c k l i s t . D i f f e r e n c e s i n d u r a t i o n and f r e q u e n c y o f b e h a v i o u r s b e t w e e n t h e two g r o u p s were d e t e r m i n e d u s i n g K r u s k a l - W a l l i s one-way a n a l y s i s o f v a r i a n c e and o t h e r d e s c r i p t i v e a n a l y s e s . F i n d i n g s d e m o n s t r a t e d t h a t a l t h o u g h c h i l d r e n i n t h e two g r o u p s d i s p l a y e d t h e same b e h a v i o u r s , t h e d u r a t i o n and f r e q u e n c y of c e r t a i n behaviors varied s i g n i f i c a n t l y between groups. Children i n the parent-present group made more attempts to cope with the pain experience by crying and complaining with the apparent expectation that t h e i r parents would comfort them, whereas childre n i n the parent-absent group made more attempts to cope with the pain experience by t r y i n g to reduce the pain themselves through rubbing t h e i r eyes and protective behaviour. Thus, i t was concluded that the parent 1s presence i n the p e d i a t r i c recovery room provides the c h i l d with an important ad d i t i o n a l way of coping e f f e c t i v e l y with the experience, including pain. Implications f o r nursing p r a c t i c e and nursing research are described i n view of the research findings and recommendations are made regarding the process of implementing parental v i s i t i n g i n p e d i a t r i c recovery rooms. iv TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i CHAPTER ONE: Introduction 1 Background 2 Problem Statement 4 D e f i n i t i o n of Terras 6 Conceptual Framework 7 Assumptions 9 Summary 9 CHAPTER TWO: Review of Selected L i t e r a t u r e 11 De f i n i t i o n s of Pain and Pain Theory 11 Def i n i t i o n s of Pain 12 Pain Theories 14 Af f e c t Theory 14 S p e c i f i c i t y Theory 14 Pattern Theory 16 Gate Control Theory 18 E f f e c t s of H o s p i t a l i z a t i o n and Parental Separation 21 Studies of E f f e c t s of Maternal Separation 21 Studies of the E f f e c t s of Rooming-in on Children 24 Studies of the E f f e c t s of Parental Presence at Procedures 2 9 Parental Presence i n the Dental Operatory 3 0 Mother Presence During Routine Hospital Admission and Anesthetic Induction 3 4 Parental Presence at Immunization 3 7 Parental Presence i n the Pe d i a t r i c Recovery Room 3 9 V i s i t i n g i n the Recovery Room 41 Assessment of Pe d i a t r i c Pain 4 3 Assessment Problems 4 3 Assessment Tools 44 Pain and Anxiety 4 6 Summary 47 CHAPTER THREE: Methodology 50 Study Design 51 Selection of Study Group 52 Age 52 Surgical Procedure 53 V C r i t e r i a f o r S e l e c t i o n 54 S e l e c t i o n Procedure 55 I n s t r u c t i o n s t o Parents 58 S e t t i n g 59 P a t i e n t Management i n the OR and PARR 60 A n e s t h e t i c Management 60 Nu r s i n g Management 61 Data C o l l e c t i o n 63 Data A n a l y s i s 65 B e h a v i o u r a l C h e c k l i s t 65 Coding o f Videotapes 66 I n t e r - r a t e r R e l i a b i l i t y 67 S t a t i s t i c a l A n a l y s i s 67 E t h i c a l C o n s i d e r a t i o n s 70 Summary 71 CHAPTER FOUR: Research F i n d i n g s 73 Summary of Demographic Data 73 F i n d i n g s o f K r u s k a l - W a l l i s One-Way A n a l y s i s o f V a r i a n c e 74 Pare n t - P r e s e n t v e r s u s Parent-Absent group 76 Females v e r s u s Males 7 6 Females Parent-Present v e r s u s Females Parent-Absent 77 Males Parent-Present v e r s u s Males Parent-Absent 77 F i n d i n g s o f D e s c r i p t i v e Analyses 77 Parent-Present v e r s u s Parent-Absent 81 Females v e r s u s Males 82 Other F i n d i n g s 82 Summary 8 3 CHAPTER FIVE: D i s c u s s i o n and I m p l i c a t i o n s 8 5 L i m i t a t i o n s 85 D i s c u s s i o n o f F i n d i n g s 87 Body Movement 88 Non-verbal V o c a l i z a t i o n 91 F a c i a l E x p r e s s i o n 92 Reaching f o r Body Contact/Hugs 93 Being Held 93 P a i n Complaints 95 F l u i d s 97 Requests f o r Mother 98 M i s c e l l a n e o u s Complaints 99 R e f u s a l Behaviour 100 Response t o O f f e r o f P a i n M e d i c a t i o n 101 O b s e r v a t i o n s o f and by Parents 102 Ob s e r v a t i o n s o f Nursing P r a c t i c e 104 I m p l i c a t i o n s f o r Nursing P r a c t i c e 105 I m p l i c a t i o n s f o r Nursing Research 108 Summary 109 CHAPTER SIX: Summary and Recommendations 111 Summary 111 v i Recommendations 114 Recommendations for Nursing Practice and Education 114 Recommendations for Nursing Research 114 REFERENCES 116 APPENDICES 123 Appendix A: Physician Consent Form 123 Appendix B: Letter to Parents 124 Appendix C: Parent Consent Form 125 Appendix D: Data C o l l e c t i o n Sheet 126 Appendix E: Behavioural Checklist and De f i n i t i o n s of Behaviours 127 Appendix F: Behavioural Checklist 130 Appendix G: In-Hospital Research Review Committee Approval 131 Appendix H: Approval from University of B r i t i s h Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects 132 LIST OF TABLES Ta b l e 1 . Means of V a r i a b l e s by Group 2. Percentage D i f f e r e n c e Between Groups For Frequency (f) and D u r a t i o n (d) of Behaviours v i i i Acknowledgements As with many things, t h i s process began and ends with family with many others a s s i s t i n g along the way. F i r s t , thank you to my parents who taught me to value and encouraged me to achieve high standards i n everything I do. Guidance through the thes i s process was provided by my committee members, Jinny Hayes and Connie Cannam, with always the r i g h t balance of scholarly c r i t i c i s m , gentle pushes, encouragement, and humour. For t h i s , and f o r making the process e x c i t i n g and sometimes even fun, I o f f e r you my sincere thanks. Special thanks to Jinny for always being there when I needed you most. Thanks also go to the Nursing Department at B.C.'s Children's Hospital for the support I was given throughout my Master's studies. In p a r t i c u l a r , my thanks to Ann-Shirley Goodell, Jean Armitage, and the nursing s t a f f of the Recovery Room. F i n a l l y , as the process ends and t h i s thesis i s completed, I wish to acknowledge my husband David. Although he may say that he contributed l i t t l e to t h i s achievement, he has given me more than he can ever know and for t h i s I w i l l always thank him. 1 Chapter One INTRODUCTION This i s the report of a study which examined the e f f e c t s of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room. The immediate postoperative period has been i d e n t i f i e d as one of the three most s t r e s s f u l periods i n a c h i l d ' s h o s p i t a l i z a t i o n (Vernon, Foley, Sipowicz, & Schulman, 1965). Although i t has been shown that the presence of parents during p a i n f u l and s t r e s s f u l procedures can reduce anxiety and influence pain perception (Broome, 1985; Hawley, 1984; Savedra, 1981), decisions regarding parental presence during health care procedures seem to be based on anecdotal experience and the comfort l e v e l of the professionals involved (Hunsberger, Love, & Byrne, 1984). As a r e s u l t , some children are denied the benefit of t h e i r parents' presence during p a i n f u l and s t r e s s f u l procedures. In many si t u a t i o n s , i t i s the nurse who advocates on behalf of the c h i l d and/or parent to allow the parent to be present during a procedure. I t i s also true that i n c l i n i c a l areas where parents are not commonly permitted to be with t h e i r c h i l d , many nurses are unsure of what the e f f e c t s of parental presence might be on the c h i l d . Currently, there i s a s c a r c i t y of research that describes the e f f e c t s of parental presence on children's behaviour pre-, during, and post-procedure (Hunsberger et a l . , 1984) or that can be used to guide health care professionals i n decision-making about parental presence when a c h i l d faces a s t r e s s f u l and p a i n f u l procedure. The 2 p e d i a t r i c recovery room i s one area i n which research on the e f f e c t s of parental presence on children's behaviour i s li m i t e d . Therefore, t h i s study was designed to examine the behaviour of two groups of childr e n - postoperative preschool age children with parents i n the Recovery Room and postoperative preschool age c h i l d r e n without parents i n the Recovery Room. This chapter introduces the research by describing the background of the problem, explaining the framework guiding the research, and i d e n t i f y i n g the s p e c i f i c research questions addressed. Background In the agency i n which the study was conducted, uni t p o l i c y does not ro u t i n e l y permit parents to be with t h e i r c h i l d i n the Recovery Room. On several occasions however, parents had been allowed to v i s i t i n Recovery Room to comfort t h e i r c h i l d or a s s i s t the nurse i n assessing the c h i l d ' s pain more accurately. On these occasions, i t was noted that some children who were thought to be experiencing pain changed t h e i r behaviour once t h e i r parents were with them. Children who were r e s t l e s s , crying, and refusing to drink stopped crying, rested q u i e t l y on t h e i r parent's lap, and appeared to be more comfortable. As a r e s u l t of the change i n behaviour demonstrated when the c h i l d ' s parent came to the Recovery Room, some children did not receive analgesics which the nurse had previously decided to administer. From these observations, the question arose as to whether the c h i l d ' s i n i t i a l behaviour had been misinterpreted and i f so, what the i n i t i a l behaviours represented. 3 Behavioural cues are frequently used by nurses i n assessing a p e d i a t r i c patient's pain (Bradshaw & Zeanah, 1986). However, assessment of pain i n p e d i a t r i c patients i s recognized as being a d i f f i c u l t problem (Abu-Saad, 1984; Jeans, 1983a). In the recovery room sett i n g , assessment of behaviour i s complicated by a number of factors. Here the chi l d r e n awaken from a p a i n f u l s u r g i c a l procedure and discover they are i n an unfamiliar place and separated from t h e i r parents. The behaviour demonstrated by c h i l d r e n i n the post anesthetic recovery area may be due to emergence from anesthetic, fear and anxiety related to separation and an unknown environment, pain, or any combination of these factors. Sternbach (1968) stated that for the young c h i l d , the experience of the pain sensation i s t y p i c a l l y associated with anxiety and the pain a c h i l d f e e l s as a r e s u l t of separation i s as r e a l as physical pain and w i l l e l i c i t the same type of responses as physical pain. Health care professionals are constantly seeking ways i n which to improve care for p e d i a t r i c patients and reduce the stress which accompanies a c h i l d ' s h o s p i t a l i z a t i o n . I t i s well documented i n the l i t e r a t u r e that parental presence does decrease the h o s p i t a l i z e d c h i l d ' s anxiety (Bowlby, 1960; Broome, 1985; Hawley, 1984; Vernon, Foley, Sipowicz, & Schulman, 1965). Many p e d i a t r i c nurses believe that for the c h i l d exposed to an unfamiliar environment, the presence of a parent seems to minimize, though not eliminate, the anxiety and fear associated with an invasive procedure (Hunsberger et a l . , 1984). This study was designed to examine whether children who have t h e i r parents with them i n the Recovery Room demonstrate d i f f e r e n t 4 behaviours than c h i l d r e n whose parents are not with them. Problem Statement Pain and separation from parents are parts of almost every c h i l d ' s experience i n h o s p i t a l . These two factors may combine with other factors to make h o s p i t a l i z a t i o n a s t r e s s f u l and frightening experience for the c h i l d (Audette, 1974; Crocker, 1980; Godfrey, 1955; Gohsman & Yunck, 1979; Hunsberger et a l . , 1984; Vernon et a l . , 1965; V i s i n t a i n e r & Wolfer, 1975; Yarrow, 1964; Zurlinden, 1985). Extensive search of the l i t e r a t u r e by t h i s author produced only two studies which addressed the issue of parental presence i n the p e d i a t r i c recovery room, and each of these studies examined only the parents', not the c h i l d ' s , view of the experience. Based on the author's observations i n the c l i n i c a l setting, i t appears that having parents i n the p e d i a t r i c recovery room may accomplish three important goals: F i r s t , as separation anxiety probably increases the c h i l d ' s perception of pain, eliminating separation anxiety i n t h i s s i t u a t i o n may a l t e r the c h i l d ' s perception of pain. Second, i f the c h i l d does not experience the fear and anxiety associated with parental separation, the behaviours the c h i l d demonstrates are more l i k e l y to be due to pain than fear and anxiety. Third, the nurse's i n t e r p r e t a t i o n of the c h i l d ' s behaviour and the decision as to whether or not the c h i l d i s experiencing pain may be more accurate when the impact of separation anxiety on behaviour i s reduced. Accurate assessment of behaviour has important implications 5 f o r appropriate management of the c h i l d i n the p e d i a t r i c recovery room. This study explores the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the recovery room by addressing the following s p e c i f i c questions: 1 . Do childr e n who have t h e i r parents with them i n the recovery room display d i f f e r e n t behaviours than those whose parents are not with them? 2. What are the d i f f e r e n t behaviours displayed by children whose parents are with them and children whose parents are not with them? 3. Do childr e n who have t h e i r parents with them i n the recovery room display pain behaviour that i s d i f f e r e n t than that demonstrated by childr e n whose parents are not with them? The r e s u l t s of the research provides objective rather than anecdotal data which w i l l a s s i s t health care professionals i n making dispassionate decisions about whether parents should be permitted i n the p e d i a t r i c recovery room. In addition, the research w i l l add to the growing body of l i t e r a t u r e which focuses on the assessment of pain i n p e d i a t r i c patients. Accurate assessment of behaviour has important implications for appropriate management of pain. Inappropriate administration of analgesics i s one outcome of inaccurate assessment of behaviour. In the recovery room, although some children receive o r a l non-narcotic analgesics, many receive i n j e c t i o n s of narcotic analgesics. In the author's experience, narcotic analgesics s i g n i f i c a n t l y a f f e c t the length of the c h i l d ' s recovery time, f e e l i n g of well-being, and the length of stay i n h o s p i t a l for a 6 c h i l d admitted f o r day care surgery. An i n j e c t i o n i s a frightening experience for a l l children but p a r t i c u l a r l y for preschoolers who may perceive i t as punishment f o r something they have done wrong (Gildea & Quirk, 1977). Inappropriate use of narcotic analgesics and i n j e c t i o n s i s inconsistent with the goals of minimizing the stress associated with h o s p i t a l i z a t i o n and making h o s p i t a l i z a t i o n as p o s i t i v e an experience as possible. In the following section, selected terms are defined i n order to a s s i s t the reader to more f u l l y understand the research study. D e f i n i t i o n of Terms For the purpose of t h i s study, the following d e f i n i t i o n s apply: Recovery room: a s p e c i a l i z e d h o s p i t a l u n i t equipped for the purpose of managing immediate post-anesthetic patients. Preschool age c h i l d : a c h i l d between the ages of three and s i x years. Parent: the c h i l d ' s natural, adoptive, and/or fos t e r mother and/or father who have primary r e s p o n s i b i l i t y f o r the c h i l d ' s care. Analgesic: medication administered for the purpose of pain r e l i e f . Narcotic analgesic: analgesic of which the use i s c o n t r o l l e d by federal Controlled Drug Regulations. Administration may be by the intra-muscular, intravenous, or o r a l route. 7 Non-narcotic analgesic: analgesic of which the use i s not c o n t r o l l e d by federal Controlled Drug Regulations. Administration may be by the o r a l or r e c t a l route. Pain: "a complex psychophysiological phenomenon involving sensory, neurochemical, cognitive, a f f e c t i v e , and motivational components which i n t e r a c t to produce a behavioural response to t i s s u e damage or i r r i t a t i o n , and which may also be produced and maintained by other antecedent or consequent stimulus conditions" (Katz, Varni, & Jay, 1984, p. 165). Daycare surgery: surgery performed on the same day as admission to and discharge from h o s p i t a l . Strabismus repair: s u r g i c a l correction of squint. The following section explains the conceptual framework which directed t h i s study. Conceptual Framework Although the e a r l i e s t pain t h e o r i s t s viewed pain as a simple stimulus response phenomenon, pain i s now recognized as a complex phenomenon. In t h i s study, pain i s defined as "a complex psychophysiological phenomenon involving sensory, neurochemical, cognitive, a f f e c t i v e , and motivational components which i n t e r a c t to produce a behavioural response to t i s s u e damage or i r r i t a t i o n , and which may also be produced and maintained by other antecedent or consequent stimulus conditions" (Katz et a l . , 1984, p. 165). This d e f i n i t i o n was chosen as i t conveys a multidimensional approach to pain, including the behavioural component, and i s therefore more useful i n the p e d i a t r i c s e t t i n g than many of the most frequently 8 quoted d e f i n i t i o n s o f p a i n . T h i s d e f i n i t i o n r e c o g n i z e s p a i n as a complex phenomenon and as such, p a i n can be examined from many p e r s p e c t i v e s . In examining t h e . e f f e c t s of p a r e n t a l presence on the behaviour o f the p o s t o p e r a t i v e p r e s c h o o l age c h i l d i n the r e c o v e r y room, the author r e c o g n i z e d t h a t one of the most s i g n i f i c a n t f a c t o r s a f f e c t i n g t h i s behaviour c o u l d be the c h i l d ' s p a i n . I t was a l s o r e c o g n i z e d t h a t one of the most important f a c t o r s a f f e c t i n g the c h i l d ' s p a i n e x p e r i e n c e c o u l d be the c h i l d ' s f e a r and a n x i e t y . Thus, i t became e v i d e n t t h a t t h i s study c o u l d be approached from two p e r s p e c t i v e s - t h a t o f the p a i n t h e o r i s t and t h a t o f the b e h a v i o r i s t . In the author's p r e l i m i n a r y review of the l i t e r a t u r e , i t became c l e a r t h a t a l t h o u g h many p a i n t h e o r i s t s i n c o r p o r a t e d or c o n s i d e r e d b e h a v i o u r a l t h e o r y i n t h e i r work, the same was not t r u e of the b e h a v i o u r a l t h e o r i s t s . For t h i s reason, p a i n t h e o r y was chosen as the t h e o r e t i c a l framework f o r the study. More s p e c i f i c a l l y , the gate c o n t r o l t h e o r y of p a i n was s e l e c t e d as i t addresses the m u l t i d i m e n s i o n a l nature o f p a i n , t h a t i s , the sensory, neurochemical, c o g n i t i v e , a f f e c t i v e , and m o t i v a t i o n a l components which i n t e r a c t t o produce a b e h a v i o u r a l response. In order t o a s s i s t the reader, a review o f the gate c o n t r o l t h e o r y of p a i n i s p r o v i d e d i n Chapter 2. In u s i n g t h i s framework t o examine the ex p e r i e n c e o f the c h i l d i n the r e c o v e r y room, the p a i n e x p e r i e n c e can t h e r e f o r e be d e s c r i b e d as a combination o f the p h y s i c a l s e n s a t i o n s a s s o c i a t e d w i t h t h e p a i n s t i m u l u s and o f the emotional d i s t r e s s a s s o c i a t e d w i t h s e p a r a t i o n from p a r e n t s and f e a r of the unknown r e s u l t i n g 9 i n a behavioural response. Assumptions In t h i s research study, there are several underlying assumptions. Those that are important for the researcher to acknowledge and fo r the reader to be cognizant of are: There i s a ph y s i o l o g i c a l , psychological, and experi e n t i a l component to each c h i l d ' s pain experience. The pain experience i s d i f f e r e n t f or every c h i l d even when the s u r g i c a l experience i s the same. The c h i l d ' s pain i s evident through the behavioural response to the stimulus. "Pain i s interwoven with emotions such as fear, anger, loneliness, and anxiety, and thus some emotion beyond the pain i t s e l f may account for the behaviours observed" (Smith, 1976, p. 205) . The behaviour of children i n the recovery room i s affected by the presence or absence of t h e i r parents. Limitations of the study w i l l be addressed i n the discussion of the findings of the study. Summary The immediate postoperative period i s one of the three most s t r e s s f u l periods i n a c h i l d ' s h o s p i t a l i z a t i o n (Vernon et a l . , 1965). Thus, t h i s study addresses an area of importance i n the nursing management of the ho s p i t a l i z e d p e d i a t r i c patient that i s , the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room. The r e s u l t s of t h i s d e s c r i p t i v e study w i l l a s s i s t health professionals i n objective decision-making about whether parental v i s i t i n g should by permitted i n the p e d i a t r i c recovery room and w i l l encourage them to examine t h e i r agency's v i s i t i n g p o l i c i e s for other si t u a t i o n s from which parents are excluded. As well, the r e s u l t s of t h i s study add to the expanding body of l i t e r a t u r e on p e d i a t r i c pain assessment. P e d i a t r i c nurses w i l l be able to use the r e s u l t s of t h i s study to a s s i s t them i n making better decisions when deciding whether or not to give a c h i l d an analgesic i n the immediate post-operative period. This chapter has introduced the research study by describing the background of the problem, i d e n t i f y i n g the framework guiding the research, and s t a t i n g the s p e c i f i c research questions addressed. The next chapter provides a review of the l i t e r a t u r e relevant to the study. In the subsequent chapters, the methodology and findings of the study w i l l be addressed i n order to a s s i s t the reader to understand the f i n a l chapters i n which the implications of the findings and the author's recommendations w i l l be discussed. Chapter Two REVIEW OF SELECTED LITERATURE Currently, there i s a s c a r c i t y of l i t e r a t u r e which s p e c i f i c a l l y addresses the e f f e c t s of parental presence on the behaviour of chi l d r e n before, during, and a f t e r procedures. I t i s recognized, however, that pain and separation from parents are experienced by almost every c h i l d i n h o s p i t a l and these two factors can influence the h o s p i t a l i z e d c h i l d ' s behaviour. An i n i t i a l review of the l i t e r a t u r e revealed that there are currently no published studies which explored the e f f e c t s of parental presence on the behaviour of the postoperative p e d i a t r i c patient i n the recovery room. Therefore, i n order to place t h i s study within the e x i s t i n g knowledge i n the area, review of the l i t e r a t u r e focused on material which s p e c i f i c a l l y addressed p e d i a t r i c pain and the experience of h o s p i t a l i z a t i o n for p e d i a t r i c patients. However, i n order to explore potential r e l a t i o n s h i p s between the pain experience and the experience of h o s p i t a l i z a t i o n , the l i t e r a t u r e reviewed for t h i s report was expanded to include a review of pain theory. This chapter i s organized into four main sections: 1) pain theory, 2) e f f e c t s of h o s p i t a l i z a t i o n and parental separation on p e d i a t r i c patients, 3) e f f e c t s of parental presence at procedures on p e d i a t r i c patients, and 4) assessment of pain i n p e d i a t r i c patients. D e f i n i t i o n s of Pain and Pain Theory D e f i n i t i o n s of pain and pain theories have undergone considerable change since the phenomenon of pain was f i r s t 12 examined by A r i s t o t l e (Kim, 1980). In t h i s portion of the chapter, d e f i n i t i o n s of pain and pain theories w i l l be discussed i n order to provide the reader with a foundation for understanding the possible influence of the experience of h o s p i t a l i z a t i o n on the c h i l d ' s perception of pain. Def i n i t i o n s of Pain The word pain i s derived from the French peine and the Greek poine meaning penalty or f i n e (Funk & Wagnall's Standard  College Dictionary. 1978). These derivations of the word pain suggest that h i s t o r i c a l l y pain was viewed as punishment for wrongdoing. Modern d e f i n i t i o n s of pain r e f l e c t how d i f f e r e n t l y pain i s viewed with most d e f i n i t i o n s of pain now incorporating p h y s i o l o g i c a l , psychological, e x p e r i e n t i a l , and c u l t u r a l components. The d i f f i c u l t y i n defining pain i s evidenced by the varied d e f i n i t i o n s of pain which currently e x i s t . Kim (1980) defined pain as "an abstract construct which ref e r s to a personal, priva t e experience of hurt whose qu a l i t y and i n t e n s i t y are known to be s i g n i f i c a n t l y influenced by psychological and s o c i o c u l t u r a l v a r i a b l e s " (p. 44). This d e f i n i t i o n , derived from the work of Melzack and Sternbach (Kim, 1980), includes a subjective sensation component but does not address the neurophysiological component of the pain experience. Sternbach's own d e f i n i t i o n , which i s one of the most frequently quoted i n the pain l i t e r a t u r e , defines pain as "an abstract concept which ref e r s to (1) a personal, private sensation of hurt; (2) a harmful stimulus which signals current or impending t i s s u e damage; (3) a pattern of responses which operate to 13 protect the organism from harm" (1968, p. 12). This d e f i n i t i o n addresses the neurophysiological component of the pain experience but does not e x p l i c i t l y acknowledge the importance of i n d i v i d u a l differences i n the perception of pain. McCaffrey (1972) defines pain as "whatever the experiencing person says i t i s , e x i s t i n g whenever he says i t does" (p. 12). This d e f i n i t i o n i s s i m i l a r to Kim's i n that i t addresses only the subjective aspect of the pain experience. In an attempt to develop a u n i v e r s a l l y acceptable d e f i n i t i o n of pain, the International Association for the Study of Pain (1979) proposed the following: "an unpleasant sensory and emotional experience associated with actual or p o t e n t i a l t i s s u e damage, or described i n terms of such" (p. 250). This d e f i n i t i o n recognizes both the neurophysiological and subjective aspects of the pain experience. However, as i d e n t i f i e d by Stevens, Hunsberger, and Browne (1987), " i n the case of young children who often can neither describe nor say what and where ' i t ' i s , these d e f i n i t i o n s may not be appropriate or u s e f u l " (p. 154). Katz et a l . (1984) define pain as "a complex psychophysiological phenomenon involving sensory, neurochemical, cognitive, a f f e c t i v e , and motivational components which interact to produce a behavioural response to t i s s u e damage or i r r i t a t i o n , and which may also be produced and maintained by other antecedent or consequent stimulus conditions" (p. 165). This d e f i n i t i o n conveys a multidimensional approach to pain, including the behavioural component, and i s therefore more useful i n the p e d i a t r i c s e t t i n g . This i s the d e f i n i t i o n of pain which was used i n t h i s research study. 