UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The post day care surgery experience for parents of toddlers and preschoolers Otterman, Pamela Joan 1988

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1989_A5_7 O87.pdf [ 6.94MB ]
Metadata
JSON: 831-1.0097414.json
JSON-LD: 831-1.0097414-ld.json
RDF/XML (Pretty): 831-1.0097414-rdf.xml
RDF/JSON: 831-1.0097414-rdf.json
Turtle: 831-1.0097414-turtle.txt
N-Triples: 831-1.0097414-rdf-ntriples.txt
Original Record: 831-1.0097414-source.json
Full Text
831-1.0097414-fulltext.txt
Citation
831-1.0097414.ris

Full Text

THE POST D A Y C A R E SURGERY EXPERIENCE FOR PARENTS OF TODDLERS AND PRESCHOOLERS By PAMELA JOAN OTTERMAN B . S . N . , The University of British Columbia,  1978  A THESIS S U B M I T T E D IN P A R T I A L F U L F I L L M E N T THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF SCIENCE IN  NURSING  in  T H E F A C U L T Y OF G R A D U A T E STUDIES (The S c h o o l o f N u r s i n g )  W e accept this thesis as c o n f o r m i n g to the r e q u i r e d standard  THE UNIVERSITY OF BRITISH December  COLUMBIA  1988  © P a m e l a Joan Otterman,  1988  OF  In  presenting  degree freely  at  the  available  copying  of  department publication  this  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his  and  scholarly  or  thesis  for  her  NURSING  The University of British Columbia Vancouver, Canada  Date  DE-6  (2/88)  JANUARY 11. 1989  I  I further  purposes  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  permission.  Department of  study.  of  be  It not  is be  that  the  for  Library  an shall  permission for  granted  by  understood allowed  the  advanced make  extensive  head  that  without  it  of  copying my  my or  written  ii Abstract  T h e Post D a y C a r e S u r g e r y E x p e r i e n c e F o r Parents o f T o d d l e r s a n d P r e s c h o o l e r s  T h i s study w a s d e s i g n e d to e x p l o r e the parents' p e r s p e c t i v e a n d p e r s o n a l interpretations o f the m e a n i n g o f their c h i l d r e n s ' first t i m e d a y care surgery e x p e r i e n c e w i t h i n the c o n t e x t o f their e v e r y d a y l i v e s . g u i d e data c o l l e c t i o n f o r this qualitative  T h e p h e n o m e n o l o g i c a l m e t h o d w a s u s e d to  study.  D a t a w e r e c o l l e c t e d t h r o u g h a series o f 16 i n - d e p t h i n t e r v i e w s w i t h n i n e parents w h o s e y o u n g c h i l d r e n underwent a d a y care s u r g i c a l procedure. c h i l d r e n w a s 23.8 m o n t h s . technique.  T h e average age o f the  Sample selection was guided by a purposive sampling  A semi-structured g u i d e o f o p e n - e n d e d questions w a s u s e d f o r parent  interviews. A n a l y s i s o f the v e r b a t i m transcriptions w a s a c c o m p l i s h e d u s i n g the technique o f constant c o m p a r a t i v e a n a l y s i s .  I n f o r m a n t s gave d e t a i l e d accounts o f their e x p e r i e n c e  a n d d e s c r i b e d the m e a n i n g s a n d interpretations they a s s i g n e d to it. T h e p a r e n t s ' accounts w e r e s y n t h e s i z e d i n t o a d e s c r i p t i v e f r a m e w o r k o f their e x p e r i e n c e w h i c h d e s c r i b e d three distinct c h r o n o l o g i c a l phases: the p r e - h o s p i t a l i z a t i o n o r preparatory phase, the h o s p i t a l i z a t i o n o r operative p h a s e , a n d the p o s t - h o s p i t a l i z a t i o n o r readjustment p h a s e .  It w a s apparent that the parents' e x p e r i e n c e e x t e n d e d w e l l  b e y o n d the f e w hours they a c t u a l l y spent i n the h o s p i t a l setting. T h e s t u d y ' s f i n d i n g s r e v e a l e d that parents p e r c e i v e d their e x p e r i e n c e as a stressful event i n their e v e r y d a y l i v e s .  N e w r e s p o n s i b i l i t i e s w e r e a d d e d to the u s u a l  tasks o f p a r e n t i n g a t o d d l e r o r p r e s c h o o l e r r e s u l t i n g i n parental r o l e strain a n d an i n c r e a s e d n e e d f o r parental support.  Parents r e p o r t e d f e e l i n g s o f fear, w o r r y , a n d  a n x i e t y i n v a r y i n g intensity throughout the three phases o f their e x p e r i e n c e . u s e d a v a r i e t y o f c o p i n g strategies to m a n a g e the stresses o f their e x p e r i e n c e .  They The  study f i n d i n g s w e r e d i s c u s s e d i n c o m p a r i s o n to other authors' p u b l i s h e d w o r k s , p l a c i n g these u n i q u e f i n d i n g s i n context o f the current literature. p r a c t i c e , e d u c a t i o n , a n d research w e r e presented.  Implications for nursing  iv  T a b l e o f Contents  Abstract  ii  Table of Contents  iv  Acknowledgements C H A P T E R 1:  C H A P T E R 2:  C H A P T E R 3:  •  vi  Introduction  1  B a c k g r o u n d to the S t u d y  2  Conceptual Framework Statement o f the P r o b l e m I n t r o d u c t i o n to the M e t h o d o l o g y Definition of Terms Assumptions Limitation Summary  5 8 8 9 10 11 11  R e v i e w of Selected Literature  13  Parental R o l e and Responsibility Changes W h e n C a r i n g for A S i c k C h i l d . . : T h e E f f e c t s M a t e r n a l A n x i e t y o n the H o s p i t a l i z e d C h i l d Parental A t t i t u d e s T o w a r d s P e d i a t r i c D a y C a r e S u r g e r y . . . . . T h e E f f e c t s o f Short T e r m H o s p i t a l i z a t i o n o n Toddlers and Preschoolers Summary  24 31  Methodology  33  Research Design S e l e c t i o n o f Participants Criteria for Selection Setting Implementation Procedures Data Collection Data Analysis Ethical Considerations Research Clearance Procedures Informed Consent Privacy Summary  33 35 35 36 36 38 41 43 43 43 44 44  14 17 21  V  C H A P T E R 4:  C H A P T E R 5:  Presentation and D i s c u s s i o n o f F i n d i n g s  45  The Study's Analytic Framework D a y C a r e S u r g e r y as a S t r e s s f u l E x p e r i e n c e Parental Responsibility R o l e Strain Coping S o c i a l Support Description o f Participant Families The Families The Children The Hospitalization T h e Parents' Accounts of Their Experience and D i s c u s s i o n . . . . T h e P r e - h o s p i t a l i z a t i o n Phase T h e Hospitalization Phase T h e Post-hospitalization Phase Summary  46 49 52 54 56 57 60 61 62 62 63 64 84 97 Ill  Summary, Conclusions, and Implications for N u r s i n g  114  Summary of Conclusions Implications Implications Implications  114 119 120 128 130  the S t u d y for Nursing Practice for Nursing Education for Nursing Research  References  133  Appendices  142 A p p e n d i x A : R e s e a r c h A p p r o v a l C e r t i f i c a t e f r o m the University of British Columbia Behavioural Sciences Screening Committee for Research a n d O t h e r Studies I n v o l v i n g H u m a n S u b j e c t s . . . . A p p e n d i x B : Research A p p r o v a l Letter f r o m B r i t i s h C o l u m b i a ' s Childrens' Hospital In-Hospital Research Review Committee A p p e n d i x C : Information Letter for Physicians and Dentists . . . A p p e n d i x D : Participant Information Letter A p p e n d i x E : Participant Consent F o r m A p p e n d i x F: Initial Interview G u i d e  143  144 145 146 148 149  vi Acknowledgements  I w o u l d l i k e to thank the m e m b e r s o f m y thesis c o m m i t t e e , J i n n y H a y e s (chair person) a n d J u d y L y n a m , f o r their u n f a i l i n g e n c o u r a g e m e n t a n d g u i d a n c e i n c o m p l e t i o n o f this r e s e a r c h project. I a m e s p e c i a l l y grateful to J i n n y f o r her patience a n d u n d e r s t a n d i n g w h i c h e x t e n d e d b e y o n d the u s u a l b o u n d s o f a faculty-student r e l a t i o n s h i p . T h e r e w e r e s e v e r a l other persons w h o supported m e throughout this p r o c e s s . M y parents, a n d m y sister a n d b r o t h e r - i n - l a w , l o v i n g l y g a v e o f their t i m e , energy, and resources to support this project. In a d d i t i o n to m y f a m i l y , there w e r e several dear f r i e n d s w h o s e support w a s a l w a y s there to e n c o u r a g e m e to " k e e p g o i n g " . M o s t i m p o r t a n t l y , I w i s h to thank m y h u s b a n d G e r a l d , w h o shared a l l o f the h i g h s and the l o w s o f this e x p e r i e n c e , a n d w i t h o u t w h o s e l o v e , p a t i e n c e , p e r s o n a l s a c r i f i c e s , a n d f a i t h i n m y a b i l i t y , this project w o u l d not h a v e been c o m p l e t e d . I w o u l d also l i k e to a c k n o w l e d g e m y s o n , M a r k , w h o s e a r r i v a l h e r a l d e d the b e g i n n i n g o f o n e m a j o r u n d e r t a k i n g w h i l e c o i n c i d i n g w i t h the c o m p l e t i o n o f another. F i n a l l y , I w o u l d l i k e to express m y thanks to the n i n e parents w h o p a r t i c i p a t e d i n this study. T h e y w i l l i n g l y gave o f their t i m e a n d the benefit o f their e x p e r i e n c e to m a k e the research p o s s i b l e .  1 CHAPTER 1  Introduction  T h i s i s the report o f a study d e s i g n e d to a n s w e r the q u e s t i o n : W h a t i s the p a r e n t s ' e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care s u r g e r y ? It i s this a u t h o r ' s o p i n i o n , based u p o n p e r s o n a l e x p e r i e n c e w o r k i n g as a p e d i a t r i c nurse, that nurses l a c k k n o w l e d g e about parents' o w n p e r c e p t i o n s o f the p o s t - h o s p i t a l i z a t i o n p e d i a t r i c d a y care surgery e x p e r i e n c e a n d h o w they m a n a g e at h o m e f o l l o w i n g their c h i l d ' s surgery.  T h e o n l y w a y to t r u l y understand this e x p e r i e n c e i s to  h a v e parents d e s c r i b e h o w the event h a s affected their d a y to d a y l i v e s .  T h i s writer  has b e e n u n a b l e to g a i n i n s i g h t i n t o this important parental e x p e r i e n c e f r o m a n y literature r e v i e w e d to date. Parents o f toddlers a n d p r e s c h o o l e r s w e r e selected f o r this study because it i s k n o w n that c h i l d r e n i n these a g e groups are p a r t i c u l a r l y v u l n e r a b l e to the r e a l a n d i m a g i n e d threats o f h o s p i t a l i z a t i o n a n d surgery ( D o r n , 1 9 8 4 ; R e d p a t h & R o g e r s , 1 9 8 4 ; R o b e r t s o n , 1 9 7 0 ; V e r n o n , S c h u l m a n & F o l e y , 1966).  It i s a l s o k n o w n that parents  c o m m o n l y f e e l a n x i o u s a n d c o n c e r n e d throughout their c h i l d ' s p o s t - h o s p i t a l i z a t i o n p e r i o d ( D r o s k e , 1978).  It w a s therefore anticipated that parents o f toddlers a n d  p r e s c h o o l e r s m a y h a v e p a r t i c u l a r needs f o l l o w i n g their c h i l d ' s d a y care surgery.  The  literature r e v i e w e d f o r this study w a s u n a b l e to offer i n s i g h t i n t o w h a t these needs might be. N u r s e s w o r k i n g i n b o t h h o s p i t a l a n d c o m m u n i t y settings h a v e opportunities to interact w i t h a n d are i n postions to i n f l u e n c e the e x p e r i e n c e o f parents w h o s e y o u n g  2 c h i l d r e n h a v e u n d e r g o n e d a y care s u r g i c a l procedures.  T h e f i n d i n g s o f this study offer  a theoretical base f r o m w h i c h appropriate a n d effective n u r s i n g care f o r s u c h parents m a y be p l a n n e d a n d c a r r i e d out. In o r d e r to i n t r o d u c e this research study, the r e m a i n d e r o f this chapter w i l l present the b a c k g r o u n d to the p r o b l e m , the c o n c e p t u a l f r a m e w o r k g u i d i n g the research, a n d the m e t h o d o l o g i c a l p e r s p e c t i v e c h o s e n to e x p l o r e the s p e c i f i c research q u e s t i o n . B a c k g r o u n d to the S t u d y P e d i a t r i c d a y care i s w i d e l y r e c o g n i z e d as a v i a b l e alternative to the traditional t w o to three d a y h o s p i t a l stay f o r c h i l d r e n u n d e r g o i n g m i n o r s u r g i c a l p r o c e d u r e s ( E l - S h a f i e & S h a p i r o , 1977; J o h n s o n , 1 9 8 3 ; L a w r i e , 1964; S h a h , R o b i n s o n , K i n n i s , & D a v e n p o r t , 1972; S h a h , 1980).  T h e p h y s i c a l a n d p s y c h o - s o c i a l benefits it offers f o r the  f a m i l y unit, as w e l l as the f i n a n c i a l s a v i n g s f o r the C a n a d i a n H e a l t h C a r e S y s t e m , h a v e b e e n w e l l d o c u m e n t e d ( A t w e l l , B u r n , D e w a r , & F r e e m a n , 1973; C l o u d , R e e d , F o r d , L i n k n e r , T r u m p & D o r m a n , 1972; L a w r i e , 1964; O t h e r s e n & C l a t w o r t h y , 1 9 6 8 ; S h a h , 1 9 8 0 ; S c h o w a l t e r , 1977). T h e f i r s t r e p o r t e d cases o f p e d i a t r i c d a y care surgery w e r e d i s c u s s e d i n the literature b y N i c o l l i n 1909.  In a ten y e a r p e r i o d p r i o r to 1909 h e s u c c e s s f u l l y  p e r f o r m e d d a y surgery o n a n estimated 9 , 0 0 0 infants a n d c h i l d r e n i n G l a s g o w , S c o t l a n d . B y 1910, the p r a c t i c e o f pediatric d a y care surgery b e g a n i n C a n a d a at T o r o n t o ' s H o s p i t a l f o r S i c k C h i l d r e n ( S h a h , 1980). S i n c e a p e d i a t r i c d a y care surgery p r o g r a m w a s first i n t r o d u c e d i n V a n c o u v e r , B r i t i s h C o l u m b i a i n 1967, the n u m b e r s o f c h i l d r e n a n d their f a m i l i e s r e c e i v i n g this s e r v i c e h a v e c o n t i n u e d to g r o w steadily e a c h y e a r ( S h a h , 1980).  T h e g r o w t h o f this  p r o g r a m i s i n k e e p i n g w i t h the b e l i e f that u p to one h a l f o f a l l s u r g i c a l p r o c e d u r e s f o r  3 N o r t h A m e r i c a n c h i l d r e n c o u l d be d o n e o n a d a y care b a s i s ( B r o w n l e e , 1 9 7 7 ; S h a h , 1980). D u r i n g the 1984/85 f i s c a l p e r i o d , the n u m b e r o f p r i m a r y (first t i m e o n l y ) p e d i a t r i c d a y care s u r g i c a l procedures p e r f o r m e d at B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l w a s 4 , 7 9 2 ( B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h , 1985).  T h i s represented o v e r  4 0 % o f the total n u m b e r o f s u r g i c a l procedures p e r f o r m e d o n c h i l d r e n at this center. T h i s n u m b e r i s 1 4 . 4 % a b o v e the p r o v i n c i a l average f o r d a y care s u r g i c a l procedures ( B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h , 1985). I n V a n c o u v e r i n 1 9 8 6 , the e v e r i n c r e a s i n g d e m a n d f o r p e d i a t r i c d a y care surgery r e s u l t e d i n m a j o r r e n o v a t i o n s to the e x i s t i n g d a y care f a c i l i t i e s at B r i t i s h C o l u m b i a ' s Childrens' Hospital.  T h e n e w l y e x p a n d e d P a y C a r e U n i t i s m o r e than d o u b l e the  o r i g i n a l s i z e a n d n o w i n c l u d e s f a c i l i t i e s f o r m e d i c a l as w e l l as s u r g i c a l d a y care patients.  T h i s e x p a n d e d M e d i c a l / S u r g i c a l D a y C a r e U n i t a c c o m m o d a t e s an average o f  2 9 patients p e r d a y ( B . L a i r d , p e r s o n a l c o m m u n i c a t i o n , A p r i l 3 , 1987). W h e n a s u r g i c a l p r o c e d u r e i s c a r r i e d out i n a D a y C a r e U n i t , the parent(s) and c h i l d s p e n d a r e l a t i v e l y short p e r i o d o f t i m e , u s u a l l y about s i x to eight hours, i n the h o s p i t a l setting.  E x p e r i e n c e has s h o w n that the success o f a n y p e d i a t r i c d a y care  surgery p r o g r a m i s h i g h l y dependent u p o n the f u l l c o - o p e r a t i o n o f parents w h o , u p o n their c h i l d ' s d i s c h a r g e f r o m h o s p i t a l , are b o t h w i l l i n g and able to assume the r o l e o f p r i m a r y c a r e g i v e r ( E l - S h a f i e & S h a p i r o , 1977; S c h o w a l t e r , 1977).  T h e acceptance o f  this " n e w " c a r e g i v e r r o l e p l a c e s i n c r e a s e d d e m a n d s o n u s u a l p a r e n t i n g r o l e s .  It requires  that parents take o v e r r e s p o n s i b i l i t i e s a n d d e c i s i o n m a k i n g that w a s , i n the past, left to the j u d g e m e n t o f health care p r o f e s s i o n a l s .  It i s this a u t h o r ' s o p i n i o n that b y  c o n f e r r i n g these n e w c a r e g i v i n g r e s p o n s i b i l i t i e s o n the parents o f pediatric d a y care  4 surgery patients, h e a l t h p r o f e s s i o n a l s h a v e m a d e a s s u m p t i o n s about the parents' e x p e r i e n c e s o n c e they l e a v e the h o s p i t a l a n d a l s o about their a b i l i t i e s to m a n a g e the p o s t - o p e r a t i v e care o f their c h i l d w i t h i n the context o f their e v e r y d a y l i v e s . O n e o f the p r i m a r y f u n c t i o n s the f a m i l y u n i t serves w i t h i n o u r s o c i e t y i s i n r e l a t i o n to the m a n a g e m e n t o f health a n d m e d i c a l care f o r its m e m b e r s ( L i t m a n , 1974). F r i e d m a n (1986) i d e n t i f i e d the " p r o v i s i o n a n d a l l o c a t i o n o f p h y s i c a l necessities a n d health c a r e " (p. 59) as one o f f i v e basic f a m i l y f u n c t i o n s .  In b o t h W e s t e r n a n d  n o n - W e s t e r n societies 7 0 % to 9 0 % o f a l l s i c k n e s s i s m a n a g e d s o l e l y w i t h i n the s o c i a l n e t w o r k o f the f a m i l y a n d the c o m m u n i t y w i t h o u t p r o f e s s i o n a l c o n s u l t a t i o n ( K l e i n m a n , 1978).  Parents then, are quite a c c u s t o m e d to u t i l i z i n g their o w n resources to m a n a g e a  c h i l d ' s m i n o r i l l n e s s w i t h i n their f a m i l y unit.  T h i s i s a n acceptable p r a c t i c e a n d w e l l  w i t h i n the s c o p e o f a p a r e n t s ' n o r m a l r e s p o n s i b i l i t i e s . W h e n a n e w situation arises w i t h i n the f a m i l y unit, h o w e v e r , s u c h as o n e w h e n a c h i l d m u s t u n d e r g o d a y care surgery, the first t i m e e x p e r i e n c e o f h o s p i t a l i z a t i o n a n d a s u r g i c a l p r o c e d u r e c a n be v e r y a n x i e t y p r o v o k i n g f o r b o t h parent a n d c h i l d .  Such  a n x i e t y m a y c o n t i n u e d u r i n g the p o s t - h o s p i t a l i z a t i o n p e r i o d ( D r o s k e , 1 9 7 8 ; M a h a f f y , 1965).  P r o f e s s i o n a l s m a y f o r m their o w n o p i n i o n s about the nature o f the parents'  e x p e r i e n c e w h e n they l e a v e the h o s p i t a l .  H o w e v e r , it has b e e n s h o w n that there w i l l  be d i s c r e p a n c i e s a n d i n c o n s i s t e n c i e s i n the w a y s i n w h i c h p r o f e s s i o n a l s a n d l a y persons v i e w the same health care situation ( K l e i n m a n , 1978; K n o x & H a y e s , 1983). T h i s study w a s d e s i g n e d to e x p l o r e i n depth parents' thoughts, f e e l i n g s and r e a c t i o n s w h e n c a r i n g f o r their y o u n g c h i l d at h o m e f o l l o w i n g d a y care surgery i n order to contribute to n u r s i n g k n o w l e d g e about this important parental e x p e r i e n c e .  The  u n d e r s t a n d i n g g a i n e d f r o m f o c u s i n g o n the parents' p o i n t o f v i e w enhances health  5 p r o f e s s i o n a l s ' a b i l i t i e s to c o m m u n i c a t e w i t h parents i n a m e a n i n g f u l w a y ( A n d e r s o n C h u n g , 1 9 8 2 ; K n o x & H a y e s , 1983).  &  A n i n d e p t h u n d e r s t a n d i n g o f the p a r e n t s '  e x p e r i e n c e p r o v i d e s nurses w i t h c l e a r d i r e c t i o n f o r assessment, p l a n n i n g a n d i m p l e m e n t a t i o n o f appropriate n u r s i n g care both d u r i n g the y o u n g c h i l d ' s p r e - h o s p i t a l i z a t i o n a n d their p o s t - h o s p i t a l i z a t i o n p e r i o d s .  T h e knowledge gained from  this study a l s o adds c l a r i t y a n d v a l i d i t y to aspects o f n u r s i n g care presently i m p l e m e n t e d b y h o s p i t a l D a y C a r e U n i t nurses f o r the parents o f p e d i a t r i c d a y care surgery patients. Conceptual Framework T h e c o n c e p t u a l f r a m e w o r k w h i c h g u i d e d the d e v e l o p m e n t o f this study w a s d e v e l o p e d b y K l e i n m a n , E i s e n b e r g , a n d G o o d (1978).  