14 Just as d e f i n i t i o n s of pain have continued to evolve over time, so have theories of pain. The following review of pain theory examines the evolution of pain theories and at the same time, i l l u s t r a t e s the multidimensional aspects of pain. Pain Theories Pain theories are commonly categorized as belonging to one of four major orientations: a f f e c t , s p e c i f i c i t y , pattern, and gate c o n t r o l . A f f e c t theory A f f e c t theory dates back to the time of A r i s t o t l e who believed pain to be "a f e e l i n g that originated i n the skin (from excessive s t i m u l i ) , t r a v e l l e d to the heart v i a the blood, and was interpreted by the heart" (Bray, 1986, p. 672) and "the a n t i t h e s i s of pleasure" (Wolf, 1980, p. 12). A f f e c t theory characterized pain as an emotion, not a sensation, which coloured a l l sensory events (Kim, 1980). As we now know, one of the most s i g n i f i c a n t aspects of a pain experience i s the sensory experience. S p e c i f i c i t y theory S p e c i f i c i t y theory i s i d e n t i f i e d by several authors as the t r a d i t i o n a l theory of pain (Melzack, 1973; Munhart & McCaffrey, 1983; Wolf, 1980). This theory, which originated i n 1644 with Descartes' straight-through channel concept, described pain i n terms of a sensory response to a noxious stimulus. Descartes proposed that the noxious stimulus caused the stimulated area to v i b r a t e and p u l l d i r e c t l y upon d e l i c a t e threads which ended i n the brain. P u l l i n g on these threads i s likened to p u l l i n g on a b e l l cord, that i s , the cord i s pulled and the b e l l rings. The basis of Descartes* theory was the d i r e c t skin to brain l i n k which r e s u l t s i n the person f e e l i n g and responding to pain when the skin i s stimulated (Melzack, 1973). Descartes' view of s p e c i f i c i t y theory existed r e l a t i v e l y unchanged u n t i l the nineteenth century when i t was elaborated upon by Max Von Frey. Between 1894 and 1895, Von Frey published a serie s of a r t i c l e s i n which he proposed a theory of the cutaneous senses. He hypothesized that there are four modalities of cutaneous sensation, touch, warmth, cold, and pain, each having i t s own type of s p e c i f i c nerve ending (Melzack, 1973). Von Frey's work was extended by other s p e c i f i c i t y t h e o r i s t s to include peripheral nerve f i b r e s and spinal cord pain pathways. Thus, s p e c i f i c i t y theory i s based on the assumption that "there are s p e c i f i c pain receptors (free nerve endings), pain f i b r e s (A-del t a and C), and t r a c t s ( l a t e r a l spinothalamic) which project to the s p e c i f i c pain centers (thalamic n u c l e i ) . A c t i v i t y along t h i s pathway from periphery to centre r e s u l t s i n the sensation of and responses to pain" (Sternbach, 1968, p. 39). Melzack (1973) i d e n t i f i e d three underlying assumptions of s p e c i f i c i t y theory: p h y s i o l o g i c a l , anatomical, and psychological. These assumptions are: 1) The phy s i o l o g i c a l assumption that each of the four receptor types has one form of energy to which i t i s e s p e c i a l l y s e n s i t i v e . 2) The anatomical assumption that each of the four modalities of cutaneous sensation has i t s own receptor type and there i s a single morphologically s p e c i f i c receptor beneath each sensory spot on the skin. 3) The psychological assumption that there i s a d i r e c t connection between the receptor to a brain centre where pain i s f e l t which implies a d i r e c t , invariant r e l a t i o n s h i p between stimulus and sensation (Melzack & Wall, 1965; Melzack, 1973). Melzack and Wall (1965) i d e n t i f i e d the psychological assumption as the weakness of s p e c i f i c i t y theory. S p e c i f i c i t y theory does not explain why i n d i v i d u a l s experiencing the same pain stimulus respond i n d i f f e r e n t ways. In addition, i t does not explain phenomena such as phantom pain, hyperalgesia, and peripheral neuralgias. Despite these l i m i t a t i o n s , Sternbach stated as l a t e as 1968 that "currently the most orthodox view of pain i s the s p e c i f i c i t y theory" (p. 39). Pattern theory A number of theories evolved as a reaction against the psychological assumption i n s p e c i f i c i t y theory. These theories are grouped together under the general heading of pattern theory. H i s t o r i c a l l y pattern theory and s p e c i f i c i t y theory have been considered to be mutually exclusive as pattern theory opposes the idea that pain has i t s own s p e c i a l i z e d receptors (Melzack & Wall, 1965). Goldscheider, a pattern t h e o r i s t , was the f i r s t to suggest that stimulus i n t e n s i t y and central summation are the c r i t i c a l determinants of pain (Melzack & Wall, 1965). Goldscheider•s theory proposes that " p a r t i c u l a r patterns of nerve impulses that evoke pain are produced by the summation of the skin sensory input at the dorsal horn c e l l s " (Melzack, 1973, p. 140). According to t h i s theory, pain can r e s u l t when impulses from the c e l l s reach a c r i t i c a l l e v e l as a r e s u l t of excessive 17 stimulation of receptors by non-noxious s t i m u l i . Several theories, a l l of which recognize the concept of patterning of the input, have emerged from Goldscheider*s work. In 1943, Livingston proposed the central pattern summation theory i n which he suggested that pathological stimulation of sensory nerves i n i t i a t e s a c t i v i t y i n internuncial neuron pools i n the s p i n a l cord and sets up reverberating c i r c u i t s i n the s p i n a l cord. Once established, t r i g g e r i n g of these c i r c u i t s by normally non-noxious inputs can generate v o l l e y s of nerve impulses that are c e n t r a l l y interpreted as pain. Even i n the absence of touch, the abnormal a c t i v i t y may continue i n the c i r c u i t and pain may therefore continue i n the absence of peripheral s t i m u l i (Melzack, 1973; Munhart & McCaffrey, 1983; Wolf, 1980). Livingston's theory i s useful i n explaining phenomena such as phantom pain, causalgia, and neuralgia but does not explain why severing pathways i n the s p i n a l cord or thalamus may not r e l i e v e pain. In 1955, S i n c l a i r and Wendall described the peripheral pattern theory (Melzack, 1973). This theory proposes that a l l f i b r e endings, except those that innervate h a i r c e l l s , are a l i k e . Pain r e s u l t s from intense peripheral stimulation which produces a pattern of nerve impulses which are c e n t r a l l y interpreted as pain (Melzack, 1973; Wolf, 1980). Noordenbos's 1959 theory of a s p e c i a l i z e d input c o n t r o l l i n g system i s also derived from Goldscheider 1s (1894) o r i g i n a l concept. This theory suggests that there are two f i b r e systems f o r pain, a slow, small f i b r e conducting system which c a r r i e s the pain signals and a more rapid, large f i b r e conducting system 18 which i n h i b i t s synaptic transmission i n the slower system. Under pathological conditions, the slow system becomes dominant over the rapid system r e s u l t i n g i n loss of i n h i b i t i o n , increased summation, and abnormal pain phenomena (Melzack, 1973; Melzack & Wall, 1965; Munhart & McCaffrey, 1983; Wolf, 1980). Although s p e c i f i c i t y theory and pattern theory each make a s i g n i f i c a n t contribution to the understanding of pain, they both f a i l to constitute a s a t i s f a c t o r y general theory of pain (Kim, 1980; Melzack & Wall, 1965; Munhart & McCaffrey, 1983) as neither of these theories address the cognitive, a f f e c t i v e , or motivational components of the pain experience as described by Katz et a l . (1984). Gate control theory The gate control theory of pain was f i r s t proposed i n 1965 by Melzack and Wall. Melzack (1973) stated that any new theory of pain must be able to account for the following: 1. The high degree of p h y s i o l o g i c a l s p e c i a l i z a t i o n of receptor-fibre units and of pathways i n the central nervous system. 2. The r o l e of temporal and s p a t i a l patterning i n the transmission of information i n the nervous system. 3. The influence of psychological processes on pain perception and response. 4. The c l i n i c a l phenomena of s p a t i a l and temporal summation, spread of pain, and persistence of pain s u f f e r i n g . (p. 153) The gate control theory of pain attempted to integrate these requirements into a comprehensive pain theory. In essence, the theory proposes three systems: (a) the gate control system, (b) the c e n t r a l control system, and (c) the action system. In the gate control system, a gating mechanism i n the 19 dorsal horn of the spinal cord acts to i n h i b i t the flow of nerve impulses from the skin to the spinal cord transmission (T) c e l l s . The flow of nerve impulses from large and small diameter peripheral f i b r e s to the central nervous system plus descending influences from the central control system regulates the degree to which the gate opens and closes. The gate regulates the amount of sensory input to the T c e l l s which i n turn activates the action system when T c e l l output exceeds a c r i t i c a l l e v e l . The c e ntral control system activates s e l e c t i v e cognitive processes through the central t r i g g e r mechanism. This central t r i g g e r influences the modulating properties of the gating mechanism through somatic, auditory, and v i s u a l inputs and through cognitive processes related to attention, past experience, and emotions. In t h i s way, the person's own thoughts, fe e l i n g s , and past experiences influence whether or not the pain impulses reach the l e v e l of awareness. The central control system acts r a p i d l y to i d e n t i f y , evaluate, and s e l e c t i v e l y modify sensory input as well as i n t e r a c t i n g with the action system. The action system i s triggered only when the f i r i n g l e v e l of the T c e l l s reaches or exceeds a c r i t i c a l l e v e l . Output from the T c e l l s r e s u l t s i n sensory-discriminative information regarding the location, magnitude, and spatio-temporal properties of the noxious stimulus as well as the motivational drive to escape or attack. Perceptual information and motivational tendency inter a c t with cognitive information to influence the motor mechanisms responsible for the overt behavioral patterns which characterize pain (Kim, 1980; Melzack, 20 1973; Sternbach, 1968; Wolf, 1980). Although the gate control theory i s now the most commonly accepted theory of pain (Stevens et a l . , 1987; Wolf, 1980), i t has been c r i t i c i z e d on the basis that: (a) the actual location and mechanisms of the gate are erroneous (Munhart & McCaffrey, 1983), (b) that s p e c i f i c psychological variables and t h e i r e f f e c t s are not described (Kim, 1980), and (c) that the theory i s based on the pain experiences of adults and does not incorporate the developmental stages of childr e n (Stevens et a l . , 1987). Even so, the gate control theory of pain i s used by many authors i n discussions of p e d i a t r i c pain (Jeans, 1983a; McCaffrey, 1977; Schechter, 1985). The strength of the gate control theory i s that i t addresses a l l of the components of the pain experience as defined by Katz et a l . (1984), that i s , the sensory, neurochemical, cognitive, a f f e c t i v e , and motivational components which i n t e r a c t to produce a behavioural response. Thus, while i t does not incorporate the varying l e v e l s of cognitive development of the young c h i l d which a f f e c t how factors such as anxiety, fear, and separation influence the c h i l d ' s pain experience, the gate control theory does recognize that factors such as these have a significant.impact on the c h i l d ' s perception of and behavioural response to the pain experience. Understanding of the gate control theory of pain contributes to our understanding of why factors such as parental presence i n the recovery room may a f f e c t the behaviour of the postoperative p e d i a t r i c patient. Given the s i g n i f i c a n c e of the variables of anxiety, fear, arid separation i n children's pain experience, the following section of the chapter w i l l review the l i t e r a t u r e which discusses the e f f e c t s of h o s p i t a l i z a t i o n and parental separation on p e d i a t r i c patients. E f f e c t s of H o s p i t a l i z a t i o n and Parental Separation Studies of E f f e c t s of Maternal Separation Vernon et a l . (1965), i n t h e i r review of over 200 a r t i c l e s and books dealing with children's psychological responses to h o s p i t a l i z a t i o n and i l l n e s s , i d e n t i f i e d four variables which are most commonly associated with psychological upset i n ho s p i t a l i z e d c h i l d r e n - separation from parents, age, pre-h o s p i t a l personality, and u n f a m i l i a r i t y with the s e t t i n g . The e f f e c t s of maternal separation on childre n have been studied since the 1950's. I n i t i a l research focused on long term i n s t i t u t i o n a l i z a t i o n , including h o s p i t a l i z a t i o n . Bowlby (1960) and Robertson (1958) studied h o s p i t a l i z e d c h i l d r e n aged s i x months to f i v e years and i d e n t i f i e d three phases that characterize young children's behaviour during long term separation - protest, despair, and detachment. Although some authors u t i l i z e the term separation anxiety to describe a l l three phases (Bransletter, 1969; Weary, 1974), Bowlby (1960) hypothesized that these three phases are manifestations of a sin g l e process with the phase of protest r a i s i n g the problem of separation anxiety, the phase of despair the problem of mourning, and the phase of detachment the problem of defense. Robertson (1970) noted that when young childre n returned home from h o s p i t a l , they "are almost inva r i a b l y anxious and d i f f i c u l t i n t h e i r behaviour... they sleep badly, go back i n t h e i r t o i l e t t r a i n i n g , panic i f mother goes even momentarily out of sight, and have outbursts of aggression" (p. 6). Although these behaviours, when noted a f t e r short separations, usually disappeared i n a few days or weeks when handled t a c t f u l l y , they did p e r s i s t i n some children for much longer (Robertson, 1970). Years ago, Yarrow (1964) and Goslin (1974) i d e n t i f i e d that research on the e f f e c t s of short term h o s p i t a l i z a t i o n i s li m i t e d . Review of the current l i t e r a t u r e by t h i s author demonstrated that t h i s i s s t i l l true i n 1989. In a study of 200 ho s p i t a l i z e d c h i l d r e n aged 2 to 12 years who were ho s p i t a l i z e d f o r an average of seven days, Prugh, Staub, Sands, Kirschbaum, and Lenihan (1953) found that immediate reactions to h o s p i t a l i z a t i o n were more frequent i n childre n aged 2 to 5 years. Behaviour displayed included crying, withdrawal from the environment, loss of bowel and bladder control, and disturbances i n a c t i v i t y . Follow-up studies done three months a f t e r discharge demonstrated that about h a l f the childre n showed some behaviour disturbances not present p r i o r to h o s p i t a l i z a t i o n . Prugh et a l . (1953) suggested that these reactions could be rel a t e d to s p e c i f i c developmental anxieties and c o n f l i c t s c h a r a c t e r i s t i c of the children's developmental stages. Vernon, Schulman, and Foley (1966) u t i l i z e d a post-h o s p i t a l i z a t i o n questionnaire to compare the behaviour of chil d r e n before and a f t e r h o s p i t a l i z a t i o n . The questionnaire consisted of 28 items related to the children's behaviour and was sent to the parents of 800 children between the ages of 1 month and 16 years. The average length of h o s p i t a l i z a t i o n was 23 8.8 days and the reasons for h o s p i t a l i z a t i o n varied. Three hundred and eighty-seven responses were received and analyzed i n order to determine the r e l a t i o n s h i p of the 28 behaviours to the variables of age, gender, incidence of p r i o r h o s p i t a l i z a t i o n , length of h o s p i t a l i z a t i o n , occupational status of parents, and b i r t h order. The 28 items on the questionnaire were subjected to factor analysis and the following s i x factors were extracted: general anxiety and regression, separation anxiety, anxiety about sleep, eating disturbance, aggression toward authority, and apathy/withdrawal. Analysis revealed s i g n i f i c a n t differences for the variables of age and duration of h o s p i t a l i z a t i o n with children between the ages of 6 months to 5 years, 11 months and children h o s p i t a l i z e d for two to three weeks demonstrating the most psychological upset. The study also demonstrated that 25% of the c h i l d r e n had t o t a l scores i n d i c a t i v e of o v e r a l l psychological benefit (Vernon et a l . , 1966). The behaviour demonstrated by children i n the p e d i a t r i c recovery room may be influenced by a v a r i e t y of factors, including separation from parents and postoperative pain. As indicated i n the discussion of the gate control theory of pain, separation from parents may also have a s i g n i f i c a n t impact on the c h i l d ' s perception of and behavioural response to the pain experience. Review of the l i t e r a t u r e r elated to the e f f e c t s of maternal separation has c l e a r l y demonstrated that c h i l d r e n who experience short term and long term separation from t h e i r mothers do demonstrate s i g n i f i c a n t behavioural changes. Recognition of the e f f e c t s of maternal separation led to l i b e r a l i z a t i o n of h o s p i t a l v i s i t i n g hours for parents. In B r i t a i n , i n 1951, 42% of B r i t i s h p e d i a t r i c wards allowed no v i s i t i n g or v i s i t i n g less than once a week (Robertson, 1970). The C i t i z e n ' s Committee on Children of New York C i t y (1955) found i n 1954 that i n 60% of member hospitals, parents were not allowed to v i s i t more than three times a week, usually for a period of one hour. As v i s i t i n g hours were l i b e r a l i z e d , i t became evident that "more l i b e r a l v i s i t i n g schedules are better for c h i l d r e n " (Citizen's Committee on Children of New York City, 1955). Support f o r t h i s viewpoint increased s u b s t a n t i a l l y during the l a t e 1950's and early 1960's (Fagin, 1962; Hunsberger et a l . , 1984; Johnson, 1962; O'Connell & Brandt, 1960) and as a r e s u l t of the success of l i b e r a l i z a t i o n of v i s i t i n g hours, the rules were relaxed even further -to allow rooming-in. As one progressive measure i n the care of childr e n i s seen to be successful, other more controversial measures, such as rooming-in and parental presence at procedures, were introduced as research or p i l o t projects. Another example of a measure considered controversial by some health care professionals i s parental v i s i t i n g i n the p e d i a t r i c recovery room. Transitions i n what i s considered acceptable or common pra c t i c e generally occur i n a systematic manner. Thus, the t r a n s i t i o n from l i b e r a l i z a t i o n of v i s i t i n g hours to rooming-in can be compared to the t r a n s i t i o n from no v i s i t i n g by parents to l i b e r a l i z a t i o n of v i s i t i n g hours. In the following section, research studies of the e f f e c t s of rooming-in are reviewed. Studies of the E f f e c t s of Rooming-in on Children The p r a c t i c e of rooming-in became more accepted when i t was demonstrated that childr e n whose parents cared for them i n h o s p i t a l showed a s i g n i f i c a n t l y better response to treatment than those whose parents did not look a f t e r them (Brain & Maclay, 1968; Mahaffy, 1965; Prugh et a l . , 1955). Brain and Maclay (1968) studied 197 c h i l d r e n under the age of s i x who underwent tonsillectomy, adenoidectomy, or both. Children assigned to the experimental group (admitted with mothers) and the control group (admitted without mothers) were admitted to h o s p i t a l on opposite weeks. Adjustment to hospital was rated by two ward s i s t e r s and an anesthetist as s a t i s f a c t o r y , l i m i t e d , or unsatisfactory. Seventy-six point two percent of the experimental group had a s a t i s f a c t o r y adjustment to h o s p i t a l as compared to 42.7% of the control group. The c h i l d ' s adjustment was considered to be: (a) s a t i s f a c t o r y i f the c h i l d indicated awareness of the s i t u a t i o n and was not "unduly disturbed" (Brain & Maclay, 1968, p. 278) ; (b) unsatisfactory i f the c h i l d reacted to h o s p i t a l i z a t i o n with panic or complete denial and withdrawal; and (c) l i m i t e d when the c h i l d "showed overt signs of emotional disturbance but was able to express i t s feel i n g s to some extent and make a p a r t i a l adjustment to the s i t u a t i o n " (p. 278) . Following discharge, childr e n were c l a s s i f i e d as disturbed i f any new behaviour disorder or neurotic t r a i t had been observed since admission to h o s p i t a l and undisturbed i f behaviour was unchanged. S i g n i f i c a n t l y fewer chi l d r e n i n the experimental group, 21.8%, were c l a s s i f i e d as disturbed than i n the control group, 55.2%. In addition, the disturbed behaviour lasted s i g n i f i c a n t l y longer i n the control group. Brain and Maclay also found that only 11% of children i n the experimental group demonstrated any postoperative complications compared to 23% i n the control group. Although Brain and Maclay describe the assignment to the experimental and control groups as being done by random process, s e l e c t i o n of the study group was not done randomly. In fact, only those c h i l d r e n whose mothers were w i l l i n g to accompany them into h o s p i t a l were selected for the study. In addition, parental v i s i t i n g i n the control group was l i m i t e d . Neither of these factors was considered i n t h e i r discussion of the findings but i t may be that mothers who had thought they would be able to remain with t h e i r c h i l d i n h o s p i t a l were upset and/or anxious when they were able to v i s i t for only short periods. I t i s possible that t h i s difference i n the mothers' behaviour was one of the contributing factors to the differences i n the children's behaviour. As stated by Brain and Maclay "children of mothers who had a very strong desire to accompany t h e i r c h i l d r e n into h o s p i t a l but were unable to do so had a very high rate of emotional disturbance (85.7%) whereas the incidence of disturbance was r e l a t i v e l y low (46.7%) when the attitude of the mother was more passive" (p. 279). Lee and Greene (1969) studied the emotional state of 144 c h i l d r e n immediately a f t e r t h e i r a r r i v a l i n the operating room su i t e f o r e l e c t i v e surgery. The children, aged one to eight years, were c l a s s i f i e d as being asleep or awake with the awake chi l d r e n being further c l a s s i f i e d as calm or crying. Analysis was done comparing the c h i l d ' s emotional state with the amount of preoperative parental contact. Three types of parental contact were considered: (a.) no contact - parents who l e f t the h o s p i t a l the evening p r i o r to surgery and d i d not return u n t i l surgery was completed, (b) parents who l e f t before the c h i l d ' s bedtime but returned before the c h i l d went to surgery the next morning, and (c) rooming-in parents. This t h i r d group included parents who d i d not stay overnight but stayed u n t i l the c h i l d ' s bedtime and returned the next morning p r i o r to surgery. Crying was found to be s i g n i f i c a n t l y greater among children under the age of f i v e years. Although not s t a t i s t i c a l l y s i g n i f i c a n t , crying was noted twice as often among children whose parents roomed-in (23.6%) than among children who had no parental contact (9.5%) or children who saw t h e i r non-rooming-in parents p r i o r to surgery (10.0%). I t should be noted that s i g n i f i c a n t l y more parents of younger childre n than older c h i l d r e n choose to room-in. Lee and Greene described these r e s u l t s as a negative c o r r e l a t i o n between parental presence and emotional state but i t may be that the increase i n crying i n the chi l d r e n whose parents roomed-in was ei t h e r a r e f l e c t i o n of the age of the c h i l d rather than of the presence or absence of parents or evidence of the c h i l d being more able to express his/her emotions with parents than with strangers. Lee and Greene concluded that there was "no evidence that parental presence favorably a f f e c t s the emotional state of a c h i l d p r i o r to anesthesia and surgery" (1969, p. 129). Although not s p e c i f i c a l l y stated i n the study, i t appears that childr e n were not randomly assigned to the i d e n t i f i e d groups. I t may therefore be possible that i t was the parents of ch i l d r e n l i k e l y to be upset that chose to room-in. I f t h i s was the case, i t i s not su r p r i s i n g that Lee and Greene concluded that there was a negative c o r r e l a t i o n between parental 28 presence and emotional state. Couture (cited i n Thompson, 1985) studied the e f f e c t s of rooming-in on 21 children aged three to s i x years admitted for tonsillectomy and/or adenoidectomy surgery. Analysis of data did not show any s i g n i f i c a n t differences i n i n - h o s p i t a l behaviour of children whose parents roomed-in, parents who v i s i t e d f o r more than eight hours a day, or parents who v i s i t e d l e s s than eight hours a day. However, analysis of parental reports of behaviour one week and one month following discharge showed that children, e s p e c i a l l y preschoolers, whose parents did not room-in demonstrated more behavioural regression than the other c h i l d r e n . McGillicuddy (cited i n Thompson, 1985) also concluded that rooming-in i s associated with p o s i t i v e changes i n post-hospital behaviour and non-rooming-in i s associated with an increase i n regressive behaviour following discharge. Lehman (cited i n Thompson, 1985) i n a study of 48 children aged three to f i v e years demonstrated that although children of rooming-in mothers displayed more aggressive behaviour while i n ho s p i t a l , these same children demonstrated le s s severe post-h o s p i t a l upset than children whose parents d i d not room-in. Lehman hypothesized that the more aggressive i n - h o s p i t a l behaviour demonstrated by children whose mothers roomed-in was a r e s u l t of these childr e n having a greater f e e l i n g of security. Lehman also examined the incidence of postoperative complications and found that children i n the rooming-in group had fewer complications. As the o r i g i n a l a r t i c l e s by Couture, Lehman, and McGillicuddy (cited i n Thompson, 1985) were not a v a i l a b l e to the researcher, i t i s not possible to c r i t i q u e e i t h e r the design or the conclusions of these studies. Three general conclusions can be drawn from these research studies of the e f f e c t s of h o s p i t a l i z a t i o n and rooming-in. F i r s t , i t appears that children i n the rooming-in groups experience fewer postoperative complications than those i n the non-rooming groups (Brain & Maclay, 1968; Lehman [cited i n Thompson, 1985]). Second, i t appears that c h i l d r e n i n the rooming-in group demonstrate fewer behavioural problems following discharge from ho s p i t a l (Brain & Maclay, 1968; Couture [c i t e d i n Thompson, 1985]; Lehman [c i t e d i n Thompson, 1985]; Vernon et a l . , 1966). Third, the impact of h o s p i t a l i z a t i o n i s greatest on childre n younger than s i x years of age (Lee & Greene, 1969; Prugh et a l . , 1955; Vernon et a l . , 1966). These findings lend support to the hypothesis that allowing parents to v i s i t i n the p e d i a t r i c recovery room may reduce the c h i l d ' s fear and anxiety and t h i s reduction i n the c h i l d ' s fear and anxiety may be evidenced by changes i n the c h i l d ' s behaviour. Just as the p o s i t i v e r e s u l t s associated with increased parental v i s i t i n g led to l i b e r a l i z a t i o n of v i s i t i n g p o l i c i e s , the p o s i t i v e e f f e c t s of rooming-in on the c h i l d ' s recovery have caused some health professionals to question whether parental presence at procedures might have s i m i l a r p o s i t i v e e f f e c t s . In the following section, research studies of the e f f e c t s of parental presence at procedures are reviewed. Studies of the E f f e c t s of Parental Presence at Procedures Although there are no published studies of the e f f e c t s of parental presence on the behaviour of the postoperative 30 p r e s c h o o l age c h i l d i n the p e d i a t r i c r e c o v e r y room, t h e e f f e c t s o f p a r e n t a l presence on c h i l d r e n ' s response t o d e n t a l procedures ( F r a n k l , S h i e r e , & F o g e l s , 1962; Venham, 1979; Venham, Bengston, & C i p e s , 1978; Winer, 1982), immunization (Shaw & Routh, 1982), h o s p i t a l admission (Vernon, F o l e y , & Schulman, 1967), and a n e s t h e t i c i n d u c t i o n (Schulman, Fo l e y , Vernon, & A l l a n , 1967; Vernon e t a l . , 1967) have been s t u d i e d w i t h i n c o n s i s t e n t r e s u l t s . These s t u d i e s were reviewed as a n a l y s i s o f t h e i r f i n d i n g s may be u s e f u l i n p r e d i c t i n g how the presence of parents might a f f e c t the behaviour of the p o s t o p e r a t i v e p r e s c h o o l age c h i l d i n the r e c o v e r y room. P a r e n t a l Presence i n the Dental Operatory Although i t may be argued t h a t t h e exp e r i e n c e a c h i l d has i n the d e n t a l o p e r a t o r y i s s i g n i f i c a n t l y d i f f e r e n t than the immediate p o s t o p e r a t i v e experience, i t can a l s o be argued t h a t i t i s s i m i l a r i n t h a t the c h i l d i s i n an u n f a m i l i a r s e t t i n g , the c h i l d i s b e i n g c a r e d f o r by u n f a m i l i a r a d u l t s , p a r e n t s a re seldom p e r m i t t e d t o be w i t h the c h i l d , and the c h i l d may exp e r i e n c e p a i n . F r a n k l , S h i e r e , and F o g e l s (1962) s t u d i e d t h e e f f e c t of s e p a r a t i o n o f the mother and c h i l d i n the d e n t a l o f f i c e . One hundred and twelve c h i l d r e n , aged 3 1/2 t o 5 1/2 y e a r s , w i t h no p r e v i o u s d e n t a l e x p e r i e n c e , were p a i r e d and matched a c c o r d i n g t o age, gender, and socio-economic background, and then a s s i g n e d t o e i t h e r the mother-present or the mother-absent group. Each p a t i e n t v i s i t e d t w i c e , once f o r examination and p r o p h y l a x i s , and once f o r r e s t o r a t i v e procedures. Behaviour was r a t e d a t each v i s i t d u r i n g f i v e procedures on a s c a l e o f one t o f o u r . On t h i s scale, behaviour was described as d e f i n i t e l y negative, negative, p o s i t i v e , and d e f i n i t e l y p o s i t i v e . D e f i n i t e l y p o s i t i v e behaviour was described as "good rapport with the dentist, interested i n the dental procedures, laughing and enjoying the s i t u a t i o n " (Frankl et a l . , 1962, p. 155). D e f i n i t e l y negative behaviour was described as "re f u s a l of treatment, crying f o r c e f u l l y , f e a r f u l or any other overt evidence of extreme negativism" (p. 155). Frankl et a l . concluded that pre-school children, e s p e c i a l l y those i n the age group from 42 to 49 months, benefited from the mother's presence during treatment as t h i s age group demonstrated the most negative responses when the mother was absent. The age group from 50 to 66 months did not e x h i b i t s i g n i f i c a n t differences i n behaviour with the mother present or absent. Although these findings support the presence of the c h i l d ' s mother i n the dental operatory, the method of c l a s s i f y i n g the c h i l d ' s behaviour as p o s i t i v e or negative was questionable. Behaviour described by Frankl et a l . as negative could be considered to be e f f e c t i v e coping behaviour as i t prevents the d e n t i s t from carrying out dental work which the c h i l d may wish to avoid. As i d e n t i f i e d previously, each c h i l d was rated a t o t a l of ten times. Any c h i l d who reacted p o s i t i v e l y f o r f i v e or more of the ten procedures was rated p o s i t i v e i n the f i n a l ratings. In using t h i s r a t i n g method, i t was therefore possible for a c h i l d who was rated as d e f i n i t e l y negative on f i v e occasions and p o s i t i v e on f i v e occasions to be rated p o s i t i v e i n the f i n a l ratings. For t h i s reason, the author questions whether the conclusions Frankl et a l . have 32 drawn are v a l i d . Venham et a l . (1978) studied 64 children between the ages of two to f i v e years during a t o t a l of 207 dental v i s i t s to examine the consequences of leaving the decision of parent-child separation up to the parent and c h i l d . The c h i l d ' s response to each v i s i t was assessed using f i v e d i f f e r e n t measures: heart rate, basal skin response, r a t i n g of c l i n i c a l anxiety and cooperative behaviour, and a projective s e l f - r e p o r t measure of anxiety, that i s , picture t e s t . Although parents were neither encouraged nor discouraged from remaining with the c h i l d , they were offered the choice. During the 207 v i s i t s , parents were absent for 46 v i s i t s , the mother was present for 110 v i s i t s , and the father was present f o r 51 v i s i t s . Venham et a l . concluded that "no s i g n i f i c a n t differences related to parents present or absent were found on any of the response measures, when each dental v i s i t was analyzed separately" (p. 215). Unfortunately, unlike Frankl et al.(1962), Venham et a l . did not do an analysis of findings by age group. I f t h i s had been done, i t i s possible that the findings of t h i s study, as i n the study reported by Frankl et a l . , would have provided support f o r parental presence i n the dental operatory. In addition, i t i s unclear i n the report of t h i s study whether the picture t e s t and to o l s for ra t i n g anxiety and behaviour had been tested f o r v a l i d i t y and r e l i a b i l i t y . In a second study done by Venham (1979), 89 children requiring two or more dental v i s i t s were randomly placed i n ei t h e r the mother-present or mother-absent group for the f i r s t treatment v i s i t and placed i n the opposite group for the second v i s i t . In addition, the children were divided into a young group, aged three to f i v e years old, and an old group, aged five-and-a-half to eight years. The same measures as i n the previous study, with the exception of the basal skin response, were used to assess the e f f e c t of the mother's presence on the c h i l d ' s response to dental stress. Each c h i l d was videotaped by a hidden camera and the videotapes were analyzed by three judges without knowledge of the presence or absence of the mother. Venham found that although there were no s i g n i f i c a n t e f f e c t s r e l a t e d to gender or mother's presence, younger childre n were s i g n i f i c a n t l y more anxious than older children. Analysis of the i n t e r a c t i o n of treatment (mother present versus absent) with age was not done. In a subsequent study of 24 children who had a second treatment v i s i t , Venham (1979) reported that younger children received s i g n i f i c a n t l y higher c l i n i c a l anxiety scores and reported s i g n i f i c a n t l y more anxiety on the picture t e s t . Venham also reported that although younger children reported less anxiety on the picture t e s t when t h e i r mother was present, they were also s l i g h t l y less cooperative than the older children. I t should be noted however that the s e l f report data were obtained p r i o r to the i n j e c t i o n of a l o c a l anesthetic while the c l i n i c a l anxiety and cooperative behaviour scores represented an average score of three observation periods which included the period following the i n j e c t i o n . Although the findings, of three of these four studies appear to support parental presence i n the dental operatory, the v a l i d i t y of these findings i s questionable due to methodological problems. These problems include v a l i d i t y and r e l i a b i l i t y of r a t i n g t o o l s , summation procedure for determining p o s i t i v e behaviour, and sequence of data c o l l e c t i o n . Examinations and p a i n f u l procedures, admission to h o s p i t a l , and the period following surgery have been i d e n t i f i e d by Vernon et a l . (1965) as three periods of high stress f o r the h o s p i t a l i z e d c h i l d . In the following section of t h i s chapter, studies of the e f f e c t of parental presence on children's behaviour i n two of these high stress periods are reviewed. Mother Presence During Routine Hospital Admission and Anesthetic  Induction Vernon, Foley, and Schulman (1967) studied 32 h o s p i t a l i z e d c h i l d r e n between the ages of two years and f i v e years, eleven months i n order to t e s t the hypothesis that " p o t e n t i a l l y s t r e s s f u l experiences are more d i s t r e s s i n g to childr e n separated from t h e i r mothers than to children accompanied by t h e i r mothers" (p. 162). The children were paired and matched according to age, gender, and birth-order and randomly assigned to e i t h e r the mother-present or the mother-absent group. A l l childre n were e l e c t i v e admissions, mostly for surgery. Children undergoing tonsillectomy were excluded. In the f i r s t part of the study, each c h i l d ' s mood was rated on a seven point scale during the four phases of the hospital admission: prethreat phase, threat phase, impact phase, and postimpact phase. The four phases .were described as follows: (a) prethreat phase was the f i r s t 15 minutes a f t e r the c h i l d ' s a r r i v a l on the ward and was spent i n a small playroom; (b) threat phase began a f t e r the c h i l d returned to his/her room at the time the mother l e f t the c h i l d or would have l e f t the c h i l d ; (c) impact phase was the period during which the c h i l d underwent the admission procedures; and (d) postimpact phase began approximately f i v e minutes a f t e r the admission procedure was completed and was a second 15 minute period of time spent i n the playroom. In addition, measures of dependency were made during the prethreat period and measures of qu a l i t y of play were made during both the prethreat and postimpact phase. A l l mothers were with t h e i r c h i l d r e n during the prethreat and postimpact phase. Children i n the mother-absent group d i d not have t h e i r mothers with them during the threat and impact phase. No differences i n mood, qu a l i t y of play, measures of dependency, or aggression were noted i n children i n the mother-present group and the mother-absent group during any assessment period. I t should be noted however that, as i n Venham*s study, no analysis was done by age. In a continuation of the same study, Vernon et a l . studied 32 d i f f e r e n t c h i l d r e n between the ages of two years and f i v e years, eleven months who were admitted f o r tonsillectomy. In addition to observing each c h i l d f o r mood, q u a l i t y of play, dependency, and aggression, the researchers u t i l i z e d a questionnaire completed by the c h i l d ' s mother describing the c h i l d ' s post-hospital behaviour. Observations were made during the prethreat f i f t e e n minute play session p r i o r to anesthetic induction, during the threat phase which was the time when the mother l e f t the c h i l d or would have l e f t the c h i l d , and during the impact phase. The impact phase was divided into two parts: impact phase A began with the s t a r t of the induction when the mask was placed on the c h i l d ' s face and continued for one minute and impact phase B began at the end of impact phase A and continued u n t i l a s u r g i c a l l e v e l of anesthesia was achieved. Results of the study demonstrated that the experience was more d i s t r e s s i n g f o r childre n separated from t h e i r mothers than for c h i l d r e n accompanied by t h e i r mothers. The difference i n mood between ch i l d r e n i n the mother-present and the mother-absent groups was s t a t i s t i c a l l y s i g n i f i c a n t f o r the impact phase B (p. <.01). Vernon et a l . speculated that the reason the e f f e c t of separation was greatest i n impact phase B, the phase j u s t p r i o r to sleep, was "due to the fac t that t h i s was the most s t r e s s f u l period of induction because of the l i k e l i h o o d of frightening physical sensations or because s e l f - c o n t r o l was r e l a t i v e l y low with a corresponding increase i n emotional expression" (1967, p. 172). Although no s i g n i f i c a n t difference i n mood was noted f o r impact phase A, Vernon et a l . noted that at t h i s time the two and three year old children appeared to be considerably more upset than the four and f i v e year o l d chil d r e n . They also reported that the differences i n mood during the other phases were greater for younger childre n than older child r e n but were not s t a t i s t i c a l l y s i g n i f i c a n t . The lack of s t a t i s t i c a l s i g n i f i c a n c e may be related to the small sample s i z e . In t h i s study, anesthetic induction was done by seven d i f f e r e n t anesthetists. Although Vernon et a l . acknowledged that the differences among the anesthetists appeared to a f f e c t the mean mood scores i n impact phase A, i t i s unclear whether t h i s impact was the same or d i f f e r e n t for the d i f f e r e n t age groups and the d i f f e r e n t treatment groups, that i s , mother-present and mother-absent. I f the differences among the anesthetists affected the younger childre n and mother-absent group more than the other groups, t h i s would lend even more support to the conclusion that the experience was le s s s t r e s s f u l for the accompanied c h i l d . Parental Presence at Immunization Shaw and Routh (1982) studied the e f f e c t s of parental presence on the behaviour of 18 month old and 5 year old childre n receiving routine immunizations. Twenty childre n i n each age group were randomly assigned to equal sized mother-present and mother-absent groups. Mothers i n both groups were present f o r the most of the c h i l d ' s examination, with those i n the mother-absent group leaving only during the period when the c h i l d received the i n j e c t i o n . The c h i l d ' s behaviour was rated i n two ways. Behaviour was rated at s p e c i f i e d times i n the c h i l d ' s v i s i t using a modified Frankl Scale (Frankl et a l . , 19 62). The four point scale was changed to a f i v e point scale by adding a f i f t h behaviour category which was described as neutral, that i s , "absence of overt negative or p o s i t i v e behaviour" (Shaw & Routh, 1982, p. 37). In addition to r a t i n g the c h i l d ' s behaviour at s p e c i f i e d times, two observers recorded at twenty second i n t e r v a l s the presence or absence of the following behaviours - fussing, crying and screaming, laughing and smiling, t a l k i n g or v e r b a l i z a t i o n , playing with toys, and pushing or covering up. Shaw and Routh concluded f o r both age groups that "when they receive i n j e c t i o n s , c h i l d r e n are rated as 38 showing more negative behaviour and cry and fuss longer when t h e i r mother i s present than when she has been asked to stay i n the waiting room" (p. 40). Although these findings are opposite to those i n the studies done by Frankl et al.(1962), Vernon et al.(1967), and Venham (1979), Shaw and Routh interpreted these findings as supportive of maternal presence at the time of immunization. Shaw and Routh provide two reasons for in t e r p r e t i n g t h e i r r e s u l t s i n t h i s way. F i r s t , "given a pa i n f u l experience, ch i l d r e n are more l i k e l y to be reinforced by e f f e c t i v e comforting when t h e i r mother i s present than when she i s absent. Thus they are more l i k e l y to cry under these circumstances" (1982, p. 41). Second, "children under stress are a c t u a l l y more emotionally upset i n the sense of phy s i o l o g i c a l arousal when t h e i r mothers are absent than when they are present" (1982, p. 41). Shaw and Routh suggested that j u s t as the anesthetic i n the study done by Vernon et a l . (1967) served as a d i s i n h i b i t o r i n impact phase B allowing free expression of the children's f e e l i n g s , the presence of the c h i l d ' s mother i n t h i s study also acted as a d i s i n h i b i t o r as the children f e l t more secure i n t h e i r mothers presence and were therefore more l i k e l y to express t h e i r f e e l i n g s . Shaw and Routh suggested that: future research aimed at unraveling further the e f f e c t s of the parent's presence or absence on the c h i l d ' s response to stress should c a r e f u l l y d i s t i n g u i s h between separation protest and response to s t r e s s f u l events [and] d i f f e r e n t i a t e emotional arousal as such from factors (such as anesthesia or parent presence) which i n h i b i t or d i s i n h i b i t i t s expression. (p. 41) The studies reviewed i n the previous section represent the only studies the author was able to f i n d i n the l i t e r a t u r e which examine the e f f e c t of parental presence on the c h i l d ' s behaviour i n any of the three si t u a t i o n s that Vernon et a l . (1965) described as the most s t r e s s f u l f o r the h o s p i t a l i z e d c h i l d , that i s , admission to h o s p i t a l , examinations and p a i n f u l procedures, and the immediate postoperative period. In order to focus on l i t e r a t u r e more c l o s e l y related to the current study, two studies which examined the issue of parental v i s i t i n g i n the p e d i a t r i c recovery room are reviewed i n the following section of the chapter. Parental Presence i n the P e d i a t r i c Recovery Room The two studies which are reviewed i n t h i s section of the chapter addressed the issue of parental v i s i t i n g i n the p e d i a t r i c recovery room from the perspective of the parent and not the c h i l d . Nonetheless, i t i s important to include these studies as the author considers the c h i l d ' s parents as important members of the health care team and frequently draws on parents' perception of t h e i r c h i l d ' s behaviour i n making nursing care decisions i n the practice s e t t i n g . Dew, Bushong, and Crumrine (1977) reported a study which was designed to determine i f parents believed that v i s i t i n g i n the recovery room served a useful purpose f o r them and t h e i r c h i l d r e n . The study sample consisted of 57 parents (49 mothers and 8 fathers) of 38 boys and 12 g i r l s between the ages of 2 weeks and 14 years, having an average age of 3.8 years. Children i n the study underwent one of the following types of s u r g i c a l procedures: urology, general surgery, otolaryngology, p l a s t i c surgery, or a diagnostic procedure. A f t e r v i s i t i n g t h e i r c h i l d i n the recovery room, each parent was asked to complete a questionnaire that consisted of 11 questions which "attempted to d i s t i n g u i s h what parents l i k e d and d i d not l i k e about v i s i t i n g and to determine whether they f e l t v i s i t i n g was b e n e f i c i a l to them and t h e i r c h i l d r e n " (p. 268). Results showed that v i s i t i n g was seen as useful as indicated by a 100% p o s i t i v e response from parents who were asked i f they would want to v i s i t recovery room again i f t h e i r c h i l d had more surgery, and an 88% response that parental presence had i n some way been h e l p f u l to t h e i r c h i l d . Parents i n the study f e l t t h e i r children were reassured by the parents 1 presence and a b i l i t y to comfort them. Dew et a l . concluded that " v i s i t i n g i n a p e d i a t r i c recovery room can be a p o s i t i v e experience f o r parents and that i t can serve a useful purpose" (p. 269) . Unfortunately, what t h i s useful purpose i s was not s p e c i f i c a l l y addressed by the authors. In another study, Diniaco and Ingoldsby (1983) used a questionnaire to evaluate parents 1 perceptions of t h e i r children's behaviour a f t e r surgery. Children from two d i f f e r e n t recovery rooms were studied. Children i n a south unit had t h e i r parents with them i n the recovery room while c h i l d r e n i n the north uni t d i d not. One week following the c h i l d ' s h o s p i t a l i z a t i o n for surgery, a questionnaire was mailed to parents of a l l children from both units u n t i l 25 families had responded from each unit. The questionnaire asked parents to se l e c t behaviours which described t h e i r c h i l d a f t e r surgery and to i d e n t i f y any new behaviours noted since surgery. Parents of childre n i n the mother-present group rated t h e i r c h i l d r e n as les s f e a r f u l , angry, c l i n g i n g , and crying a f t e r surgery than parents of children i n the mother-absent group. The questionnaire did not specify at what point a f t e r surgery the parent was to r e f e r to i n describing t h e i r c h i l d ' s behaviour. For example, i t i s possible that the mothers i n the mother-present group might have described t h e i r c h i l d ' s behaviour i n the recovery room while the mothers i n the mother-absent group might have described t h e i r c h i l d ' s behaviour the night a f t e r surgery. In addition, the following variables were not c o n t r o l l e d for i n the study: age, type of s u r g i c a l procedure, type of anesthetic, type of admission, that i s , inpatient or outpatient, parental presence for overnight admissions. Although Diniaco and Ingoldsby concluded that having parents present i n the recovery room a l l e v i a t e s the negative e f f e c t s of h o s p i t a l i z a t i o n on the c h i l d , generalizations regarding the e f f e c t s of parental presence i n recovery room cannot be made from these r e s u l t s because of the methodological problems i d e n t i f i e d . V i s i t i n g i n the Recovery Room In a study which provides an i n t e r e s t i n g comparison to those done by Dew et a l . (1977) and Diniaco and Ingoldsby (1983), Vogelsang (1987) examined the re l a t i o n s h i p between v i s i t a t i o n or no v i s i t a t i o n by a f a m i l i a r person i n the recovery room and state anxiety scores i n adult s u r g i c a l patients. Sixty patients undergoing a v a r i e t y of s u r g i c a l procedures were selected and assigned to one of three groups depending on the a v a i l a b i l i t y of family v i s i t o r s and the nurse investigator: (a) Group 1 - no v i s i t a t i o n ; (b) Group 2 - v i s i t a t i o n by family members or s i g n i f i c a n t others; and (c) Group 3 - v i s i t a t i o n by f a m i l i a r nurse investigator. In reviewing the report of t h i s study, i t appears that s e l e c t i o n of study patients and assignment to study groups was not randomized. However, Vogelsang states that "demographic data for the three groups did not indicate i n d i v i d u a l differences among groups...[and there was no s t a t i s t i c a l l y ] s i g n i f i c a n t r e l a t i o n s h i p between the variables and state anxiety difference scores" (p. 26-27). State anxiety was measured by the nurse investigator the evening p r i o r to surgery and twenty to t h i r t y hours post-recovery using the S t a t e - T r a i t Anxiety Inventory. The difference between the preoperative and postoperative score as measured by the State-T r a i t Anxiety Inventory was the state anxiety score f o r the patient. Intra-group and inter-group differences were analyzed using paired-difference t - t e s t s . Vogelsang found that patients i n Groups 2 and 3 demonstrated a s t a t i s t i c a l l y s i g n i f i c a n t intra-group reduction i n state anxiety scores. Although patients i n Group 1 who had no v i s i t a t i o n demonstrated a reduction i n state anxiety score, the difference was not s i g n i f i c a n t . Other variables which may have influenced the study r e s u l t s were not i d e n t i f i e d by the author. Differences between groups were not s t a t i s t i c a l l y s i g n i f i c a n t . This study "found patients r e l i e v e d at the sight of a f a m i l i a r person" (Vogelsang, 1987, p. 28) and a l l patients i n the two treatment groups stated they would request v i s i t a t i o n i n the recovery room i f they had surgery again. Although these findings are s p e c i f i c to the adult s u r g i c a l patient, they do provide support for parental v i s i t i n g i n the p e d i a t r i c recovery room. If adult patients, who are aware of what to expect and are accustomed to being separated from t h e i r family, f e e l r e l i e v e d with v i s i t a t i o n from a f a m i l i a r person, i t i s l i k e l y that the p e d i a t r i c patient separated from parents i n the unfamiliar s e t t i n g of the recovery room w i l l also f e e l r e l i e v e d and possibly less anxious and f e a r f u l . In the recovery room, anxiety and pain are experienced by many patients. While adult patients i n the recovery room are often able to verbalize t h e i r feelings and concerns and pain complaints, p e d i a t r i c patients often cannot due to t h e i r lack of verbal s k i l l s , l e v e l of cognitive s k i l l s , and u n f a m i l i a r i t y with the pain experience. Therefore, the nurse must assess from the c h i l d ' s behaviour how and what the c h i l d i s f e e l i n g . One of the questions that directed t h i s study was: Do c h i l d r e n who have t h e i r parents with them display pain behaviour that i s d i f f e r e n t than that demonstrated by children whose parents are not with them? Therefore, the l i t e r a t u r e related to assessment of p e d i a t r i c pain behaviour was reviewed and i s presented i n the following section of the chapter. Assessment of P e d i a t r i c Pain Assessment Problems Assessment of pain i n p e d i a t r i c patients i s recognized as being a d i f f i c u l t problem (Abu-Saad, 1984; Jeans, 1983a). Although adults are generally able to quantify t h e i r pain experience, child r e n often are not because they are hampered by a v a r i e t y of developmental factors including cognitive a b i l i t y , verbal competency, and lack of previous experience (Hester, 1979). In addition, i n t e r p r e t a t i o n of the behaviour of preschool age children i s d i f f i c u l t because of va r i a t i o n s i n i n t e l l e c t u a l and developmental l e v e l , age, and communicative immaturity (Eland & Anderson, 1977; Hester, 1979; Jeans, 1983b; Kline, 1984). The need f o r research which focuses on methods to assess p e d i a t r i c pain behaviour i s frequently i d e n t i f i e d i n nursing and medical l i t e r a t u r e (Eland & Anderson, 1977; Hester, 1979; Lynn, 1986; McCaffrey, 1969; Schechter, 1985). Research to date has been directed p r i m a r i l y toward development of tools which children can use to indicate t h e i r degree of pain (Eland & Anderson, 1977; Hester, 1979). Assessment Tools Although many pain assessment tools have been developed for use by adults, most of these r e l y on the use of s k i l l s not yet developed by young children. Thus, pain to o l s which have been developed f o r use with children often r e l y on proj e c