T h e K l e i n m a n et a l . (1978)  f r a m e w o r k adheres to t w o f u n d a m e n t a l n o t i o n s : T h e first is a d i s t i n c t i o n b e t w e e n the c o n c e p t s o f " d i s e a s e " , " i l l n e s s " a n d " s i c k n e s s " , a n d the s e c o n d i s a c o n c e p t u a l i z a t i o n o f a health care s y s t e m w i t h three different but interacting s o c i a l " a r e n a s " .  The framework  h o l d s that a c l e a r understanding o f the perceptions a n d e x p l a n a t o r y m o d e l s o f i n d i v i d u a l s i n e a c h o f the arenas i n the health care s y s t e m w i l l l e a d to i m p r o v e m e n t i n the areas o f patient c o m m u n i c a t i o n , c o m p l i a n c e , a n d satisfaction. K l e i n m a n et a l . (1978) d e s c r i b e " d i s e a s e " as a b i o l o g i c a l m a l f u n c t i o n , a n d " i l l n e s s " as a p e r s o n a l , i n t e r p e r s o n a l , a n d c u l t u r a l r e a c t i o n to the disease (p. 2 5 2 ) . S i m p l y put, diseases are treated a n d i l l n e s s e s are e x p e r i e n c e d .  S i c k n e s s i s d e f i n e d as a  c o m p l e x h u m a n p h e n o m e n o n e n c o m p a s s i n g b o t h disease a n d i l l n e s s .  The human  e x p e r i e n c e o f s i c k n e s s has interacting b i o l o g i c a l , p s y c h o l o g i c a l , a n d s o c i o c u l t u r a l components.  It i s the s i c k n e s s e x p e r i e n c e a n d the r e s u l t i n g d i f f i c u l t i e s it b r i n g s to  aspects o f d a i l y l i v i n g that is o f p r i m a r y c o n c e r n to patients i n the h e a l t h care s y s t e m .  6 K l e i n m a n (1978) m a i n t a i n s that i n order to o v e r c o m e s i c k n e s s , o r to s u c c e s s f u l l y c o m p l e t e the h e a l i n g p r o c e s s , there must b e a r e s o l u t i o n o f b o t h the b i o l o g i c a l disease a n d the i l l n e s s e x p e r i e n c e . T h e three s o c i a l arenas o f K l e i n m a n ' s health care s y s t e m are referred to as the p o p u l a r , p r o f e s s i o n a l , a n d f o l k arenas.  T h e three arenas serve to s o c i a l l y l e g i t i m i z e  s i c k n e s s a n d health care f o r the i n d i v i d u a l s they represent.  I n health care relationships  transactions o c c u r b e t w e e n i n d i v i d u a l s i n e a c h o f these three arenas. T h e p o p u l a r arena i s c o m p r i s e d o f i n d i v i d u a l s , farriilies, a n d s o c i a l / c o m m u n i t y networks.  T h e m a j o r i t y o f health care activities take p l a c e i n this arena. T h e  p r o f e s s i o n a l arena i n c l u d e s s c i e n t i f i c m e d i c i n e a n d i n d i g e n o u s h e a l i n g traditions, the f o l k arena i n c l u d e s n o n - p r o f e s s i o n a l h e a l i n g specialists.  E a c h o f these arenas  "possesses its o w n e x p l a n a t o r y s y s t e m s , s o c i a l r o l e s , interaction settings, a n d institutions"  ( K l e i n m a n et a l . , 1 9 7 8 , p. 2 5 4 ) .  T h e f o l l o w i n g f i g u r e depicts K l e i n m a n ' s (1978) health care s y s t e m . Popular Sector  L  -  Points of Interaction Entrance and Exit  F i g u r e 1. K l e i n m a n ' s H e a l t h C a r e S y s t e m (1978)  while  7 In e a c h o f these three arenas, e x p l a n a t o r y m o d e l s c a n be e l i c i t e d f r o m i n d i v i d u a l s to e x p l a i n a n d d e f i n e p a r t i c u l a r s i c k n e s s e p i s o d e s .  I n d i v i d u a l s use p e r s o n a l  e x p l a n a t o r y m o d e l s to determine a n d d e s c r i b e w h a t is w r o n g w i t h t h e m o r others, a n d a l s o to r e c o m m e n d w h a t steps s h o u l d be taken f o r s u c c e s s f u l treatment.  Explanatory  m o d e l s are c o n s t r u c t e d o r shaped b y an i n d i v i d u a l ' s culture, s o c i e t y , k n o w l e d g e base, b e l i e f s , v a l u e s , and past e x p e r i e n c e s .  B e c a u s e i n d i v i d u a l s f r o m different arenas w i l l  h a v e different e x p l a n a t o r y m o d e l s f o r the same health care situations, the result i s often " d i s c r e p a n t expectations a n d m i s c o m m u n i c a t i o n " ( K l e i n m a n , 1 9 7 8 , p. 88).  A  common  e x a m p l e o f this type o f d i s c r e p a n c y i s that i n m o s t situations i n the p r o f e s s i o n a l arena, s i c k n e s s i s c o n s t r u e d as " d i s e a s e " w h i l e the i n the p o p u l a r arena it i s m o s t o f t e n v i e w e d as " i l l n e s s " . A c c o r d i n g to the K l e i n m a n et a l . (1978) f r a m e w o r k , i f nurses are to i m p r o v e the care p r o v i d e d to parents, they m u s t be c o n c e r n e d w i t h the w a y s i n w h i c h parents v i e w their c h i l d r e n ' s i l l n e s s e s s i n c e interpretation o f a situation m a y be m a d e v e r y d i f f e r e n t l y b y parents a n d p r o f e s s i o n a l s .  In g e n e r a l , parents o f p e d i a t r i c d a y care surgery patients  are f a m i l y m e m b e r s representing the p o p u l a r arena.  T h e parents' explanatory models  f o r the post d a y care surgery e x p e r i e n c e c a n be u n d e r s t o o d b y e l i c i t i n g their perceptions a n d e x p l a n a t i o n s about this e x p e r i e n c e .  A n u n d e r s t a n d i n g o f the parents' e x p l a n a t o r y  m o d e l s w i l l p r o v i d e a s o l i d basis f o r c l e a r c o m m u n i c a t i o n b e t w e e n the nurse and the parents a n d h e l p to facilitate e f f e c t i v e n u r s i n g intervention.  Others have previously  d e m o n s t r a t e d the r e l e v a n c e o f this f r a m e w o r k i n n u r s i n g research a n d a p p l i c a t i o n s to nursing care (Anderson, 1981; D u n n , 1985; K n o x & H a y e s , 1983; R o b i n s o n , 1983; T h o r n e , 1983).  8 Statement o f the P r o b l e m T h e g e n e r a l p r o b l e m that this study addresses i s a l a c k o f n u r s i n g k n o w l e d g e about the p a r e n t s ' e x p e r i e n c e at h o m e f o l l o w i n g their c h i l d ' s short t e r m h o s p i t a l stay f o r d a y care surgery a n d the m e a n i n g a s s i g n e d to this e x p e r i e n c e f r o m the parents' perspective.  T h e r e f o r e , this study w a s d e s i g n e d to g a i n an u n d e r s t a n d i n g o f parents'  f i r s t t i m e e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery.  T h e results p r o v i d e i n s i g h t i n t o the subjective m e a n i n g o f the post-operative  p e d i a t r i c d a y care surgery e x p e r i e n c e b y e l u c i d a t i n g the p a r e n t s ' p e r s o n a l e x p l a n a t i o n s , p e r c e p t i o n s , a n d d e f i n i t i o n s o f their situation, a n d also the w a y s i n w h i c h they desire to be h e l p e d .  H e n c e , the study addressed the f o l l o w i n g q u e s t i o n :  W h a t i s the parents'  e x p e r i e n c e o f h a v i n g a toddler o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery? I n t r o d u c t i o n to T h e M e t h o d o l o g y T h e q u a l i t a t i v e research m e t h o d o f p h e n o m e n o l o g y w a s selected to address the r e s e a r c h q u e s t i o n p o s e d b y this study.  P h e n o m e n o l o g y i s not j u s t a r e s e a r c h m e t h o d  but i s a l s o a p h i l o s o p h y a n d an a p p r o a c h ( O i l e r , 1982).  C o n s i d e r e d to be a v i a b l e and  v a l u a b l e q u a l i t a t i v e m e t h o d o l o g y , it w a s c h o s e n because it e m p l o y s d e s c r i p t i o n to i d e n t i f y a n d understand p h e n o m e n a ( O m e r y , 1983).  A s R i s t (1979) stated, this type o f  r e s e a r c h m e t h o d " e n a b l e s a c o m p r e h e n s i o n o f h u m a n b e h a v i o r i n greater d e p t h than i s p o s s i b l e f r o m the study o f surface b e h a v i o r , f r o m p a p e r a n d p e n c i l tests, and f r o m s t a n d a r d i z e d i n t e r v i e w s " (p. 20). P h e n o m e n o l o g y represents an effort to d e s c r i b e the h u m a n e x p e r i e n c e as it is l i v e d b y the i n d i v i d u a l s b e i n g studied.  A l l p h e n o m e n a , i n c l u d i n g the i n d i v i d u a l ' s  p e r c e p t i o n s o f the h u m a n e x p e r i e n c e and their effect o n h i m / h e r , are i n v e s t i g a t e d a n d d e s c r i b e d ( O m e r y , 1983).  A l l data g i v e n b y the subjects are d e e m e d to be relevant.  9 A researcher u s i n g the p h e n o m e n o l o g i c a l m e t h o d must a p p r o a c h the research e n c o u n t e r n a i v e l y a n d w i t h an " o p e n m i n d " ( O m e r y , 1983).  T h e researcher must  r e c o g n i z e h i s / h e r o w n p r e c o n c e i v e d ideas and attempt to set t h e m aside ( O i l e r , 1981). T h e researcher accepts the generated data as subjective d e s c r i p t i o n s o f the m e a n i n g the e x p e r i e n c e has f o r the i n d i v i d u a l s b e i n g studied, and he/she does not attempt to m o d i f y it to fit a p r e c o n c e i v e d d e f i n i t i o n o f the p h e n o m e n o n ( O m e r y , 1983). P h e n o m e n o l o g y i s an appropriate m e t h o d to study the parents' e x p e r i e n c e at h o m e f o l l o w i n g their c h i l d ' s d a y care surgery because it strives to understand a l l data i n the e x p e r i e n c e f r o m the perspective o f the parents t h e m s e l v e s .  In a d d i t i o n , the  p h e n o m e n o l o g i c a l m e t h o d i s congruent w i t h K l e i n m a n ' s f r a m e w o r k ( 1 9 7 8 ) , as b o t h approaches e m p h a s i z e that i n d i v i d u a l s g i v e subjective m e a n i n g to the situations they experience in everyday life. Definition of Terms T h e f o l l o w i n g terms are d e f i n e d i n o r d e r to c l a r i f y their use i n this study: D a y Care Surgery:  an e l e c t i v e s u r g i c a l p r o c e d u r e c a r r i e d out i n a s p e c i a l  h o s p i t a l u n i t w h e r e the patient i s admitted a n d d i s c h a r g e d f r o m h o s p i t a l o n the same d a y ( D a v e n p o r t , S h a h , & R o b i n s o n , 1971). Family:  t w o o r m o r e persons l i v i n g together j o i n e d b y m u t u a l consent a n d  bonds of blood, marriage, or adoption.  T h e s e p e r s o n s share a c o m m o n culture a n d  a s s u m e s o c i a l l y r e c o g n i z e d r o l e s s u c h as m o t h e r and father, sister a n d brother, s o n a n d daughter ( F r i e d m a n , 1986). Parent:  a n adult p e r s o n w h o f u l f i l s the p r i m a r y c a r e t a k i n g r o l e f o r a c h i l d .  T h i s p e r s o n m a y be the c h i l d ' s b i o l o g i c a l , a d o p t i v e , step, o r foster parent.  10 Parents' Experience:  parents' reactions, thoughts a n d f e e l i n g s , a n d the p e r s o n a l  m e a n i n g that they h o l d f o r t h e m , w h i c h together c o m p r i s e the p a r e n t ' s response to c a r i n g f o r a c h i l d at h o m e f o l l o w i n g d a y care surgery. Post-hospitalization Period:  that p e r i o d o f time w h i c h c o m m e n c e s w h e n the  parent a n d c h i l d l e a v e the h o s p i t a l setting u n a c c o m p a n i e d b y any h o s p i t a l p e r s o n n e l , a n d ends w h e n the c h i l d has r e c o v e r e d p h y s i c a l l y and e m o t i o n a l l y f r o m the surgery and a l l f a m i l y m e m b e r s h a v e returned to their r e g u l a r patterns a n d activities o f d a i l y l i v i n g . Preschooler:  a c h i l d w h o s e current age at the t i m e o f the d a y care surgery is  w i t h i n the r a n g e o f three to f i v e years. Short-term C o n d i t i o n or Illness:  a n o n - c h r o n i c , non-recurrent, disease o r a i l m e n t  w h i c h i s s e l f - l i m i t i n g i n nature but requires s u r g i c a l i n t e r v e n t i o n i n o r d e r to o b t a i n correction or resolution. Toddler:  a c h i l d w h o s e current age at the t i m e o f d a y care surgery i s w i t h i n the  age r a n g e o f o n e to three years. Assumptions T h e a s s u m p t i o n s that g u i d e d this study are as f o l l o w s : 1. T h e c o n s t r u c t i o n o f a n e x p e r i e n c e b y the i n d i v i d u a l s i n v o l v e d i n it i s a v a l i d representation o f the e x p e r i e n c e a n d c a n p r o m o t e further u n d e r s t a n d i n g o f the p h e n o m e n o n ( O m e r y , 1983). 2. P a r e n t s ' e x p e r i e n c e s f o l l o w i n g their c h i l d ' s d a y care surgery, a n d the m e a n i n g s they a s s i g n to these e x p e r i e n c e s w i t h i n the c o n t e x t o f their situation, c a n be p e r c e i v e d a n d u n d e r s t o o d b y the researcher u s i n g a p h e n o m e n o l o g i c a l m e t h o d . 3. T h e researcher a c t i v e l y participates i n the constitution o f the actual research data b y v i r t u e o f o p e n d i a l o g u e w i t h participants a n d a f o c u s o n their subjective  11 e x p e r i e n c e s ( G i o r g i , 1975a). 4 . Parents o f c h i l d r e n a g e d one to f i v e years w h o w e r e selected to participate i n this study o f f e r e d c o m p r e h e n s i v e , relevant a n d r e l i a b l e i n f o r m a t i o n to the researcher ( M o r s e , 1986). Limitation T h e f o l l o w i n g study l i m i t a t i o n w a s i d e n t i f i e d : 1.  T h e r e a l i t y o f a n e x p e r i e n c e constructed b y parents i n i n t e r a c t i o n w i t h the  researcher i s i n f l u e n c e d b y the s o c i a l , c u l t u r a l , e n v i r o n m e n t a l , a n d p e r s o n a l contexts o f the situation.  G e n e r a l i z a b i l i t y o f f i n d i n g s b a s e d o n this type o f research i s l i m i t e d to  s i m i l a r m e a n i n g s f o u n d i n the data ( O m e r y , 1983) s i n c e e v e r y q u a l i t a t i v e research situation i s " u l t i m a t e l y about a p a r t i c u l a r researcher i n interaction w i t h a p a r t i c u l a r subject i n a p a r t i c u l a r c o n t e x t " ( S a n d e l o w s k i , 1 9 8 6 , p. 31).  T h e data therefore represent  the e x p e r i e n c e s o f o n l y those parents w h o p a r t i c i p a t e d i n the study. Summary A g r o w i n g n u m b e r o f f a m i l i e s are e x p e r i e n c i n g d a y care surgery as an alternative to m o r e t r a d i t i o n a l f o r m s o f health care d e l i v e r y f o r y o u n g c h i l d r e n .  During  the p o s t - h o s p i t a l i z a t i o n p e r i o d f o l l o w i n g a m i n o r s u r g i c a l p r o c e d u r e , p a r e n t s ' attitudes a n d a b i l i t i e s to c o p e h a v e been s h o w n to h a v e a p r o f o u n d effect o n a y o u n g c h i l d ' s w e l l - b e i n g a n d r e c o v e r y ( P r u g h , Staub, S a n d s , K i r s c h b a u m , & L e n i h a n , 1 9 5 3 ; R o b e r t s o n , 1970). T h i s study i s d e s i g n e d to e x p l o r e i n - d e p t h the parents' p e r c e p t i o n s a n d p e r s o n a l interpretations o f the post d a y care surgery e x p e r i e n c e w i t h i n the c o n t e x t o f their e v e r y day lives.  K l e i n m a n (1978) purports, a n d other authors h a v e d e m o n s t r a t e d , that  e l i c i t i n g c l i e n t s ' e x p l a n a t o r y m o d e l s enhances health p r o f e s s i o n a l s ' u n d e r s t a n d i n g o f  i l l n e s s as a p e r s o n a l , s o c i a l a n d c u l t u r a l e x p e r i e n c e a n d facilitates the p r o v i s i o n o f care that i s m u t u a l l y s a t i s f y i n g ( A n d e r s o n , 1 9 8 1 ; A n d e r s o n & C h u n g , 1 9 8 2 ; K n o x &  Hayes,  1983). T h e results o f this research address the l a c k o f e m p i r i c a l k n o w l e d g e c o n c e r n i n g this i m p o r t a n t parental e x p e r i e n c e .  T h e f i n d i n g s o f this study direct nurses to p l a n a n d  p r o v i d e e m p a t h i c n u r s i n g care w h i c h reflects the nature a n d m e a n i n g o f the post d a y care surgery e x p e r i e n c e f o r this c l i e n t g r o u p . literature pertinent to this i n v e s t i g a t i o n .  C h a p t e r 2 p r o v i d e s a r e v i e w o f the  13 CHAPTER  2  Review of Selected Literature  T h i s chapter presents a r e v i e w o f the literature pertinent to this s t u d y ' s research problem.  T h e intent o f the r e v i e w i s to establish a b a c k g r o u n d f o r w h a t i s understood  to date about the p o s t - h o s p i t a l i z a t i o n e x p e r i e n c e f o r parents w h o s e c h i l d r e n h a v e u n d e r g o n e a d a y care surgery p r o c e d u r e a n d to locate this study w i t h i n the context o f r e l a t e d p r o f e s s i o n a l literature.  O n s e a r c h i n g literature f r o m n u r s i n g a n d other  d i s c i p l i n e s , this author w a s unable to locate a study that discusses parents' perceptions o f the p o s t - h o s p i t a l i z a t i o n p e d i a t r i c day care surgery e x p e r i e n c e n o r their a b i l i t y to m a n a g e at h o m e d u r i n g this t i m e .  T h e p a u c i t y o f literature about the post d a y care  surgery e x p e r i e n c e f r o m the parents' p e r s p e c t i v e h i g h l i g h t s a n e e d f o r further investigation. T h i s selected r e v i e w o f literature w i l l i n c l u d e both e x p e r i e n t i a l l y a n d r e s e a r c h - b a s e d p u b l i c a t i o n s f r o m f o u r relevant subject areas i n o r d e r to establish a b a c k g r o u n d o f i n f o r m a t i o n about the s t u d y ' s research q u e s t i o n .  T h e s e f o u r subject  areas e x p l o r e the m o r e g e n e r a l i m p a c t o f a c h i l d ' s i l l n e s s , h o s p i t a l i z a t i o n and/or surgery o n the c h i l d a n d h i s / h e r parents.  T h e first subject area e x a m i n e s parental r o l e and  r e s p o n s i b i l i t y c h a n g e s w h e n a c h i l d b e c o m e s i l l o r requires h o s p i t a l i z a t i o n .  T h e second  subject area relates s p e c i f i c a l l y to the effects o f m a t e r n a l a n x i e t y o n the h o s p i t a l i z e d child.  T h e t h i r d subject area, d i r e c t l y related to the i s s u e i n q u e s t i o n , e x p l o r e s parental  attitudes t o w a r d s p e d i a t r i c d a y care surgery.  A n d f i n a l l y , the f o u r t h subject area  e x a m i n e s short t e r m h o s p i t a l i z a t i o n o f toddlers a n d p r e s c h o o l e r s a n d r e s u l t i n g  14 p o s t - h o s p i t a l i z a t i o n b e h a v i o r changes. A l t h o u g h the literature r e v i e w e d here is related to the research q u e s t i o n , it is not m e a n t to generate a m i n d set about the nature a n d m e a n i n g o f the post d a y care s u r g e r y e x p e r i e n c e f o r parents.  T h i s i s consistent w i t h the c o n c e p t u a l f r a m e w o r k a n d  the p h e n o m e n o l o g i c a l m e t h o d o l o g y . T h e r e m a i n d e r o f the chapter i s o r g a n i z e d i n t o sections c o r r e s p o n d i n g w i t h the selected subject areas.  R e l a t e d theory a n d research w i l l be e x a m i n e d a g a i n i n C h a p t e r  4 , w h e n the f i n d i n g s o f this study are presented a n d d i s c u s s e d . Parental R o l e and Responsibility Changes W h e n C a r i n g for A S i c k C h i l d T h e literature supports that a p a r e n t ' s r o l e c h a n g e s w h e n a c h i l d b e c o m e s i l l ( H y m o v i c h , 1 9 7 6 , 1 9 8 1 ; L i t m a n , 1974; P r u g h et a l . , 1953).  Parents o f y o u n g c h i l d r e n  are p a r t i c u l a r l y susceptible to such c h a n g e s because they r e l y o n their c h i l d r e n s ' responses a n d b e h a v i o r s to h e l p define their parental r o l e .  Conversely, young children  r e l y a l m o s t e x c l u s i v e l y o n their parents to interpret their e n v i r o n m e n t a n d translate it i n a m e a n i n g f u l w a y to t h e m ( F r i e d m a n , 1986). L i t m a n , i n h i s 1974 study o f the f a m i l y as a b a s i c u n i t i n health and m e d i c a l care, s h o w e d that the f a m i l y " i n one w a y o r another tends to be i n v o l v e d i n the d e c i s i o n - m a k i n g a n d the therapeutic p r o c e s s at e v e r y stage o f m e m b e r ' s i l l n e s s , f r o m d i a g n o s i s to treatment a n d r e c u p e r a t i o n " (p. 5 0 1 ) . i l l n e s s affects a c h i l d .  