t i v e techniques or behavioural observation. Pain assessment tool s which r e l y on projective techniques are e s s e n t i a l l y non-verbal i n character. These t o o l s include colour scales (Eland, 1985), v i s u a l analogue scales (Abu-Saad, 1984; Abu-Saad & Holzemer, 1981), a poker chip t o o l (Hester, 1979) , pain "thermometers" (Molsberry, c i t e d i n Hawley, 1984), and a number of picture scales (Eland, c i t e d i n Lynn, 1974; Hester, 1979; Beyer & Byers, 1985). However, l i t t l e research has been done to measure the v a l i d i t y and r e l i a b i l i t y of these pr o j e c t i v e t o o l s (Aradine, Beyer, & Tompkins, 1988; Beyer & Knapp, 1988; Stevens et a l , 1987; Wong & Baker, 1988). In addition to concerns related to the v a l i d i t y and r e l i a b i l i t y of p r o j e c t i v e t o o l s , two other concerns can be i d e n t i f i e d when attempting to use tools such as these i n the recovery room s e t t i n g with the preschool age c h i l d . F i r s t , although these t o o l s are e s s e n t i a l l y non-verbal i n nature, they s t i l l r e l y on the c h i l d ' s a b i l i t y to understand and follow verbal i n s t r u c t i o n s . Second, these tools require substantial patient cooperation which may not be a v a i l a b l e i n the frightened preschool age c h i l d (Schechter, 1985) and/or the recovery room se t t i n g . A second method of assessing a c h i l d ' s pain i s through observation of the c h i l d ' s behaviour. Examples of t o o l s which can be used to categorize pain behaviour include the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) (McGrath, Johnson, Goodman, S c h i l l i n g e r , Dunn, & Chapman, 1985), the P e d i a t r i c Pain Inventory ( L o l l a r , Smits, & Patterson, 1982), the Inventory f o r the Diagnosis of Pain (Smith, 1976), the Infant Pain Behaviour Rating Scale (Craig, McMahon, Morison, & Zaskow, 1984), the Procedural Behavioural Rating Scale (Katz, Kellerman, & Siegel, 1980) and the Observational Scale of Behavioural Distress (Jay, Ozolins, & E l l i o t , 1983). Although several authors suggest that behavioural scales are a r e l i a b l e measure of a c h i l d ' s pain (Abu-Saad & Holzemer, 1981; Craig et a l . , 1984; Katz et a l . , 1984; McGrath et a l . , 1985; Taylor, 1983), others suggest that t h i s i s not the case (Beyer & Byers, 1985; Beyer & Levin, 1987; Jeans, 1983b; McCaffrey, 1969). For example, McCaffrey (1969) i d e n t i f i e d that behaviours associated with pain are often s i m i l a r to those seen i n other si t u a t i o n s which upset the c h i l d . One such s i t u a t i o n for the preschool age c h i l d i s separation from parents. Beyer and Levin c r i t i c i z e d the use of behavioural measures s t a t i n g that "when t h i s i s done, i t remains unclear whether the d i s t r e s s responses are due to pain, fear, anxiety, separation, or some other phenomena" (1987, p. 670). Beyer and Knapp (1986) suggest that "the major challenge to researchers i s the necessity for discriminating measures of pain i n t e n s i t y from measures of fear and anxiety" (p. 239) . Taking d i r e c t i o n from t h i s suggestion, studies that examine the re l a t i o n s h i p between pain and anxiety are explored i n the following section of'the chapter. Pain and Anxiety The r e l a t i o n s h i p between pain and anxiety i s complex. Chapman (1984) i d e n t i f i e d anxiety as the basic a f f e c t i v e condition that may modulate the pain experience. This r e l a t i o n s h i p between pain and anxiety was recognized by Melzack (1973) who stated that "the gate control theory proposes that cognitive a c t i v i t i e s such as anxiety...can influence pain by acting at the e a r l i e s t l e v e l s of sensory transmission" (p. 199-200). An increase i n anxiety l e v e l i s frequently c i t e d as one reason f o r an increase i n perceived pain i n t e n s i t y (Abu-Saad, 1981; Bowers, 1968; Chapman, 1984; Melzack, 1973; Merskey, 1980; Schalling, 1985; Taylor, 1983). Conversely, reducing anxiety i s frequently c i t e d as one means of reducing perceived pain i n t e n s i t y (Beales, 1982; Beyer & Levin, 1987; Chapman, 1984; Hawley, 1984; Katz et a l . , 1984; Melzack, 1973; McGuire & Dizard, 1982; Sternbach, 1968). Allowing parents to remain with t h e i r c h i l d r e n when they experience p a i n f u l or s t r e s s f u l procedures i s frequently suggested as one method of reducing t h e i r c h i l d ' s anxiety l e v e l (Hawley, 1984; Hunsberger et a l . , 1984; Lutz, 1986; McCaffrey, 1977; O'Connell & Brandt, 1960). As seen throughout t h i s review of the l i t e r a t u r e , parental presence at procedures and at the c h i l d ' s bedside, s i g n i f i c a n t l y impacts on the c h i l d ' s a b i l i t y to cope with the stresses of h o s p i t a l i z a t i o n , including the pain experience. The immediate postoperative period has been i d e n t i f i e d as one of the most s t r e s s f u l periods i n a c h i l d ' s h o s p i t a l i z a t i o n . Allowing parents to be with t h e i r c h i l d at t h i s time may contribute to a reduction i n the c h i l d ' s anxiety l e v e l thereby a l t e r i n g both the c h i l d ' s perception of the pain experience and the c h i l d ' s behaviour. As Melzack (1973) stated, " i t i s c l e a r that the search f o r new approaches to pain therapy might well p r o f i t by d i r e c t i n g thinking towards the contributions of motivational and cognitive processes" (p. 200). Summary I n i t i a l review of the l i t e r a t u r e revealed that there are currently no published studies which examine the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room. For t h i s reason, the author reviewed l i t e r a t u r e that would contribute to understanding factors which influence the behaviour of h o s p i t a l i z e d children. S p e c i f i c a l l y , the l i t e r a t u r e r elated to pain theory, the experience of h o s p i t a l i z a t i o n f o r p e d i a t r i c patients, p e d i a t r i c pain assessment, and the e f f e c t of parental presence at procedures was reviewed order to place t h i s 48 i n v e s t i g a t i o n within the current knowledge base. This review of the l i t e r a t u r e has i d e n t i f i e d that: the immediate postoperative period i s one of the three most s t r e s s f u l i n the c h i l d ' s h o s p i t a l i z a t i o n ; pain and separation from parents are two common experiences f o r h o s p i t a l i z e d children; perception of pain can be influenced by a v a r i e t y of factors including fear and separation anxiety; and, parental presence at procedures i s commonly advocated as a means of reducing anxiety and pain perception i n p e d i a t r i c patients. The change i n v i s i t i n g p ractices i n h o s p i t a l s from allowing parents short v i s i t s once or twice a week to allowing rooming-in has taken over 30 years. I t i s only within the l a s t ten years that the practice of allowing parents to be present during medical procedures has begun to gain acceptance. In many hospitals, parents are not yet permitted to be with t h e i r c h i l d i n the recovery room. In fact, the e x i s t i n g research base provides l i t t l e objective data to support the concept of parental presence at medical procedures or i n areas such as the recovery room that have previously been considered to be o f f l i m i t s to parents. Despite the f a c t that the immediate postoperative period has been i d e n t i f i e d as one of the most s t r e s s f u l periods i n a c h i l d ' s h o s p i t a l i z a t i o n (Vernon et a l . , 1965), there are no studies reported i n the l i t e r a t u r e on one of the most r e a d i l y a v a i l a b l e interventions that could s i g n i f i c a n t l y reduce the h o s p i t a l i z e d c h i l d ' s s t ress. This intervention i s , of course, the presence of the c h i l d ' s parents i n the recovery room. Thus, i t can be seen that t h i s i nvestigation of the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room makes a s i g n i f i c a n t contribution to a currently inadequate research base, and thereby enhances the a b i l i t y of health care professionals to make objective decisions regarding parental presence i n the p e d i a t r i c recovery room. The next chapter describes the methodology of the author 1s research study which was undertaken i n order to add to t h i s l i m i t e d and inadequate body of knowledge. Chapter Three METHODOLOGY Review of the l i t e r a t u r e i n the previous chapter has shown that the immediate postoperative period i s one of the most s t r e s s f u l periods i n a c h i l d ' s h o s p i t a l i z a t i o n . Although i t can be suggested from t h i s review that parents could play a s i g n i f i c a n t r o l e i n reducing the c h i l d ' s feelings of fear, anxiety, and perception of pain during t h i s period, no research studies were found that s p e c i f i c a l l y address the e f f e c t of parental presence i n the p e d i a t r i c recovery room. Thus, t h i s study was designed to examine the e f f e c t s of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room. This l e v e l one desc r i p t i v e study was done using a quasi-experimental design. This design was selected as an experimental treatment was used to examine the differences i n behaviour between the two groups of children and a true random sample was not p r a c t i c a l (Campbell & Stanley, 1963). The behaviour of two groups of children, one group having parents present, and one group not having parents present i n the Recovery Room, was recorded on videotape during the immediate postoperative period. The videotapes were then analyzed and compared fo r differences i n behaviour between the two groups of chil d r e n . Physiological parameters were not assessed as these would have been affected by the anesthetic agents and medications the children received. In t h i s chapter, the study methodology w i l l be reviewed with s p e c i f i c reference to the experimental treatment, selection of the study group, data c o l l e c t i o n and analysis, and e t h i c a l considerations. Study Design A quasi-experimental design was used i n order to address the following s p e c i f i c questions: 1 . Do chi l d r e n who have t h e i r parents with them i n the recovery room display d i f f e r e n t behaviours than those whose parents are not with them? 2. What are the d i f f e r e n t behaviours displayed by children whose parents are with them and children whose parents are not with them? 3. Do chi l d r e n who have t h e i r parents with them i n the recovery room display pain behaviour that i s d i f f e r e n t than that demonstrated by children whose parents are not with them? Thus, the independent variable was the presence or absence of the c h i l d ' s parent i n the Recovery Room and the dependent va r i a b l e was the behaviour of the c h i l d i n the Recovery Room. Two groups of children admitted to the Surgical Day Care Unit of a metropolitan children's h o s p i t a l f o r s u r g i c a l repair of strabismus were observed with h a l f of the children being assigned to the parent-present group and h a l f of the children being assigned to the parent-absent group. The parent-present group consisted of children having surgery on odd numbered days. The parent-absent group consisted of children having surgery on even numbered days. Selection of Study Group Age The sample was chosen from the preschool age population as i t i s generally accepted that separation from parents i s most traumatic for t h i s age group (Audette, 1974; Crocker, 1980; Vernon et a l . , 1980; V i s i n t a i n e r & Wolfer, 1975). Children between the ages of three to s i x years are i n a c r u c i a l developmental stage. Piaget and Inhelder (1969) describe c h i l d r e n between the ages of two and seven years as being i n the preoperational period. Preoperational c h i l d r e n are unable to understand cause and e f f e c t r e l a t i o n s h i p s ( P h i l l i p s , 1981) and are often described as having magical thinking (Abu-Saad, 1981; Lutz, 1986; P e t r i l l o & Sanger, 1972). Because of t h i s , preschoolers often do not understand the reason for t h e i r h o s p i t a l i z a t i o n or t h e i r pain and these may be viewed as punishment fo r something they have done wrong (Abu-Saad, 1981; Hurley & Whelan, 1988; Lynn, 1986; McBride, 1977; McCaffrey, 1969; Smith, 1976). As well, h o s p i t a l i z a t i o n and pain may make the c h i l d f e e l his/her parents do not love him/her because i f they did, they would not have allowed these things to happen to him/her (Korsch, 1975; Vernon et a l . , 1965). Three c h a r a c t e r i s t i c s of the preoperational period are concreteness, egocentrism, and transductive reasoning, a l l of which influence how children perceive pain (Smith, 1976). The preschool age c h i l d "who i s i n the preconceptual, preoperational stage of cognitive development, may perceive and respond to p a i n f u l s i t u a t i o n s with much more fear than i s seen i n younger infants or older c h i l d r e n " (Jeans, 1983a, p. 27). Smith (1976) i d e n t i f i e d that the preoperational c h i l d ' s i n t e r p r e t a t i o n of pain increases the c h i l d ' s anxiety, thereby increasing his/her perception of the pain (Smith, 1976). Several authors have i d e n t i f i e d that anxiety l e v e l appears to be inversely related to age; that i s , younger children display more anxiety behaviours over a longer period of time during p a i n f u l medical procedure's than older c h i l d r e n (Frankl et a l . , 1962; Jay et a l . , 1983; Katz et a l . , 1980; LeBaron and Zelter, 1984; Venham, 1979). Given a l l of these facts, i t i s l i k e l y that i f parental presence i n the recovery room does a f f e c t how the c h i l d behaves, the behavioral changes would be most evident i n c h i l d r e n between the ages of 3 years to 6 years. Surgical Procedure The researcher choose to study children who were a l l undergoing the same su r g i c a l procedure i n order to control one of many vari a b l e s i n the study. I t was assumed that although the pain experience i s d i f f e r e n t for every c h i l d when the s u r g i c a l procedure i s the same, children undergoing the same s u r g i c a l procedure would be more l i k e l y to display s i m i l a r behaviours than a group of children undergoing a v a r i e t y of s u r g i c a l procedures. Strabismus repair was chosen as the s u r g i c a l procedure as t h i s procedure i s commonly done ,between the ages of three to s i x years and the researcher could therefore a n t i c i p a t e having an adequate sample s i z e . Strabismus repair i s c a r r i e d out i n order to s u r g i c a l l y rotate the eye to a d i f f e r e n t p o s i t i o n than i t was pre-operatively. The procedure involves rot a t i n g the eye i n the eye socket i n order to access the extra-ocular muscles, cutting one 54 or more of the extra-ocular muscles, and reattaching the muscle on the s c l e r a e i t h e r i n back of or ahead of i t s o r i g i n a l point of attachment (Luckmann & Sorensen, 1980). Adult patients frequently describe the f e e l i n g following strabismus repair as one of having sand i n the eye. C r i t e r i a for Selection The s p e c i f i c c r i t e r i a established to s e l e c t c h i l d r e n for the study group were: 1. The c h i l d was between the age of three to s i x years. 2. The strabismus repair was not done using an adjustable suture. 3. The c h i l d had had no previous surgery. 4. The c h i l d had not been h o s p i t a l i z e d within the previous twelve months. 5. The c h i l d and accompanying parent spoke and understood English. 6. The c h i l d had no chronic health problem, mental handicap, and/or physical handicap. 7. The c h i l d met normal developmental milestones expected for his/her chronological age as i d e n t i f i e d by medical and nursing assessment. 8. The c h i l d had not received a narcotic pre-operatively or i n t r a - o p e r a t i v e l y . Children undergoing strabismus repair requiring an adjustable suture were excluded as t h i s procedure requires patching of the eye. Children with patched eyes may behave d i f f e r e n t l y when emerging from anesthetic than children without patched eyes. Excluding t h i s group of chi l d r e n eliminated an a d d i t i o n a l v a r i a b l e which could s i g n i f i c a n t l y impact on the findings. Children who had previously undergone surgery or who had been h o s p i t a l i z e d within the l a s t twelve months were i n i t i a l l y excluded from the study as i t was possible that the nature of these experiences and the c h i l d 1 s memory of them could influence how the c h i l d behaved during t h i s experience. Two months a f t e r data c o l l e c t i o n had begun the author recognized that t h i s exclusion c r i t e r i a applied to a s i g n i f i c a n t number of p o t e n t i a l p a r t i c i p a n t s . I t was decided to change the s e l e c t i o n c r i t e r i a to include children who had previously had surgery i n order to allow the author to obtain an adequate sample s i z e within a reasonable time period. The language requirement was included to ensure that both the parents and the children were able to understand explanations provided by the researcher as well as by the medical and nursing personnel caring for the c h i l d . In addition, i f personnel caring f o r the c h i l d could not understand what the c h i l d was t r y i n g to communicate to them, t h i s could influence the c h i l d ' s anxiety l e v e l and possibly a f f e c t the c h i l d ' s behaviour. The requirements related to health, lack of mental and/or physical handicaps, developmental l e v e l , and narcotics were included as a l l of these factors can influence the c h i l d ' s behaviour. Eliminating these items allowed the author to reduce the number of uncontrolled variables which would require consideration i n the analysis of the data. Selection Procedure The four opthamologists who do strabismus repair at the study h o s p i t a l consented to recruitment of subjects from t h e i r patient l i s t (see Appendix A, p. 123). A l e t t e r explaining the study (see Appendix B, p. 124) was given, by the physician's o f f i c e s t a f f , to parents of a l l children who met the study c r i t e r i a at l e a s t one day p r i o r to the c h i l d ' s scheduled s u r g i c a l date. Children who met the c r i t e r i a were i d e n t i f i e d through a three step process. F i r s t , the researcher reviewed the Operating Room Booking Card for a l l childr e n undergoing strabismus r e p a i r during the period of the study and l i s t e d a l l c h i l d r e n who met the c r i t e r i a f or age and type of strabismus re p a i r . Second, the researcher i d e n t i f i e d c h i l d r e n on t h i s l i s t to the physician's o f f i c e s t a f f . Charts for these childr e n were reviewed j o i n t l y by the researcher and the o f f i c e s t a f f . Children meeting a l l the c r i t e r i a were i d e n t i f i e d and t h e i r parents were given a copy of the l e t t e r explaining the study. The f i n a l decision regarding the c h i l d ' s s u i t a b i l i t y f or in c l u s i o n i n the study was made by the researcher on the day of surgery a f t e r the researcher reviewed the admission assessment done by the Surgical Day Care Unit nurse. On the day of the c h i l d ' s surgery, the researcher was n o t i f i e d of the c h i l d ' s a r r i v a l by the re c e p t i o n i s t i n the Surgical Day Care Unit. The researcher then approached the c h i l d and the parent(s) and asked i f they had received a l e t t e r from the physician's o f f i c e regarding the researcher's study. Parents of a l l of the children i d e n t i f i e d by the researcher as meeting the study c r i t e r i a had received l e t t e r s . The researcher asked the parents i f there were any questions regarding the l e t t e r or the study and answered any the parents posed. In addition, the researcher v e r b a l l y described the study to the parents and asked them i f they understood t h i s explanation. Parents were made aware at t h i s time that they would be t o l d only a f t e r signing the consent which group t h e i r c h i l d would be assigned to, that i s , the parent-present or the parent-absent group. In addition, parents were reminded that t h e i r r e f u s a l to allow t h e i r c h i l d to p a r t i c i p a t e i n the study and/or withdraw t h e i r c h i l d from the study at any time would not a f f e c t t h e i r c h i l d ' s health care i n any way. Parents were then asked i f they were w i l l i n g to have t h e i r c h i l d included i n the study. I f the parents agreed to inc l u s i o n of t h e i r c h i l d i n the study, they then signed a written consent form (see Appendix C, p. 125). Only one set of parents refused to have t h e i r c h i l d included i n the study. One parent was w i l l i n g to have her c h i l d included only i f her c h i l d was assigned to the parent-present group. The researcher considered t h i s to be a conditional consent and choose not to include t h i s c h i l d i n the study. Once the consent form had been signed, the parents were t o l d whether t h e i r c h i l d would be i n the parent-present group or the parent-absent group. I t was explained to the parents that the decision as to which group the c h i l d was assigned to was done by assigning children having surgery on odd numbered days to the parent-present group and children having surgery on even numbered days to the parent-absent group. A l l childr e n i n the study having surgery on the same day were assigned to the same group i n order that the assignment of the children to the groups would appear to be f a i r to the children's parents. Parents of chi l d r e n i n the parent-absent group were reassured by the researcher that i f t h e i r c h i l d was extremely upset and asking 58 f o r them, the parent would be i n v i t e d t o come t o the Recovery Room and s i t w i t h t h e i r c h i l d . T h i s was not r e q u i r e d f o r any of the c h i l d r e n i n the parent-absent group. T h i s reassurance was g i v e n as p a r e n t s are sometimes asked t o v i s i t i n the Recovery Room i f a c h i l d i s asse s s e d as b e i n g extremely upset by the Recovery Room n u r s i n g s t a f f . I n s t r u c t i o n s g i v e n t o pa r e n t s o f c h i l d r e n i n the pa r e n t -p r e s e n t group are reviewed i n the f o l l o w i n g s e c t i o n o f the chap t e r . I n s t r u c t i o n s t o Parents A l l p a r e n t s o f c h i l d r e n who were a s s i g n e d t o the p a r e n t -p r e s e n t group were p r o v i d e d w i t h the f o l l o w i n g i n s t r u c t i o n s and i n f o r m a t i o n by the r e s e a r c h e r : 1. Parents were t o r e t u r n t o the S u r g i c a l Day Care U n i t no l a t e r than 45 minutes f o l l o w i n g the c h i l d ' s d e p a r t u r e f o r su r g e r y . T h i s was done t o ensure t h a t p a r e n t s would be immediately a v a i l a b l e when they were c a l l e d f o r by the Recovery Room nurse. 2. Parents were t o l d t h a t they would be c a l l e d t o the Recovery Room as soon as the nurse had checked t h e i r c h i l d and determined t h a t t h e i r c h i l d was " f i n e " . 3. Parents were t o l d t h a t t h e i r c h i l d would pr o b a b l y be s l e e p i n g and s t i l l s l i g h t l y under the e f f e c t s o f the a n e s t h e t i c when they f i r s t saw him/her. Parents were t o l d t h a t t h e i r c h i l d c o u l d c o n t i n u e t o s l e e p f o r as l o n g as an hour b e f o r e waking up. 4. Parents were t o l d t h a t as a p a r t o f the r o u t i n e care g i v e n i n the Recovery Room, the c h i l d would have an oxygen mask on and t h i s mask could stay on u n t i l t h e i r c h i l d began to wake up. 5. Parents were t o l d that they could comfort t h e i r c h i l d as they normally would, even i f t h i s included picking up and holding t h e i r c h i l d . Setting This study was conducted i n the Post Anesthetic Recovery Room (PARR) at a metropolitan, t e r t i a r y r e f e r r a l children's h o s p i t a l . A l l childr e n having surgery at t h i s h o s p i t a l are admitted to t h i s Recovery Room following surgery. In addition, c h i l d r e n undergoing medical procedures which require that the c h i l d be heavily sedated, such as upper endoscopy and Computerized A x i a l Tomography scanning (CAT scan), are admitted to PARR u n t i l they are assessed to be suitable f o r discharge back to the ward. On an average day, between 30 to 40 patients are managed i n PARR over a ten hour period. PARR i s a large, open, b r i g h t l y l i t , and usually noisy room. There are stretcher bays on both sides of the room and two nursing desks i n the middle of the room. Each of the stretcher bays i s i d e n t i f i e d by number to f a c i l i t a t e t r a f f i c flow and patient assignment. Although there i s room for 13 patients i n PARR at any one time, the usual patient census i s 8. Nonetheless, PARR i s usually a very crowded looking room e s p e c i a l l y when there are additional people.such as parents present. 60 Patient Management i n the OR and PARR Anesthetic s t a f f and nursing s t a f f i n the PARR were t o l d that the purpose of the study was to i d e n t i f y whether children i n the recovery room who have t h e i r parents with them display d i f f e r e n t behaviours than those whose parents are not with them. PARR nursing s t a f f were made aware of which group the c h i l d was assigned to i n order that they know which children's parents were to come to PARR. This information was not given to the anesthetic s t a f f . Both groups of s t a f f expressed i n t e r e s t i n the study and ve r b a l l y communicated to the researcher t h e i r willingness to a s s i s t i n the study. A l l c h i l d r e n i n the study were managed according to the routine i d e n t i f i e d i n the following section except that children i n the parent-present group had t h e i r parents j o i n them i n the PARR as soon as the Recovery Room routine admitting procedure was completed and the nurse had assessed that the c h i l d had no signs of cardiac or respiratory i n s t a b i l i t y . Nursing s t a f f were reminded i f the c h i l d was i n the parent-present group when the c h i l d was admitted to PARR. In addition, with the f i r s t few children i n the parent-present group, the nurse had to be reminded by the researcher to c a l l f or the c h i l d ' s parents. A l l parents who were to j o i n t h e i r c h i l d i n the PARR did so before the c h i l d began to rouse and a l l parents remained with t h e i r c h i l d throughout the entir e PARR period. Anesthetic Management Anesthetists are normally assigned to designated operating rooms on a ro t a t i n g basis. This method of assignment was not alt e r e d f o r the purposes of the study. In t o t a l , 1 1 anesthetists were involved i n the anesthetic management of the 20 c h i l d r e n i n the whole study group. However, i n order to a s s i s t with v a r i a b l e control, the anesthetists agreed that each c h i l d would receive a standard anesthetic which consisted of: 1. Intravenous induction of anesthetic with Sodium Pentothal 4.7 - 6.8 milligrams per kilogram of body weight, Atropine .01 - .02 milligrams per kilogram of body weight, and Succinylcholine 1.1 - 2.3 milligrams per kilogram of body weight. 2. Maintenance of anesthetic with oxygen, nitrous oxide, and halothane. 