T h i s i s p a r t i c u l a r l y true w h e n the  H e e m p h a s i z e d the i m p o r t a n c e o f the f a m i l y ' s response  ( e s p e c i a l l y the w i f e - m o t h e r ) to a n y m e m b e r ' s i l l n e s s a n d noted that i n a d d i t i o n to b e i n g the " c e n t r a l agent o f c u r e a n d c a r e " (p. 5 0 5 ) she a l s o m a y e x h i b i t c o n s i d e r a b l e v a r i a t i o n i n her " a b i l i t y to r e c o g n i z e d i s c o m f o r t o r i l l n e s s i n a f a m i l y m e m b e r " (p. 5 0 5 ) .  Litman  (1974) a l s o f o u n d that because o f the d e m a n d s o f her u s u a l r o l e , a m o t h e r often f o u n d  15 it d i f f i c u l t to f u l f i l her o b l i g a t i o n s to a l l m e m b e r s o f the h o u s e h o l d w h e n o n e m e m b e r was ill. B a s e d o n o b s e r v a t i o n a n d e x p e r i e n c e , H y m o v i c h (1976) d e s c r i b e d i n d e t a i l the needs o f parents w h e n their c h i l d i s s i c k .  S h e states that: " w h e t h e r the i l l n e s s i s acute,  c h r o n i c , o r fatal, treated at h o m e o r i n the h o s p i t a l , it w i l l have s o m e i m p a c t o n a l l m e m b e r s o f the f a m i l y , not j u s t the i l l c h i l d " (p. 9).  P r u g h et a l . (1953) a l s o  d o c u m e n t e d that w h e n a c h i l d b e c o m e s i l l a c h a n g e takes p l a c e i n the p a r e n t - c h i l d relationship. If the c h i l d ' s i l l n e s s necessitates h o s p i t a l i z a t i o n , changes o c c u r i n parental r o l e s a n d i n their e v e r y d a y r e s p o n s i b i l i t i e s .  D u r i n g the c h i l d ' s h o s p i t a l i z a t i o n m o s t parents,  a l t h o u g h w i l l i n g to participate i n their c h i l d ' s care, are unsure o f their r o l e i n the h o s p i t a l setting ( A l g r e n , 1 9 8 5 ; K n o x & H a y e s , 1 9 8 3 ; M e r r o w & J o h n s o n , 1968). A l g r e n (1985) r e v e a l e d that parents r e c e i v e m i n i m a l d i r e c t i o n f r o m n u r s i n g staff to c l a r i f y their r o l e uncertainty. T h e h o s p i t a l i z a t i o n o f a c h i l d results i n parental separation a n d r e l i n q u i s h m e n t  of  the c h i l d ' s care to p e r s o n s u n k n o w n at a time w h e n parent and c h i l d h a v e a greater n e e d f o r o n e another ( G o f m a n , B u c k m a n & S c h a d e , 1957).  Parents b e c o m e v u l n e r a b l e  a n d n e e d s p e c i a l reassurance a n d e x p l a n a t i o n ( K e a n e , G a r r a l d a , & K e e n , 1 9 8 6 ; K n o x H a y e s , 1 9 8 3 ; W i l k e n s o n , 1978).  D u r i n g this t i m e parents e x p e r i e n c e f e e l i n g s o f fear,  g u i l t , frustration a n d a n x i e t y ( D r o s k e , 1978; G o f m a n et a l . , 1 9 5 7 ; S m i t h e r m a n , 1 9 7 9 ; W h a l e y & W o n g , 1 9 8 7 ; W o l f e r & V i s i n t a i n e r , 1975).  A s these e m o t i o n s increase i n  i n t e n s i t y , j u d g e m e n t a n d m e m o r y c a n be i m p a i r e d a n d l e a r n i n g responses b e c o m e less effective.  &  16 A s m a l l a m o u n t o f literature exists w h i c h supports the p r e m i s e that the p o s t - h o s p i t a l i z a t i o n p e r i o d m a y also be p a r t i c u l a r l y d i f f i c u l t f o r parents ( D r o s k e , 1978; F r i e b e r g , 1 9 7 2 ; W i l k e n s o n , 1978).  P r u g h et a l . (1953) p a r t i a l l y attributed parents'  p r e - o p e r a t i v e a n x i e t y to c o n c e r n s about d e a l i n g w i t h the c h i l d o n c e he/she returned home. U y e r (1986) d e s c r i b e d a study o f 2 0 0 y o u n g mothers w h o brought their s i c k c h i l d r e n to an Out-patient C l i n i c f o r treatment o f a v a r i e t y o f m i n o r i l l n e s s e s .  Uyer  (1986) b e l i e v e s that i n o r d e r to understand a n d m a n a g e her c h i l d ' s i l l n e s s , a m o t h e r m u s t accurately interpret the facts c o n c e r n i n g the c h i l d ' s d i a g n o s i s , treatment, c a r e , a n d follow-up.  T h i s author f o u n d that 7 2 % o f the mothers left the C l i n i c w i t h i n c o r r e c t or  i n c o m p l e t e i n f o r m a t i o n r e g a r d i n g the necessary care f o r their i l l c h i l d . 4 4 % a l s o h a d inadequate i n f o r m a t i o n r e g a r d i n g treatment a n d f o l l o w - u p .  A n average o f U y e r found  that the i m p l e m e n t a t i o n o f an e x p e r i m e n t a l " n u r s i n g a p p r o a c h " w i t h the e x p e r i m e n t a l g r o u p o f mothers s i g n i f i c a n t l y i m p r o v e d their c o m p r e h e n s i o n o f their s i c k c h i l d r e n ' s treatment a n d care thus d e m o n s t r a t i n g the v a l u e o f n u r s i n g i n t e r v e n t i o n i n i m p r o v i n g patient c o m m u n i c a t i o n a n d e d u c a t i o n . U y e r ' s (1986) study r e i n f o r c e s the fact that mothers d o not a l w a y s r e m e m b e r o r v a l u e the i n f o r m a t i o n that h e a l t h p r o f e s s i o n a l s d e e m to be " i m p o r t a n t " .  In certain  cases, it i s p o s s i b l e that the w e l l - b e i n g a n d r e c o v e r y o f the c h i l d m a y be at r i s k i f r e c o m m e n d a t i o n s are not f o l l o w e d . In s u m m a r y , the literature supports that parents h a v e u n i q u e needs a n d r o l e s w h e n a c h i l d becomes i l l and/or hospitalized.  A c h i l d ' s i l l n e s s a n d the parental  r e a c t i o n s to it m a y affect the f u n c t i o n i n g o f a n entire f a m i l y unit.  P a r e n t a l support i s  c r u c i a l to the p h y s i c a l a n d p s y c h o s o c i a l r e c o v e r y o f a c h i l d , a n d yet a c h i l d ' s  17 h o s p i t a l i z a t i o n m a y be e x t r e m e l y anxiety p r o v o k i n g f o r parents, e s p e c i a l l y mothers. M u c h i s s t i l l not k n o w n about the p a r e n t s ' e x p e r i e n c e at h o m e f o l l o w i n g a child's hospitalization:  H o w d o parents c o p e w i t h n e w r e s p o n s i b i l i t i e s a n d their  increased need for information? post-hospitalization period?  H o w d o they adjust to r o l e c h a n g e s d u r i n g the  W h e n d o they readjust to f o r m e r r o l e s a n d r e g u l a r patterns  o f d a i l y l i v i n g after the c h i l d has been d i s c h a r g e d f r o m h o s p i t a l ? B e c a u s e the p e r c e p t i o n o f a n event i s m o r e s i g n i f i c a n t than the actual c i r c u m s t a n c e s ( W h a l e y & W o n g , 1987), it i s necessary to learn about an e x p e r i e n c e as it a c t u a l l y l i v e d b y the persons i n v o l v e d i n it.  It w a s thought that a study such as this  o n e i n v e s t i g a t i n g the post d a y care surgery p e r i o d w o u l d p r o v i d e i n s i g h t i n t o h o w w e c a n better prepare parents f o r the transitions they m u s t f a c e d u r i n g this t i m e . T h e E f f e c t s o f M a t e r n a l A n x i e t y o n the H o s p i t a l i z e d C h i l d T h e r e h a v e b e e n several studies w h i c h h a v e demonstrated the degree a n d effects o f m a t e r n a l a n x i e t y d u r i n g a c h i l d ' s p r e - a n d post-operative h o s p i t a l i z a t i o n p e r i o d .  In  the three studies to be e x a m i n e d here, a l l o f the c h i l d r e n u n d e r w e n t m i n o r e l e c t i v e s u r g i c a l p r o c e d u r e s w h i l e h o s p i t a l i z e d f o r short p e r i o d s o f  time.  T h e s e studies are  s i g n i f i c a n t because, b y 1988 standards, m o s t o f the s u r g i c a l p r o c e d u r e s d e s c r i b e d i n t h e m w o u l d b e c o n s i d e r e d suitable p e d i a t r i c d a y care surgery cases.  T h e findings of  these studies, d o c u m e n t i n g l e v e l s o f m a t e r n a l a n x i e t y , m a y be g e n e r a l i z a b l e to the r e a c t i o n s o f mothers w h e n their c h i l d r e n u n d e r g o these same types o f p r o c e d u r e s o n a d a y c a r e surgery basis. M a h a f f y (1965) studied a s a m p l e o f 4 3 r a n d o m l y selected c h i l d r e n a g e d t w o to ten years w h o w e r e a d m i t t e d f o r t o n s i l l e c t o m y a n d a d e n o i d e c t o m y . T h e s e c h i l d r e n h a d no previous hospitalizations.  M a h a f f y p r o p o s e d that h o s p i t a l i z a t i o n i s an a n x i e t y  18 p r o v o k i n g e x p e r i e n c e f o r b o t h parent a n d c h i l d a n d that a " m o t h e r m u s t be c o m f o r t a b l e a n d s e c u r e " (p. 12) i n order to meet her c h i l d ' s needs. T h e researcher i n t r o d u c e d an i n d e p e n d e n t v a r i a b l e o f " s u p p o r t i v e n u r s i n g c a r e " to mothers o f the 21 c h i l d r e n i n the e x p e r i m e n t a l group i n o r d e r to test the h y p o t h e s i s that r e d u c i n g parental stress w o u l d m e a s u r a b l y r e d u c e distress i n the c h i l d b o t h d u r i n g the h o s p i t a l i z a t i o n a n d post-hospitalization period.  T h e s t u d y ' s f i n d i n g s c l e a r l y supported the h y p o t h e s i s ,  a l t h o u g h g e n e r a l i z a b i l i t y o f M a h a f f y ' s (1965) f i n d i n g s m u s t be m a d e w i t h c a u t i o n as the study size w a s s m a l l a n d not a l l dependent v a r i a b l e s w e r e c o n t r o l l e d . M a h a f f y r e v e a l e d , b y m e a n s o f a p o s t - h o s p i t a l i z a t i o n q u e s t i o n n a i r e , that a l l o f the c h i l d r e n w h o p a r t i c i p a t e d i n the study s h o w e d b e h a v i o r a l m a n i f e s t a t i o n s o f anxiety i n the p o s t - h o s p i t a l i z a t i o n p e r i o d . T h e r e w e r e , h o w e v e r , statistically s i g n i f i c a n t d i f f e r e n c e s b e t w e e n the c o n t r o l a n d e x p e r i m e n t a l g r o u p s i n the m a n i f e s t a t i o n o f three types o f b e h a v i o r .  A greater n u m b e r o f c h i l d r e n i n the c o n t r o l g r o u p (their mothers d i d  not r e c e i v e " s u p p o r t i v e n u r s i n g care") e x h i b i t e d d i s t u r b e d sleep, fear o f m e d i c a l p e r s o n n e l , a n d an i n c r e a s e d d e p e n d e n c y o n their mothers.  T h e i m p l i c a t i o n o f this  f i n d i n g i s that the e x p e r i m e n t a l n u r s i n g i n t e r v e n t i o n used w i t h the mothers m a y h a v e h a d an effect o n the c h i l d ' s b e h a v i o r u p o n r e t u r n i n g h o m e .  T h i s finding can be  e x p l o r e d further b y i n v e s t i g a t i n g the p o s t - h o s p i t a l i z a t i o n p e r i o d as d e s c r i b e d b y the parents t h e m s e l v e s , a task undertaken b y the author o f this research report. I n a s i m i l a r study, W o l f e r a n d V i s i n t a i n e r (1975) h y p o t h e s i z e d that c h i l d r e n and parents w h o r e c e i v e s p e c i a l p s y c h o l o g i c a l preparation a n d c o n t i n u e d supportive care f r o m a C l i n i c a l N u r s e S p e c i a l i s t ( C N S ) w o u l d s h o w less b e h a v i o r a l upset a n d better c o p i n g a b i l i t i e s d u r i n g the h o s p i t a l i z a t i o n p e r i o d a n d f e w e r p o s t - h o s p i t a l adjustment problems.  E i g h t y c h i l d r e n aged three to 14 years s c h e d u l e d f o r m i n o r surgery a n d their  19 parents w e r e r a n d o m l y a s s i g n e d to c o n t r o l a n d e x p e r i m e n t a l groups.  The children had  not b e e n h o s p i t a l i z e d i n the p r e v i o u s y e a r a n d w e r e a d m i t t e d f o r p r o c e d u r e s s u c h as tonsillectomy, adenoidectomy, myringotomy, and inguinal or u m b i l i c a l herniorrhaphy. A s w i t h M a h a f f y ' s (1965) study, there w a s e v i d e n c e o f a n x i e t y i n b o t h the c o n t r o l a n d e x p e r i m e n t a l groups.  Parents i n the latter g r o u p ( w i t h C N S support)  h o w e v e r , h a d s i g n i f i c a n t l y l o w e r self ratings o f a n x i e t y , h i g h e r ratings o f a d e q u a c y o f i n f o r m a t i o n p r o v i d e d , a n d greater satisfaction w i t h the care g i v e n .  T h e c h i l d r e n i n the  e x p e r i m e n t a l group s h o w e d s i g n i f i c a n t p h y s i o l o g i c a l e v i d e n c e o f r e d u c e d a n x i e t y w h i l e i n h o s p i t a l (eg., l o w e r b l o o d pressure r e a d i n g s , r e d u c e d i n c i d e n c e o f c r y i n g &  vomiting,  etc.) a n d a l s o o b t a i n e d s i g n i f i c a n d y l o w e r p o s t - h o s p i t a l adjustment scores o n the P o s t h o s p i t a l B e h a v i o r Q u e s t i o n n a i r e ( V e r n o n , S c h u l m a n , & F o l e y , 1966).  These  f i n d i n g s a d d support to the p r e m i s e that n u r s i n g i n t e r v e n t i o n p l a y s a r o l e i n r e d u c i n g a n x i e t y i n h o s p i t a l i z e d parents a n d c h i l d r e n . O f further interest w a s W o l f e r a n d V i s i n t a i n e r ' s (1975) f i n d i n g that the anxiety ratings i n b o t h parental g r o u p s p r o v e d to be s i g n i f i c a n t l y h i g h e r f o r parents o f y o u n g children.  In a d d i t i o n , c h i l d r e n w h o s e ages w e r e b e t w e e n three a n d s i x years  c o n s i s t e n t l y d e m o n s t r a t e d greater upset a n d less c o o p e r a t i o n than those i n o l d e r age groups.  T h e s e f i n d i n g s support the n e e d f o r an i n v e s t i g a t i o n w h i c h f o c u s e s o n the  e x p e r i e n c e o f parents o f c h i l d r e n under the age o f f i v e .  It i s i m p o r t a n t to note that the  W o l f e r a n d V i n s i n t a i n e r (1975) study h a d a n u m b e r o f m e t h o d o l o g i c a l p r o b l e m s r e g a r d i n g the p o s s i b l e bias o f parents i n the e x p e r i m e n t a l g r o u p w i t h w h o m the r e s e a r c h nurse spent c o n s i d e r a b l y m o r e t i m e than those parents i n the c o n t r o l g r o u p . In 1 9 7 8 , V a r d a r o reported an i n v e s t i g a t i o n d e s i g n e d to determine a r e l a t i o n s h i p b e t w e e n a n x i e t y i n the p r e s c h o o l c h i l d a n d anxiety i n the parent p r i o r to the c h i l d ' s  20 h o s p i t a l i z a t i o n f o r e l e c t i v e surgery. their m o t h e r s .  S h e studied 18 subjects aged 18 to 6 6 m o n t h s and  T h e children had no previous hospitalization experience or  preparation. V a r d a r o (1978) e m p l o y e d three different instruments to m e a s u r e a n x i e t y :  A  u r i n e test f o r 1 7 - h y d r o x y c o r t i c o s t e r i o d w a s d o n e o n s a m p l e s c o l l e c t e d f r o m b o t h m o t h e r a n d c h i l d ; the State-Trait A n x i e t y I n v e n t o r y S e l f - E v a l u a t i o n Q u e s t i o n n a i r e ( S T A I ) w a s g i v e n to the m o t h e r ; a n d the P r e h o s p i t a l B e h a v i o r Q u e s t i o n n a i r e w a s g i v e n to the m o t h e r to f i l l out about her c h i l d . S t a t i s t i c a l a n a l y s i s o f the data s h o w e d a h i g h l y s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n b e t w e e n a n x i e t y i n the m o t h e r about h o s p i t a l i z a t i o n o f her p r e s c h o o l c h i l d f o r e l e c t i v e surgery a n d a n x i e t y i n the p r e s c h o o l c h i l d .  A c c o r d i n g to the State Q u e s t i o n n a i r e o f the  S T A I , e i g h t y - n i n e p e r cent o f the mothers e x p e r i e n c e d m e d i u m o r h i g h a n x i e t y w h e n c o m p l e t i n g the questionnaire at h o m e t w o d a y s p r i o r to the h o s p i t a l a d m i s s i o n .  Of  interest w a s the f i n d i n g that the l e v e l o f m a t e r n a l anxiety w a s s i g n i f i c a n t l y h i g h e r f o r m o t h e r s o f o n e c h i l d v e r s u s those mothers w i t h m o r e than o n e c h i l d .  Limitations of  this study i n c l u d e the s m a l l s a m p l e s i z e , use o f a P r e h o s p i t a l B e h a v i o r Q u e s t i o n n a i r e w h i c h l a c k e d p r e v i o u s r e l i a b i l i t y a n d v a l i d i t y testing, a n d u s i n g mothers w h o w e r e e x p e r i e n c i n g a n x i e t y to rate the b e h a v i o r o f their o w n c h i l d . T h e f i n d i n g s o f the three p r e c e d i n g studies as w e l l as those d o n e b y F r i e b e r g ( 1 9 7 2 ) , S k i p p e r , L e o n a r d , a n d R h y m e s (1968) a n d P r u g h et a l . (1953) p r o v i d e support f o r the " e m o t i o n a l c o n t a g i o n h y p o t h e s i s " w h i c h h o l d s that a p a r e n t ' s e m o t i o n a l state m a y be r e a d i l y transmitted to a y o u n g c h i l d ( W o l f e r a n d V i s i n t a i n e r , 1975). E m o t i o n a l l y upset parents are often u n a b l e to assist their c h i l d r e n to c o p e w i t h a stressful s i t u a t i o n , yet parental support a n d c o m f o r t i s essential w h e n a y o u n g c h i l d i s  21 f a c i n g any t y p e o f n e w e x p e r i e n c e ( V a r d a r o , 1978). M a t e r n a l a n x i e t y m a y effect the c h i l d ' s e m o t i o n a l responses b o t h d u r i n g h o s p i t a l i z a t i o n a n d i n the p o s t - h o s p i t a l i z a t i o n p e r i o d .  T h e literature a l s o supports the  p r e m i s e that selected n u r s i n g interventions c a n h a v e a s i g n i f i c a n t i m p a c t o n r e d u c i n g parental a n x i e t y d u r i n g a c h i l d ' s h o s p i t a l i z a t i o n .  In s u m m a r y , the f i n d i n g s d i s c u s s e d i n  this s e c t i o n support an i n v e s t i g a t i o n to e x p l o r e the p a r e n t s ' e x p e r i e n c e f r o m their p e r s p e c t i v e i n o r d e r to address parental needs.  A s the f i n d i n g s o f these studies  r e v e a l e d , i n s e e k i n g to m e e t parental needs health p r o f e s s i o n a l s w i l l a l s o i n d i r e c t l y meet the needs o f their p e d i a t r i c patients w h o m a y be s i g n i f i c a n t l y affected b y their parents' p e r c e p t i o n s o f the health care encounter. Parental Attitudes Towards Pediatric D a y Care Surgery T h e literature searched f o r the p u r p o s e o f this report has not r e v e a l e d any studies w h i c h s p e c i f i c a l l y e x a m i n e parents' e x p e r i e n c e i n the p o s t - h o s p i t a l i z a t i o n p e r i o d f o l l o w i n g their y o u n g c h i l d ' s d a y care surgery.  T h e r e are, h o w e v e r , three studies that  addressed the attitudes a n d i m p r e s s i o n s o f parents t o w a r d s their c h i l d ' s d a y care surgery b e f o r e it w a s u n d e r t a k e n .  T h e s e are i n c l u d e d here because a l l three w e r e c o n d u c t e d i n  the same c i t y as the current research. In 1 9 6 9 , p r i o r to the establishment o f a p e d i a t r i c d a y care f a c i l i t y i n V a n c o u v e r , B r i t i s h C o l u m b i a , S h a h , P a p a g i o r g i s , R o b i n s o n , K i n n i s a n d Israels s u r v e y e d the attitudes o f a g r o u p o f 611 parents t o w a r d s this alternative f o r m o f health care d e l i v e r y . c h i l d r e n o f the p a r t i c i p a n t parents r a n g e d i n age f r o m i n f a n c y to 18 years.  The  T h e authors  c o l l e c t e d n o m i n a l l e v e l data b y the a d m i n i s t r a t i o n o f a q u e s t i o n n a i r e to selected parents f o l l o w i n g their c h i l d ' s c o n v e n t i o n a l h o s p i t a l stay f o r a m i n o r e l e c t i v e s u r g i c a l procedure.  T h e quantitative questionnaire r e q u i r e d parental responses w h i c h i n d i c a t e d  22 o n l y agreement o r d i s a g r e e m e n t w i t h the statements presented. T h e m a j o r f i n d i n g o f their study w a s that 4 5 . 3 % o f those parents w h o q u a l i f i e d f o r d a y care stated they w o u l d h a v e preferred d a y care i f s u c h a n alternative h a d b e e n a v a i l a b l e at the t i m e .  In r e l a t i o n to the q u e s t i o n n a i r e ' s statements assessing l e v e l o f  a n x i e t y , the authors f a i l e d to r e v e a l s i g n i f i c a n t d i f f e r e n c e s b e t w e e n the responses o f the t w o parent g r o u p s ( c h o o s i n g d a y care o r c o n v e n t i o n a l h o s p i t a l i z a t i o n ) .  B o t h groups  agreed that they w e r e a n x i o u s w h e n their c h i l d r e n w e r e i n the h o s p i t a l a n d also that their c h i l d r e n w e r e a n x i o u s d u r i n g this t i m e . O n e interesting f i n d i n g o f the study w a s that certain s u r g i c a l p r o c e d u r e s (ie., r e p a i r o f h e r n i a o r squint) w e r e associated w i t h greater parental preference f o r c o n v e n t i o n a l h o s p i t a l i z a t i o n than others (ie., cast c h a n g e o r r e m o v a l , c y s t o s c o p y ) .  