3. Administration of intravenous Droperidol 61 - 88 micrograms per kilogram of body weight as an antiemetic p r i o r to the end of the s u r g i c a l procedure. Nursing Management Nursing s t a f f i n PARR are routinely assigned to care for patients i n two designated stretcher bays. The stretcher bays assigned to each nurse are determined by the time of day the nurse begins her s h i f t . A l l patients i n the study were cared for i n e i t h e r stretcher bay number two or number three and were therefore cared for by the nurse who started her s h i f t at 0800. When t h i s nurse was on a scheduled break, the patient was cared for by the f l o a t nurse as i s the normal pr a c t i c e i n the PARR. This method of assigning the nursing s t a f f to care for the study patients minimized the influence of researcher bias i n the assignment process. In t o t a l , 12 female nurses were involved i n providing nursing care to patients i n the study. A l l c h i l d r e n i n the study were managed according to the normal n u r s i n g r o u t i n e i n the Recovery Room. T h i s r o u t i n e i n c l u d e d : 1. A d m i t t i n g procedure - f o l l o w i n g completion o f the s u r g i c a l procedure, the c h i l d was p o s i t i o n e d i n a s i d e l y i n g p o s i t i o n on the s t r e t c h e r and was accompanied t o PARR by an a n e s t h e t i s t and an o p e r a t i n g room nurse. Report was g i v e n t o the PARR nurse by the a n e s t h e t i s t and o p e r a t i n g room nurse and i n c l u d e d a d e s c r i p t i o n o f the c h i l d ' s p r e - o p e r a t i v e and i n t r a -o p e r a t i v e course w i t h s p e c i f i c a t t e n t i o n t o any problems which had o c c u r r e d . Assessment o f the c h i l d ' s l e v e l o f consciousness, r e s p i r a t o r y s t a t u s , c i r c u l a t o r y s t a t u s , temperature, and o p e r a t i v e s i t e was done by the PARR nurse and the r e s u l t s communicated t o the a n e s t h e t i s t . When the PARR nurse was s a t i s f i e d w i t h the p a t i e n t ' s s t a t u s , she i n d i c a t e d t o the a n e s t h e t i s t t h a t she was prepared t o accept r e s p o n s i b i l i t y f o r the p a t i e n t . 2. F o l l o w i n g admission, assessment o f the p a t i e n t ' s l e v e l o f c o n s c i o u s n e s s , r e s p i r a t o r y s t a t u s , c i r c u l a t o r y s t a t u s , and o p e r a t i v e s i t e was completed a t l e a s t every f i f t e e n minutes. A n a l g e s i c s and o r a l f l u i d s were g i v e n a t the nurse's d i s c r e t i o n i f t h e s e had been ordered by the p h y s i c i a n . 3 . In the PARR where the study was completed, c h i l d r e n undergoing strabismus r e p a i r remain a minimum of t h i r t y minutes. I f t h e c h i l d r e c e i v e s an a n a l g e s i c by the i n t r a - m u s c u l a r o r the in t r a v e n o u s r o u t e , the c h i l d remains i n PARR a minimum of t h i r t y minutes from the time the a n a l g e s i c i s g i v e n . C h i l d r e n are d i s c h a r g e d from PARR o n l y a f t e r they meet a l l c r i t e r i a i d e n t i f i e d i n the PARR d i s c h a r g e p o l i c y and a d i s c h a r g e order 63 has been signed by an anesthetist. Data C o l l e c t i o n Postoperative behaviour of a l l children i n the study group was recorded using a video camera. Recording was started as soon as the c h i l d was placed i n the assigned PARR stretcher bay. Although the researcher 1s i n i t i a l plan was to videotape each c h i l d f o r a minimum of one ha l f hour and a maximum of one hour, i t was necessary to videotape some children f o r up to two hours as they were s t i l l sleeping at the end of one hour. Videotaping of the c h i l d was stopped when the c h i l d was discharged from the PARR. Although fi l m i n g was of the c h i l d at a l l times, the parent and s t a f f members in t e r a c t i n g with the c h i l d were also filmed. That i s , the camera remained focused on the c h i l d at a l l times and other people were filmed only when they came into the camera's range of focus. O r i g i n a l l y the researcher had planned to do a l l of the videotaping h e r s e l f but was unable to do so due to a change i n employment part way through the study. In t o t a l , the researcher videotaped 12 of the children and three assistants, trained by the researcher i n the study protocol, videotaped the other 10 chi l d r e n . Two of these childr e n were subsequently dropped from the study as one c h i l d was i d e n t i f i e d as being developmentally delayed and one c h i l d experienced post anesthetic respiratory problems. Technical d i f f i c u l t i e s with the videotaping, although minimal, did create some in t e r e s t i n g problems and anxious moments fo r the researcher. Given the f i n a n c i a l resources 64 a v a i l a b l e f o r the project, the researcher used video equipment borrowed from the School of Nursing. One of the l i m i t a t i o n s of the equipment was that i t did not record the date and time of the recording on the videotape. This contributed to making coding of the videotapes more d i f f i c u l t and time consuming than was i n i t i a l l y anticipated. In addition, there was no mobile t r i p o d a v a i l a b l e for use to allow the researcher to move the camera as the c h i l d moved about i n bed. In order to make the camera mobile, the researcher taped the camera and stationary t r i p o d to a table on wheels. This worked extremely well except for the one occasion on which the camera and t r i p o d f e l l o f f the table. On another occasion, the video camera would not work and neither the researcher nor her assistant were able to quickly i d e n t i f y why. In t h i s instance, the researcher, who was f a m i l i a r with the data c o l l e c t i o n t o o l which would be used i n coding the videotapes, observed the c h i l d u n t i l the camera was f i x e d . I t i s fortunate that the c h i l d remained asleep u n t i l the camera was f i x e d as, i n retrospect, i t would have been d i f f i c u l t to i d e n t i f y and time d i f f e r e n t behaviours i f they had occurred simultaneously. Data were l o s t on some occasions when the camera was not moved as quickly as the c h i l d moved, for example when the c h i l d moved quickly from side to side, and when the camera's view of the c h i l d was temporarily obstructed eit h e r by the parent or the nurse. Demographic data for each c h i l d (see Appendix D, p. 126) were c o l l e c t e d prospectively and r e t r o s p e c t i v e l y by the researcher from the c h i l d ' s parents and the chart. Detailed data regarding administration of medications, including 65 analgesics (see Appendix D, p. 126), were c o l l e c t e d r e t r o s p e c t i v e l y from the c h i l d ' s chart. Data Analysis A l l videotapes were coded by a research assistant who was f a m i l i a r with the PARR because of her past employment, was oriented to the study c r i t e r i a , and had assisted the researcher with the videotaping. Behavioural Checklist Preliminary coding of the videotapes was done using the behavioural c h e c k l i s t developed for the study proposal. This c h e c k l i s t recorded three categories of behaviour: (a) v o c a l i z a t i o n s ; (b) f a c i a l expressions; and (c) body movement. The content v a l i d i t y of these categories and words was based on the work of Johnson (1977), McCaffrey (1972), McGrath et a l . (1985), Munhart and McCaffrey (1983), and the researcher's experience as a p e d i a t r i c nurse i n a v a r i e t y of c l i n i c a l settings, including the recovery room. De f i n i t i o n s for some of these behaviours were developed by the researcher as d e f i n i t i o n s were not available i n the work done by these authors. During preliminary coding of the videotapes, several behaviours were i d e n t i f i e d which had not been included i n the behavioural c h e c k l i s t developed f o r the study proposal. Therefore, the behavioural c h e c k l i s t was revised to include these a d d i t i o n a l behaviours (see Appendix E, p. 127) and the videotapes were recoded by the research assistant. Although not a l l of the new behaviours can be considered pain behaviours, i t was useful to include them i n the analysis as they add s i g n i f i c a n t l y to the understanding of the e f f e c t of parental presence on the postoperative c h i l d ' s behaviour i n the PARR. These new behaviours included the c h i l d ' s pain complaints ( s o l i c i t e d and u n s o l i c i t e d ) , denial of pain, touching the operative s i t e , reaching for eyes, kicking, frowning, grimacing, smiling, reaching for body contact, giving hugs, being held by parent or nurse, requesting f l u i d s ( s o l i c i t e d and u n s o l i c i t e d ) , drinking, eating a popsicle, asking for his/her mother, miscellaneous complaining ( s o l i c i t e d and u n s o l i c i t e d ) , responding to offer(s) for pain medication, and r e f u s a l behaviour. F a c i a l expression was extremely d i f f i c u l t to i d e n t i f y on the videotapes due to the distance of the camera from the patient. As the following f a c i a l expressions were not noted during the coding of the videotapes, they were dropped from the o r i g i n a l behavioural c h e c k l i s t : b i t i n g of lower l i p , clenched teeth, t i g h t l y shut l i p s , wide-open eyes, and wrinkled forehead. Broad f a c i a l expressions such as frown, grimace, and smile were more e a s i l y i d e n t i f i e d and, as indicated previously, were added to the revised behavioural c h e c k l i s t (see Appendix E, p. 127). The items previously named gasping, immobile, and rhythmic were dropped from the o r i g i n a l behavioural c h e c k l i s t as they were not demonstrated by any of the children i n the study. Coding; of Videotapes Each videotape was analyzed from the f i r s t signs of the c h i l d awakening to the time the c h i l d was discharged from the PARR. The duration and frequency of each of the behaviours on the revised c h e c k l i s t was recorded. In addition, the duration of behaviour that could not be coded due to obstruction of the video camera, that i s , l o s t data, was recorded. A behaviour began when the c h i l d i n i t i a t e d the v o c a l i z a t i o n , f a c i a l expression, or body movement. A behaviour ended with the completion of the v o c a l i z a t i o n , f a c i a l expression, or body movement or when there was a s i g n i f i c a n t pause or interruption i n the ongoing behaviour. Inter-rater R e l i a b i l i t y Sample episodes of f i v e videotapes were coded by the researcher i n order to e s t a b l i s h the i n t e r - r a t e r r e l i a b i l i t y of the behavioural c h e c k l i s t and d e f i n i t i o n s . Inter-rater r e l i a b i l i t y between the researcher and the research assistant was r = .91. I t was not necessary to revise any of the d e f i n i t i o n s as both the researcher and the research assistant were consistent i n t h e i r l a b e l l i n g of the behaviours. Labelling of the behaviours was directed by the behaviour d e f i n i t i o n s . S t a t i s t i c a l Analysis Although the experimental treatment of the study was the presence of parents i n the p e d i a t r i c Recovery Room, i n i t i a l review of the data suggested that there could be i n t e r e s t i n g and perhaps s i g n i f i c a n t differences between genders i n both the parent-present and the parent-absent groups. Therefore, the independent variable for a l l t e s t s was eithe r the presence or absence of the c h i l d ' s parent i n the PARR, the gender of the c h i l d , or a combination of both and analysis was done f o r the following groups: (a) parent-present, (b) parent-absent, (c) males, (d) females, (e) females parent-present, (f) females 68 parent-absent, (g) males parent-present, and (h) males parent-absent. The dependent variable was the c h i l d ' s behaviour i n the PARR which was s p e c i f i c a l l y i d e n t i f i e d on the behavioural c h e c k l i s t (see Appendix F, p. 130). A si g n i f i c a n c e l e v e l of p <.05 was preselected for a l l t e s t s . P r i o r to analysis of data, t - t e s t , c h i square, and c a l c u l a t i o n and comparison of the mean for each of the groups i d e n t i f i e d above were used to t e s t for s i g n i f i c a n t differences f o r the following var i a b l e s : (a) age of the c h i l d , (b) anesthetic time (c) length of PARR stay, (d) administration of analgesic medications, (e) administration of narcotic analgesics, (f) administration of non-narcotic analgesics, and (g) previous experience with surgery. No s i g n i f i c a n t differences were found between groups f o r these variables with the exception of administration of analgesic medication i n the female parent-absent and the male parent-absent groups. As can be seen i n Table 1, p. 75, f i v e children i n the female parent-present and 2 children i n the male parent-absent group received analgesic medication. Following coding of the videotapes, the mean duration per second and mean frequency per minute of each behaviour was calculat e d f o r each c h i l d a f t e r adjusting for l o s t data (behaviour which could not be recorded due to obstruction of the video camera). A l l items on the behavioural c h e c k l i s t (see Appendix E, p. 127) were then reviewed for frequency of occurrence and s i m i l a r items, such as grimace and frown, were combined i n order to f a c i l i t a t e the analysis. The f i n a l behavioural c h e c k l i s t (see Appendix F, p. 130) had 26 items as 69 compared to 30 on the o r i g i n a l c h e c k l i s t . Data analysis was f i r s t performed using a non-parametric s t a t i s t i c a l t e s t , that i s , Kruskal-Wallis one-way analysis of variance. Kruskal-Wallis tests whether a l l samples are from the same population through a two step process. F i r s t , a l l cases from the groups are ranked i n a single s e r i e s . The Kruskal-Wallis H s t a t i s t i c , which has approximately a chi-square d i s t r i b u t i o n , i s then calculated (Hull & Nie, 1981). Following review of a l l the data, i t was decided to perform Kruskal-Wallis analysis f o r any behaviour which was demonstrated by seven or more chi l d r e n . Thus, Kruskal-Wallis one-way analysis of variance was completed for 14 of the 26 behaviours to t e s t for s i g n i f i c a n c e of difference between r e s u l t s i n the following groups: (a) parent-present and parent-absent, (b) females and males, (c) females parent-present and females parent-absent, (d) males parent-present and males parent-absent , (e) females parent-present and males parent-present, and (f) females parent-absent and males parent-absent. In addition to the Kruskal-Wallis one-way analysis of variance, further d e s c r i p t i v e analyses were done between the same groups f o r a l l items on the behavioural c h e c k l i s t (see Appendix F, p. 130). The average frequency per second and average duration per minute of each behaviour f o r each group was determined by f i r s t c a l c u l a t i n g the t o t a l frequency and duration of the behaviour i n each group and then d i v i d i n g these t o t a l s by the number of children i n the group. Following t h i s , the difference i n average frequency per second and average duration per minute of each behaviour between the groups previously 70 i d e n t i f i e d was c a l c u l a t e d i n per cent (see T a b l e 2, p. 78). For example, c h i l d r e n i n the p a r e n t - p r e s e n t group demonstrated p u r p o s e l e s s behaviour 7% more f r e q u e n t l y and 30% l o n g e r than c h i l d r e n i n the parent-absent group. E t h i c a l C o n s i d e r a t i o n s In o r d e r t o ensure t h a t the r i g h t s of the c h i l d r e n and t h e i r p a r e n t s were p r o t e c t e d , the r e s e a r c h e r observed the f o l l o w i n g p r o t o c o l : 1. Access was gained t o the study s e t t i n g by s u b m i t t i n g t h e r e s e a r c h p r o p o s a l t o the I n - H o s p i t a l Research Review Committee and r e c e i v i n g a p p r o v a l t o c a r r y out the r e s e a r c h study (see Appendix G, p. 131). 2. Approval t o conduct the r e s e a r c h study was requested and r e c e i v e d from The U n i v e r s i t y o f B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s (see Appendix H, p. 132). 3. C o n f i d e n t i a l i t y was ensured. The f a m i l y ' s p a r t i c i p a t i o n i n the study was made known o n l y t o the h e a l t h c a r e p r o f e s s i o n a l s who were a c t i v e l y i n v o l v e d i n c a r i n g f o r the c h i l d . A l l o f the v i d e o t a p e s and data c o l l e c t i o n sheets were coded, without any p e r s o n a l l y i d e n t i f y i n g marks, and s t o r e d i n a l o c k e d f i l i n g c a b i n e t . Access t o the v i d e o t a p e s was r e s t r i c t e d t o the r e s e a r c h e r , the r e s e a r c h a s s i s t a n t , and the two members of the r e s e a r c h e r ' s t h e s i s committee. The v i d e o t a p e s and data sheets w i l l not be d e s t r o y e d as a l l p a r e n t s gave the r e s e a r c h e r s i g n e d consent t o use the v i d e o t a p e s f o r t e a c h i n g purposes (see Appendix C, p. 125). 4. The r e s e a r c h e r r e s p e c t e d the r i g h t s o f the parent t o r e f u s e t o have t h e i r c h i l d p a r t i c i p a t e i n the study o r t o withdraw t h e i r c h i l d from the study a t any time. T h i s was communicated t o the parent i n the l e t t e r the pa r e n t r e c e i v e d and was r e i t e r a t e d when the r e s e a r c h e r met the parent on the day of the c h i l d ' s s u r g e r y . 5. The r e s e a r c h e r made allowances t o b r i n g the pa r e n t s of c h i l d r e n i n t h e parent-absent group t o the Recovery Room i f t h i s was seen as necessary by the c h i l d ' s nurse. T h i s was communicated t o pa r e n t s o f c h i l d r e n i n t h i s group b e f o r e data c o l l e c t i o n began. I t was not necessary t o do t h i s f o r any of the c h i l d r e n i n the study. 6. The r e s e a r c h e r agreed t o share the f i n d i n g s o f the study w i t h p a r e n t s who requested t h i s on the consent form. Summary T h i s c h a p t e r has d e s c r i b e d the q u a s i - e x p e r i m e n t a l approach used i n o r d e r t o a l l o w the r e s e a r c h e r t o i n t r o d u c e p a r e n t s i n t o the p e d i a t r i c Recovery Room as the experimental treatment i n a study o f the e f f e c t o f t h e i r presence on the p o s t o p e r a t i v e behaviour o f the p r e s c h o o l age c h i l d r e n . As no s t u d i e s o f t h i s s u b j e c t have been found i n the r e s e a r c h e r ' s review o f the l i t e r a t u r e , v i d e o t a p i n g was chosen as the data c o l l e c t i o n method i n o r d e r t o o b t a i n as much data as p o s s i b l e . D e s p i t e some l o g i s t i c a l problems, t h i s method of data c o l l e c t i o n r e s u l t e d i n a r i c h and v e r y u s e f u l body of i n f o r m a t i o n . As can be seen i n the f o l l o w i n g chapter, the r e s e a r c h e r ' s f i n d i n g s from the a n a l y s i s o f the data r e p r e s e n t a s i g n i f i c a n t c o n t r i b u t i o n t o the research base of the behaviour of p e d i a t r i c patients i n the recovery room. Chapter Four RESEARCH FINDINGS The behaviour of 20 postoperative preschool age children i n the p e d i a t r i c Recovery Room was captured i n 2 6 hours of videotapes. Following t h i s , the videotapes were systematically analyzed; the findings of the analysis are presented i n t h i s chapter. As w i l l be seen by the reader, the data give a r i c h and meaningful picture of the behaviour of two groups of preschool age children i n the p e d i a t r i c Recovery Room - children whose parents were with them i n the Recovery Room and those whose parents were not present i n the Recovery Room. Summary of Demographic Data Twenty children, 10 male and 10 female, and t h e i r parents p a r t i c i p a t e d i n the research study. Half of the children, 5 male and 5 female, had t h e i r parent(s) with them i n the Recovery Room. Nine of the children i n the parent-present group were accompanied by t h e i r mother only and one male c h i l d had both parents with him. Ten children, 5 male and 5 female, d i d not have t h e i r parent(s) with them i n the Recovery Room. Seventeen chi l d r e n underwent b i l a t e r a l strabismus repair while the other three c h i l d r e n had strabismus repair of one eye only. The study c r i t e r i a required the children to be between the age of three to s i x years. The actual range of ages of the children included i n the study was three years to f i v e years, s i x months. The average age of the children i n the study was four years. As reported e a r l i e r , children who had previously undergone surgery were i n i t i a l l y excluded from the study. However, t h i s s e l e c t i o n c r i t e r i o n was changed to include c h i l d r e n who had previously had surgery i n order to allow the researcher to obtain an adequate sample s i z e within a reasonable time period. Of the 20 children who pa r t i c i p a t e d i n the study, 8 had undergone surgery previously. These childre n were equally d i s t r i b u t e d between the parent-present and the parent-absent groups. Demographic data related to administration of medication i n the Recovery Room were c o l l e c t e d r e t r o s p e c t i v e l y . Analgesics were the only medications administered during t h i s period. Twelve ch i l d r e n received a narcotic analgesic by e i t h e r the intra-muscular route (7 children) or the o r a l route (5 ch i l d r e n ) . Two children were given a non-narcotic analgesic by the o r a l route. Three children received an analgesic medication i n the Surgical Day Care Unit a f t e r t h e i r return from the Recovery Room. Two of these childr e n had not been medicated i n the Recovery Room and one had been given a narcotic analgesic i n the Recovery Room. Table 1 (see p. 75) i l l u s t r a t e s the mean of each of these variables, as well as the variables of anesthetic time and length of PARR stay. As can be seen i n t h i s table, these uncontrolled variables were evenly d i s t r i b u t e d between the groups and the groups were therefore considered to be p a r a l l e l . Findings from Kruskal-Wallis One-Way Analysis of Variance The experimental treatment i n t h i s study was parental presence i n the p e d i a t r i c Recovery Room. Preliminary review of 75 Table 1 Mean of Variables by Group No. No. No. Receiving No. Group Age (Months) Anesthetic Time (Minutes) PARR Time (Minutes) Receiving Analgesic Medication Receiving Narcotic Medication Non Narcotic Medication Having Previous Surgery Parent Present 48.1 57.0 80.6 7 6 1 4 Parent Absent 48.7 49.0 73.6 7 6 1 4 Female 49.2 49.7 72.0 9 7 1 3 Hale 47.6 56.3 82.2 5 4 1 5 Female Parent Present 48.8 50.0 77.0 4 3 1 1 Female Parent Absent 49.6 49.0 66.0 5 4 1 2 Hale Parent Present 47.4 64.0 84.0 3 3 0 3 Hale Parent Absent 47.8 48.0 80.0 2 2 0 2 the raw data suggested however that there could be in t e r e s t i n g and possibly s i g n i f i c a n t differences between groups other than the parent-present and the parent-absent groups. Therefore, the independent v a r i a b l e f o r a l l tests was eithe r the presence or absence of the c h i l d ' s parent i n the PARR, the gender of the c h i l d , or a combination of both, and the dependent variable was 76 the c h i l d ' s behaviour i n the PARR. Kruskal-Wallis one-way analysis of variance was used to t e s t f o r s i g n i f i c a n c e of difference for s p e c i f i c behaviours between the following groups: (a) parent-present and parent-absent, (b) females and males, (c) females parent-present and females parent-absent, (d) males parent-present and males parent-absent, (e) females parent-present and males parent-present, and (f) females parent-absent and males parent-absent. S t a t i s t i c a l l y s i g n i f i c a n t differences were found i n four of these s i x groups. No s t a t i s t i c a l l y s i g n i f i c a n t differences were found i n the male parent-present group versus the female parent-present group or the male parent-absent group versus the female parent-absent group. The behaviours f o r which s t a t i s t i c a l l y s i g n i f i c a n t differences were found are presented i n the following sections. Parent-Present versus Parent-Absent Group Children i n the parent-present group were held more frequently (p = .006) and for longer (p = .004) than children i n the parent-absent group (see Table 2, column 2, p. 7 8 ) . Duration of drinking was also greater (p = .019) f o r children i n the parent-present group than the parent-absent group. Children i n the parent-absent group demonstrated protective behaviour more frequently (p = .019) and for longer duration (p = .034) than children i n the parent-present group. No other s t a t i s t i c a l l y s i g n i f i c a n t differences were found between the parent-present group and the parent-absent group. Females versus Males Females demonstrated the behaviour of rubbing the operative s i t e more frequently (p = .023) and for longer (p = .049) than males (see Table 2, column 3, p. 78). No other s t a t i s t i c a l l y s i g n i f i c a n t differences were found between the female and male groups. Females Parent-Present versus Female Parent-Absent Females i n the parent-present group were held more frequently (p = .019) and for longer (p = .019), drank for longer (p = .047), and had more frequent voluntary miscellaneous complaints (p = .019) than females i n the parent-absent group (see Table 2, column 4, p. 78). No other s t a t i s t i c a l l y s i g n i f i c a n t differences were found between these two groups. Males Parent-Present versus Male Parent-Absent The only s i g n i f i c a n t difference i n behaviour between these groups was that males i n the parent-absent group displayed protective behaviour of greater duration (p = .028) than males i n the parent-present group (see Table 2, column 5, p. 78). Findings of Descriptive Analyses In addition to the Kruskal-Wallis one-way analysis of variance, further d e s c r i p t i v e analyses were calculated for the same groups of children f o r a l l items on the behavioural c h e c k l i s t (see Appendix F, p. 130). While i t i s recognized that the number of children i n some of the groups was small, these analyses i d e n t i f i e d more differences between groups than the Kruskal-Wallis s t a t i s t i c s . The findings of these further analyses are presented i n the following section and are i l l u s t r a t e d i n Table 2 (p. 78-80). 78 Table 2 Percentage Difference Between Groups for Frequency (f) and Duration (d) of Behaviours Group Behavior Parent Present/ Parent Absent Female/ Hale Female Parent Present/Absent Male Parent Present/Absent Female and Male Parent Present Female and Male Parent Absent Purposeless No. in group with behaviour f: d: 7/9 > 7% >30X 7/9 <49% <56% 3/4 < 4% < 32% 4/5 >12% <29% 3/4 < 53% < 57% 4/5 <44% <55% Rubbing No. i n group with behaviour f: d: 10/10 <37% <59% 10/10 >65% * >67X * 5/5 <42X <66% 5/5 <21X <36% 5/5 >57% >49% 5/5 >69% >73% Protective No. in group with behaviour f: d: 10/7 <36% * <57% * 7/10 >53% >40% 2/5 <8% <23% 5/5 <75% <92% 2/5 >81% >81% 5/5 >27% >27% Touch No. in group with behaviour f: d: 2/5 <87% <95% 5/2 >77% >41% 2/3 <84% <91% 0/2 <100% <100X 2/0 >100% >100% 3/2 >73% >36% Reach for eyes No. in group with behaviour f: d: 2/3 <21% <40% 4/1 >79% >86% 2/2 >13X <93% 0/1 <100% <100% 2/0 >100% >100% 2/1 >54% >98% Kick No. in group with behaviour f: d: 1/3 <88% <95% 1/3 <56% <66% 0/1 <100% <100% 1/2 <82% <93% 0/1 <100% <100% 1/2 <48% <64% Cry/Sob No. in group with behaviour f: d: 8/7 >35% >46% 8/7 >25% <20% 4/4 >27% >64% 4/3 >45% >27X 4/4 >16% > 3% 4/3 >37% <50% Sc ream/ExcIama t i on No. in group uith behaviour 4/1 f: >12% d: <63% 2/3 >48% >63% 1/1 <59% <100% 1/0 >100% >100% 1/3 <45% <100% 1/0 >100% >100% * P < .05 (Table continues) 7 9 Table 2 Percentage Difference Between Groups for Frequency (f) and Duration (d) of Behaviours Group Behaviour Parent Present/ Female/ Parent Absent Hale Female Parent Male Parent Female and Male Female and Male Present/Absent Present/Absent Parent Present Parent Absent Smi I e No. in group with behaviour f: d: 2/1 <10X >25X 2/1 >69% >76X 1/1 <55X >13X 1/0 >100X >100X 1/1 <1X >48X 1/0 >100X >100% Grimace/Frown No. in group uith behaviour f: d: 5/6 <17X >80% 5/6 >21X <75X 3/2 <47X >34% 2/4 >30X >87X 3/2 <25% <83X 2/4 >50X <12% Reach for body contact/hugs No. in group uith behaviour 4/1 4/1 3/1 f: >81X >92X >80X d: >95% >100X >95X 1/0 >100X 3/1 >90X >100X VO >100X >100X Being Held No. in group uith behaviour f: d: 7/1 >90X * >98X * 4/4 > 7X >22X 4/0 >100X * >100X * 3/1 >77X >94X 4/3 >24X >26X 0/1 <100X <100X C/o pain - unsolicited No. in group uith behaviour 4/3 f: >39X 5/2 >73X 3/2 >30X 1/1 >66X 3/1 >66X 2/1 >83X C/o pain - s o l i c i t e d No. in group uith behaviour 7/8 f: <17X 8/7 >50X 4/4 <12X 3/4 <26X 4/3 >54X 4/4 >45X No c/o pain • s o l i c i t e d No. in group uith behaviour 1/4 f: <77X 1/4 <84X 0/1 <100X 1/3 <72X 0/1 <100X 1/3 <80X Fluid request - unsolicited No. in group uith behaviour 3/1 f: >52X 2/2 >14X 2/0 >100X 1/1 <58X 2/1 >75X 0/1 <100X Yes to fluids No. in group uith behaviour f: * P < .05 5/4 >30X 3/6 <35X 2/1 >87% 3/3 2/3 1/3 <34X , >31X <88X (Table continues) 80 Table 2 Percentage Difference 8etween Groups for Frequency (f) and Duration (d) of Behaviours Group Behaviour Parent Present/ Female/ Parent Absent Male Female Parent Male Parent Female and Male Female and Male Present/Absent Present/Absent Parent Present Parent Absent No to fl u i d s No. in group with behaviour f: 3/2 >48X 2/3 <43X 1/1 >22X 2/1 >60X 1/2 <55X 1/1 <13X Takes f l u i d s No. in group with behaviour f: d: 9/8 >37% >42X * 9/8 >30X <33X 5/4 >49X >75X 4/4 >18X > 8X 5/4 >42X > 2X 4/4 > 6X <72X Asks for mom on own No. in group with behaviour 0/6 f: <100X 2/4 <78X 0/2 <100X 0/4 <100X 0/0 2/4 <78X Wants mom when asked No. in group with behaviour 0/5 f: <100X 4/1 >72X 0/4 <100X 0/1 <100X 0/0 4/1 <72X Hisc c/o - unsolicited No. in group with behaviour 6/2 f: >48X 4/4 <29X 4/0 >100X 2/2 >29X 4/2 >41X 0/2 <100X Misc c/o - s o l i c i t e d No. in group with behaviour 2/1 f: >48X 2/1 >82X 1/1 <72X 1/0 >100X 1/1 >16X 1/0 >100X Refusal Behaviour No. in group with behaviour 2/2 f: <86X 3/1 >73X 2/1 <82X 0/1 <100X 2/0 >100X 1/1 >68X Yes to medication No. in group with behaviour 0/3 f: <100X 3/0 >100X 0/3 <100X 0/0 0/0 3/0 >100X No to medication No. in group with behaviour 2/1 f: >33X 1/2 <60X 1/0 >100X 1/1 <10X 1/1 <33% 0/1 <100X * P < .05 81 Parent-Present versus Parent-Absent As can be seen i n Table 2 on p. 78, children i n the parent-absent group demonstrated more body movement and les s v o c a l i z a t i o n than children i n the parent-present group. Although a l l childr e n i n both groups rubbed t h e i r eyes, children i n the parent-absent group demonstrated t h i s behaviour with greater frequency and duration. Fewer children i n the parent-absent group demonstrated protective behaviour but on average they demonstrated t h i s behaviour with greater frequency and duration than childr e n i n the parent-present group. Children i n the parent-absent group demonstrated touch, reaching for eyes, and kicking with greater frequency and duration than childr e n i n the parent-present group. When children were asked whether they were having pain or were sore, children i n the parent-absent group denied having pain with greater frequency than children i n the parent-present group. While r e f u s a l behaviour was demonstrated by an equal number of children i n the two groups, childre n i n the parent-absent group demonstrated t h i s behaviour with more frequency than children i n the parent-present group. Children i n the parent-present group expressed u n s o l i c i t e d complaints of pain, u n s o l i c i t e d requests for f l u i d s , and u n s o l i c i t e d miscellaneous complaints more frequently than ch i l d r e n i n the parent-absent group. Children i n the parent-present group also drank more frequently and f o r longer, reached for body contact and hugs more frequently, and were held more frequently and f o r longer than children i n the parent-absent group. While only one c h i l d i n the parent-absent group was held, i t i s i n t e r e s t i n g to note that not a l l parents picked up 82 t h e i r c h i l d r e n despite being previously t o l d by the researcher that they could. In fact, three of the ten ch i l d r e n i n the parent-present group were not picked up by t h e i r parent. A l l c h i l d r e n i n the parent-absent group expressed a desire to have t h e i r mother with them. Six of these childr e n spontaneously asked to have t h e i r mother while the other four answered yes when t h e i r nurse asked i f they wanted t h e i r mothers. The number of times a c h i l d asked f o r his/her mother ranged from 2 to 36. Females versus Males Females demonstrated rubbing, protective behaviour, touching, reaching f o r eyes, crying/sobbing, and screaming/exclaiming with greater frequency and duration than males. One female i n the parent-present group sobbed f o r almost the e n t i r e time she was i n PARR, including time periods during which she appeared to be sleeping. Screaming was usually associated with getting an i n j e c t i o n . Females reached f o r body contact and hugs more frequently than males but males asked for t h e i r mothers more frequently. Females complained of pain more frequently both v o l u n t a r i l y and when asked while males denied having pain more frequently when asked. Consistent with t h i s i s the f a c t that more females said yes and more males said no to pain medication when asked. Refusal behaviour was demonstrated more frequently by females than males. Other Findings In t h i s study, 17 of the 20 children complained of pain. Although 7 of these 17 children made u n s o l i c i t e d complaints of 83 p a i n , the o t h e r 10 d i d not complain o f p a i n u n t i l asked. Of the 3 remaining c h i l d r e n who d i d not v e r b a l l y acknowledge p a i n , one was asked i f she was having p a i n and d i d not answer and the o t h e r two were not asked. A n a l g e s i c m e d i c a t i o n was g i v e n t o 14 of the 20 c h i l d r e n i n the study. Of the 14 c h i l d r e n who r e c e i v e d a n a l g e s i c s , 3 s a i d yes when asked i f they wanted p a i n m e d i c a t i o n and the o t h e r 11 were not asked i f they wanted p a i n m e d i c a t i o n . Two o f these c h i l d r e n who were not asked e i t h e r whether they were having p a i n o r whether they wanted p a i n m e d i c a t i o n , were g i v e n a n a l g e s i c m e d i c a t i o n . Of the 6 c h i l d r e n who were not g i v e n a n a l g e s i c m e d i c a t i o n , 3 s a i d no when asked i f they wanted p a i n m e d i c a t i o n and 3 were not asked i f they wanted p a i n m e d i c a t i o n . The t h r e e c h i l d r e n who s t a t e d they d i d not want p a i n m e d i c a t i o n had p r e v i o u s l y s t a t e d t h a t they were having p a i n . F l u i d s , e i t h e r i n the form o f j u i c e o r p o p s i c l e s , were taken by 17 o f the 20 c h i l d r e n i n the study. Three of these r' c h i l d r e n asked f o r f l u i d s on t h e i r own and one c h i l d asked f o r f l u i d s but d i d not d r i n k them when o f f e r e d . Of the o t h e r 16 c h i l d r e n i n the study, 13 were asked whether they wanted f l u i d s . F i v e c h i l d r e n s a i d no but f o u r o f these d i d take some f l u i d s d u r i n g t h e i r PARR s t a y . Of the o t h e r 9 c h i l d r e n who were g i v e n f l u i d s , 3 were not asked i f they wanted f l u i d s and 3 d i d not answer when asked. Summary The f i n d i n g s o f K r u s k a l - W a l l i s one-way a n a l y s i s o f v a r i a n c e as w e l l as f u r t h e r d e s c r i p t i v e a n a l y s e s demonstrate t h a t t h e r e 84 are s i g n i f i c a n t differences i n the behaviour of postoperative preschool age children i n the p e d i a t r i c recovery room when parents are and are not present. In summary, s t a t i s t i c a l l y s i g n i f i c a n t differences were found between childre n i n the parent-present and parent-absent groups with childr e n i n the parent-present group being held more frequently and for longer, drinking for longer, and demonstrating protective behaviour with le s s frequency and shorter duration than children i n the parent-absent group. Females demonstrated rubbing behaviour with s i g n i f i c a n t l y more frequency and duration than males. Other s t a t i s t i c a l l y s i g n i f i c a n t differences included males i n the parent-absent group di s p l a y i n g protective behaviour of greater duration than males i n the parent-present group and females i n the parent-present group being held more frequently and for longer, drinking f o r longer, and v e r b a l i z i n g voluntary miscellaneous complaints more frequently than females i n the parent-absent group. Further de s c r i p t i v e analyses i d e n t i f i e d more differences between groups than Kruskal-Wallis one-way analysis of variance. These differences included children i n the parent-present group demonstrating less body movement and more v o c a l i z a t i o n than ch i l d r e n i n the parent-absent group. Children i n the parent-present group also expressed more complaints, demonstrated more re f u s a l behaviour, drank more, and sought body contact more frequently than children i n the parent-absent group. Discussion of these i n t e r e s t i n g findings and t h e i r s i g n i f i c a n c e follows i n the next chapter. 85 Chapter Five DISCUSSION and IMPLICATIONS This study explored the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room by addressing three questions: 1. Do childre n who have t h e i r parents with them i n the recovery room display d i f f e r e n t behaviours than those whose parents are not with them? 2. What are the d i f f e r e n t behaviours displayed by children whose parents are with them and children whose parents are not with them? 3. Do children who have t h e i r parents with them i n the recovery room display pain behaviour that i s d i f f e r e n t than that demonstrated by children whose parents are not with them? In t h i s chapter, the research findings described i n the previous chapter are discussed; i n addition, nursing implications of the research findings are presented. In order to a s s i s t the reader to c l e a r l y understand the context i n which the findings are discussed, l i m i t a t i o n s of the research study are reviewed p r i o r to the discussion of the research findings. Limitations Several major l i m i t a t i o n s of t h i s study are acknowledged. For l o g i s t i c a l reasons, children i n the study were not a l l cared for by the same anesthetic or nursing s t a f f . Therefore, the e f f e c t of the care giver on the c h i l d ' s behaviour could not be co n t r o l l e d f o r . However, even i f a l l the children had been cared for by the same s t a f f members, i t would have been 86 d i f f i c u l t to control for other factors including mood of the s t a f f members and noise l e v e l i n the PARR. In addition, parental anxiety l e v e l s were not measured and the e f f e c t of parental anxiety on the c h i l d ' s behaviour could not be cont r o l l e d f o r . I t has been suggested by several authors that a highly anxious parent may transmit t h i s emotional state to the c h i l d , thereby i n t e n s i f y i n g the c h i l d ' s own fear and anxiety (Jay, Ozolins, & E l l i o t , 1983; Kl i n z i n g & Kli n z i n g , 1977; Lutz, 1986; Wolfer & V i s i n t a i n e r , 1975). The majority of children i n the study received analgesic medication during t h e i r stay i n the Recovery Room. Although no attempt was made by the researcher to correlate differences i n behaviour displayed by a c h i l d before and a f t e r receiving t h i s medication, i t i s recognized that analgesic medication may have affected the behaviour observed. I t should be noted however that the majority of the behaviour observed was demonstrated before the analgesic would have begun to take e f f e c t as most of the c h i l d r e n l e f t the Recovery Room approximately one-half hour a f t e r receiving an analgesic. Data were c o l l e c t e d i n t h i s study by videotaping a l l of the subjects during t h e i r stay i n PARR. While t h i s proved to be an e f f e c t i v e means of capturing a r i c h assortment of data, some data were l o s t when the camera was obstructed by s t a f f and/or parents and when the c h i l d turned away from the camera. F a c i a l expression was not well captured on the videotape as the camera had to be placed f a r enough from the c h i l d to capture a l l body movement. At the expense of d e t a i l of f a c i a l expression, which would require close-up, use of two cameras would a s s i s t i n 87 preventing loss of data. Lack of time overlay on the videotapes made coding of the videotapes more d i f f i c u l t . F i n a l l y , given the siz e and nature of the sample, the research findings are s p e c i f i c to the study group and cannot be considered broadly generalizable. Discussion of Findings S t a t i s t i c a l l y s i g n i f i c a n t differences between the parent-present versus the parent-absent groups were found for 3 of the 26 items on the behavioural c h e c k l i s t . Children i n the parent-present group were held more frequently and f o r longer, drank more frequently and f o r longer, and demonstrated protective behaviour l e s s frequently and f o r shorter duration than children i n the parent-absent group. Discussion of these findings i s integrated with the discussion of findings of further d e s c r i p t i v e analyses which demonstrated other differences between the parent-present versus parent-absent groups considered noteworthy by the researcher. Tools used to assess p e d i a t r i c pain often r e l y on proj e c t i v e techniques or behavioural observation. Behavioural observation t o o l s usually include observations of body movement, f a c i a l expression, and v o c a l i z a t i o n (Craig, Mcmahon, Morison, & Zaskow, 1984; McCaffrey, 1969; McGrath, Johnson, Goodman, S c h i l l i n g e r , Dunn, & Chapman, 1985). Children i n both groups demonstrated many behaviours, such as rubbing, protective behaviour, crying, screaming, and frowning, which are commonly included i n p e d i a t r i c pain assessment t o o l s . This suggests that, although many of these too l s have not been tested for 88 v a l i d i t y and r e l i a b i l i t y , they are useful as one means of assessing p e d i a t r i c pain. In the following section of the chapter, the research findings are discussed using the framework of the behavioural c h e c k l i s t (see Appendix F, p. 130). As body movement, vo c a l i z a t i o n , and f a c i a l expression are the items most commonly found on p e d i a t r i c pain assessment t o o l s , these items are discussed f i r s t . Body Movement As can be seen i n Table 2 on p. 78, a l l behaviours i n t h i s category, with the exception of purposeless behaviour, were demonstrated with greater frequency and duration by childr e n i n the parent-absent group than the parent-present group. Purposeless, protective, and rubbing behaviour was displayed by more than h a l f the children i n the study while touch, reaching for t h e i r eyes, and kicking behaviour was displayed by le s s than h a l f the childr e n i n the study. This difference i n the behaviour displayed by d i f f e r e n t children i n the study supports the following assumptions which were stated i n Chapter One: (a) the pain experience i s d i f f e r e n t for every c h i l d even when the pain experience i s the same and the c h i l d ' s pain i s evident through the behavioural response to the stimulus and (b) "pain i s interwoven with emotions such as fear, anger, loneliness, and anxiety, and thus some of the emotion beyond the pain i t s e l f may account f o r the behaviours observed" (Smith, 1976, p. 205). Children i n the parent-present group were frequently t o l d by t h e i r parents not to rub t h e i r eyes. Nonetheless, these ch i l d r e n continued to do so. On some occasions, childr e n who 89 were reaching f o r t h e i r eyes were stopped by t h e i r parents but as soon as the parent l e t go of the c h i l d ' s hand the c h i l d would once again reach for or rub the eye. Both rubbing and protective behaviour can be described as means of attempting to reduce the discomfort associated with the surgery. Adults frequently describe the f e e l i n g of having sand i n the eye following strabismus repair and rubbing i s an i n s t i n c t i v e response to t h i s sensation. In the researcher's experience, increased s e n s i t i v i t y to and discomfort i n bright l i g h t i s a common complaint of children following strabismus rep a i r . While most children i n the study kept t h e i r eyes closed the majority of the time, protective behaviour was seen both when they had t h e i r eyes open and closed and was seldom used to keep the nurse from inspecting the operative s i t e . This behaviour was displayed with s i g n i f i c a n t l y l e s s frequency and duration by childr e n i n the parent-present group than children i n the parent-absent group. Touching behaviour was b r i e f i n duration and appeared to be very gentle and exploratory i n nature, that i s , the children appeared to be making sure that t h e i r eyes were s t i l l there and a l r i g h t . I t d i d not appear that touching was used to reduce discomfort. Kicking was demonstrated by only four childr e n but three of those were from the parent-absent group. Kicking i s described by some authors as a pain behaviour (Gross & Gardner, 1980; McGrath, Johnson, Goodman, S c h i l l i n g e r , Dunn, & Chapman, 1985; Smith, 1976) but i n the researcher's experience, t h i s behaviour i s also demonstrated by children who are f e e l i n g frustrated or angry. In t h i s study, the researcher concluded that one c h i l d 90 i n the parent-absent group demonstrated kicking behaviour to express fee l i n g s of f r u s t r a t i o n and/or anger. No conclusion was reached regarding the meaning of the kicking behaviour of the other three children. Of the four behaviours described i n the preceding section, that i s , rubbing, protective, purposeless, and kicking, the behaviours of rubbing and s e l f - p r o t e c t i o n are considered by the researcher to be means of coping with pain. Considering these behaviours as pain coping mechanisms can lead to one of two conclusions: (a) children i n the parent-absent group experienced more pain than childr e n i n the parent-present group, or (b) c h i l d r e n i n the two groups experienced the same amount of pain but coped with i t i n d i f f e r e n t ways. Purposeless behaviour i s not a behaviour usually included on pain too l s but i t was included f o r the purposes of t h i s study as i t i s the researcher's experience that childr e n emerging from anesthetic usually demonstrate purposeless behaviour. Children i n the parent-present group demonstrated such behaviour with greater frequency and duration than children i n the parent-absent group. Children i n the parent-absent group were stimulated by the nurse only during the taking of v i t a l signs or attempts to rouse the c h i l d . Children i n the parent-present group received more stimulation as parents s i t t i n g with t h e i r c h i l d were frequently observed to be t a l k i n g to the c h i l d and/or stroking the c h i l d . This difference i n stimulation may account for the difference i n purposeless behaviour between the two groups. Non-Verbal Vo c a l i z a t i o n V o c a l i z a t i o n behaviour was condensed to two data categories on the f i n a l behavioural c h e c k l i s t - crying/sobbing and screaming/exclaiming as defined i n Appendix E (see p. 127). Crying/sobbing was demonstrated by 8 children i n the parent-present group versus 7 children i n the parent-absent group. Screaming/exclaiming was demonstrated by 4 children i n the parent-present group versus 1 c h i l d i n the parent-absent group. Children i n the parent-present group demonstrated crying/sobbing with greater duration and both crying/sobbing and screaming/exclaiming more frequently than c h i l d r e n i n the parent-absent group. Only one c h i l d i n the parent-absent group demonstrated screaming/exclaiming but she d i d so with greater frequency and duration than any c h i l d i n the parent-present group. While i t may be that t h i s i s the c h i l d ' s usual behaviour when she i s separated from her parents, placed i n an unfamiliar environment, or experiencing pain, there may i n fact be reasons other than these for t h i s behaviour. Nonetheless, the researcher concluded that t h i s behaviour was the c h i l d ' s way of expressing her fear and anxiety i n t h i s unfamiliar environment. Crying has been described by some authors as a negative behaviour i n reports of studies of the e f f e c t of parental presence on children's behaviour during dental procedures and anesthetic induction (Frankl, Shiere, & Fogels, 1962; Shaw & Routh, 1982). Shaw and Routh (1982) concluded, however, that the presence of the c h i l d ' s mother acted as a d i s i n h i b i t o r as the c h i l d r e n f e l t more secure i n t h e i r mothers' presence and were therefore more l i k e l y to express t h e i r f e e l i n g s . 92 Hunsberger, Love, and Byrne (1984) stated that "often the crying or fussing c h i l d i s equated with the non-coping c h i l d " (p. 152). In t h i s study, crying/sobbing and screaming/exclaiming appeared to be used as e f f e c t i v e coping mechanisms. Parents reacted to t h e i r c h i l d ' s crying/sobbing and screaming/exclaiming by t a l k i n g to the c h i l d i n a soothing voice, by stroking some part of the c h i l d ' s body, or by holding the c h i l d . Although three c h i l d r e n i n the parent-present group were never picked up and held by t h e i r parent, i t i s i n t e r e s t i n g to note that two of these c h i l d r e n never demonstrated crying/sobbing or screaming/exclaiming behaviour. Although nursing s t a f f also talked to or stroked childr e n demonstrating these behaviours, they did so le s s frequently than parents did and f o r shorter time periods. Only one c h i l d i n the parent-absent group was picked up and held by a nurse. In the researcher's opinion, childre n i n the parent-absent group demonstrated these behaviours with less frequency and duration because they may not have perceived them as leading to the comfort they sought. F a c i a l Expression As stated previously, f a c i a l expression was very d i f f i c u l t to code from the videotapes. Grimacing/frowning was demonstrated by 5 children i n the parent-present group and 6 c h i l d r e n i n the parent-absent group. Children i n the parent-absent group demonstrated grimacing/frowning le s s frequently but with greater duration than children i n the parent-absent group. This suggests once again that children i n the parent-absent group e i t h e r experienced more pain than children i n the parent-present group or coped with i t i n d i f f e r e n t ways. 93 Reaching for Body Contact/Hugs This behaviour was displayed by f i v e c h i l d r e n i n t o t a l . Four of these children were from the parent-present group and one of these four was not held by her parent. This behaviour suggested to the researcher that children i n the postoperative period w i l l i n i t i a t e body contact and hugging with a parent but w i l l not usually do so with a previously unknown care giver. As nursing s t a f f d i d not i n i t i a t e hugging or body contact, i t i s not known whether the children i n t h i s group would have allowed themselves to be hugged or held by a nurse who d i d i n i t i a t e t h i s behaviour. I t i s the researcher's opinion that the childr e n who demonstrated t h i s behaviour did so i n order to be comforted by t h e i r parents. Therefore, h o s p i t a l p o l i c i e s which do not permit parental v i s i t i n g i n the recovery room deny childre n the opportunity to seek comfort from and be comforted by t h e i r parents. Being Held As stated previously, seven children i n the parent-present group and one c h i l d i n the parent-absent group were picked up and held. In viewing the videotapes, i t was observed that some parents appeared p h y s i c a l l y uncomfortable a f t e r holding t h e i r c h i l d f o r prolonged periods of time. Nonetheless, they continued to hold t h e i r c h i l d and i n several cases, the c h i l d was not returned to the bed u n t i l i t was time to take the c h i l d to the Surgical Day Care Unit. The one c h i l d who was picked up and held by a nurse asked to be put back to bed a f t e r a short period of time. None of the children held by parents spontaneously asked to return to bed. Although there may be many reasons why the c h i l d i n the parent-absent group was the only one who asked to go back to bed, i t i s the researcher's opinion that t h i s c h i l d may have made the request as he did not f e e l as safe and secure with the nurse as he does with h i s parent. I t i s i n t e r e s t i n g to note that not a l l parents automatically picked up and held t h e i r c h i l d . Parents who did hold t h e i r c h i l d r e n d i d so only a f t e r asking the nurse i f i t was a l l r i g h t to do so. Although two of the chi l d r e n i n the parent-present group did not demonstrate crying/sobbing during t h e i r PARR stay, i t seems reasonable to suggest, based on the behaviour of parents who did pick up t h e i r children, that the other parents would have picked up t h e i r c h i l d r e n i f the nurse had taken the i n i t i a t i v e to t e l l them i t was a l r i g h t to do so. In the researcher's experience, nurses working i n the PARR i n which the study was done often hold infants who are crying but seldom pick up and hold older children. This nursing behaviour may be a function of the patient assignment i n the PARR. Each nurse i s assigned two patients and while i t may be possible to move around e a s i l y and observe a second patient while holding an infant, i t i s not as easy to do t h i s while holding a preschool age c h i l d . In many cases, the nurses w i l l c a l l the c h i l d ' s parent into the PARR, contrary to current PARR po l i c y , i n order to comfort the c h i l d rather than pick up and hold the c h i l d themselves. This behaviour demonstrates that nursing s t a f f believe that parents can play an important r o l e i n the Recovery Room and therefore supports the argument for parental v i s i t i n g i n t h i s s e t t i n g . 