The  authors suggested that this d i f f e r e n c e m i g h t be because "parents are m o r e a n x i o u s about p r o c e d u r e s w h i c h result i n r e a d i l y v i s i b l e c h a n g e s o r effects o f p r o c e d u r e s w h i c h are c o n s i d e r e d serious f o r a d u l t s " (p. 3 4 6 ) . U n f o r t u n a t e l y , the authors use o f a structured, c l o s e - e n d e d q u e s t i o n n a i r e d i d not a l l o w the study participants to o p e n l y express o p i n i o n s o r c o n c e r n s s u c h as those related to their f e e l i n g s o f a n x i e t y .  T h e questionnaire f o r c e d parents to r e s p o n d to the  p e r c e i v e d c o n c e r n s o f the researchers rather than those i d e n t i f i e d b y the parents themselves. A s a f o l l o w - u p to the 1969 study, S h a h et a l . (1972), undertook a c o n t r o l l e d study o f m e d i c a l c o m p l i c a t i o n s a n d parental attitudes f o l l o w i n g the d a y care surgery o f 318 children.  T h e c h i l d r e n w e r e alternately a s s i g n e d to either the c o n t r o l o r the  e x p e r i m e n t a l g r o u p s a n d w e r e m a t c h e d f o r age, sex, type o f surgery a n d s o c i o - e c o n o m i c class.  A l t h o u g h the authors f a i l e d to c o m m e n t o n the r e l i a b i l i t y a n d v a l i d i t y o f their  23 data c o l l e c t i o n t o o l s , they r e p o r t e d that 5 6 percent o f the parents i n the study c h o s e the d a y care o p t i o n f o r their c h i l d ' s surgery as o p p o s e d to h a v i n g the c h i l d stay i n h o s p i t a l overnight. S h a h et a l . (1972) c o n c l u d e d that it w a s p r o b a b l y a h i g h e r degree o f a n x i e t y i n the parents c a r i n g f o r their c h i l d r e n at h o m e w h i c h a c c o u n t e d f o r a s i g n i f i c a n t l y h i g h e r n u m b e r o f p o s t - o p e r a t i v e reports o f p a i n a n d c o u g h i n g i n this g r o u p .  T h e d a y care  surgery parents also e x p r e s s e d a stronger preference f o r p o s t - h o s p i t a l i z a t i o n h o m e v i s i t s b y a nurse a n d c o n s i d e r e d this v i s i t to b e important. to an i n c r e a s e d n e e d f o r reassurance.  T h e authors attributed this f i n d i n g  D e s p i t e a c k n o w l e d g i n g that the post-  h o s p i t a l i z a t i o n p e r i o d f o l l o w i n g a c h i l d ' s d a y care surgery c a n be a n a n x i o u s t i m e f o r parents, these authors d i d not suggest further i n v e s t i g a t i o n o f these f i n d i n g s a n d i n fact r e c o m m e n d e d that the o n e support that w a s a v a i l a b l e to the parents—the h o m e v i s i t s b y the nurse—be d i s c o n t i n u e d i n l i g h t o f the f e w m e d i c a l c o m p l i c a t i o n s i n the postoperative period.  T h i s a c t i o n f a i l e d to take i n t o account the i m p a c t o f the m o t h e r ' s e m o t i o n a l  w e l l - b e i n g o n that o f the postoperative c h i l d . In another b a s i c l e v e l d e s c r i p t i v e study, D a v e n p o r t et a l . (1971) r e p o r t e d o n a study p o p u l a t i o n o f 833 c h i l d r e n w h o underwent d a y care surgery o v e r a 27 m o n t h period.  N i n e t y - s i x percent o f the subjects h a d a h o s p i t a l stay o f eight hours o r less.  D u r i n g the last three m o n t h s o f their data c o l l e c t i o n p e r i o d f o r other research p u r p o s e s , 184 study parents w e r e contacted b y telephone o n the d a y after the c h i l d ' s operation a n d a s k e d to r e s p o n d w i t h y e s / n o answers to eight attitude statements c o n c e r n i n g their e x p e r i e n c e w i t h the d a y care surgery p r o g r a m .  A large m a j o r i t y o f parents agreed that  their c h i l d w a s b o t h h a p p i e r (94.6%) and safer (90.8%) at h o m e than i n h o s p i t a l f o l l o w i n g surgery.  \  24 In this study there w a s n o h o m e v i s i t m a d e b y a nurse after d i s c h a r g e f r o m hospital.  O v e r 9 0 % o f the parents r e s p o n d e d " n o " to the statement that h o m e v i s i t s b y  a nurse w o u l d h a v e been o f v a l u e .  T h i s contrasts the f i n d i n g s o f other authors and  l e n d s support to an i n v e s t i g a t i o n o f the p o s t - h o s p i t a l i z a t i o n p e r i o d to e x a m i n e i n detail the p a r e n t s ' p e r s p e c t i v e s o f their e x p e r i e n c e s .  T h e authors o f this study stated that the  p a r e n t s ' attitude towards the h o m e v i s i t w a s " l o g i c a l i n l i g h t o f the f e w and m i l d c o m p l i c a t i o n s f o l l o w i n g s u r g e r y " (p. 5 0 0 ) .  It i s n o t e w o r t h y that this c o n c l u s i o n does  not c o n c u r w i t h the f i n d i n g s o f other studies r e v i e w e d i n this s e c t i o n w h i c h h a v e c l e a r l y d e m o n s t r a t e d the v a l u e o f n u r s i n g i n t e r v e n t i o n i n d e c r e a s i n g a n x i e t y i n the parent w i t h subsequent b e n e f i c i a l effects f o r the c h i l d .  A g a i n , this study d i d not a l l o w  the parents an o p p o r t u n i t y f o r o p e n e x p r e s s i o n r e g a r d i n g their e x p e r i e n c e . In s u m m a r y , parents support the c o n c e p t o f d a y care surgery f o r their c h i l d r e n . T h e f i n d i n g s the studies presented i n this s u b - s e c t i o n d i d not e x p l o r e the p e d i a t r i c d a y care surgery e x p e r i e n c e f r o m the parents' p o i n t o f v i e w a n d f a i l to p r o v i d e any i n s i g h t i n t o the p a r e n t a l p o s t d a y care surgery p e r i o d e x p e r i e n c e .  B e c a u s e o f the strength o f  the p a r e n t / c h i l d r e l a t i o n s h i p a n d the potential effect that o n e m e m b e r o f the d y a d c o u l d h a v e u p o n the other, literature d e s c r i b i n g the effects o f a short t e r m h o s p i t a l i z a t i o n o n toddlers a n d p r e s c h o o l e r s w i l l b e r e v i e w e d here. T h e Effects o f Short T e r m Hospitalization o n Toddlers and Preschoolers P i o n e e r i n g research o n the e m o t i o n a l s i g n i f i c a n c e o f i l l n e s s , h o s p i t a l i z a t i o n , and s u r g e r y o n y o u n g c h i l d r e n w a s d o n e i n the 1930s a n d 4 0 s .  A u t h o r s s u c h as B e v e r l y  ( 1 9 3 6 ) , J a c k s o n (1942), a n d L a n g f o r d (1948) d e s c r i b e d i n d e t a i l the p s y c h o l o g i c a l a n d p h y s i o l o g i c a l i m p a c t o f parental separation a n d h o s p i t a l i z a t i o n f o r c h i l d r e n o f ages.  B o w l b y ' s 1952 report to the G e n e v a C o n f e r e n c e o f the W o r l d H e a l t h  different  25 O r g a n i z a t i o n brought further attention to the p s y c h o l o g i c a l c o n s e q u e n c e s o f h o s p i t a l i z i n g children.  In 1 9 5 3 , P r u g h et a l . p u b l i s h e d w h a t i s n o w c o n s i d e r e d to be a c l a s s i c study  i n v e s t i g a t i n g the e m o t i o n a l reactions o f c h i l d r e n a n d f a m i l i e s to l o n g t e r m hospitalization.  In 1 9 5 8 , R o b e r t s o n p u b l i s h e d the f i r s t e d i t i o n o f h i s insights i n t o the  behavior o f young children i n hospital. B y 1 9 6 5 , V e r n o n , F o l e y , S i p o w i c z , a n d S c h u l m a n presented a r e v i e w o f o v e r 2 0 0 p u b l i c a t i o n s that dealt w i t h the effects o f h o s p i t a l i z a t i o n a n d i l l n e s s o n c h i l d r e n . T h e s e e a r l y w o r k s m a d e s i g n i f i c a n t c o n t r i b u t i o n s to o u r present u n d e r s t a n d i n g o f the e m o t i o n a l reactions o f c h i l d r e n to the e x p e r i e n c e s o f i l l n e s s , h o s p i t a l i z a t i o n , a n d surgery. D e s p i t e a n a b u n d a n c e o f literature d i r e c t l y c o n c e r n i n g the h o s p i t a l i z a t i o n o f c h i l d r e n , there has b e e n less attention p a i d to the p s y c h o l o g i c a l c o n s e q u e n c e s o f the e x p e r i e n c e o n c e the c h i l d has returned h o m e .  C h i l d r e n often e x h i b i t s o m e degree o f  b e h a v i o r a l c h a n g e f o l l o w i n g a n y type o f i l l n e s s , not j u s t one i n v o l v i n g o r surgery ( W i l k e n s o n , 1978).  hospitalization  T h e t e r m " p s y c h o l o g i c a l upset" has b e e n u s e d here to  refer to a n y adverse b e h a v i o r a l c h a n g e o b s e r v e d i n c h i l d r e n f o l l o w i n g the e x p e r i e n c e o f i l l n e s s , h o s p i t a l i z a t i o n a n d / o r surgery.  T h e r e m a i n d e r o f this s e c t i o n w i l l d i s c u s s the  f i n d i n g s o f s e v e r a l researchers w h o h a v e e x a m i n e d p s y c h o l o g i c a l upset i n c h i l d r e n f o l l o w i n g their h o s p i t a l i z a t i o n .  T h i s r e v i e w i s i n c l u d e d here because it w a s felt that the  nature o f the c h i l d ' s e x p e r i e n c e m a y affect the p a r e n t ' s e x p e r i e n c e d u r i n g the posthospitalization period. V e r n o n et a l . (1966) w e r e forerunners i n e x a m i n i n g p o s t - h o s p i t a l i z a t i o n b e h a v i o r changes in young children.  In the e a r l y 1 9 6 0 ' s they d e v e l o p e d the P o s t h o s p i t a l i z a t i o n  B e h a v i o r Q u e s t i o n n a i r e . T h e questionnaire i s a 28 i t e m instrument w h i c h has since been  u s e d w i d e l y i n the f i e l d o f p o s t - h o s p i t a l b e h a v i o r changes i n c h i l d r e n a n d has extensive reliability and validity ( B r o w n , 1979; Hannallah & Rosales, 1983; M a h a f f y , 1965; S i p o w i c z & V e r n o n , 1 9 6 5 ; V e r n o n , S c h u l m a n , & F o l e y , 1966; W o l f e r & 1975).  Visintainer,  F o r e a c h o f the 28 i t e m s i n the q u e s t i o n n a i r e , the parent c o m p a r e s the c h i l d ' s  t y p i c a l b e h a v i o r before h o s p i t a l i z a t i o n w i t h his/her b e h a v i o r d u r i n g the first w e e k after hospitalization. T h e f i r s t p u b l i s h e d study u t i l i z i n g the P o s t h o s p i t a l i z a t i o n B e h a v i o r Q u e s t i o n n a i r e ( P B Q ) w a s c o n d u c t e d b y S i p o w i c z a n d V e r n o n (1965).  They conducted a comparative  study o f 2 4 sets o f t w i n s , w h e r e one o f e a c h set w a s not h o s p i t a l i z e d a n d o n e w a s hospitalized for m e d i c a l or surgical intervention. o n e to m o r e than t w e n t y - o n e d a y s . discharge.  T h e range o f the h o s p i t a l stay w a s  T h e P B Q w a s m a i l e d to e a c h m o t h e r s i x d a y s after  T h e results s h o w e d that the m a j o r i t y o f the h o s p i t a l i z e d t w i n s , p a r t i c u l a r l y  those a g e d 6 m o n t h s to 4 years, s h o w e d m o r e p s y c h o l o g i c a l upset u p o n return h o m e than the n o n - h o s p i t a l i z e d t w i n .  A l t h o u g h the n u m b e r o f subjects w a s s m a l l , this  s t u d y ' s strength l i e s i n the fact that the m e t h o d o l o g y i n c l u d e d a w e l l m a t c h e d c o n t r o l group. V e r n o n et a l . (1966) studied the post h o s p i t a l i z a t i o n b e h a v i o r o f 3 8 7 c h i l d r e n aged o n e m o n t h to 16 years w h o w e r e h o s p i t a l i z e d f o r a v a r i e t y o f s u r g i c a l a n d medical conditions.  T h e m e a n d u r a t i o n o f their h o s p i t a l stay w a s 8.8 d a y s .  In this  study the P B Q w a s m a i l e d to e a c h set o f parents s i x d a y s after d i s c h a r g e therefore o n l y parents w h o w e r e m o t i v a t e d to d o so returned the questionnaire.  T h e researchers  a c k n o w l e d g e d that e v e n though not a l l items o n the questionnaire w e r e suitable f o r a l l o f the age g r o u p s i n the study, a l l the i t e m s were scored.  F a c t o r a n a l y s i s o f the  q u e s t i o n n a i r e responses r e v e a l e d s i x categories o f p o s t - h o s p i t a l i z a t i o n b e h a v i o r  27 disturbances. T h e s e w e r e : general a n x i e t y a n d r e g r e s s i o n , separation a n x i e t y , sleep anxiety, eating disturbances, aggression, and apathy-withdrawl.  T h e investigators  e x a m i n e d their f i n d i n g s i n l i g h t o f several v a r i a b l e s : gender, p r i o r h o s p i t a l i z a t i o n , degree o f p a i n e x p e r i e n c e d d u r i n g h o s p i t a l i z a t i o n , b i r t h order, a g e , d u r a t i o n o f h o s p i t a l i z a t i o n , a n d parental o c c u p a t i o n a l status.  O n l y the latter three v a r i a b l e s w e r e  s h o w n to b e s i g n i f i c a n t l y related to one o r m o r e o f the p o s t - h o s p i t a l i z a t i o n b e h a v i o r disturbances. T h e authors o f this study c o n c l u d e d that c h i l d r e n b e t w e e n the ages o f s i x m o n t h s a n d f o u r years w e r e m o s t l i k e l y to demonstrate p s y c h o l o g i c a l upset i n the post-hospitalization period.  T h e b e h a v i o r s m a n i f e s t e d b y this age group w o u l d b e :  i n c r e a s e d sleep a n d separation a n x i e t y , a n d i n c r e a s e d a g g r e s s i o n t o w a r d s authority. S u c h f i n d i n g s support an i n v e s t i g a t i o n o f the e x p e r i e n c e o f parents o f toddlers a n d p r e s c h o o l e r s d u r i n g the p o s t - h o s p i t a l i z a t i o n p e r i o d as the parental e x p e r i e n c e c o u l d be s i g n i f i c a n t l y affected b y the c h i l d ' s p s y c h o l o g i c a l upset. U s i n g an e x p e r i m e n t a l d e s i g n , D a v e n p o r t a n d W e r r y (1970) i n v e s t i g a t e d the p o s t - h o s p i t a l i z a t i o n effects o f b r i e f h o s p i t a l i z a t i o n , m i n o r surgery, a n d general anesthesia o n 145 c h i l d r e n a g e d o n e to 15 years w h o w e r e h o s p i t a l i z e d f o r less than 48 h o u r s . T h i r t y percent o f the subjects i n their study w e r e a g e d s i x m o n t h s to f o u r years.  The  c h i l d r e n w e r e selected f r o m t w o different hospitals a n d m a t c h e d w i t h a c o r r e s p o n d i n g non-hospitalized control group.  T h e c o n t r o l g r o u p s w e r e c o m p r i s e d o f s i b l i n g s o f the  p a r t i c i p a n t s o r c h i l d r e n w h o attended a p e d i a t r i c O u t - P a t i e n t C l i n i c f o r a routine physical examination. T h e Posthospitalization Behavior Questionnaire was verbally administered by a r e s e a r c h assistant to the m o t h e r o f e a c h c h i l d o n the d a y o f her c h i l d ' s a d m i s s i o n and  28 a g a i n t w o w e e k s after h o s p i t a l d i s c h a r g e .  D a v e n p o r t a n d W e r r y f a i l e d to f i n d  statistically s i g n i f i c a n t e v i d e n c e o f r e s i d u a l p o s t - h o s p i t a l i z a t i o n p s y c h o l o g i c a l upset i n either the e x p e r i m e n t a l o r c o n t r o l g r o u p s o f their subjects as rated b y the subjects' mothers.  T h i s f i n d i n g i s inconsistent w i t h that o f other researchers u s i n g the same  instrument.  T h i s i n c o n s i s t e n c y i n f i n d i n g s l e n d s support to an i n v e s t i g a t i o n d e s i g n e d to  e x p l o r e the nature o f the p o s t - h o s p i t a l i z a t i o n p e r i o d f r o m the parents p e r s p e c t i v e . B r o w n (1979) studied the p o s t - h o s p i t a l i z a t i o n b e h a v i o r o f 4 0 c h i l d r e n w h o s e ages r a n g e d b e t w e e n three a n d s i x years. a tonsillectomy and adenoidectomy.  E a c h c h i l d was hospitalized for five days for  B r o w n c o n d u c t e d three i n t e r v i e w s w i t h e a c h  m o t h e r u s i n g the categories i n the P o s t h o s p i t a l i z a t i o n B e h a v i o r Q u e s t i o n n a i r e ( V e r n o n et a l . , 1966).  A l l i n t e r v i e w s w e r e c o n d u c t e d i n the c h i l d ' s h o m e .  S h e f o u n d that there  w e r e f o u r categories o f b e h a v i o r w h i c h w e r e d e s c r i b e d b y parents as " w o r s e " at one m o n t h p o s t - h o s p i t a l i z a t i o n but " i m p r o v e d " at s i x m o n t h s .  T h e s e categories w e r e :  general a n x i e t y , separation a n x i e t y , a g g r e s s i o n , a n d sleep disturbances.  T h e researcher  f o u n d that instances o f p s y c h o l o g i c a l upset d e c r e a s e d w i t h the d u r a t i o n o f the posthospitalization period.  A l t h o u g h age, length o f h o s p i t a l i z a t i o n a n d type o f surgery were  i n c l u d e d i n the study d e s i g n , other p o t e n t i a l l y i n f l u e n c i n g v a r i a b l e s w e r e not m e n t i o n e d . B r o w n ' s f i n d i n g s agree w i t h those o f V e r n o n et a l . (1966) a n d p o i n t to a n e e d to further investigate the p o s t - h o s p i t a l i z a t i o n p e r i o d f r o m the parents' p e r s p e c t i v e . H a n n a l l a h a n d R o s a l e s (1983) undertook a study to e x a m i n e the effects o f e l i m i n a t i n g p a r e n t - c h i l d separation d u r i n g anaesthesia i n d u c t i o n f o r p r e s c h o o l c h i l d r e n u n d e r g o i n g d a y care surgery.  T h e p u r p o s e o f their study w a s to d e t e r m i n e whether o r  not it w a s safe and f e a s i b l e to a l l o w parents o f y o u n g c h i l d r e n to be present d u r i n g the anesthesia i n d u c t i o n o f their c h i l d .  T h e c h i l d r e n , a g e d o n e to f i v e years, w e r e admitted  29 f o r a v a r i e t y o f d a y care s u r g i c a l procedures s u c h as dental w o r k , h e r n i a repairs, c i r c u m c i s i o n , a n d e y e surgery. i n d u c t i o n a n d f i f t y d i d not.  F i f t y c h i l d r e n h a d parents present d u r i n g anesthesia  A notable f i n d i n g o f this study w a s r e l a t e d to the results  o f the P o s t h o s p i t a l i z a t i o n B e h a v i o r Q u e s t i o n n a i r e ( V e m o n et a l . 1966) c o m p l e t e d b y parents t h r o u g h a n i n t e r v i e w t w o w e e k s after their c h i l d ' s surgery w h i c h r e v e a l e d a s i g n i f i c a n t n u m b e r o f p o s t - h o s p i t a l i z a t i o n b e h a v i o r disturbances.  O v e r 6 0 % o f the  c h i l d r e n i n the e x p e r i m e n t a l a n d c o n t r o l groups m a n i f e s t e d b e h a v i o r s related to sleep a n x i e t y , o v e r 4 5 % demonstrated separation a n x i e t y , a n d o v e r 3 4 % s h o w e d i n c r e a s e d signs o f a g g r e s s i o n .  T h e authors f a i l e d to a c k n o w l e d g e the h i g h i n c i d e n c e s o f these  post d a y care surgery b e h a v i o r a l disturbances o r d i s c u s s the parents' r e a c t i o n s to t h e m . T h e p r e c e d i n g studies have investigated the o c c u r r e n c e o f p o s t - h o s p i t a l i z a t i o n p s y c h o l o g i c a l upset i n y o u n g c h i l d r e n .  A s m a n y o f the researchers a c k n o w l e d g e , it i s a  d i f f i c u l t area to study because p s y c h o l o g i c a l upset i n the p o s t - h o s p i t a l i z a t i o n p e r i o d is i n f l u e n c e d b y n u m e r o u s v a r i a b l e s related to the c h i l d , the f a m i l y , a n d the actual hospitalization experience.  K n o w n v a r i a b l e s that affect the e x p e r i e n c e i n c l u d e :  age o f  the c h i l d , p r e - h o s p i t a l p e r s o n a l i t y , past e x p e r i e n c e w i t h h o s p i t a l i z a t i o n , parental separation, q u a l i t y o f the p a r e n t a l - c h i l d r e l a t i o n s h i p , l e v e l o f m a t e r n a l a n x i e t y , status o f f a m i l y e q u i l i b r i u m , l e n g t h o f h o s p i t a l i z a t i o n , reason f o r h o s p i t a l i z a t i o n , a n d preparation f o r h o s p i t a l i z a t i o n ( B e l m o n t , 1970; V e r n o n et a l . , 1966; W i l k i n s o n , 1978). w e a k n e s s i n the d e s i g n o f m o s t o f the studies r e v i e w e d here i s the m i n i m a l  A  definite control  e x e r t e d o v e r these v a r i a b l e s d u r i n g the research. In o r d e r to q u a n t i f y p s y c h o l o g i c a l upset i n the p o s t - h o s p i t a l i z a t i o n p e r i o d , most researchers u s e d the P o s t h o s p i t a l i z a t i o n B e h a v i o r Q u e s t i o n n a i r e ( V e r n o n et a l . , 1966). P u b l i s h e d reports o f r e l i a b i l i t y a n d v a l i d i t y o f this instrument have been m a d e b y  30 s e v e r a l authors ( V e r n o n et a l . , 1966; V e r n o n , F o l e y , a n d S c h u l m a n , 1967).  Although  the q u e s t i o n n a i r e w a s apparently d e s i g n e d to be a d m i n i s t e r e d w i t h i n o n e w e e k after d i s c h a r g e f r o m h o s p i t a l , s o m e investigators h a v e u s e d it up to s i x m o n t h s h o s p i t a l d i s c h a r g e ( B r o w n , 1979).  following  A l s o contrary to its o r i g i n a l intent, it has been  a d m i n i s t e r e d to parents o f n o n - h o s p i t a l i z e d c h i l d r e n ( D a v e n p o r t & W e r r y , 1970) a n d to parents o f c h i l d r e n w h o f e l l outside o f the age groups to w h i c h s o m e o f the questions a p p l y ( V e r n o n et a l . , 1966). O f the studies r e v i e w e d here, a l l but o n e ( D a v e n p o r t & W e r r y , 1970) reported that subjects e x h i b i t e d b e h a v i o r d u r i n g the p o s t - h o s p i t a l i z a t i o n p e r i o d that w a s different f r o m their p r e - h o s p i t a l i z a t i o n b e h a v i o r .  T h e c h i l d r e n ' s b e h a v i o r changes w e r e  interpreted to be as a result o f the h o s p i t a l i z a t i o n / s u r g i c a l e x p e r i e n c e a n d c o n s e q u e n t l y w o u l d l i k e l y affect the p a r e n t ' s perceptions a n d e x p e r i e n c e d u r i n g the post-hospitalization period. I n 1981 F l e t c h e r r e v i e w e d the a v a i l a b l e literature related to p s y c h o l o g i c a l upset in post-hospitalized children.  H e c o n c l u d e d that the i d e n t i f i c a t i o n o f p s y c h o l o g i c a l  upset i s c o n s i d e r a b l y m o r e c o m p l e x than " f o c u s i n g o n the h o s p i t a l i z e d c h i l d and c o m p a r i n g pre- a n d p o s t - h o s p i t a l i z a t i o n b e h a v i o r " (p. 193).  T h i s w r i t e r w a s unable to  l o c a t e a n y studies e x a m i n i n g p o s t - h o s p i t a l i z a t i o n b e h a v i o r c h a n g e s i n c h i l d r e n u s i n g a qualitative methodology.  Y e t this p e r s p e c t i v e w o u l d a d d m u c h n e e d e d d e s c r i p t i o n a n d  depth to this c o m p l i c a t e d issue as w e l l as p r o v i d e s o m e i n s i g h t i n t o h o w the parents m i g h t r e s p o n d to these changes i n the c h i l d d u r i n g the p o s t - h o s p i t a l i z a t i o n p e r i o d . In s u m m a r y , the r e v i e w o f this section o f literature appears to support the statement that "the c o m b i n a t i o n o f h o s p i t a l i z a t i o n a n d i l l n e s s i s p s y c h o l o g i c a l l y u p s e t t i n g to c h i l d r e n i n g e n e r a l , e v e n i n the case o f b r i e f h o s p i t a l i z a t i o n f o r routine  31 illness"  ( S i p o w i c z & V e r n o n , 1965, p. 2 3 0 ) .  C h i l d r e n b e t w e e n the ages o f s i x months  a n d f i v e years are p a r t i c u l a r l y susceptible to " p s y c h o l o g i c a l upset"  following  h o s p i t a l i z a t i o n a n d surgery because o f their l e v e l o f c o g n i t i v e d e v e l o p m e n t a n d c o p i n g m e c h a n i s m s ( D o r n , 1984).  P s y c h o l o g i c a l upset i n this age group m a n i f e s t s i t s e l f m o s t  c o m m o n l y as sleep disturbances, separation a n x i e t y , a n d a g g r e s s i o n .  B e c a u s e such  b e h a v i o r s c a n be r e i n f o r c e d a n d i n t e n s i f i e d b y parental a n x i e t y , nurses m u s t e x p l o r e the m e a n i n g parents a s s i g n to these changes i n their c h i l d ' s b e h a v i o r , a n d ascertain h o w the p a r e n t ' s p o s t - h o s p i t a l i z a t i o n e x p e r i e n c e m a y be i n f l u e n c e d b y c h a n g e s . Summary T h i s chapter has r e v i e w e d selected literature related to f o u r m a j o r subject areas i n o r d e r to e s t a b l i s h w h a t i s k n o w n about the post d a y care surgery e x p e r i e n c e f o r parents o f y o u n g c h i l d r e n .  T h i s author w a s unable to locate a study w h i c h s p e c i f i c a l l y  investigates the post d a y care surgery e x p e r i e n c e f r o m the p a r e n t ' s p o i n t o f v i e w o r e v e n d e s c r i b e s the i m p a c t o f this type o f health care e n c o u n t e r o n the parent.  This  literature r e v i e w therefore e x p l o r e d the m o r e general i m p a c t o f a c h i l d ' s h o s p i t a l i z a t i o n a n d surgery o n the parents, a n d o n the c h i l d r e n t h e m s e l v e s .  T h e current p u b l i s h e d  r e s e a r c h does not p r o v i d e an i n d e p t h understanding o f the p a r e n t s ' e x p e r i e n c e i n the p o s t - h o s p i t a l i z a t i o n p e r i o d f o l l o w i n g their c h i l d ' s day care surgery. In 1 9 7 2 , S h a h et a l . c a m e to the f o l l o w i n g c o n c l u s i o n after s t u d y i n g m e d i c a l c o m p l i c a t i o n s a n d parental attitudes towards d a y care surgery f o r c h i l d r e n : W h i l e it i s necessary to s a m p l e the attitudes a n d o p i n i o n s o f c o n s u m e r s o f health s e r v i c e s c o n c e r n i n g changes i n care, this study s h o w s that w h e n the expert p r o v i d e r s endorse c h a n g e i n the pattern o f d e l i v e r y o f c a r e , patients w i l l accept expert a d v i c e a n d j u d g e m e n t , (p. 48)  T o - d a y , m a n y parents h a v e i n fact " a c c e p t e d " d a y care surgery as an alternative to the t r a d i t i o n a l o v e r n i g h t stay i n h o s p i t a l f o r their c h i l d r e n .  D e s p i t e this apparent  parental acceptance there is s t i l l stress a n d a n x i e t y a s s o c i a t e d w i t h this e x p e r i e n c e .  As  h e a l t h p r o f e s s i o n a l s it i s i m p o r t a n t that w e d o not assume to k n o w the p a r e n t s ' p e r s p e c t i v e o n this f o r m o f health care d e l i v e r y .  N u r s e s w o r k i n g i n b o t h d a y care  surgery units a n d c o m m u n i t y health settings need to understand the e x p e r i e n c e o f parents i n o r d e r to p r o v i d e appropriate preparation, support, i n f o r m a t i o n , a n d g u i d a n c e . T h i s study w a s therefore u n d e r t a k e n f o r the p u r p o s e o f e l i c i t i n g p a r e n t s ' p e r s p e c t i v e o n the post d a y care surgery e x p e r i e n c e a n d its i m p a c t o n their d a y to day lives.  T h e results o f this w r i t e r ' s i n v e s t i g a t i o n are a s i g n i f i c a n t a d d i t i o n to current  knowledge.  T h e next chapter o u t l i n e s the i m p l e m e n t a t i o n o f the selected m e t h o d o l o g y  f o r this study.  33 CHAPTER 3  Methodology  T h i s chapter describes the a p p l i c a t i o n o f the p h e n o m e n o l o g i c a l m e t h o d o f i n q u i r y i n a study o f the parents' e x p e r i e n c e o f h a v i n g a toddler o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery. C h a p t e r 1.  A b r i e f i n t r o d u c t i o n to p h e n o m e n o l o g y w a s i n t r o d u c e d i n  T h e p u r p o s e o f this chapter i s to r e v i e w the d e s i g n o f this m e t h o d o l o g y  in  further d e t a i l a n d d i s c u s s the i m p l e m e n t a t i o n o f p h e n o m e n o l o g y i n r e l a t i o n to this study's:  s e l e c t i o n o f participants, setting, i m p l e m e n t a t i o n p r o c e d u r e s , data c o l l e c t i o n ,  data a n a l y s i s , a n d e t h i c a l c o n s i d e r a t i o n s . Research Design " T h e p h e n o m e n o l o g i c a l m e t h o d i s an i n d u c t i v e , d e s c r i p t i v e r e s e a r c h m e t h o d . " ( O m e r y , 1 9 8 3 , p. 5 0 ) .  T h e o r i g i n s o f p h e n o m e n o l o g y b e g a n w i t h the w o r k o f the  E u r o p e a n p h i l o s o p h e r , E d m u n d H u s s e r l , w h o b e l i e v e d that "the study o f p h i l o s o p h y s h o u l d h a v e not o n l y ' r i g o r ' but a l s o a n e w h u m a n i s m " ( R a y , 1 9 8 5 , p. 83). P h e n o m e n o l o g i s t s b e l i e v e that h u m a n beings act i n a c c o r d a n c e w i t h the w a y they construct m e a n i n g s f o r the situations they face ( D a v i s , 1978).  Phenomenologists  e m p h a s i z e the " l i v e d c o n t e x t " o f phenomena—life i n the e v e r y d a y w o r l d as it is u n d e r s t o o d a n d interpreted b y one l i v i n g t h r o u g h the situation ( G i o r g i , 1975a). " P h e n o m e n o l o g y accepts e x p e r i e n c e as it exists i n the c o n s c i o u s n e s s o f the i n d i v i d u a l " ( F i e l d & M o r s e , 1 9 8 5 , p. 2 8 ) . It i s the p h e n o m e n o l o g i s t ' s task to ensure that the s u b j e c t ' s v i e w p o i n t o f the situation u n d e r study i s r e v e a l e d through d e s c r i p t i o n i n an u n b i a s e d w a y ( G i o r g i ,  • 1975b).  34  It i s the s u b j e c t ' s p o i n t o f v i e w that p r o v i d e s the " r i c h data w h i c h m u s t be  o b t a i n e d " ( G i o r g i , 1 9 7 5 a , p. 100).  B e c a u s e language i s the m a j o r m e a n s o f  c o m m u n i c a t i o n i n e v e r y d a y l i f e , p h e n o m e n o l o g y depends a l m o s t e x c l u s i v e l y o n l a n g u a g e to o b t a i n a d e s c r i p t i o n o f the e x p e r i e n c e u n d e r study.  A n y t h i n g that the  subject feels i s w o r t h y o f m e n t i o n i n g i s registered as data.  T h i s a l l o w s the reality  of  the s u b j e c t ' s e x p e r i e n c e to be f u l l y e x p r e s s e d ( R a y , 1985).  It i s t h r o u g h this process o f  e x h a u s t i v e d e s c r i p t i o n that one d e v e l o p s an understanding o f the p h e n o m e n o n under study ( L y n c h - S a u e r , 1985). C r i t i c a l to the r e s e a r c h e r ' s a p p r o a c h i n a p h e n o m e n o l o g i c a l study i s a heightened awareness o f the participant, the setting, a n d a m i n i m u m o f p r e c o n c e p t i o n s about the e x p e r i e n c e u n d e r study ( D a v i s , 1978).  A truly presuppositionless description o f a  p h e n o m e n o n i s i m p o s s i b l e because a researcher w i l l presuppose i m p l i c i t l y i n the questions a n d answers o f an o p e n - e n d e d d i a l o g u e a c c o r d i n g to the intentions a n d a i m s o f h i s / h e r r e s e a r c h ( D a v i s , 1 9 7 8 ; G i o r g i , 1975a).  W h a t i s s u s p e n d e d b y the researcher,  h o w e v e r , are a s s u m p t i o n s w h i c h e x t e n d b e y o n d h i s / h e r i n i t i a l questions.  T h e researcher  accepts the data as they appear w i t h o u t t r y i n g to m o d i f y t h e m to fit a p r e c o n c e i v e d d e f i n i t i o n o f the p h e n o m e n o n ( O m e r y , 1983). T h e g o a l o f the p h e n o m e n o l o g i c a l m e t h o d i s to d e r i v e c o n s e n s u a l l y v a l i d a t e d k n o w l e d g e f r o m a systematic e x a m i n a t i o n o f h u m a n e x p e r i e n c e ( L y n c h - S a u e r , 1985). V a l i d i t y i n the p h e n o m e n o l o g i c a l m e t h o d i s " f o r m u l a t e d i n l i g h t o f a c l i e n t ' s c o n c e p t i o n o f h i m s e l f o r h e r s e l f i n the w o r l d " ( R a y , 1 9 8 5 , p. 89).  D e s c r i p t i o n s o f an e x p e r i e n c e  s h o u l d be r e c o g n i z e d as true b y those w h o l i v e the e x p e r i e n c e . C o n t r o l i n p h e n o m e n o l o g i c a l research c o m e s not f r o m an e x p e c t a t i o n f o r d u p l i c a t e b e h a v i o r f r o m d u p l i c a t e data but rather f r o m the r e s e a r c h e r ' s p e r s p e c t i v e o f  35 the data.  T h e k e y c r i t e r i o n i s not w h e t h e r another p o s i t i o n w i t h respect to the data  c o u l d be a d o p t e d , but whether a reader, a d o p t i n g the same v i e w p o i n t a n d situation o f the researcher, c o u l d a l s o seen w h a t the researcher s a w , w h e t h e r o r not he/she agrees w i t h it ( G i o r g i , 1 9 7 5 a ; S a n d e l o w s k i , 1986). Selection o f Participants In a p h e n o m e n o l o g i c a l study, the participants m u s t h a v e l i v e d o r be l i v i n g the experience under investigation.  T h e y m u s t a l s o be interested i n u n d e r s t a n d i n g a n d  e x p r e s s i n g the f e e l i n g s w h i c h a c c o m p a n y their e x p e r i e n c e ( O m e r y , 1983).  Consistent  w i t h the p h e n o m e n o l o g i c a l m e t h o d a n d the p u r p o s e o f this study, the participants sought w e r e parents w h o c a r e d f o r toddlers a n d p r e s c h o o l e r s at h o m e after the c h i l d ' s surgery b e c a u s e they c o u l d p r o v i d e the data to " i l l u m i n a t e the p h e n o m e n o n b e i n g s t u d i e d " ( S a n d e l o w s k i , 1 9 8 6 , p. 31). A p u r p o s i v e s a m p l i n g technique w a s u t i l i z e d to select study participants ( D i e r s , 1 9 7 9 ; M o r s e , 1986).  U s i n g this n o n p r o b a b i l i t y m e t h o d , parents w e r e selected o n the  basis o f s p e c i f i c characteristics w h i c h w o u l d enable the researcher to c o l l e c t the i n - d e p t h data r e q u i r e d to a n s w e r this s t u d y ' s research q u e s t i o n . fathers w e r e a p p r o a c h e d to participate i n the study.  B o t h mothers a n d  A l l o f the parents w h o agreed to  participate w e r e selected f r o m the D a y C a r e U n i t o f a tertiary l e v e l pediatric h o s p i t a l i n Vancouver, British Columbia. Criteria for Selection T h e s p e c i f i c c r i t e r i a e s t a b l i s h e d to select the f a m i l i e s f o r p a r t i c i p a t i o n i n this study w e r e that: 1. years.  T h e age o f the c h i l d at the t i m e o f surgery r a n g e d b e t w e e n o n e a n d f i v e ,  36 2.  T h e c h i l d r e s i d e d w i t h h i s / h e r parent(s).  3.  T h e c h i l d h a d not h a d p r e v i o u s d a y care surgery o r o v e r n i g h t h o s p i t a l  admissions. 4.  T h e c h i l d w a s a d m i t t e d f o r e l e c t i v e s u r g i c a l c o r r e c t i o n o f a short-term  condition or illness. 5.  T h e c h i l d w a s d i s c h a r g e d h o m e to the care o f h i s / h e r parent(s) o n the same  day of hospital admission. 6.  T h e parent(s) a s s u m e d the care o f the c h i l d d u r i n g the p o s t - h o s p i t a l i z a t i o n  7.  T h e parent(s) w e r e able to understand, speak, a n d r e a d E n g l i s h , regardless o f  period.  ethnic b a c k g r o u n d . 8.  T h e parent(s) h a d not h a d p r e v i o u s e x p e r i e n c e w i t h a c h i l d w h o  underwent  d a y care surgery. 9.  T h e f a m i l y r e s i d e d i n the V a n c o u v e r M e t r o p o l i t a n area. Setting  T h e setting c h o s e n f o r the data c o l l e c t i o n p r o c e s s w a s the p a r e n t s ' o w n h o m e s . T h e p a r e n t s ' h o m e e n v i r o n m e n t w a s c h o s e n i n o r d e r to ensure p r i v a c y a n d to p r o m o t e their c o m f o r t a n d ease w h e n d e s c r i b i n g p e r s o n a l e x p e r i e n c e s .  W h e n u s i n g the  p h e n o m e n o l o g i c a l m e t h o d " a r e l a x e d atmosphere a n d s u f f i c i e n t t i m e to express the f e e l i n g o r e x p e r i e n c e are e s s e n t i a l " ( O m e r y , 1 9 8 3 , p. 56). Implementation Procedures T h e f o l l o w i n g steps w e r e f o l l o w e d i n o r d e r to i m p l e m e n t this study: 1.  A f t e r p e r m i s s i o n to c o n d u c t the study w a s o b t a i n e d f r o m the appropriate  s c r e e n i n g c o m m i t t e e s ( A p p e n d i c e s A & B , p p . 143 &  144), the researcher met w i t h the  37 H e a d N u r s e o f the D a y C a r e U n i t to i n f o r m her about the nature o f the p r o p o s e d study a n d seek her c o - o p e r a t i o n i n c a r r y i n g it out.  A s requested b y the H e a d N u r s e , a  s u m m a r y o f the research p r o p o s a l w a s p r e p a r e d a n d m a d e a v a i l a b l e to a l l o f the n u r s i n g staff o n the unit. 2.  A l l o f the p h y s i c i a n s a n d dentists w h o a d m i t t e d c h i l d r e n to the D a y C a r e  U n i t r e c e i v e d a letter f r o m the researcher i n f o r m i n g t h e m about the nature a n d p u r p o s e o f the study ( A p p e n d i x C , p. 145).  F u r t h e r details o f the research project w o u l d b e  p r o v i d e d i f they w i s h e d to contact the researcher d i r e c t l y .  T h e researcher d i d not  r e c e i v e any i n q u i r i e s about the project f r o m this g r o u p o f p r o f e s s i o n a l s . 3.  In o r d e r to select parents w h o met the e s t a b l i s h e d s e l e c t i o n c r i t e r i a , the  researcher v i s i t e d the D a y C a r e U n i t o n the e v e n i n g before a r e g u l a r s u r g i c a l d a y to r e v i e w the o p e r a t i n g r o o m schedule a n d the patient charts f o r the f o l l o w i n g d a y . 4.  O n the d a y o f surgery, the researcher p e r s o n a l l y c o n t a c t e d the p o t e n t i a l study  participants i n the D a y C a r e U n i t after their c h i l d h a d been taken to the o p e r a t i n g r o o m (the r a t i o n a l e f o r this a p p r o a c h i s d i s c u s s e d u n d e r E t h i c a l C o n s i d e r a t i o n s p. 4 3 ) .  The  researcher i n t r o d u c e d h e r s e l f a n d o f f e r e d a b r i e f v e r b a l e x p l a n a t i o n about the study. A f t e r d e t e r m i n i n g i f the parent(s) met the s e l e c t i o n c r i t e r i a , the researcher o f f e r e d a w r i t t e n letter o f i n f o r m a t i o n w h i c h e x p l a i n e d the p u r p o s e , nature, r i s k s , a n d benefits o f the p r o p o s e d study ( A p p e n d i x D , p. 146).  It w a s suggested to parents that they m i g h t  r e a d the r e s e a r c h e r ' s i n f o r m a t i o n letter d u r i n g the w a i t i n g p e r i o d p r i o r to their c h i l d ' s return to the D a y C a r e U n i t f r o m the post-anesthetic r e c o v e r y r o o m ( P A R R ) . 5.  A f t e r c o n s u l t a t i o n w i t h the n u r s i n g staff i n the D a y C a r e U n i t , the researcher  r e t u r n e d to see the parents after their c h i l d returned f r o m P A R R i n o r d e r to address any questions o r c o n c e r n s r e g a r d i n g the study i n f o r m a t i o n letter.  T h i s method o f approach  38 w a s u s e d w i t h the first three participant f a m i l i e s , a n d it w a s f o u n d that p a r e n t s ' i n t e r e s t / w i l l i n g n e s s to participate i n the study w a s q u i c k l y e s t a b l i s h e d d u r i n g their first contact w i t h the researcher.  It w a s a l s o f o u n d that parents w e r e o c c u p i e d w i t h c o n c e r n s  r e l a t e d to the w e l l - b e i n g o f their c h i l d after his/her return f r o m P A R R .  Therefore in  o r d e r to be sensitive to parental needs at this time, it w a s d e c i d e d that f o r the r e m a i n d e r o f the p a r t i c i p a n t s e l e c t i o n p r o c e s s the researcher w o u l d not return to see the parents a s e c o n d t i m e i n the D a y C a r e U n i t . 6.  If the parents agreed to be so contacted, the researcher t e l e p h o n e d t h e m at  h o m e the f o l l o w i n g m o r n i n g to ascertain o r c o n f i r m their w i l l i n g n e s s to participate i n the study a n d , as appropriate, arrange a c o n v e n i e n t t i m e to v i s i t .  T h e parent's verbal  agreement a n d release o f their telephone n u m b e r to the researcher constituted p e r m i s s i o n f o r further contact. 7.  I n f o r m e d w r i t t e n consent f r o m the participants w a s o b t a i n e d b y the  researcher at the first h o m e v i s i t a n d p r i o r to c o m m e n c i n g a n i n t e r v i e w ( A p p e n d i x E , p. 148).  S u b s e q u e n t i n t e r v i e w s w e r e arranged o n a date a n d t i m e c o n v e n i e n t f o r the  parent(s). Data Collection " T h e g o a l o f p h e n o m e n o l o g y i s to d e s c r i b e 'accurately the e x p e r i e n c e o f the p h e n o m e n o n u n d e r s t u d y " ( F i e l d & M o r s e , 1 9 8 5 , p. 28).  