95 Pain Complaints Pain complaints were separated into two categories i n the data coding - those that were u n s o l i c i t e d or made spontaneously by the c h i l d and those that were made when the c h i l d was asked "Does i t hurt?", "Are your eyes sore?", "How do your eyes f e e l ? " , "Are your eyes ok?", and other s i m i l a r questions. Four ch i l d r e n i n the parent-present group and three childr e n i n the parent-absent group spontaneously complained of pain but chil d r e n i n the parent-present group complained more frequently. When asked i f they were having pain, seven childr e n i n the parent-present group and eight children i n the parent-absent group stated they were, but one c h i l d i n the parent-present group and four children i n the parent-absent group stated they were not. Four childr e n answered both yes and no when asked i f they were having pain. No c o r r e l a t i o n could be seen between the change i n answer and the c h i l d having received pain medication. However, two of the children changed t h e i r answer from yes to no a f t e r being asked i f they wanted some medicine "to make t h e i r eyes f e e l better". This behaviour suggests that these two chil d r e n wished for some reason to avoid taking the medicine offered and therefore changed t h e i r answer to no. Although i t has been suggested by some authors that young chi l d r e n cannot accurately report on t h e i r pain experience (Lynn, 1986; McBride, 1977), others suggest that child r e n as young as three and four years of age are able to report accurately on both l o c a t i o n and i n t e n s i t y of pain (Aradine, Beyer, & Tompkins, 1988; Eland, 1977). The findings of t h i s study support the b e l i e f that children as young as three years of age can accurately report on the presence or absence of pain. As no attempts were made to have the childr e n quantify t h e i r pain experience, no conclusion can be drawn regarding the accuracy of young childre n i n reporting pain i n t e n s i t y . The only s i g n i f i c a n t difference i n pain reporting behaviour between groups was that those children i n the parent-present group complaining of pain d i d so more frequently than children i n the parent-absent group. I t i s assumed that most parents would normally attempt to respond to t h e i r c h i l d ' s pain complaints with some form of action (Hunsberger, Love, & Byrne, 1984; Jay, Ozolins, & E l l i o t , 1983; Stevens, Hunsberger, & Browne, 1987) . Therefore, i t i s l i k e l y that childr e n i n the parent-present group continued to complain with the expectation that t h e i r parent would help them i n some way. Hunsberger, Love, and Byrne (1984) suggested that because of the t r u s t r e l a t i o n s h i p between the parent and the c h i l d , the parent can help the c h i l d i d e n t i f y and express t h e i r concerns. I t i s the researcher's opinion that childr e n i n the parent-absent group may have stopped complaining when they did not get the response from the nurse, f o r example being picked up and held, that they would normally have gotten from t h e i r parent. I t may also be true that childr e n i n the parent-absent group did not f e e l safe enough with the nurse to continue to complain. As i d e n t i f i e d previously, these children demonstrated more rubbing of t h e i r eyes and s i g n i f i c a n t l y more protective behaviour than children i n the parent-present group did i n order to cope with the pain experience. The most s i g n i f i c a n t finding regarding pain reporting behaviour i s that although 35% of the children i n the study made u n s o l i c i t e d complaints of pain, 75% of children i n the study complained of pain when asked. Thus, i t appears that the most important component of the nurse's assessment of the c h i l d ' s pain, that i s , the c h i l d ' s perception of the pain experience, i s one which the nurse must a c t i v e l y s o l i c i t . Without t h i s information, the pain assessment of a conscious c h i l d cannot be said to be complete (Beales, 1982). Fluids F l u i d s , e i t h e r i n the form of j u i c e or popsicles, were taken by 9 chi l d r e n i n the parent-present group and 8 children i n the parent-absent group. Children i n the parent-present group asked more frequently for f l u i d s and responded more frequently to o f f e r s of f l u i d s than children i n the parent-absent group. Although there were no s i g n i f i c a n t differences i n the number of children i n each group who took f l u i d s , children i n the parent-present group drank f o r s i g n i f i c a n t l y longer than childre n i n the parent-absent group. Children i n the parent-present group drank 37% more frequently and 42% longer than ch i l d r e n i n the parent-absent group. Children having a general anesthetic are required to fast f o r at l e a s t s i x hours p r i o r to surgery and intravenous f l u i d s are not rout i n e l y administered i n the Operating Room to children having strabismus repair. Fluids are routinely offered i n the Recovery Room i n order to o f f s e t any dehydration the c h i l d may experience as a r e s u l t of fa s t i n g . Rehydration contributes to the c h i l d ' s f e e l i n g of well-being postoperatively and, as can be seen, childr e n i n the parent-present group received more f l u i d s 98 than c h i l d r e n i n the parent-absent group. Although almost equal numbers of c h i l d r e n i n both groups were given popsicles, c h i l d r e n i n the parent-absent group were frequently observed not to eat the popsicle or to f a l l asleep while holding the popsicle. Children i n the parent-present group received both encouragement and help i n eating the popsicle and usually f i n i s h e d the popsicles they were given. Thus, i t can be seen that parents played an important r o l e i n f a c i l i t a t i n g the c h i l d ' s rehydration and consequently the c h i l d ' s recuperation. I t appears that the o f f e r i n g of f l u i d s has become so routine f o r nurses i n the Recovery Room that, i n some cases, they neither asked the children i f they wanted f l u i d s nor gave them a choice i n the type of f l u i d s they were given. In fact, three c h i l d r e n who were not asked i f they wanted f l u i d s , three childre n who were asked but did not answer, and four children who said they d i d not want f l u i d s were given f l u i d s anyway. This behaviour on the part of nursing s t a f f demonstrates an inconsistency i n practice which must be altered i f patients are to believe that they can have input regarding the care they are to receive. Requests for Mother I t i s natural that chil d r e n i n the parent-absent group were the only c h i l d r e n to ask for t h e i r mothers. I t i s i n t e r e s t i n g to note, however, that no children i n the parent-present group asked for the other, non-attending parent. Although only s i x of the childr e n i n the parent-absent group made u n s o l i c i t e d requests f o r t h e i r mothers, a l l children nodded yes when asked i f they wanted to go see t h e i r mothers. 99 Many of the ch i l d r e n i n t h i s group were crying at the same time that they were asking for t h e i r mother. Only one c h i l d asked for h i s father and he alternated t h i s with h i s request for h i s mother. I t i s the researcher's b e l i e f that chil d r e n asked for t h e i r parents i n order to be comforted and f e e l more secure i n an unfamiliar environment. Although males made more u n s o l i c i t e d requests f o r t h e i r mothers, the researcher i s unable to provide an explanation f o r t h i s gender difference. Miscellaneous Complaints Miscellaneous complaints included "I'm dizzy", "I can't see", "I'm t h i r s t y " , "I want the covers on", "I'm t i r e d of rocking", "I want to go back to bed", "I'm hungry", "I want my soother", "I want to get up", " I t ' s too bright", and "I'm t i r e d " . The same complaint was seldom repeated more than twice by one c h i l d and none of the complaints i d e n t i f i e d were voiced by more than two children. Children i n the parent-present group voiced miscellaneous u n s o l i c i t e d and s o l i c i t e d complaints 48% more frequently than ch i l d r e n i n the parent-absent group and although a l l childr e n who were asked a question which related to a miscellaneous complaint responded with a complaint, nine childr e n were never asked t h i s type of question. Seven of these nine childr e n were from the parent-absent group. I t i s l i k e l y that i f these ch i l d r e n had been asked i f they had complaints, the answer would have been yes. Once again, i t appears that while childr e n i n the parent-present group were comfortable i n expressing t h e i r complaints to t h e i r mother, children i n the parent-absent group were not comfortable i n spontaneously expressing t h e i r 1 0 0 complaints to an unknown care giver. These findings also suggest that nursing s t a f f were more apt to ask the c h i l d about complaints when a parent was present and observing the qu a l i t y and quantity of care t h e i r c h i l d was receiving. The other s i g n i f i c a n t f inding regarding miscellaneous complaints was that four children i n the parent-present group asked to go home. Given that they were i n an unfamiliar environment but had t h e i r mother with them, i t seems l o g i c a l that these c h i l d r e n would ask to return to a f a m i l i a r environment. I t i s the researcher's opinion that these children f e l t more secure with t h e i r parents and wanted to achieve a greater f e e l i n g of security by going home whereas childre n i n the parent-absent group attempted to reach the same, i n i t i a l l e v e l of se c u r i t y by getting t h e i r parent to be with them. Refusal Behaviour Refusal behaviours included pushing away medication, pushing away f l u i d s , p u l l i n g away from nurse during taking of v i t a l signs, refusing to put on a h o s p i t a l gown, and refusing to go back to bed. Although t h i s behaviour was demonstrated by an equal number of childr e n i n the parent-present and parent-absent groups, c h i l d r e n i n the parent-absent group demonstrated refusal behaviour 86% more frequently. I t was noted that when children i n the parent-present group demonstrated r e f u s a l behaviour t h e i r parents usually convinced them or attempted to convince them to carry out the desired action. In most cases, parents are w i l l i n g partners i n the care of t h e i r c h i l d provided they are given the opportunity and encouragement to a s s i s t i n the c h i l d ' s care. 101 Response to Offer of Pain Medication Six of the twenty children were asked i f they wanted pain medication. An equal number of children answered yes and no to t h i s question yet a l l of them stated that they were having pain when asked. Although i t i s not possible to state why the ch i l d r e n answered i n t h i s way, i t i s l i k e l y that the children's responses r e l a t e to t h e i r previous experience with medication. I f , i n the c h i l d ' s past experience, the c h i l d had received medication and f e l t better because of i t , i t i s more l i k e l y that the c h i l d would have answered yes to the o f f e r of pain medication. I f , i n the c h i l d ' s past experience, the c h i l d received medication that tasted bad or d i d not make the c h i l d f e e l better or the c h i l d has been t o l d that medicine i s a bad thing, i t i s more l i k e l y that the c h i l d would answer no to the o f f e r of pain medication. Thus, management of the c h i l d ' s pain could be improved i f the nurse was knowledgeable regarding the c h i l d ' s previous experience with pain and pain medication. Based on t h i s review and discussion of the findings s p e c i f i c to items on the behavioural c h e c k l i s t , i t can be concluded that childr e n who have t h e i r parents with them i n the recovery room display general behaviours which are s i m i l a r to those demonstrated by children whose parents are not with them. However, i t can also be said that there are s i g n i f i c a n t and meaningful differences between these two groups i n the frequency and duration of some of the behaviours displayed. These differences led the researcher to the conclusion that although ch i l d r e n who have t h e i r parents with them do not display pain behaviour that i s d i f f e r e n t than that demonstrated by children 1 0 2 whose parents are not with them, these two groups of children cope with the pain experience i n d i f f e r e n t ways. Simply stated, c h i l d r e n with parents make more attempts to cope with the pain experience by crying and verbal complaining, perhaps with the expectation that t h e i r parent w i l l comfort them, whereas chi l d r e n without parents make more attempts to cope with the pain experience by t r y i n g to reduce the pain themselves through rubbing and protective behaviour. Observations Of and By Parents While i t was not the researcher's intention to study the parents behaviour i n the PARR, i t i s worthwhile to comment on some observations made during the research study. F i r s t , a l l of the parents when approached regarding t h e i r c h i l d ' s i n c l u s i o n i n the research study stated that they wished to be with t h e i r c h i l d i n the Recovery Room. Yet, no parents withdrew t h e i r c h i l d from the study when they discovered that t h e i r c h i l d would be i n the parent-absent group. These parents indicated that they f e l t the research project was important and expressed the hope that i f t h e i r c h i l d had to have surgery again, the research study would have demonstrated that a l l parents should be allowed i n the Recovery Room and they would be able to be with t h e i r c h i l d the next time. Several of the parents i n the parent-present group t o l d the researcher that they f e l t better knowing they would be with t h e i r c h i l d i n the Recovery Room. In addition, two comments noted on the videotape were "I wish I could have done t h i s the f i r s t time" and "She'd be d i f f e r e n t i f I weren't here". This l a s t comment was made by a mother whose c h i l d rested q u i e t l y on her lap for most of the PARR stay. The researcher noted that many parents seemed hesitant i n touching t h e i r c h i l d at f i r s t and frequently required encouragement to do so. Most parents also seemed hesitant to make requests of the nursing s t a f f . In addition, during the periods i n which t h e i r children were sleeping, many parents who were seen to be looking around the room appeared anxious. Some of the parents conversed f r e e l y with the person doing the videotaping but conversations between parents and the nursing s t a f f were l i m i t e d . This may have occurred for three reasons. F i r s t , the person doing the videotaping was near the c h i l d ' s stretcher at a l l times. I t may be that the parent was bored or thought the person doing the videotaping was bored and therefore i n i t i a t e d conversation as a method of diversion. Second, the person doing the videotaping may have been perceived by the parents to be les s threatening and less invested i n t h e i r c h i l d ' s care. F i n a l l y , the nursing s t a f f i n the Recovery Room often appear to be very busy and the parent may not have f e l t i t was appropriate to engage the nursing s t a f f i n conversation. However, i f parental v i s i t i n g i n the recovery room i s to become a routine practice, nursing s t a f f must not only develop more s e n s i t i v i t y to the needs of the parent and recognize that parental anxiety may be transmitted to the c h i l d (Klinzing & Kl i n z i n g , 1977), they must also develop the s k i l l to i n i t i a t e therapeutic interactions which serve to reduce parental anxiety. 104 Observations of Nursing Practice While i t was also not the researcher's purpose to observe nursing p r a c t i c e i n the PARR, i t i s worthwhile to comment on some observations made during the research study. Assessment of pain i n p e d i a t r i c patients i s recognized as being a d i f f i c u l t problem (Abu-Saad, 1984; Jeans, 1983a). In the researcher's opinion, obtaining the c h i l d ' s perception of the pain experience i s one of the most important aspects of the PARR assessment process. In t h i s study, a l l but two of the chi l d r e n were asked at l e a s t one question r e l a t i n g to t h e i r perception of t h e i r pain. I t was noted that many of the nurses asked what could be considered leading questions such as "Are your eyes sore? 1 and "Do your eyes hurt?" rather than neutral questions such as "How do your eyes f e e l ? " . I t i s unknown whether the type of questioning influenced the childrens• responses to the nurses questioning but i t i s generally accepted that neutral questions or statements of empathy are more appropriate when attempting to obtain accurate information (Egan, 1986). I t was also noted that the nursing s t a f f only occasionally requested the parent's opinion regarding the c h i l d ' s pain or lack of pain. The most s i g n i f i c a n t observation regarding nursing practice i s the f a c t that the nursing s t a f f also d i d not consistently involve the childre n i n decision making about pain medication. I t i s the b e l i e f of the researcher that preschool age children can accurately report on the presence or absence of pain and that these c h i l d r e n should be involved i n the decisions about administration of pain medication. Of the fourteen children i n 105 the study who were given analgesic medication, only three were asked i f they wanted something for pain. One nurse t o l d the mother she was giving the c h i l d the pain medication to prevent the c h i l d from having pain. Clearly these practices are inconsistent with providing patients with care i n d i v i d u a l i z e d to meet t h e i r needs. Implications for Nursing Practice This study has c l e a r l y demonstrated that parents do have an e f f e c t on the behaviour of postoperative preschool age children i n the p e d i a t r i c recovery room. As stated previously, children with accompanying parents make more attempts to cope with the pain experience by crying and complaining with apparent expectation that t h e i r parent w i l l comfort them whereas children without parents make more attempts to cope with the pain experience by t r y i n g to reduce the pain themselves through rubbing and protective behaviour. Allowing parents to be with t h e i r c h i l d i n the p e d i a t r i c recovery room therefore provides the c h i l d with additional or d i f f e r e n t ways of coping with the pain experience i n what i s often an unfamiliar and frightening environment. The findings of t h i s study reinforce the need for nurses to advocate, on behalf of p e d i a t r i c patients, f o r change i n p o l i c i e s which currently r e s t r i c t parents from being with t h e i r c h i l d r e n i n the postoperative recovery room. I f t h i s i s achieved, i t must be recognized that the r o l e of the nurse i n the recovery room w i l l change. As parents begin to provide some of the hands on care, such as giving f l u i d s and sponging the c h i l d , the nurse's r o l e w i l l be changed to give up some of these measures and take on r e s p o n s i b i l i t i e s related to parental support and education. Nurses w i l l be accountable to provide parents v i s i t i n g t h e i r children i n t h i s s e t t i n g with an adequate or i e n t a t i o n both to the se t t i n g and to the r o l e of the parent i n the PARR. Parents must be provided with s u f f i c i e n t information to allow them to p a r t i c i p a t e as a partners i n t h e i r children's care and to meet t h e i r children's needs (Lutz, 1986; McCaffrey, 1969; Mahaffy, 1965; McGuire & Dizard, 1982; Stevens, Hunsberger, & Browne, 1987). However, i t i s also the nurse's r e s p o n s i b i l i t y to determine how involved parents wish to be i n t h e i r c h i l d ' s care and to reassure the parent that, i f they do not f e e l able to stay i n the recovery room, a nurse w i l l always be av a i l a b l e to t h e i r c h i l d (Broome, 1985). I f the parent decides to v i s i t i n the recovery room, the nurse has a r e s p o n s i b i l i t y to make the parent f e e l comfortable i n t h i s environment as the benefit to the c h i l d of having a parent i n the recovery room may be diminished i f the parent does not f e e l he/she i s allowed to hold the c h i l d , touch or t a l k to the c h i l d , and i s a f r a i d to ask the nurse i f t h i s i s permitted. This study also demonstrated that, even when parents were present i n the Recovery Room, nurses seldom used them as a resource i n planning f o r t h e i r c h i l d ' s care. Stevens, Hunsberger, and Browne (1987) state " l i t t l e evidence e x i s t s to support the notion that parents can v a l i d l y assess t h e i r c h i l d ' s pain" (p. 163). However, parents can help the c h i l d i d e n t i f y and express t h e i r concerns (Hunsberger, Love, & Byrne, 1984) and suggest to the nurse which means of d i s t r a c t i o n are most e f f e c t i v e i n comforting t h e i r c h i l d (Broome, 197 5). In addition, parents can share with the nurse t h e i r perception of the meaning of the c h i l d ' s behaviour. In the recovery room, t h i s i s p a r t i c u l a r l y c r i t i c a l as the nurse has not usually seen the c h i l d before and therefore cannot be expected to have an understanding of how the c h i l d deals with pain, fear, or anxiety. Thus, the parents can provide the nurse with meaningful information which can be used by the nurse i n making pain management decisions. Every nurse demonstrates a d i f f e r e n t degree of expertise i n communication s k i l l s . However, i n the p e d i a t r i c recovery room, nurses usually communicate only with the other health care professionals and the patient. I f parents are to be allowed to v i s i t r o utinely i n the p e d i a t r i c recovery room, nursing s t a f f must be provided the opportunity to relearn and enhance the s k i l l s required for e f f e c t i v e and meaningful communication with parents. Without t h i s s k i l l , i t i s the researcher's experience that many nurses do not f e e l comfortable i n communicating with parents about t h e i r children's care. Nursing s t a f f may also need to enhance t h e i r communication s k i l l s with childr e n i n order to f e e l comfortable when observed by parents during conversations with childr e n and provision of care. P e d i a t r i c pain assessment tools w i l l continue to evolve as research i n t h i s f i e l d continues. Tools i n i t i a l l y used to assess p e d i a t r i c pain focussed primarily on behaviours i n the categories of body movement, f a c i a l expression, and v o c a l i z a t i o n . Given the d e f i n i t i o n of pain provided by Katz et. a l . (1984) on p. 7, too l s which are used to assess p e d i a t r i c 108 pain behaviour must begin to include such behaviours as verbal complaints, verbal requests, reaching for hugs, smiling, and re f u s a l behaviour. These findings demonstrate the need for nurses i n t h i s PARR, and perhaps others, to more a c t i v e l y s o l i c i t the c h i l d ' s perception regarding the pain experience and the need for pain medication. In t h i s study, several children received analgesic medication even though they had not been asked i f they wanted i t and i n some cases, when they were asked and stated they d i d not want i t . Nursing which i s practiced i n t h i s way i s inconsistent with the goals of minimizing the stress associated with h o s p i t a l i z a t i o n and making h o s p i t a l i z a t i o n as p o s i t i v e an experience as possible as i t r e s u l t s i n nurses 'doing to' rather than 'caring f o r ' the c h i l d (Richards, 1975). In the unfamiliar and often frightening environment of the recovery room, allowing the c h i l d to p a r t i c i p a t e i n the decision making process may increase the c h i l d ' s sense of control over the s i t u a t i o n r e s u l t i n g i n a possible decrease i n the c h i l d ' s anxiety l e v e l (Hunsberger, Love, & Byrne, 1984). Implications f o r Nursing Research Many questions have been raised as a r e s u l t of t h i s research study. The most important question to be answered i s whether the findings of t h i s study are v a l i d f o r children of d i f f e r e n t ages and children undergoing procedures other than s u r g i c a l repair of strabismus. This question can only be answered i f s i m i l a r studies are done with d i f f e r e n t and larger study groups such as toddlers undergoing s u r g i c a l r e p a i r of 109 hernia and school age children undergoing s u r g i c a l removal of t o n s i l s . Other questions of in t e r e s t are: (1) Can pain scoring t o o l s be used e f f e c t i v e l y i n the p e d i a t r i c recovery room setting? (2) Do children i n the parent-present group have lower, equal, or higher pain scores than children i n the parent-absent group when scored by the c h i l d , the nurse, and the parent? (3) Do children i n the parent-present group demonstrate d i f f e r e n t p o s t - h o s p i t a l i z a t i o n behaviours than childr e n i n the parent-absent group? and (4) Do pain scores of children i n the parent-present and parent-absent group correlate i n any way with the differences i n behaviour between the two groups? Use of videotaping i n t h i s study proved to be an e f f e c t i v e means of capturing a r i c h body of data. Given that technological changes are ra p i d l y occurring i n the world of video, i t i s the researcher's opinion that videotaping should be used more frequently for data c o l l e c t i o n as i t i s , when used to i t s p o t e n t i a l , f a r more accurate than a human observer i n recording human behaviour. In addition, use of videotaping addresses some of the problems of t e s t i n g r e l i a b i l i t y , both i n t e r - r a t e r and i n t r a - r a t e r , and some forms of v a l i d i t y . Summary This chapter has discussed selected findings of the research study and some implications of these findings for nursing p r a c t i c e . The researcher concluded that although ch i l d r e n i n the two groups did not demonstrate many s i g n i f i c a n t l y d i f f e r e n t behaviours, the duration and frequency 110 of c e r t a i n behaviors varied s i g n i f i c a n t l y between the groups. Possible explanations f o r these differences i n behaviour have been explored, leading the researcher to conclude that, for t h i s sample of children, t h e i r parents' presence i n the recovery room provided them with an important additional way of coping e f f e c t i v e l y , including with the pain experience. In addition, the findings lead to other research questions which merit i n v e s t i g a t i o n . The next chapter w i l l present a summary of the research and ou t l i n e a s e l e c t i o n of the conclusions and recommendations generated by the study. I l l Chapter Six SUMMARY and RECOMMENDATIONS Summary This study was designed to examine the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room. Extensive review of the l i t e r a t u r e i d e n t i f i e d that: the immediate postoperative period i s one of the three most s t r e s s f u l i n the c h i l d ' s h o s p i t a l i z a t i o n ; pain and separation from parents are two common experiences f o r ho s p i t a l i z e d children; perception of pain can be influenced by a va r i e t y of factors including fear and separation anxiety; and, parental presence i s commonly advocated as a means of reducing anxiety and pain perception i n p e d i a t r i c patients. There were, however, l i t t l e objective data to support the concept of parental presence i n areas such as the recovery room. Thus, the research study explored the e f f e c t of parental presence on the behaviour of the postoperative preschool age c h i l d i n the p e d i a t r i c recovery room by addressing the following s p e c i f i c questions: 1. Do children who have t h e i r parents with them i n the recovery room display d i f f e r e n t behaviours than those whose parents are not with them? 2. What are the d i f f e r e n t behaviours displayed by children whose parents are with them and children whose parents are not with them? 3 . Do chi l d r e n who have t h e i r parents with them i n the recovery room display pain behaviour: that i s d i f f e r e n t than that 112 demonstrated by c h i l d r e n whose pa r e n t s are not w i t h them? In o r d e r t o attempt t o answer these q u e s t i o n s , the r e s e a r c h e r v i d e o t a p e d 20 c h i l d r e n between the ages of t h r e e and s i x y e a r s f o r the d u r a t i o n of t h e i r PARR s t a y f o l l o w i n g s u r g i c a l r e p a i r o f strabismus. The experimental treatment was p a r e n t a l presence i n the Recovery Room wit h equal numbers of c h i l d r e n b e i n g a s s i g n e d t o the p a r e n t - p r e s e n t and the parent-absent groups. A n a l y s i s of the r e s e a r c h f i n d i n g s demonstrated t h a t a l t h o u g h c h i l d r e n who had t h e i r p a rents w i t h them demonstrated b e h a v i o u r s s i m i l a r t o those who d i d not have t h e i r p a r e n t s w i t h them, the d u r a t i o n and frequency w i t h which some beha v i o u r s were d i s p l a y e d v a r i e d s u b s t a n t i a l l y between the two groups. C h i l d r e n i n the p a r e n t - p r e s e n t group were h e l d w i t h s i g n i f i c a n t l y g r e a t e r frequency and d u r a t i o n , demonstrated p r o t e c t i v e behaviour w i t h s i g n i f i c a n t l y l e s s d u r a t i o n and frequency, and drank w i t h s i g n i f i c a n t l y g r e a t e r d u r a t i o n than c h i l d r e n i n the p a r e n t -absent group. Although not s t a t i s t i c a l l y s i g n i f i c a n t , c h i l d r e n i n the p a r e n t - p r e s e n t group e x h i b i t e d l e s s body movement and more v o c a l i z a t i o n than c h i l d r e n i n the parent-absent group. C h i l d r e n i n the p a r e n t - p r e s e n t group a l s o expressed more comp l a i n t s , demonstrated more r e f u s a l behaviour, and sought body c o n t a c t more than c h i l d r e n i n the parent-absent group. In a d d i t i o n , a l t h o u g h c h i l d r e n i n the p a r e n t - p r e s e n t group d i d not d i s p l a y p a i n behaviour t h a t was d i f f e r e n t than t h a t d i s p l a y e d by c h i l d r e n i n the parent-absent group, the r e s e a r c h e r concluded t h a t the d i f f e r e n c e i n d u r a t i o n and frequency o f behaviour demonstrated by the two groups o f c h i l d r e n r e p r e s e n t e d d i f f e r e n t 113 means of coping with the pain experience. Children i n the parent-present group made more attempts to cope with the pain experience by crying and complaining with the apparent expectation that t h e i r parent would comfort them whereas chi l d r e n i n the parent-absent group made more attempts to cope with the pain experience by t r y i n g to reduce the pain themselves through rubbing and protective behaviour. Use of videotaping as the method of data c o l l e c t i o n also allowed the researcher to make some unplanned observations regarding nursing practice and the r o l e of parents i n the Recovery Room. Decisions by nursing s t a f f regarding the ch i l d ' s pain and pain management were seldom made i n consultation with the c h i l d and/or the c h i l d ' s parents. Parents seldom i n i t i a t e d conversations with nursing s t a f f , frequently appeared to be looking anxiously around the Recovery Room, and seldom i n i t i a t e d physical contact with t h e i r c h i l d without asking permission to do t h i s . I t was the researcher's conclusion that parental presence i n the recovery room provides children with add i t i o n a l ways of coping with the pain experience i n the unfamiliar and often frightening environment of the recovery room. However, the researcher also concluded that many parents appeared to be uncomfortable i n the Recovery Room se t t i n g . In the opinion of the researcher, t h i s study provides objective findings to support the concept of parental presence i n the recovery room. S p e c i f i c recommendations regarding t h i s and other conclusions from these findings are presented i n the following section of t h i s chapter. 