In order to a n s w e r the  r e s e a r c h q u e s t i o n p o s e d b y this study, the data c o l l e c t i o n p r o c e s s c o n s i s t e d o f i n - d e p t h i n t e r v i e w s c o n d u c t e d b y the researcher.  A total o f 16 i n t e r v i e w s w e r e c a r r i e d out w i t h  n i n e parents o f p o s t - o p e r a t i v e toddlers a n d p r e s c h o o l e r s o v e r a s i x m o n t h p e r i o d . f i r s t i n t e r v i e w s a n d eight s e c o n d i n t e r v i e w s w e r e c o n d u c t e d .  Eight  39 P r i o r to a r r a n g i n g e a c h o f the i n t e r v i e w s it w a s m a d e c l e a r that b o t h parents w e r e i n v i t e d to participate.  I n a l l cases except one h o w e v e r , the i n t e r v i e w s w e r e  c o n d u c t e d w i t h the m o t h e r alone.  In the case o f o n e f a m i l y , m o t h e r a n d father w e r e  present f o r the first a n d s e c o n d i n t e r v i e w s .  T h e p a r e n t ' s i n d i v i d u a l d e c i s i o n to  participate i n the i n t e r v i e w s , e v e n i f their spouse d i d not c h o o s e to d o s o , is consistent w i t h this s t u d y ' s m e t h o d o l o g y . T h e i n t e r v i e w s w e r e d e s i g n e d to e x p l o r e "the m e a n i n g o f that e x p e r i e n c e as it u n f o l d s f o r the p a r t i c i p a n t s " ( O m e r y , 1 9 8 3 , p. 5 4 ) .  T h e i n t e r v i e w s w e r e semi^-structured  i n nature a n d r a n g e d i n length f r o m 4 5 to 105 m i n u t e s .  A n interview guide (Appendix  F , p. 149) w a s u s e d d u r i n g the first i n t e r v i e w to facilitate the e x p l o r a t i o n o f general content areas a n d h e l p e l i c i t the parents' d e s c r i p t i o n s o f their e x p e r i e n c e .  T h e guide  c o n s i s t e d o f s e v e r a l o p e n - e n d e d questions w h i c h h a d e v o l v e d f r o m the s t u d y ' s theoretical f r a m e w o r k a n d the r e v i e w o f relevant literature.  O p e n - e n d e d questions are  d e s i g n e d to create a c o n v e r s a t i o n a l atmosphere a n d a l l o w f o r free e x p r e s s i o n ( D i e r s , 1979). C o n s i s t e n t w i t h the a n a l y t i c m e t h o d , the content o f the s e c o n d i n t e r v i e w s w a s d r a w n f r o m a n a l y s i s o f the m a t e r i a l d i s c u s s e d d u r i n g the f i r s t i n t e r v i e w s a n d f r o m i n t e r v i e w s w i t h other parents.  D u r i n g the s e c o n d i n t e r v i e w the researcher sought  c l a r i f i c a t i o n a n d a deeper u n d e r s t a n d i n g o f issues i n i t i a l l y r a i s e d .  The second  i n t e r v i e w s a l s o g a v e o p p o r t u n i t y to attend to n e w t o p i c s that w e r e r a i s e d b y the parent. T h i r d i n t e r v i e w s , a l t h o u g h a n o p t i o n , w e r e not d e e m e d to be necessary f o r further c l a r i f i c a t i o n o f data. F o r s i x o f the eight f a m i l i e s the first i n t e r v i e w s w e r e c o n d u c t e d o n the c h i l d ' s first post-operative day.  D u e to d i f f i c u l t i e s c o - o r d i n a t i n g the r e s e a r c h e r ' s s c h e d u l e w i t h  40 the f a m i l y ' s s c h e d u l e , t w o f a m i l i e s w e r e seen f o r the first t i m e o n the c h i l d ' s s e c o n d post-operative day.  T h e s e c o n d i n t e r v i e w s w e r e c o n d u c t e d b e t w e e n the c h i l d ' s seventh  a n d tenth p o s t - o p e r a t i v e d a y .  T h e s e t i m e p e r i o d s w e r e c h o s e n i n o r d e r to e l i c i t parents'  i m m e d i a t e responses to the e x p e r i e n c e a n d as w e l l to g i v e t h e m s o m e t i m e to assimilate its i m p a c t .  S e v e r a l investigators ( D r o s k e , 1 9 7 8 ; F r i e b e r g , 1 9 7 2 ; R o b e r t s o n , 1970) have  d o c u m e n t e d an i n c r e a s e d parental c o n c e r n r e g a r d i n g p o s t - h o s p i t a l i z a t i o n b e h a v i o r c h a n g e s , s u c h as sleep a n x i e t y a n d i n c r e a s e d d e p e n d e n c y , i n toddlers a n d p r e s c h o o l e r s o n e to t w o w e e k s after h o s p i t a l d i s c h a r g e . A s w a s agreed to b y the participants, a l l o f the i n t e r v i e w s w e r e a u d i o - r e c o r d e d i n o r d e r to o b t a i n accurate v e r b a t i m accounts o f the i n t e r v i e w e e ' s responses.  T h e tape  r e c o r d i n g s w e r e t r a n s c r i b e d either b y the researcher o r a q u a l i f i e d dicta-typist. F o l l o w i n g t r a n s c r i p t i o n , the i n t e r v i e w data w a s then a n a l y z e d b y the researcher.  A s an  a d d e n d u m to the taped i n t e r v i e w s , the researcher kept w r i t t e n f i e l d notes o f telephone c o n v e r s a t i o n s a n d d i s c u s s i o n s w i t h the parents that w e r e not a u d i o - r e c o r d e d ( A n d e r s o n , 1 9 8 1 ; L o f l a n d & L o f l a n d , 1984).  S p e c i f i c data related to the characteristics o f the  parents a n d f a m i l i e s , a n d general o b s e r v a t i o n s about the i n t e r v i e w p r o c e s s w e r e a l s o c o m p i l e d as f i e l d notes. It w a s necessary o n t w o o c c a s i o n s , due to f a i l u r e o f the a u d i o - r e c o r d e r , to r e c o r d p o r t i o n s o f the parent i n t e r v i e w s as f i e l d notes.  T h e s e notes w e r e m a d e f r o m the  r e s e a r c h e r ' s m e m o r y i m m e d i a t e l y after l e a v i n g the f a m i l y ' s h o m e . T h e a p p r o a c h to data c o l l e c t i o n as d e s c r i b e d i n this section i s i n k e e p i n g w i t h the f r a m e w o r k a n d m e t h o d o l o g y c h o s e n f o r this study as it a l l o w s f o r e x p l o r a t i o n a n d c l a r i f i c a t i o n o f issues related to a p a r t i c u l a r e x p e r i e n c e .  T h e f i e l d notes a n d the  v e r b a t i m transcripts o f the taped i n t e r v i e w s c o m p r i s e d the data f o r this study.  41 Data Analysis I n a q u a l i t a t i v e r e s e a r c h m e t h o d o l o g y , data c o l l e c t i o n and data a n a l y s i s are not d i s t i n c t phases o f the research project.  A c c o r d i n g to M o r s e ( 1 9 8 6 ) , i n a qualitative  m e t h o d o l o g y , data c o l l e c t i o n a n d a n a l y s i s d o not cease u n t i l "the theory is c o m p l e t e , does not h a v e gaps, m a k e s sense, a n d has been c o n f i r m e d " (p. 184).  T h e process of  c o l l e c t i n g , c o d i n g a n d a n a l y z i n g data b e g a n at onset o f this study a n d c o n t i n u e d after c o m p l e t i o n o f a l l the i n t e r v i e w s u n t i l the parents' accounts w e r e s y n t h e s i z e d i n t o a d e s c r i p t i v e f r a m e w o r k o f their e x p e r i e n c e w i t h a t o d d l e r o r p r e s c h o o l e r after the c h i l d ' s d a y care surgery. F o r the p u r p o s e s o f this research project the data w e r e a n a l y z e d a c c o r d i n g to the f i v e step m e t h o d p r o p o s e d b y G i o r g i ( 1 9 7 5 a ; 1 9 7 5 b ) : 1)  F o l l o w i n g transcription o f a taped i n t e r v i e w w i t h a parent(s), the researcher  r e a d the entire d e s c r i p t i o n t h r o u g h i n o r d e r to get a sense o f the w h o l e . 2)  N e x t the transcript w a s reread s l o w l y a n d delineated e a c h t i m e that a  t r a n s i t i o n i n m e a n i n g w a s p e r c e i v e d w i t h respect to the p o s t d a y care surgery e x p e r i e n c e f o r parents o f toddlers a n d p r e s c h o o l e r s . the i d e n t i f i c a t i o n o f a series o f " m e a n i n g u n i t s " .  T h e result o f this p r o c e d u r e w a s  F o r e x a m p l e , o n e o f the m e a n i n g  units i d e n t i f i e d after r e a d i n g a n d r e r e a d i n g s e v e r a l transcripts w a s the fear and anxiety f e l t b y parents d u r i n g the p r e - h o s p i t a l i z a t i o n p e r i o d a n d related to the u n k n o w n o u t c o m e o f their c h i l d ' s s u r g i c a l a n d / o r anesthetic p r o c e d u r e . L o f l a n d a n d L o f l a n d (1984) state that m e a n i n g s are " c o n s c i o u s l y s i n g l e d out as i m p o r t a n t aspects o f r e a l i t y " (p. 71).  M e a n i n g units i n q u a l i t a t i v e data a n a l y s i s are  d e s c r i b e d as " t r a n s b e h a v i o r a l " ( L o f l a n d & L o f l a n d , 1984, p. 72)--they not o n l y describe b e h a v i o r but a l s o d e f i n e , j u s t i f y , a n d interpret  it.  42 3)  I n the t h i r d step, the i d e n t i f i e d m e a n i n g units w e r e c o m p a r e d to e a c h other  a n d to the sense o f the w h o l e . c l a r i f i e d a n d elaborated.  R e d u n d a n c i e s w e r e e l i m i n a t e d a n d r e m a i n i n g units w e r e  T h i s c o m p a r a t i v e a n a l y s i s c o n t i n u e d w i t h i n the i n d i v i d u a l  transcript, b e t w e e n transcripts f r o m the same parents, a n d a m o n g transcripts f r o m other parents.  T h e r e w a s c o n t i n u a l m o v e m e n t b a c k a n d f o r t h b e t w e e n the transcripts.  4)  N e x t the researcher " s y s t e m a t i c a l l y i n t e r r o g a t e d " ( G i o r g i , 1 9 7 5 b , p. 7 5 ) e a c h  o f the i d e n t i f i e d m e a n i n g units i n o r d e r to r e v e a l its c o n t r i b u t i o n to the post d a y care surgery e x p e r i e n c e f o r parents o f toddlers a n d p r e s c h o o l e r s . M a n y o f the m e a n i n g units w e r e c o m m o n across the p a r e n t s ' accounts o f their e x p e r i e n c e .  T h e m e a n i n g units w e r e  then t r a n s f o r m e d f r o m the e v e r y d a y language o f the participants i n t o the l a n g u a g e o f nursing science.  F o r e x a m p l e , o n e m e a n i n g u n i t i d e n t i f i e d w a s an i n c r e a s e i n the  f r e q u e n c y o f parental o b s e r v a t i o n s o f the c h i l d d u r i n g the i n i t i a l p o s t - o p e r a t i v e p e r i o d . T h i s f i n d i n g w a s t r a n s f o r m e d i n t o a concrete c l a s s i f i c a t i o n c a l l e d " p r o t e c t i v e b e h a v i o r s " . 5)  In the f i f t h step, the researcher integrated a n d s y n t h e s i z e d the m e a n i n g units  d r a w n f r o m the p a r e n t s ' a c c o u n t s i n t o c o m m o n themes a n d c o n c e p t s f o r m i n g a d e s c r i p t i v e f r a m e w o r k o f the m e a n i n g o f the post d a y care surgery e x p e r i e n c e f o r parents o f toddlers a n d p r e s c h o o l e r s .  T h e final p o i n t o f the p h e n o m e n o l o g i c a l a p p r o a c h  is c o m m u n i c a t i o n o f the f i n d i n g s to other researchers f o r the p u r p o s e o f c o n f i r m a t i o n o r criticism. A s w a s p r e v i o u s l y stated, these steps w e r e not c a r r i e d out sequentially but rather f o r m e d the b a s i s o f the a n a l y t i c p r o c e s s that w a s o n g o i n g d u r i n g a n d after the data c o l l e c t i o n f o r this project.  T h e f i n a l result o f the p r o c e s s i s a synthesis o f the parents'  accounts o f their e x p e r i e n c e w i t h a post d a y care surgery t o d d l e r o r p r e s c h o o l e r i n t o the f r a m e w o r k d e s c r i b e d i n C h a p t e r 4.  43 Ethical Considerations In o r d e r to ensure that the rights o f the parents w h o p a r t i c i p a t e d i n this study w e r e p r o t e c t e d , certain e t h i c a l r e c o m m e n d a t i o n s w e r e f o l l o w e d ( C a n a d a C o u n c i l , 1977; D i e r s , 1979).  These were:  R e s e a r c h C l e a r a n c e P r o c e d u r e s . A p p r o v a l to c a r r y out the p r o p o s e d research w a s sought a n d r e c e i v e d f r o m b o t h the U n i v e r s i t y o f B r i t i s h C o l u m b i a 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 C o m m i t t e e f o r R e s e a r c h a n d O t h e r Studies I n v o l v i n g H u m a n S u b j e c t s and British C o l u m b i a ' s Childrens' Hospital In-Hospital Research R e v i e w Committee ( A p p e n d i c e s A & B , p p . 143 & Informed Consent.  144).  P o t e n t i a l participants w h o m e t the study c r i t e r i a w e r e c o n t a c t e d i n  p e r s o n b y the researcher a n d r e c e i v e d v e r b a l a n d w r i t t e n i n f o r m a t i o n about the p u r p o s e , nature, i m p l i c a t i o n s , r i s k s , a n d benefits o f the study ( A p p e n d i x D , p. 146).  D u e to the  m e t h o d u s e d f o r b o o k i n g c h i l d r e n f o r d a y care surgery p r o c e d u r e s at B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l at the t i m e the study w a s c o n d u c t e d , there w a s n o p r a c t i c a l o p p o r t u n i t y to contact parents b y m a i l i n a d v a n c e o f their a r r i v a l at the D a y C a r e U n i t o n the d a y o f the c h i l d ' s surgery.  T h e r e w a s n o c o l l u s i o n o r d e c e p t i o n b y the  researcher i n her a p p r o a c h to p o t e n t i a l study participants. T h e r i g h t to refuse to participate o r w i t h d r a w f r o m the study at a n y time w i t h o u t p r e j u d i c e to current o r future h e a l t h care f o r their c h i l d r e n , w a s e x p l a i n e d v e r b a l l y and i n w r i t i n g to a l l p a r t i c i p a n t s .  T h e r i g h t to refuse to a n s w e r any q u e s t i o n s , o r to d e c l i n e  the use o f a tape r e c o r d e r w a s a l s o m a d e clear. T h e participants w e r e a s k e d to r e a d a n d s i g n a consent f o r m ( A p p e n d i x E , p. 148) i n the presence o f the researcher after she h a d ensured a l l questions h a d been a n s w e r e d to the p a r e n t ' s satisfaction, and p r i o r to c o m m e n c i n g data c o l l e c t i o n .  44 Privacy.  In o r d e r to ensure c o n f i d e n t i a l i t y a n d a n o n y m i t y , p a r t i c i p a n t ' s w e r e assured  that their n a m e s a n d a l l other i d e n t i f y i n g i n f o r m a t i o n d i d not appear o n a n y i n t e r v i e w tapes or transcripts. transcripts.  A c o d e , k n o w n o n l y to the researcher, w a s u s e d to i d e n t i f y the  A c c e s s to the c o d e d data w a s restricted to the researcher, the t w o m e m b e r s  o f h e r thesis c o m m i t t e e , a n d the typist (the latter t w o i n o n l y a l i m i t e d m a n n e r ) .  The  data w e r e stored i n a l o c k e d f i l i n g cabinet. T h e data c o l l e c t e d w e r e u s e d f o r the stated research o b j e c t i v e s o n l y . P a r t i c i p a n t s w i l l not be p e r s o n a l l y i d e n t i f i e d either d i r e c t l y o r i n d i r e c t l y i n any p u b l i c a t i o n r e l a t e d to this study.  A r r a n g e m e n t s w e r e m a d e to erase the tapes a n d shred  the transcripts, the f i e l d notes, a n d the study consent f o r m s w i t h i n three to f i v e years o f the study. A b r i e f s u m m a r y o f the s t u d y ' s f i n d i n g s w a s s u b m i t t e d to the c l i n i c a l a g e n c y a n d a l s o to those parents w h o h a d p r e v i o u s l y i n d i c a t e d their w i s h to be so i n f o r m e d . Summary T h i s chapter d i s c u s s e d the i m p l e m e n t a t i o n o f the p h e n o m e n o l o g i c a l m e t h o d to study p a r e n t s ' p o s t - h o s p i t a l i z a t i o n e x p e r i e n c e w i t h toddlers a n d p r e s c h o o l e r s w h o u n d e r w e n t d a y c a r e surgery. interviews were conducted.  N i n e parents participated i n the study a n d 16 i n - d e p t h T h e researcher a s s u m e d the r o l e o f f a c i l i t a t o r i n the  e x p l o r a t i o n o f the m e a n i n g o f this parental e x p e r i e n c e a n d c o n t r i b u t e d to the c o n s t r u c t i o n o f the a c c o u n t s .  Data collection and analysis were intertwined.  Chapter 4  represents the r e s e a r c h e r ' s interpretation a n d synthesis o f the p a r t i c i p a n t s ' accounts i n t o a d e s c r i p t i o n o f the m e a n i n g o f the post d a y care surgery e x p e r i e n c e f o r parents o f toddlers a n d p r e s c h o o l e r s .  C h a p t e r 4 a l s o discusses a n d interprets the s t u d y ' s f i n d i n g s  w i t h i n the c o n t e x t o f current, related literature.  V  45 CHAPTER 4  Presentation and Discussion of Findings  W h a t i s the p a r e n t s ' e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery? are presented i n this chapter.  T h e f i n d i n g s o f the study d e s i g n e d to a n s w e r this question T h e s e f i n d i n g s p r o v i d e i n s i g h t i n t o the p a r e n t s ' b r o a d  p e r s p e c t i v e o f the p e d i a t r i c d a y care surgery e x p e r i e n c e w i t h i n the context o f their everyday lives. A l t h o u g h it w a s the r e s e a r c h e r ' s o r i g i n a l intent to d e s c r i b e the " p o s t " d a y care surgery e x p e r i e n c e f o r parents o f toddlers a n d p r e s c h o o l e r s , it s o o n b e c a m e apparent d u r i n g the data c o l l e c t i o n p r o c e s s that the p o s t - h o s p i t a l i z a t i o n e x p e r i e n c e w a s o n l y m e a n i n g f u l w h e n v i e w e d w i t h i n the context o f the events a n d o c c u r r e n c e s that h a d l e d up to it.  Parents articulated that the total e x p e r i e n c e b e g a n w i t h their r e a l i z a t i o n that  s o m e t h i n g w a s " w r o n g " w i t h their c h i l d a n d e n d e d o n l y w h e n the c h i l d ' s b e h a v i o r a n d appearance, as w e l l as the activities a n d routines o f a l l f a m i l y m e m b e r s , h a d returned to acceptable patterns.  T h i s "large p i c t u r e " p r o v i d e d the context f o r the e x p e r i e n c e o f  h a v i n g a t o d d l e r o r p r e s c h o o l e r u n d e r g o d a y care surgery. T h e p a r e n t s ' b r o a d v i e w o f their pediatric d a y care surgery e x p e r i n c e contrasts w i t h the n a r r o w e r p e r s p e c t i v e h e l d b y m a n y health care p r o f e s s i o n a l s .  U n l i k e parents,  w h o d e s c r i b e their e x p e r i e n c e as o c c u r r i n g o v e r a span o f time r a n g i n g f r o m w e e k s to y e a r s , h e a l t h care p r o f e s s i o n a l s tend to v i e w the parents' e x p e r i e n c e p r i m a r i l y w i t h i n the c o n t e x t o f the i m m e d i a t e p r e o p e r a t i v e , operative, a n d i n i t i a l p o s t - o p e r a t i v e s u r g i c a l d a y s ( D a v e n p o r t , S h a h , & R o b i n s o n , 1971).  Parents w h o p a r t i c i p a t e d i n this study w e r e  clearly focused on the management of their "illness experience" rather than the treatment of their child's "disease" therefore consistent with the way the two concepts are defined by Kleinman et al. (1978). This chapter begins with an introduction to the study's analytic framework. Next, the concepts and themes which form the analytic framework will be presented and discussed in relation to existing theory in the literature. The purpose of incorporating the literature in this manner is to present a deeper understanding of the concepts and themes forming the analytic framework through the presentation and discussion of relevant theoretical perspectives. This chapter also includes a detailed description of the participant families, and a detailed presentation of the parents' accounts organized according to the structure of the analytic framework. Throughout the section of this chapter presenting the parents' accounts, both theory and research based publications will be incorporated in order to examine, support, compare, or contrast the study's findings in the context of theory currently available in the literature. Although there has been much literature published on the advantages of pediatric day care surgery, this author has been unable to locate any published studies which explore the pediatric day care surgery experience from the parents' perspective. Some of the empirical studies previously reviewed in Chapter 2 that were conducted with parents of children hospitalized for reasons other than day care surgery, will be reevaluated here from the perspective of the current findings. The Study's Analytic Framework: This study's analytic framework is the writer's interpretation and conceptualization of the similarities and shared aspects of the parent's accounts of their experiences as revealed by in-depth data analysis. These shared aspects have been  47 s y n t h e s i z e d a n d o r g a n i z e d i n t o c o n c e p t s , themes, a n d sub-themes a n d three t e m p o r a l phases.  T h i s c o n c e p t u a l structure f o r m s the theory generated f r o m this study.  A l t h o u g h it i s the a u t h o r ' s intent to present data w h i c h e n h a n c e the r e a d e r ' s u n d e r s t a n d i n g o f the shared aspects o f the parents' e x p e r i e n c e s , it r e m a i n s important to r e c o g n i z e the u n i q u e nature o f the e x p e r i e n c e s o f the i n d i v i d u a l parents w h o p a r t i c i p a t e d i n this study. B e c a u s e the p a r e n t s ' p e r c e p t i o n s o f the e x p e r i e n c e a n d the intensity o f their r e a c t i o n s a n d responses to it c h a n g e d o v e r the span o f their total e x p e r i e n c e , the c o n c e p t o f t i m e i s i m p o r t a n t i n a n e x a m i n a t i o n o f this s t u d y ' s f i n d i n g s .  During  a n a l y s i s o f the parents' a c c o u n t s , it b e c a m e apparent to the researcher that the parents' w e r e d e s c r i b i n g three distinct, c h r o n o l o g i c a l stages to their e x p e r i e n c e .  T h e w r i t e r has  n a m e d these three t e m p o r a l phases a n d , u s i n g parameters d e s c r i b e d b y the participants, d e f i n e d their b o u n d a r i e s a n d their characteristics. T h e three phases o f the p a r e n t s ' e x p e r i e n c e w e r e : a p r e - h o s p i t a l i z a t i o n o r preparatory p h a s e , a h o s p i t a l i z a t i o n o r operative phase, a n d a p o s t - h o s p i t a l i z a t i o n o r readjustment phase.  T h e three phases w i l l be b r i e f l y i n t r o d u c e d to the reader here a n d  w i l l b e d e s c r i b e d i n d e t a i l later i n this chapter.  T h e p r e - h o s p i t a l i z a t i o n o r preparatory  p h a s e b e g a n w i t h the p a r e n t s ' r e a l i z a t i o n that s o m e t h i n g w a s " w r o n g " w i t h their c h i l d a n d e n d e d w i t h the c h i l d ' s a d m i s s i o n to h o s p i t a l to u n d e r g o c o r r e c t i v e surgery.  During  this p h a s e the parents r e a d i e d themselves a n d their f a m i l i e s e m o t i o n a l l y a n d p h y s i c a l l y f o r the d a y care surgery event.  T h e h o s p i t a l i z a t i o n o r operative phase o c c u r r e d d u r i n g  the three to s i x h o u r s that the parent(s) and c h i l d w e r e a c t u a l l y i n the h o s p i t a l setting. T h i s w a s a h i g h l y e m o t i o n a l , intense phase o f the e x p e r i e n c e as the f i n a l preparations f o r s u r g e r y w e r e m a d e a n d the parent(s) r e l i n q u i s h e d their c h i l d to the care o f health  48 care p r o f e s s i o n a l s i n o r d e r that the surgery c o u l d be p e r f o r m e d .  T h e post-  h o s p i t a l i z a t i o n o r readjustment phase began u p o n h o s p i t a l d i s c h a r g e a n d c o n t i n u e d u n t i l the c h i l d h a d r e c o v e r e d p h y s i c a l l y a n d e m o t i o n a l l y f r o m the surgery a n d a l l f a m i l y m e m b e r s h a d returned to acceptable patterns o f d a i l y l i v i n g .  It w a s the p a r e n t s '  i n d i v i d u a l e x p e r i e n c e s that dictated the rate at w h i c h they m o v e d t h r o u g h these three phases. T h e i d e n t i f i c a t i o n o f the three phases o f the p a r e n t s ' e x p e r i e n c e not o n l y reflects a c o m m o n thread i n the parents' accounts o f their e x p e r i e n c e s , but a l s o serves to p r o v i d e a structure f o r the a n a l y t i c a l f r a m e w o r k i n o r d e r to e x a m i n e a n d contrast the parents' thoughts, f e e l i n g s , b e h a v i o r s , a n d reactions as the events o f the e x p e r i e n c e e v o l v e d i n sequence o v e r  time.  T h r o u g h o u t the three phases o f the e x p e r i e n c e parents  e x p e r i e n c e d d i f f e r e n t f e e l i n g s a n d e m o t i o n s i n v a r y i n g intensities.  Parents a l s o u s e d a  v a r i e t y o f c o p i n g m e c h a n i s m s a n d s o c i a l supports to m a n a g e d u r i n g the v a r i o u s phases o f their e x p e r i e n c e . T h e c o r e c o n c e p t that e m e r g e d f r o m an a n a l y s i s o f the s t u d y ' s data w a s stress—parents w h o p a r t i c i p a t e d i n this study p e r c e i v e d their e x p e r i e n c e as a stressful event i n their e v e r y d a y l i v e s r e s u l t i n g i n f e e l i n g s o f fear, w o r r y , a n d a n x i e t y throughout the three c o n c e p t u a l phases o f the e x p e r i e n c e .  T h e c o r e c o n c e p t o f stress is the basis  o f the s t u d y ' s a n a l y t i c f r a m e w o r k a n d e n c o m p a s s e s u n d e r l y i n g themes, a n d sub-themes d e v e l o p e d f r o m a n a l y s i s o f the data. T h e m a j o r themes i d e n t i f i e d i n data a n a l y s i s represent d i m e n s i o n s o f the parents' e x p e r i e n c e s that c o n t r i b u t e d to their interpretation o f the event as stressful. i n c r e a s e d parental r e s p o n s i b i l i t y a n d r o l e strain.  T h e s e were  A d d i t i o n a l themes f r o m the parents'  a c c o u n t s a l s o r e v e a l d i m e n s i o n s o f their e x p e r i e n c e that e n h a n c e d o r i n h i b i t e d their  49 a b i l i t y to m a n a g e w i t h i n the context o f their e v e r y d a y l i v e s .  T h e s e themes have been  i d e n t i f i e d as c o p i n g strategies a n d s o c i a l support. T h e s t u d y ' s c o n c e p t u a l f r a m e w o r k is therefore b a s e d o n a c o r e theme o f stress a n d i s o r g a n i z e d a c c o r d i n g to a c h r o n o l o g i c a l structure c o n s i s t i n g o f three distinct phases.  T h e c o m p o n e n t s o f the f r a m e w o r k , a l o n g w i t h u n d e r l y i n g themes a n d  s u b - t h e m e s , are s i g n i f i c a n t i n terms o f h o w the parents understand a n d e x p l a i n their e x p e r i e n c e w i t h their c h i l d ' s d a y care surgery a n d w i l l be i n t r o d u c e d to the reader here. D a y C a r e S u r g e r y as a S t r e s s f u l E x p e r i e n c e T h e literature abounds w i t h references to the h o s p i t a l i z a t i o n o f a c h i l d as a stressful event f o r the parents ( F r e i b e r g , 1 9 7 2 ; G o f m a n , B u c k m a n , & S c h a d e , 1957; K n o x & H a y e s , 1 9 8 3 ; P r u g h et a l . , 1 9 5 3 ; T e r r y , 1 9 8 7 ; W o l f e r & V i s i n t a i n e r , 1975). A l t h o u g h these a f o r e m e n t i o n e d studies w e r e c o n d u c t e d p r i m a r i l y w i t h parents o f c h i l d r e n w h o w e r e h o s p i t a l i z e d f o r p e r i o d s l o n g e r than those a s s o c i a t e d w i t h d a y care surgery, the f i n d i n g s o f the current study r e v e a l that the parents' e x p e r i e n c e w i t h a c h i l d ' s short t e r m h o s p i t a l i z a t i o n f o r a d a y care surgery p r o c e d u r e is also stressful. O n e m o t h e r d e s c r i b e d h e r e x p e r i e n c e w i t h her d a u g h t e r ' s d a y care surgery as s o m e t h i n g that " c h a n g e d her l i f e f o r a little w h i l e . " A l t h o u g h the c o n c e p t o f stress has b e e n d e f i n e d i n the literature as both a s t i m u l u s a n d a r e s p o n s e , f o r the purposes o f this study stress is d e f i n e d as a " t r a n s a c t i o n b e t w e e n the i n d i v i d u a l a n d h i s internal o r external e n v i r o n m e n t " 1 9 8 4 , p. 4).  (Clarke,  T h i s interactional o r p h e n o m e n o l o g i c a l d e f i n i t i o n o f stress is based u p o n  the w o r k o f L a z a r u s a n d c o l l e a g u e s ( L a z a r u s , 1966; L a r a r u s & F o l k m a n , 1984; L a z a r u s & L a u n i e r , 1978).  L a z a r u s , A v e r i l l , & O p t o n , 1974; T h e s e authors adhere to the  v i e w that stress is a p e r s o n a l e x p e r i e n c e that reflects a d e f i c i t b e t w e e n the w a y an  50 i n d i v i d u a l p e r c e i v e s a d e m a n d m a d e b y the e n v i r o n m e n t a n d the p e r s o n ' s a b i l i t y to m a n a g e o r tolerate the d e m a n d . T h e t h e o r e t i c a l p e r s p e c t i v e o f stress a n d c o p i n g d e v e l o p e d b y the a f o r e m e n t i o n e d authors p r o v i d e s a basis f o r understanding h o w parents w h o p a r t i c i p a t e d i n this study interpreted a n d a s s i g n e d m e a n i n g to the d a y care surgery e x p e r i e n c e a n d c o p e d w i t h it i n their e v e r y d a y l i v e s .  A c c o r d i n g to L a z a r u s a n d c o l l e a g u e s , e a c h situation o r d e m a n d  i n the e n v i r o n m e n t i s c o g n i t i v e l y a p p r a i s e d o r evaluated b y the i n d i v i d u a l a c c o r d i n g to its m e a n i n g o r s i g n i f i c a n c e f o r the p e r s o n ' s w e l l - b e i n g .  It i s the m e a n i n g that the  situation h o l d s f o r the i n d i v i d u a l that determines i f the situation is a p p r a i s e d as i r r e l e v a n t , b e n i g n - p o s i t i v e , o r stressful ( L a z a r u s & F o l k m a n , 1984).  T h i s theoretical  p e r s p e c t i v e w a s p a r t i c u l a r l y h e l p f u l because it h o l d s that stress i s an interactive p h e n o m e n o n a n d takes into account o n e ' s a b i l i t y to act o n the e n v i r o n m e n t . T h e parents w h o p a r t i c i p a t e d i n this study a p p r a i s e d the situation o f their c h i l d ' s d a y c a r e surgery as a stressful o n e .  T h i s w a s p a r t i c u l a r l y apparent w h e n parents w e r e  u n a b l e to c o p e i n u s u a l w a y s to meet the d e m a n d s o f their n e w situation.  For  e x a m p l e , o n e m o t h e r d e s c r i b e d the stress she e x p e r i e n c e d the m o r n i n g o f surgery d u e to her i n a b i l i t y to meet her c h i l d ' s d e m a n d s i n u s u a l w a y s : I w a s c o n c e r n e d a little bit h o w I w a s g o i n g to k e e p h i m h a p p y f o r a f e w hours before h i s surgery because, y o u k n o w , I c o u l d n ' t f e e d h i m and I thought, " O h , this little g u y ' s g o i n g to be h u n g r y a n d c r a n k y .  It's  g o i n g to be h o r r i b l e . " I f a situation i s a p p r a i s e d b y i n d i v i d u a l as b e i n g stressful, the transaction i s further a p p r a i s e d as c h a l l e n g i n g , threatening, a n d / o r i n v o l v i n g h a r m o r l o s s ( L a z a r u s & F o l k m a n , 1984).  Threat i s e x p e r i e n c e d i f a situation is a p p r a i s e d as p h y s i c a l l y o r  51 psychologically hazardous.  " T h r e a t c o n c e r n s h a r m s o r losses that h a v e not yet taken  p l a c e but are a n t i c i p a t e d " ( L a z a r u s & F o l k m a n , 1984, p. 3 2 ) . c o n s c i o u s o r c a n o c c u r o u t s i d e the r e a l m o f awareness.  Threat a p p r a i s a l c a n be  F o r the parents w h o  p a r t i c i p a t e d i n this study, their c h i l d ' s d a y care surgery represented a m a j o r event i n their l i v e s .  T h e parents e x p r e s s e d that the s u r g i c a l event h e l d serious i m p l i c a t i o n s f o r  the c h i l d ' s present a n d future w e l l - b e i n g as w e l l as a p o t e n t i a l l y fatal o u t c o m e . m o t h e r w a s v e r y f r a n k about her fears:  One  " M y b i g c o n c e r n w a s t h a t . . h e [child] w a s  g o i n g to d i e . " H o w an i n d i v i d u a l appraises o r p e r c e i v e s a situation depends u p o n a n u m b e r o f i n f l u e n c i n g factors.  L a z a r u s a n d F o l k m a n (1984) d i s c u s s eight properties o f situations  that m a y c o n t r i b u t e to their a p p r a s i a l o f b e i n g h a r m f u l , d a n g e r o u s , o r threatening to the individual.  T w o o f these properties—event uncertainty a n d t e m p o r a l i i n m i n e n c e — w e r e  f o u n d to c o n t r i b u t e to this s t u d y ' s p a r t i c i p a n t s ' perceptions o f their c h i l d r e n ' s d a y care surgery situation as "threatening". worry, and anxiety.  Parents a l s o r e p o r t e d e x p e r i e n c i n g e m o t i o n s o f fear,  T h e s e e m o t i o n s h a v e b e e n d e s c r i b e d i n the literature as  c o n s e q u e n c e s o f a "threat" a p p r a i s a l ( L a z a r u s & F o l k m a n , 1984). It has b e e n a c k n o w l e d g e d that stressful situations are an e x p e c t e d c o m p o n e n t o f f a m i l y l i f e a n d that there are m a n y m a t u r a t i o n a l o r d e v e l o p m e n t a l stressors associated w i t h p a r e n t i n g y o u n g c h i l d r e n ( A g u i l e r a a n d M e s s i c k , 1978; F r i e d m a n , 1 9 8 6 ; M i l l e r S o l l i e , 1986).  &  A g u i l e r a a n d M e s s i c k (1978) c l a s s i f y the h o s p i t a l i z a t i o n o f a c h i l d as a  s i t u a t i o n a l stressor—"a r a n d o m stress event not related to the d e v e l o p m e n t a l stage o f the f a m i l y " ( M i l e s , S p i c h e r , & H a s s a n e i n , 1984, p. 3 3 4 ) .  In the e x p e r i e n c e s o f the f a m i l i e s  w h o p a r t i c i p a t e d i n this study, the stress associated w i t h their c h i l d ' s d a y care surgery w a s s u p e r i m p o s e d o n the stress a s s o c i a t e d w i t h p a r e n t i n g a y o u n g c h i l d i n e v e r y d a y  life. Parents w h o p a r t i c i p a t e d i n this study a l s o d e s c r i b e d i n c r e a s e d parental r e s p o n s i b i l i t i e s a n d r o l e strain as factors c o n t r i b u t i n g to the stressful nature o f their experience.  In o r d e r to understand h o w a d d i t i o n a l parenting r e s p o n s i b i l i t i e s  contributed  to the stresses associated w i t h this e x p e r i e n c e it i s necessary to e x a m i n e s o m e o f the literature r e l a t e d to n o r m a l o r u s u a l parenting r e s p o n s i b i l i t i e s . Parental Responsibility P a r e n t h o o d i s a p o s i t i o n f i r m l y e m b e d d e d i n o u r s o c i a l structure a n d one that i s b e s t o w e d w i t h the p r i n c i p a l task o f p r e p a r i n g c h i l d r e n to b e c o m e adult m e m b e r s o f s o c i e t y ( H a n d e l , 1970).  P a r e n t i n g r e s p o n s i b i l i t i e s b e g i n d u r i n g the prenatal p e r i o d , are  i n t e n s i f i e d w i t h the b i r t h o f the first c h i l d , a n d c o n t i n u e 2 4 h o u r s per d a y throughout i n f a n c y , c h i l d h o o d a n d s o m e t i m e s b e y o n d ( F r i e d m a n , 1986).  L e v i n e (1974) describes  three categories o f p a r e n t i n g r e s p o n s i b i l i t i e s : 1) to p r o m o t e the health a n d p h y s i c a l s u r v i v a l o f the c h i l d to ensure that the c h i l d l i v e s l o n g e n o u g h to p r o d u c e c h i l d r e n o f their o w n ; 2) to foster the s k i l l s a n d abilities that the c h i l d w i l l n e e d f o r e c o n o m i c and s e l f - m a i n t e n a n c e as a adult; a n d 3) to foster the c a p a b i l i t i e s f o r m a x i m i z i n g c u l t u r a l beliefs and values.  O t h e r authors have d o c u m e n t e d extensive lists o f s p e c i f i c p a r e n t i n g  r e s p o n s i b i l i t i e s ( A r n o l d , 1 9 7 8 ; H a n d e l , 1970) w h i c h c o u l d be e n c o m p a s s e d w i t h i n L e v i n ' s (1974) categories. T h e r e s p o n s i b i l i t i e s f o r p a r e n t i n g a y o u n g c h i l d are e v e r constant.  A  young  c h i l d ' s n e e d f o r s u r g i c a l i n t e r v e n t i o n to correct a short-term c o n d i t i o n o r i l l n e s s heightens a p a r e n t ' s awareness o f h i s / h e r r e s p o n s i b i l i t i e s to ensure the health and p h y s i c a l safety o f a son/daughter.  O n e m o t h e r d e s c r i b e d her f e e l i n g s o f r e s p o n s i b i l i t y  to protect her s o n f r o m the p a i n a n d d i s c o m f o r t she associated w i t h surgery this w a y :  53 " Y o u d o n ' t w a n t a n y t h i n g to hurt y o u r little b a b y [four years o l d ] .  H e could fall down  o n the street a n d p r o b a b l y get hurt more...but i t ' s different [surgery]. e x p l a i n it.  It's  I just can't  different."  B y v i r t u e o f the nature o f the e x p e r i e n c e , d a y care surgery a l s o adds r e s p o n s i b i l i t i e s f o r the p r e p a r a t i o n a n d care o f the operative c h i l d o v e r a n d a b o v e u s u a l parenting.  T h e s e a d d e d r e s p o n s i b i l i t i e s , inherent i n w h a t i s p e r c e i v e d to be a  p o t e n t i a l l y serious event, contribute to the stresses o f this e x p e r i e n c e . P a r e n t a l r e s p o n s i b i l i t i e s c h a n g e o v e r the years as the c h i l d matures a n d parents adapt to their c h i l d r e n ' s d e v e l o p m e n t a l needs.  D u r i n g the t o d d l e r a n d p r e s c h o o l e r  y e a r s , parental r e s p o n s i b i l i t i e s are f o c u s e d o n c a r e t a k i n g , p r o t e c t i o n , l i m i t setting, n u r t u r i n g , a n d the f o s t e r i n g o f s o c i a l a n d independent b e h a v i o r s .  Feeding, bathing,  toilet t r a i n i n g , d i s c i p l i n i n g , m a i n t a i n i n g c l o s e p h y s i c a l contact, a n d p r o v i d i n g f o r a safe e n v i r o n m e n t ( F r i e d m a n , 1 9 8 6 ; H a n d e l 1970) are s p e c i f i c b e h a v i o r s parents c a r r y out to f u l f i l the r e s p o n s i b i l i t i e s o f their p a r e n t i n g r o l e f o r y o u n g c h i l d r e n .  A s the average age  o f the c h i l d r e n w h o s e parents p a r t i c i p a t e d i n this study w a s 23.8 m o n t h s , the study participants w e r e a c c u s t o m e d to c a r r y i n g out the p r e v i o u s l y m e n t i o n e d p a r e n t i n g b e h a v i o r s to ensure their c h i l d r e n ' s w e l l - b e i n g . K e s t e n b e r g (1970) offers a theoretical p e r s p e c t i v e o f p a r e n t s ' i n v o l v e m e n t w i t h , a n d r e s p o n s i b i l i t y for, the c h i l d f r o m b i r t h to s c h o o l age.  H e refers to parenting the  c h i l d f i v e years o f age o r y o u n g e r as "total p a r e n t h o o d " .  A c c o r d i n g l y , parents are h e l d  a c c o u n t a b l e f o r their c h i l d r e n ' s w e l l - b e i n g at a l l times a n d therefore m u s t take direct r e s p o n s i b i l i t y f o r the c h i l d at a l l times o r ensure that s o m e o n e else does ( B o u l t o n , 1983).  A l o n g w i t h this r e s p o n s i b i l i t y c o m e s an element o f " c o n t r o l " o v e r the c h i l d and  his/her environment.  T h e parents w h o p a r t i c i p a t e d i n this study w e r e a c c u s t o m e d to  54 h a v i n g the r e s p o n s i b i l i t y o f parental " s u r v e i l l a n c e " a n d c o n t r o l o v e r their c h i l d a n d his/her " w o r l d " .  D u r i n g the h o s p i t a l i z a t i o n phase o f d a y care surgery parents w e r e  r e q u i r e d to r e l i n q u i s h this c o n t r o l to health care p r o f e s s i o n a l s .  O n e m o t h e r d e s c r i b e d it  this w a y , " Y o u ' r e p u t t i n g h i m i n t o s o m e o n e e l s e ' s hands a n d , y o u k n o w , i t ' s j u s t c o m p l e t e l y out o f y o u r c o n t r o l f r o m then o n . " S o c i e t y p l a c e s expectations f o r the f u l f i l l m e n t o f r e s p o n s i b i l i t i e s o n r o l e s ( J o h n s o n , 1979).  R e s p o n s i b i l i t i e s g u i d e the parent i n w h e n , w h e r e , a n d h o w to p e r f o r m  o r enact their r o l e .  W h e n parents are unable to f u l f i l their p a r e n t i n g r e s p o n s i b i l i t i e s  t h r o u g h the i m p l e m e n t a t i o n o f their parent r o l e , the result i s r o l e strain.  R o l e strain i s  another o f the m a j o r themes i d e n t i f i e d f r o m an a n a l y s i s o f this s t u d y ' s data a n d w i l l be d i s c u s s e d next. R o l e Strain Adequate role functioning is crucial for a f a m i l y ' s successful functioning ( F r i e d m a n , 1986).  R o l e i s d e f i n e d as a " m o r e o r less h o m o g e n e o u s sets o f b e h a v i o r s  w h i c h are n o r m a t i v e l y d e f i n e d a n d e x p e c t e d o f an o c c u p a n t o f a g i v e n s o c i a l p o s i t i o n " ( N y e , 1 9 7 6 , p. 7).  R o l e s are b a s e d o n r o l e r e s p o n s i b i l i t i e s o r expectations a n d are  l e a r n e d t h r o u g h past e x p e r i e n c e s a n d c u l t u r a l u p b r i n g i n g . " r e l e v a n t o t h e r " ( J o h n s o n , 1979, p. 3 2 0 ) . c o m p l i m e n t a r y to the c h i l d ' s r o l e .  