114 Recommendat ions A number of recommendations s p e c i f i c to nursing practice, education, and research a r i s e from the findings of t h i s study. Recommendations for Nursing Practice and Education The findings of t h i s study suggest that parental presence i n the p e d i a t r i c recovery room provides the c h i l d with an important add i t i o n a l way of coping with the pain experience. I t i s therefore recommended that: 1. Nursing management of p e d i a t r i c patients i n recovery rooms be reviewed and consideration be given to the p o t e n t i a l r o l e of parents i n t h i s s e t t i n g . 2. P e d i a t r i c h o s p i t a l continuing education programs include content which w i l l provide nursing s t a f f with the opportunity to enhance s k i l l s i n communication with c h i l d r e n and parents and p e d i a t r i c pain assessment and management. Recommendations for Nursing Research This research study represents a beginning step i n the examination of the e f f e c t of parental presence on the behaviour of c h i l d r e n i n settings where parents are not now routinely permitted to v i s i t . I t i s therefore recommended that: 1. Studies of t h i s nature be repeated i n a v a r i e t y of c l i n i c a l settings i n order to more f u l l y examine the r e l a t i o n s h i p between parental presence and children's behaviour. 2. Researchers continue to t e s t the v a l i d i t y and r e l i a b i l i t y of p e d i a t r i c pain assessment tool s to a s s i s t c l i n i c i a n s i n more c l e a r l y d i f f e r e n t i a t i n g pain behaviours from other behaviours demonstrated by childr e n i n the immediate postoperative period. 115 3. V i d e o t a p i n g be used more f r e q u e n t l y as a method of data c o l l e c t i o n as i t maximizes the amount o f r e l i a b l e , v a l i d data which can be examined by r e s e a r c h e r s . In a d d i t i o n , v i d e o t a p e s can be used e f f e c t i v e l y i n the p r e s e n t a t i o n o f r e s e a r c h f i n d i n g s and the ongoing e d u c a t i o n o f nurses. In c o n c l u s i o n , t h i s r e s e a r c h study i n t o the e f f e c t o f p a r e n t a l presence on the behaviour o f the p o s t o p e r a t i v e p r e s c h o o l age c h i l d i n the p e d i a t r i c r e c o v e r y room c o n t r i b u t e s t o the knowledge base nurses can use i n a s s e s s i n g p e d i a t r i c p a i n and i n a d v o c a t i n g f o r p a r e n t a l presence i n t h e p e d i a t r i c r e c o v e r y room. S p e c i f i c a l l y , the f i n d i n g s o f t h i s study d e s c r i b e p e d i a t r i c p a i n and s e p a r a t i o n behaviour more completely than t h e c u r r e n t l i t e r a t u r e and demonstrate the d i f f e r e n c e between two groups o f c h i l d r e n i n such a way t h a t the b e n e f i t s o f p a r e n t a l v i s i t i n g a re apparent. In a d d i t i o n , the f i n d i n g s o f the study add t o the knowledge of c h i l d r e n ' s behaviour i n the p e d i a t r i c r e c o v e r y room and i d e n t i f y s e v e r a l areas, such as f l u i d management, p a i n assessment and management, p a r e n t a l support and e d u c a t i o n , i n which o p p o r t u n i t i e s e x i s t t o improve n u r s i n g p r a c t i c e and c h i l d / p a r e n t c a r e . F i n a l l y , t h i s study emphasizes the need f o r con t i n u e d r e s e a r c h i n the area o f p e d i a t r i c p a i n assessment and p a i n management. 116 References Abu-Saad, H. (1984). Assessing children's responses to pain. Pain. 19. 163-171. Abu-Saad, H. & Holzemer, W. L. (1981). Measuring children's self-assessment of pain. Issues i n Comprehensive P e d i a t r i c  Nursing. 5, 337-349. Aradine, C. R., Beyer, J . E., & Tompkins, J . M. (1988). Children's pain perception before and a f t e r analgesia: A study of instrument construct v a l i d i t y and r e l a t e d issues. Journal of P e d i a t r i c Nursing. 3., 11-23. Audette, M. (1974). The s i g n i f i c a n c e of regressive behaviour for the h o s p i t a l i z e d c h i l d . Maternal-Child Nursing Journal. 3, 31-40. Beales, J . G. (1982). The assessment and management of pain i n c h i l d r e n . In P. Karoly, J . J . Steffen, & D.J. O'Grady (Eds.), C h i l d health psychology: Concepts and issues (pp.154-179). New York: Pergamon. Beyer, J . E., & Byers, M. L. (1985). Knowledge of p e d i a t r i c pain: The state of the a r t . Children's Health Care. 13., 150-159. Beyer, J . E., & Knapp, T. R. (1986). Methodological issues i n the measurement of children's pain. Children's Health Care. 14, 233-241. Beyer, J . E., & Levin, C. R. (1987). Issues and advances i n pain control i n children. Nursing C l i n i c s of North America. 22., 661-676. Bradshaw, C., & Zeanah, P. D. (1986). P e d i a t r i c nurses' assessments of pain i n children. Journal of P e d i a t r i c  Nursing. 1, 314-322. Brain, D. J . , & Maclay, I. (1968). Controlled study of mothers and c h i l d r e n i n h o s p i t a l . B r i t i s h Medical Journal. 1, 278-280. Bransletter, E. (1969). The young c h i l d ' s response to h o s p i t a l i z a t i o n : Separation anxiety or lack of mothering care? American Journal of Public Health. 59, 92-97. Bray, C. A. (1986). Postoperative pain: a l t e r i n g the patient's experience through education. Association of Operating Room  Nurses Journal. 43., 673-683. Bowers, K. S. (1968). Pain, anxiety, and perceived control. Journal of Consulting and C l i n i c a l Psychology. 32. 596-602. 117 Bowlby, J . (1960). Separation anxiety. The International  Journal of Psycho-analysis. 40, 89-113. Broome, M. E. (1985). The c h i l d i n pain: A model for assessment and intervention. C r i t i c a l Care Quarterly. 8(1), 47-55. Campbell, D. T., & Stanley, J . C. (1963). Experimental and  quasi-experimental designs for research. Chicago: Rand McNally College Publishing. Chapman, C. R. (1984). New di r e c t i o n s i n the understanding and management of pain. S o c i a l Science and Medicine, 19, 1261-1277. C i t i z e n s 1 Committee on Children of New York C i t y , Inc. (1955). L i b e r a l v i s i t i n g p o l i c i e s for children i n ho s p i t a l s . Journal  of P e d i a t r i c s . 46, 710-716. Craig, K. D., McMahon, R. J . , Morison, J . D., & Zaskow, C. (1984). Developmental changes i n infant pain expression during immunization i n j e c t i o n s . S o c i a l Science and Medicine, 19, 1331-1337. Crocker, E. (1980). Preparation for e l e c t i v e surgery: Does i t make a difference. Journal of the Association f o r the Care  of Children i n Hospital. 9(1), 3-11. Dew, T., Bushong, M., & Crumrine, R. (1977). Parents i n p e d i a t r i c RR. Association of Operating Room Nurses Journal. 26. 266-272. Diniaco, M., & Ingoldsby, B. (1983). Parental presence i n recovery room. Association of Operating Room Nurses Journal. 38. 685-689. Egan, G. (1986). The s k i l l e d helper (3rd ed.). Monterey, CA: Brooks/Cole. Eland, J . M. (1985). The c h i l d who i s hurting. Seminars i n Oncology Nursing. 1, 116-122. Eland, J . M., & Anderson, J . E. (1977). The experience of pain i n c h i l d r e n . In A. K. Jacox (Ed.), Pain: A source book for nurses and other health care professionals (pp. 453-473). Boston: L i t t l e , Brown. Fagin, C. M. (1962). Why not involve parents when children are hospitalized? American Journal of Nursing. 62(6), 78-79. Frankl, S. N., Shiere, F. R., & Fogels, H. R. (1962). Should the parent remain with the c h i l d i n the dental operatory? Journal of Dentistry for Children. 29, 150-163. 118 Funk & Wagnall's standard college dictionary. (1978). Toronto: Fitzhenry & Whiteside. Gildea, J . H., & Quirk, T. R. (1977). Assessing the pain experience i n children. Nursing C l i n i c s of North America. 12, 631-637. Godfrey, A. E. (1955). A study of nursing care designed to a s s i s t h o s p i t a l i z e d children and t h e i r parents i n t h e i r separation. Nursing Research. 4, 52-70. Gohsman, B., & Yunck, M. (1979). Dealing with the threats of h o s p i t a l i z a t i o n . P e d i a t r i c Nursing, 5(5), 32-35. Goslin, E. R. (1978). H o s p i t a l i z a t i o n as a l i f e c r i s i s for the preschool c h i l d : A c r i t i c a l review. Journal of Community  Health. 3, 321-346. Gross, S. C., & Gardner, C. G. (1980). C h i l d pain: Treatment approaches. In W. L. Smith, H. Merskey, & S. C. Gross (Eds.), Pain: Meaning and management (pp. 127-142). New York: SP Medical And S c i e n t i f i c Books. Hawley, D. D. (1984). Postoperative pain i n ch i l d r e n : Misconceptions, descriptions, and interventions. P e d i a t r i c  Nursing. !Q(1), 20-23. Hester, N. K. O. (1979). The preoperational c h i l d ' s reaction to immunization. Nursing Research. 28, 250-255. H u l l , H. C , & Nie, N. H. (Eds.). (1981). SPSS Update 7-9: New  procedures and f a c i l i t i e s for releases 7-9. New York: McGraw-Hill. Hunsberger, M., Love, B., & Byrne, C. (1984). A review of current approaches used to help children and parents cope with health care procedures. Maternal-Child Health Journal. 13, 145-165. Hurley, A. & Whelan, E. G. (1988). Cognitive development and children's perception of pain. P e d i a t r i c Nursing. 14, 21-24. International Association for the Study of Pain. (1979). Pain terms: A l i s t with d e f i n i t i o n s and notes on usage. Pain, 6, 249-252. Jay, S. M., Ozolins, M., & E l l i o t , C. H. (1983). Assessment of children's d i s t r e s s during p a i n f u l medical procedures. Health Psychology. 2, 133-147. Jeans, M. E. (1983a). Pain i n children - A neglected area. In P. Firestone, P. McGrath, & W. Feldmore (Eds.). Advances i n  behavioural medicine for children and adolescents (pp. 23-37). H i l l s d a l e , NJ: L. Erlban. 119 Jeans, M. E. (1983b). The measurement of pain i n children. In R. Melzack (Ed.), Pain measurement and assessment (pp. 183-189). New York: Raven Press. Johnson, D. E. (1962). The meaning of maternal deprivation and separation anxiety for nursing p r a c t i c e . American Nurses'  Association C l i n i c a l Sessions. 2, 23-33. Katz, E. R., Kellerman, J . , & Siegel, S. E. (1980). Behavioural d i s t r e s s i n children with cancer undergoing medical procedures: Developmental considerations. Journal of  C l i n i c a l Psychology. 48, 356-365. Katz, E. R., Varni, J . W., & Jay, S. M. (1984). Behavioural assessment and management of p e d i a t r i c pain. Progress i n  Behaviour Modification. 18, 163-193. Kim, S. (1980). Pain: Theory, research and nursing p r a c t i c e . Advances i n Nursing Science. 2(2), 43-59. Kline, J . (1984). Recovery room care for the c h i l d i n pain. American Journal of Maternal Child Nursing. 9, 261-264. Kl i n z i n g , D. R., & Kl i n z i n g , D. G. (1977). The h o s p i t a l i z e d  c h i l d : Communication techniques for health professionals. Englewood C l i f f s , NJ: Prentice-Hall. Korsch, B. M. (1975). The c h i l d and the operating room. Anesthesiology. 43., 251-257. LeBaron, S., & Zelter, L. (1984). Assessment- of acute pain and anxiety i n childre n and adolescents by s e l f - r e p o r t s , observer reports, and a behaviour c h e c k l i s t . Journal of Consulting  and C l i n i c a l Psychology. 52, 729-738. Lee, J . S., & Greene, N. M. (1969). Parental presence and emotional state of children p r i o r to surgery. C l i n i c a l  P e d i a t r i c s . 8(3), 126-130. L o l l a r , D. J . , Stanley, J . S., & Patterson, D. L. (1982). Assessment of p e d i a t r i c pain: An empirical perspective. Journal of P e d i a t r i c Psychology. 7, 267-277. Luckmann, J . , & Sorensen, K. C. (1980). Medical-surgical nursing: A psychophysiological approach (2nd. ed.). London: Saunders. Lutz, W. J . (1986). Helping h o s p i t a l i z e d c h i l d r e n and t h e i r parents cope with p a i n f u l procedures. Journal of P e d i a t r i c  Nursing. 1, 24-32. Lynn, M. R. (1986). Pain i n the p e d i a t r i c patient: A review of the research. Journal of P e d i a t r i c Nursing. 1, 198-201. 120 Mahaffy, P. R. (1965). 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 ch i l d r e n admitted for tonsillectomy and adenoidectomy. Nursing Research. 14, 12-19. McBride, M. M. (1977). Assessing children with pain. P e d i a t r i c Nursing. 3(4), 7-16. McCaffrey, M. (1969). B r i e f episodes of pain i n children. Current concepts i n c l i n i c a l nursing. 2, 178-191. McCaffrey, M. (1972). Nursing management of the patient with  pain. Philadelphia: J . B. Lippincott. McCaffrey, M. (1977). Pain r e l i e f for the c h i l d : Problem areas and selected nonpharmacological methods. P e d i a t r i c  Nursing, 3.(4) , 11-16. McGrath, P. J . , Johnson, G., Goodman, J . T., S c h i l l i n g e r , J . , Dunn, J . , & Chapman, J . (1985). CHEOPS: A behavioural scale f o r r a t i n g postoperative pain.in children. In H. L. F i e l d s (Ed.), Advances i n Pain Research and Therapy: Vol 9 (pp. 395-402). New York: Raven. McGuire, L., & Dizard, S. (1982). Managing pain i n the young patient. Nursing 82. 12(8), 52, 54, 55. Melzack, R. (1973). The puzzle of pain. New York: Basic Books. Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science. 150, 971-979. Merskey, H. (1980). The nature of pain. In W. L. Smith, H. Merskey, & S. C. Gross (Eds.), Pain: Meaning and management (pp. 71-74). New York: SP Medical and S c i e n t i f i c Books. Munhart, N. T., & McCaffrey, M. (1983). Pain: A nursing approach to assessment and analysis. Norwalk, CT: Appleton-Century-Crofts. O'Connell, E. A., & Brandt, P. (1960). L i b e r a l v i s i t i n g hours for parents. American Journal of Nursing. 60, 812-815. P e t r i l l o , M., & Sanger, S. (1972). Emotional care of  h o s p i t a l i z e d children: An environmental approach. Philadelphia: Lippincott. P h i l l i p s , J . L., J r . (1981). Piaget's theory: A primer. San Francisco: W. H. Freeman. Piaget, J . , & Inhelder, B. (1969). The psychology of the  c h i l d . New York: Basic Books. Prugh, D. G., Staub, E. M., Sands, H. H., Kirschbaum, R. M., & Lenihan, E. A. (1953). A study of the emotional reactions 121 of c h i l d r e n and families to h o s p i t a l i z a t i o n and i l l n e s s . American Journal of Orthopsychiatry. 23., 70-106. Richards, F. (1975). Do you care for or care about? Association of Operating Room Nurses Journal. 22., 792, 794, 796, 798. Robertson, J . (1958). Young children i n h o s p i t a l . New York: Basic Books. Robertson, J . (1970). Young children i n ho s p i t a l (2nd ed.). London: Tavistock. Savedra, M. (1981). Parental responses to a p a i n f u l procedure performed on t h e i r c h i l d . In P. Azarnoff & C. Hardgrove (Eds.), The family i n c h i l d health care (pp. 73-87). New York: John Wiley and Sons. Schalling, D. (1985). Anxiety, pain, and coping. Issues i n  Mental Health Nursing. 7, 437-460. Schechter, N. L. (1985). Pain and pain control i n children. Current Problems i n Pe d i a t r i c s . 15_(5) , 1-67. Schulman, J . L., Foley, J . M., Vernon, D. T. A., & Al l a n , D. (1967). A study of the e f f e c t of the mother's presence during anesthesia induction. P e d i a t r i c s . 39, 111-114. Shaw, E. G., & Routh, D. K. (1982). E f f e c t of mother presence on children's reaction to aversive procedures. Journal of  Pe d i a t r i c Psychology. l_i 33-42. Smith, M. E. (1976). The preschooler i n pain. Current  Practice i n Pe d i a t r i c Nursing. 1, 198-209. Sternbach, R. A. (1968). Pain: A psychophysiological analysis. New York: Academic Press. Stevens, B., Hunsberger, M., & Browne, G. (1987). Pain i n chi l d r e n : Theoretical, research, and pra c t i c e dilemmas. Journal of P e d i a t r i c Nursing. 2, 154-166. Taylor, P. L. (1983). Post-operative pain i n toddler and pre-school age children. Maternal-Child Nursing Journal. 12, 35-50. Thompson, R. H. (1985). Psychosocial research on p e d i a t r i c  h o s p i t a l i z a t i o n and health care: A review of the l i t e r a t u r e . S p r i n g f i e l d : Charles C. Thomas. Venham, L. L. (1979). The e f f e c t of mother's presence on c h i l d ' s response to dental treatment. Journal of Dentistry  fo r Children. 46. 219-225. 122 Venham, L. L., Bengston, D., & Cipes, M. (1978). Parent's presence and the c h i l d ' s response to dental stress. Journal  of Dentistry for Children. 45, 213-217. Vernon, D. T. A., Foley, J . M., & Schulman, J . J . (1967). E f f e c t of mother-child separation and b i r t h order on young children's responses to two p o t e n t i a l l y s t r e s s f u l experiences. Journal of Personality and S o c i a l Psychology, 5, 162-174. Vernon, D. T. A., Foley, J . M., Sipowicz, R.R., & Schulman, J . L. (1965). The psychological responses of childr e n to  h o s p i t a l i z a t i o n and i l l n e s s : A review of the l i t e r a t u r e . S p r i n g f i e l d : Charles C. Thomas. Vernon, D. T. A., Schulman, J . L., & Foley, J . M. (1966). Changes i n children's behaviour a f t e r h o s p i t a l i z a t i o n . American Journal of Diseases i n Children. I l l , 581-593. V i s i n t a i n e r , M. A., & Wolfer, J . A. (1975). Psychological preparation f o r s u r g i c a l p e d i a t r i c patients: The e f f e c t of children's and parent's stress responses and adjustment. P e d i a t r i c s . 56, 187-202. Vogelsang, J . (1987). Nursing interventions to reduce patient anxiety: V i s i t o r s i n the PACU. Journal of Post Anesthesia  Nursing. 2, 25-31. Weary, E. T. (1974). Separation anxiety reconsidered: Nursing implications. Maternal-Child Nursing Journal. 3., 9-18. Winer, G. A. (1982). A review and analysis of children's f e a r f u l behaviour i n dental settings. Child Development. 53 1111-1133. Wolf, Z. R. (1980). Pain theories: An overview. Topics i n  C l i n i c a l Nursing. 2, 9-18. Wolfer, J . A., & V i s i n t a i n e r , M. A. (1975). P e d i a t r i c s u r g i c a l patients' and parents' stress responses and adjustments as a function of psychologic preparation and stress-point nursing care. Nursing Research. 24., 244-255. Wong, D. L., & Baker, C. M. (1988). Pain i n children: A comparison of assessment scales. P e d i a t r i c Nursing. 14., 9-17. Yarrow, L. J . (1964). Separation from parents during early childhood. Review of C h i l d Development Research, 1, 89-136. Zurlinden, J . K. (1985). Minimizing the impact of h o s p i t a l i z a t i o n for children and t h e i r f a m i l i e s . American  Journal of Maternal Child Nursing. 10, 178-182. 123 Appendix A Physician Consent Form I, the undersigned, understand that Laurel Brunke, a Master's i n Nursing candidate at University of B r i t i s h Columbia w i l l be contacting parents of children under my medical care for in c l u s i o n of t h e i r c h i l d r e n i n a study of "The E f f e c t of Parental Presence i n Recovery Room on Postoperative P e d i a t r i c Pain Behaviour". Parents w i l l receive an introductory l e t t e r from my o f f i c e i n which Laurel Brunke explains the study. I understand that the Recovery Room p o l i c y at Hospital X does not permit parents to v i s i t i n the Recovery Room. However, I understand that f o r the purposes of t h i s study, the parents of h a l f the children w i l l be i n v i t e d to be with t h e i r c h i l d i n Recovery Room u n t i l he/she returns to the Daycare Surgery Unit. I understand that Laurel Brunke w i l l be videotaping the chi l d r e n included i n the study for a maximum of one hour following t h e i r admission to the Recovery Room and that these videotapes w i l l be analyzed for differences i n behaviours of chil d r e n i n the parent-present and the parent-absent groups. I understand that a l l information obtained i n the study w i l l remain c o n f i d e n t i a l and anonymous. In signing t h i s form, I am agreeing to the po t e n t i a l i n c l u s i o n of my patients that meet the study c r i t e r i a i n t h i s study providing that parental consent for the patients has also been obtained. Signature Date 126 Appendix D Data C o l l e c t i o n Sheet Code: Gender: Date: DOB: Hospital orie n t a t i o n : Yes No Video: Yes No Parent with c h i l d i n RR: Mother Father Both None Operative s i t e : Right eye Left eye Both eyes Muscles: Surgeon: RR nurse: Adm time (RR): Disc time (RR): Anesthetist: Anesthetic time: Ready for discharge: Disc time (DCU): _ Induction: Wt: STP: Drop: Dose Mask IV Halothane Nitrous Other Atr: Sux: Pan: Time Other: Meds: Name Name Dose Dose Route Route Time Time 127 Appendix E Behavioural Checklist and D e f i n i t i o n s of Behaviours Vocalizations A l l emitted sounds that are not language or are incomprehensible to an observer. Cry - vocal expression characterized by prolonged rhythmic and high-pitched sounds accompanied by tears running down face. Excludes meaningful utterances. Scream - nonverbal expression d i s t i n c t from crying. Single, prolonged high-pitched sound. Sob - crying accompanied by audible, convulsive catches of the breath. Exclamation - abrupt or emphatic utterance. F a c i a l expressions Frown - furrowing of the eyebrows and forehead. Grimace - pained expression r e s u l t i n g from d i s t o r t i o n of a l l f a c i a l features. Smile - a pleased or amused expression. Body movement Protective - placement of hand or arm over the s u r g i c a l s i t e . Movement of the head away from the nurse to avoid the nurse touching the s u r g i c a l s i t e . Purposeless - tossing and turning i n bed and/or random gross movements of arms and legs without intention to make aggressive contact. Touch - gentling touching the s u r g i c a l s i t e without rubbing i t or covering i t . Reach f o r eyes - reaching for but not touching the operative s i t e . Kick - s t r i k i n g out with the foot or feet. Rubbing - applying pressure to the s u r g i c a l s i t e with hand, arm, or bed l i n e n . 128 F l u i d Requests U n s o l i c i t e d f l u i d request - request for drink or popsicle by t h e c h i l d without questioning or prompting by the nurse or parent. Yes to f l u i d s - c h i l d answers yes to o f f e r of f l u i d s . No to f l u i d s - c h i l d answers no to o f f e r of f l u i d s . Pain complaints U n s o l i c i t e d pain complaints - statements of pain made by the c h i l d without questioning or prompting by the nurse or parent. S o l i c i t e d pain complaints - statements of pain made by the c h i l d i n response to questioning or prompting by the nurse or parent. Denies pain - statements of denial of pain made by the c h i l d i n response to questioning or prompting by the nurse or parent. Miscellaneous Complaints U n s o l i c i t e d miscellaneous complaints - miscellaneous complaints made by the c h i l d without questioning or prompting by the nurse or parent. S o l i c i t e d miscellaneous complaints - c h i l d makes miscellaneous complaints i n response to questioning or prompting by the nurse or parent. Other Behaviours Reaching f o r body contact - behaviour i n i t i a t e d by the c h i l d intended to r e s u l t i n body contact with e i t h e r nurse or parent. Hugs - c h i l d i n i t i a t e s hugging behaviour with nurse or parent. Being held - c h i l d i s held by nurse or parent eith e r i n bed or chair. Taking f l u i d s - c h i l d i s drinking f l u i d s or eating a popsicle. Asks f o r mom on own - request by c h i l d f or mom without questioning or prompting by nurse. Wants mom when asked - c h i l d answers yes when asked i f he\she wants to see mom. Refusal behaviour - c h i l d v e r b a l l y refuses to do something he\she i s asked to do by nurse or parent or c h i l d p u l l s away to avoid having something done to him\her. Yes to medication - c h i l d answers yes to o f f e r of pain medication. No to medication - c h i l d answers no to o f f e r of medication. 130 Appendix F Behavioural Checklist 1. Purposeless 2. Rubbing 3. Protective 4. Touch 5. Reach fo r eyes 6. Kick 7. Cry/sob 8. S cream/exc1amat ion 9. Smile 10. Gr imace/frown 11. Reach fo r body contact/hugs 12. Being held 13. Pain complaints - s o l i c i t e d 14. Pain complaints - u n s o l i c i t e d 15. Denies pain 16. F l u i d request - u n s o l i c i t e d 17. Yes to f l u i d s 18. No to f l u i d s 19. Takes f l u i d s 20. Asks for mom on own 21. Wants mom when asked 22. Miscellaneous complaints - s o l i c i t e d 23. Miscellaneous complaints - u n s o l i c i t e d 24. Refusal behaviour 25. Yes to medication 26. No to medication Appendix G In-Hospital Research Review Committee Approval 131 Dear Ms. Brunke: Re: Application to the In-Hospital Research Review Committee The In-Hospital Research Review Committee of Children's Hospital has approved your proposed research project e n t i t l e d " E f f e c t of P a r e n t a l Presence on the Behaviour of the P o s t - O p e r a t i v e Preschool Age Ch i l d i n the Paediatric Recovery Room". Good luck with your research. Sincerely, 

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