E v e r y r o l e has a partner o r a  F o r parents, their mother/father r o l e i s  Parents enact their r o l e expectations o r  r e s p o n s i b i l i t i e s f o r parenting a y o u n g c h i l d through b e h a v i o r s s u c h as f e e d i n g , b a t h i n g , a n d e n s u r i n g contentment a n d safety. G o o d e (1960) d e f i n e s r o l e strain as the stress generated w i t h i n a p e r s o n w h e n o n e either cannot c o m p l y o r has d i f f i c u l t y c o m p l y i n g w i t h the expectations o f a r o l e or sets o f r o l e s .  In other w o r d s , the i n d i v i d u a l has d i f f i c u l t y i n attempting to f u l f i l l role  55 r e s p o n s i b i l i t i e s o r o b l i g a t i o n s ( F r i e d m a n , 1986).  Parents i n this study e x p e r i e n c e d r o l e  strain w h e n they w e r e unable to f u l f i l l n o r m a l r o l e expectations.  A t certain points  d u r i n g the e x p e r i e n c e , c o m p l i a n c e w i t h s u r g i c a l standards/instructions interfered w i t h p a r e n t s ' a b i l i t y to f u l f i l l their n o r m a l r o l e s o f n u r t u r i n g , c a r i n g , a n d p r o t e c t i n g the operative c h i l d .  T h i s w a s p a r t i c u l a r l y apparent f o r the parents i n this study d u r i n g the  p r e - h o s p i t a l i z a t i o n a n d h o s p i t a l i z a t i o n phases o f their e x p e r i e n c e .  Feelings of worry,  a n x i e t y , a n d g u i l t often result f r o m the stress o f r o l e strain ( N y e , 1976) because i n d i v i d u a l s f e e l that they are inadequate i n their enactment o f the r e s p o n s i b i l i t i e s o f their n e w r o l e ( F r i e d m a n , 1986).  A s one m o t h e r stated i n reference to her c h i l d ' s d a y  care s u r g e r y , " Y o u t e n d to, w h e n y o u d o n ' t k n o w , y o u t e n d to w o r r y about e v e r y little thing, I think." W h e n a f a m i l y m e m b e r b e c o m e s i l l , roles a m o n g the f a m i l y m e m b e r s c h a n g e ( J o h n s o n , 1979).  W h e n a c h i l d has to u n d e r g o a d a y care s u r g i c a l p r o c e d u r e , the  parents m u s t a s s u m e r o l e b e h a v i o r s related to p r e a n d p o s t - o p e r a t i v e expectations f o r care o f the c h i l d .  " L e a r n i n g a new role or changing a role can be very stressful" even  i n n o r m a l c i r c u m s t a n c e s ( J o h n s o n , 1 9 7 9 , p. 3 2 1 ) .  B e c a u s e it w a s their first t i m e  e x p e r i e n c e w i t h p e d i a t r i c day care surgery, the parents i n this study h a d little o p p o r t u n i t y to l e a r n the r o l e associated w i t h c a r i n g f o r the s u r g i c a l c h i l d .  F o r example,  o n e m o t h e r d e s c r i b e d f e e l i n g v e r y unsure o f w h a t w a s appropriate to take w i t h her to the h o s p i t a l a n d h o w she s h o u l d dress her c h i l d .  S h e a c t u a l l y p h o n e d the h o s p i t a l ,  s p o k e to a nurse a n d s a i d , " W e l l , this i s p r o b a b l y a d u m b q u e s t i o n , but w h a t s h o u l d [child] w e a r ? "  T h e result o f not k n o w i n g h o w to f u l f i l her n e w r o l e w a s r o l e strain.  In o r d e r to m a n a g e the stresses associated w i t h r o l e strain a n d other aspects o f their e x p e r i e n c e , parents c o p e d i n a v a r i e t y o f w a y s .  T h e f o l l o w i n g section w i l l  56 d e s c r i b e the theme o f c o p i n g a n d h o w it w a s u s e d b y the parents i n this study. Coping C o p i n g i s d e f i n e d as a process o f p r o b l e m s o l v i n g (thoughts a n d actions) d i r e c t e d t o w a r d m e e t i n g the d e m a n d s o f the situation a n d / o r c o n t r o l o f the e m o t i o n a l f e e l i n g s e n g e n d e r e d b y it ( L a z a r u s & L a u n i e r , 1 9 7 8 ; L a z a r u s , A v e r i l l , & O p t o n , 1974). F u n d a m e n t a l to the c o n c e p t o f c o p i n g i s the a s s u m p t i o n that i n d i v i d u a l s are a c t i v e l y r e s p o n s i v e to f o r c e s that i m p i n g e u p o n t h e m ( P e a r l i n & S c h o o l e r , 1978).  Through  patterns o f d a i l y l i v i n g the i n d i v i d u a l learns to use m a n y m e t h o d s to c o p e w i t h stress a n d decrease a n x i e t y .  L a z a r u s a n d c o l l e a g u e s d e s c r i b e a s e c o n d a r y a p p r a i s a l process  u s e d b y i n d i v i d u a l s to assess a v a i l a b l e c o p i n g o p t i o n s i n l i g h t o f a p a r t i c u l a r appraisal.  situation  A n i n d i v i d u a l ' s s e l e c t i o n o f a response is b a s e d u p o n actions that have  s u c c e s s f u l l y r e l i e v e d anxiety a n d tension i n the past ( A g u i l e r a & M e s s i c k , 1978). A s parents c o p e d w i t h the e x p e r i e n c e o f their c h i l d ' s d a y care surgery w i t h i n the context o f their e v e r y d a y l i v e s , they m a d e concrete changes to their e s t a b l i s h e d patterns and activities of daily l i v i n g .  S o m e o f these changes w e r e a direct result o f the nature  o f the s u r g i c a l p r o c e d u r e (eg., casts, bandages) w h e r e a s others w e r e a result o f the p a r e n t s ' interpretation o f their situation a n d their best c h o i c e f o r m a n a g e m e n t . Parents i n this study u s e d both direct a n d i n d i r e c t c o p i n g strategies ( C l a r k e , 1984) t h r o u g h o u t their e x p e r i e n c e i n efforts to meet the d e m a n d s o f their situation and c o p e w i t h the stress they e x p e r i e n c e d .  T h e p a r e n t s ' use o f c o p i n g strategies e n a b l e d  t h e m to act as " k e y f i g u r e s i n m i n i m i z i n g the sequelea r e s u l t i n g f r o m stressor events" ( M i l e s , C a r t e r , S p i c h e r , & H a s s a n e i n , 1 9 8 4 , p. 3 3 4 ) .  D i r e c t c o p i n g i n v o l v e s a c t i o n that  w i l l affect the d e m a n d o f the situation i n some w a y .  F o r example, one mother was  c r e a t i v e i n her attempts to distract her h u n g r y c h i l d i n the p e r i o d j u s t p r i o r to the actual  57 surgical procedure:  "It t o o k us o n l y t w o toys.  O n e toy got us [ f r o m h o m e to 2/3 o f  the w a y to the hospital] a n d the other toy f r o m [there] r i g h t up to j u s t before they c a l l e d h i m f o r the surgery.  H e w a s getting r e a l f i d g e t y a n d h u n g r y t h e n . "  Indirect c o p i n g consists o f "strategies w h i c h d o not alter the d e m a n d i n reality but alter the w a y the i n d i v i d u a l e x p e r i e n c e s the d e m a n d o r his o w n c o p i n g , o r b o t h " ( C l a r k e , 1 9 8 4 , p. 11).  T w o mothers i n this study d e s c r i b e d a c o p i n g strategy o f  " t h i n k i n g p o s i t i v e " as a w a y o f c o p i n g w i t h " u n k n o w n s " that c o n t r i b u t e d to their f e e l i n g s o f stress.  F o r e x a m p l e , o n e m o t h e r stated:  I a l w a y s l o o k o n the p o s i t i v e .  I k n e w it [surgery] h a d to b e d o n e , so  w h a t ' s the p o i n t o f m a k i n g such a b i g t h i n g out o f it?  It has to be  d o n e , that's it, y o u k n o w . D e s p i t e the stressful nature o f the parents' e x p e r i e n c e , the participants e x p r e s s e d that they felt they w e r e able to c o p e e f f e c t i v e l y w i t h their c h i l d ' s d a y care surgery experience.  F o r e x a m p l e , " S o far, i t ' s o n l y b e e n a w e e k [post-operatively], i t ' s been  p l e a s a n t l y s u r p r i s i n g I guess, that h o w easy i t ' s b e e n . " It w a s e v i d e n t f o r the f a m i l i e s w h o p a r t i c i p a t e d i n this study, s o c i a l support w a s a factor c o n t r i b u t i n g to their a b i l i t y to c o p e e f f e c t i v e l y throughout the e x p e r i e n c e .  One  m o t h e r stated that f o r her the k e y to c o p i n g w i t h her s o n ' s d a y care surgery w a s her " [ H u s b a n d ] b e i n g there a n d a l l the support I've h a d f r o m e v e r y b o d y . "  T h i s f i n a l theme  o f s o c i a l support, d e v e l o p e d f r o m a n a l y s i s o f the data, w i l l be d i s c u s s e d next. Social Support T h e d i m e n s i o n s o f the theme o f s o c i a l support b e c a m e apparent as parents shared aspects o f their e x p e r i e n c e s w h i c h they p e r c e i v e d as both s u p p o r t i v e a n d non-supportive.  S u c h aspects i n c l u d e d interactions w i t h f a m i l y m e m b e r s , f r i e n d s , and  58 health p r o f e s s i o n a l s throughout a l l phases o f the e x p e r i e n c e . F o r the parents w h o p a r t i c i p a t e d i n this study, their needs f o r s o c i a l support c h a n g e d o v e r the three phases o f their e x p e r i e n c e .  C e r t a i n types o f support w e r e  p e r c e i v e d b y the parents to be m o r e appropriate at p a r t i c u l a r points o f their e x p e r i e n c e . F o r e x a m p l e , e m o t i o n a l support a n d i n f o r m a t i o n to r e d u c e a n x i e t y a n d the distress o f uncertainty w e r e an o b v i o u s n e e d d u r i n g the p r e - h o s p i t a l i z a t i o n a n d h o s p i t a l i z a t i o n phases o f this e x p e r i e n c e .  S u p p o r t i n the f o r m o f i n f o r m a t i o n a n d tangible assistance  to assist the parent to m a n a g e a r e c o m m e n d e d treatment r e g i m e w a s m o s t appropriate d u r i n g the p o s t - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e . S o c i a l support has been d e s c r i b e d as a m a j o r factor i n adaptation to stressful l i f e events ( C o b b , 1 9 7 6 ; K a p l a n , C a s s e l , & G o r e , 1977).  It i s g e n e r a l l y agreed that " h u m a n  b e i n g s n e e d s o c i a l support, that r e c e i v i n g it contributes to w e l l - b e i n g a n d a b i l i t y to w i t h s t a n d stress, a n d that the n e e d f o r s o c i a l support persists throughout l i f e " & J o n e s , 1 9 8 3 , p. 2 3 8 ) .  (Dimond  S o c i a l support i s an i n t e r p e r s o n a l transaction that f u n c t i o n s to  " b u f f e r " o r protect i n d i v i d u a l s f r o m the effects o f m a n y k i n d s o f l i f e stresses ( C a s s e l , 1 9 7 6 ; C o b b , 1 9 7 6 ; C o h e n , 1 9 8 5 ; P i l i s u k & F r o l a n d , 1978).  In a d d i t i o n , s o c i a l support  has " a m e d i a t i n g effect that stimulates the d e v e l o p m e n t o f c o p i n g strategies" ( D i m o n d & J o n e s , 1 9 8 3 , p. 2 4 2 ) .  In other w o r d s , p e o p l e m o b i l i z e n e e d e d support to c o p e w i t h  c h a n g e ( R o b e r t s , 1988). D i m o n d a n d Jones (1983) r e v i e w e d the vast literature o n s o c i a l support, and p r o p o s e d a c o m p o s i t e d e f i n i t i o n o f the c o n c e p t o f s o c i a l support e m p h a s i z i n g f o u r m a i n p o i n t s : c o m m u n i c a t i o n o f p o s i t i v e affect, s o c i a l integration, i n s t r u m e n t a l b e h a v i o r , and reciprocity.  C o m m u n i c a t i o n o f p o s i t i v e affect i n v o l v e s f e e d b a c k o f i n f o r m a t i o n that  encourages self-esteem a n d offers w a r m t h , c a r i n g a n d c o n c e r n ( C o b b , 1976).  Social  integration offers support b y v i r t u e o f b e l o n g i n g to a g r o u p , s h a r i n g c o m m o n e x p e r i e n c e s , a n d k n o w i n g that there are others w h o w i l l c o m e to o n e ' s a i d i n t i m e o f n e e d ( P i l i s u k & F r o l a n d , 1978).  Instrumental b e h a v i o r as a c o m p o n e n t o f support  i n v o l v e s the p r o v i s i o n o f m a t e r i a l o r tangible a i d ( S u s s m a n , 1965).  R e c i p r o c i t y refers  t o m u t u a l i t y i n a r e l a t i o n s h i p a n d a n e x c h a n g e o f n e e d g r a t i f i c a t i o n b e t w e e n the parties i n v o l v e d ( C a p l a n , 1976). T h e structure o f a s o c i a l n e t w o r k a n d its i n t e r a c t i o n a l properties determine the a d e q u a c y a n d appropriateness o f s o c i a l support i n times o f stress ( D i m o n d & 1983).  Jones,  M o s t o f t e n , s o c i a l support d e r i v e s f r o m a n e t w o r k o f f a m i l y , f r i e n d s ,  n e i g h b o u r s , a n d / o r c o m m u n i t y groups ( F e r r a r i , 1986).  " N e i g h b o r s c a n best h a n d l e  i m m e d i a t e e m e r g e n c i e s ; k i n are m o s t appropriate f o r l o n g - t e r m c o m m i t m e n t s , and f r i e n d s c a n h e l p i n areas that r e q u i r e agreement a n d p o s i t i v e affect" ( L i t w a k a n d S z e l e n y i , 1969).  P r o f e s s i o n a l s a n d c l e r g y are u s e f u l authority r e s o u r c e s d u r i n g times o f  uncertainty as they m a y o f f e r g u i d a n c e ( D i m o n d & J o n e s , 1983).  It i s i m p o r t a n t to  note that " a n e t w o r k structure that m a y assure effective s o c i a l support i n one situation m a y not be e f f e c t i v e i n a l l situations" ( D i m o n d & J o n e s , 1 9 8 3 , p. 2 3 8 ) .  Because social  support i s an i n t e r p e r s o n a l transaction, there are times w h e n interactions are not p e r c i e v e d as s u p p o r t i v e but rather are c o n s t r u e d as stressful ( H e l l e r , 1979). In s u m m a r y , this s t u d y ' s a n a l y t i c f r a m e w o r k i s g r o u n d e d i n f i n d i n g that the p e d i a t r i c d a y care surgery e x p e r i e n c e w a s stressful f o r parents.  T h e m a j o r themes  i d e n t i f i e d i n data a n a l y s i s represent d i m e n s i o n s o f the p a r e n t s ' e x p e r i e n c e s that c o n t r i b u t e d to their interpretation o f the event as stressful. i n c r e a s e d parental r e s p o n s i b i l i t y a n d r o l e strain.  A s stated earlier, these w e r e  A d d i t i o n a l themes f r o m the parents'  accounts a l s o r e v e a l e d d i m e n s i o n s o f their e x p e r i e n c e that e n h a n c e d o r i n h i b i t e d their  60 a b i l i t y to m a n a g e it w i t h i n the context o f their e v e r y d a y l i v e s , n a m e l y , c o p i n g strategies a n d s o c i a l support.  T h e f r a m e w o r k presents the themes i d e n t i f i e d i n the data w i t h i n the  c o n t e x t o f the t e m p o r a l phases o f the e x p e r i e n c e because the latter p r o v i d e s a c h r o n o l o g i c a l s e q u e n c i n g f o r the e x p e r i e n c e . Description of Participant F a m i l i e s In o r d e r to f a m i l i a r i z e the reader w i t h the f a m i l i e s w h o p a r t i c i p a t e d i n this study, their general characteristics a n d d e m o g r a p h i c s w i l l be d e s c r i b e d here. Parents f r o m eight f a m i l y g r o u p s participated i n this e x p l o r a t i o n o f the parental experience.  A total o f 16 i n t e r v i e w s w e r e c a r r i e d out o v e r a s i x m o n t h p e r i o d w i t h  n i n e parents o f post-operative toddlers a n d p r e s c h o o l e r s .  P r i o r to a r r a n g i n g e a c h o f the  i n t e r v i e w s it w a s m a d e c l e a r that b o t h parents w e r e i n v i t e d to participate. e x c e p t o n e h o w e v e r , the i n t e r v i e w s w e r e c o n d u c t e d w i t h the m o t h e r alone. o f this o n e f a m i l y , m o t h e r a n d father w e r e i n t e r v i e w e d together.  In a l l eases In the case  T h e parent's  i n d i v i d u a l d e c i s i o n to participate i n the i n t e r v i e w s , e v e n i f h i s / h e r spouse d i d not c h o o s e to d o so, i s consistent w i t h the p h e n o m e n o l o g i c a l m e t h o d . S i x parents w h o m e t the study c r i t e r i a a n d i n i t i a l l y e x p r e s s e d interest i n p a r t i c i p a t i n g , d e c l i n e d to d o so w h e n contacted o n the c h i l d ' s first p o s t - o p e r a t i v e d a y . T h e reasons they c i t e d i n c l u d e d f a m i l y c o m m i t m e n t s (lack o f t i m e ) , parental i l l n e s s , and e x p e r i e n c i n g a "terrible n i g h t " w i t h the post-operative c h i l d .  D u r i n g telephone  c o n v e r s a t i o n s w i t h m o s t o f these parents, they i n d i c a t e d they w e r e f e e l i n g s o m e w h a t o v e r w h e l m e d w i t h the r e s p o n s i b i l i t i e s o f m e e t i n g their u s u a l f a m i l y c o m m i t m e n t s as w e l l as the needs o f the post-operative c h i l d .  T h i s o b s e r v a t i o n is consistent w i t h the  theme o f stress w h i c h w a s p r o m i n e n t throughout the accounts o f the p a r t i c i p a t i n g parents.  T h e parents w h o c h o s e not to participate m a d e it c l e a r that an a d d i t i o n a l  61 comirutrnent to participate i n the research study w a s s i m p l y not f e a s i b l e f o r t h e m . D e c l i n i n g to participate i n this study w a s a k n o w n v a r i a b l e p a r e n t s ' c o u l d c l e a r l y c o n t r o l i n their attempts to m a n a g e the e x p e r i e n c e w i t h i n the context o f the t i m e and e n e r g y c o m m i t m e n t s o f their e v e r y d a y l i v e s . A l l o f the parents w h o d i d participate i n the study t h a n k e d the researcher f o r the v i s i t s a n d stated they w e r e p l e a s e d to h a v e opportunities to share their p e r s o n a l " s t o r i e s " a n d contribute to an u n d e r s t a n d i n g o f parents' e x p e r i e n c e w i t h p e d i a t r i c day care surgery. The Families A l l eight o f the participant f a m i l i e s w e r e d u a l parent f a m i l i e s a l t h o u g h this w a s not o n e o f the study s e l e c t i o n c r i t e r i a . had two children. professionals. time.  Three families had only one c h i l d ; five families  A l l o f the husband/fathers w e r e e m p l o y e d f u l l t i m e ; f o u r w e r e  O f the eight w i f e / m o t h e r s , three w e r e e m p l o y e d part t i m e a n d one f u l l  T w o h a d p r e v i o u s l y been e m p l o y e d o n a seasonal b a s i s but w e r e not w o r k i n g at  the t i m e o f the c h i l d ' s surgery.  S e v e n o f the eight f a m i l i e s o w n e d their o w n h o m e s .  In s i x o f the eight f a m i l i e s the parents w e r e b o r n a n d r a i s e d i n C a n a d a .  O n e set  o f parents h a d i m m i g r a t e d to C a n a d a f r o m a G e r m a n c o m m u n i t y i n S o u t h A m e r i c a ; one set o f parents h a d i m m i g r a t e d f r o m C h i n a .  T h e latter parents h a d o n l y a basic  c o n v e r s a t i o n a l c o m m a n d o f the E n g l i s h l a n g u a g e .  A l t h o u g h this w a s inconsistent w i t h  the s e l e c t i o n c r i t e r i a , it w a s d e c i d e d to i n c l u d e t h e m i n this study because it w a s the r e s e a r c h e r ' s o n l y o p p o r t u n i t y to e x p l o r e the p o s t day care surgery e x p e r i e n c e f r o m a father's perspective.  It w a s a l s o felt that the i n f l u e n c e o f the C h i n e s e c o u p l e ' s c u l t u r a l  b a c k g r o u n d c o u l d a d d another d i m e n s i o n to the data.  It is interesting to note that  G o u l d - M a r t i n a n d N g i n (1981), i n their study o f the m e d i c a l practices o f i m m i g r a n t  62 C h i n e s e - A m e r i c a n s , stated that tasks i n v o l v i n g m e d i c a l i n f o r m a t i o n a n d d e c i s i o n s are " v e r y l i k e l y to i n v o l v e m e n " (p. 152). The Children T h e age range o f the c h i l d r e n w h o u n d e r w e n t s u r g i c a l p r o c e d u r e s i n the D a y C a r e U n i t w a s f r o m 11 to 4 5 m o n t h s .  T h e i r average age w a s 23.8 m o n t h s .  g r o u p , s e v e n w e r e d e f i n e d as toddlers a n d one as a p r e s c h o o l e r .  In the  O n e 11 m o n t h o l d  i n f a n t w a s i n c l u d e d i n the study because h i s parents met a l l o f the o t h e r s e l e c t i o n c r i t e r i a a n d w e r e v e r y interested i n p a r t i c i p a t i n g i n the study.  F i v e o f the c h i l d r e n w e r e  b o y s a n d three w e r e g i r l s . T h e c h i l d r e n u n d e r w e n t a v a r i e t y o f s u r g i c a l d a y care p r o c e d u r e s :  T w o had  c o r r e c t i v e e y e surgery (unilateral), t w o h a d bilateral m a n i p u l a t i o n s a n d easts f o r e q u i n o v a r u s , t w o h a d h e r n i a repairs (one u m b i l i c a l , one i n g u i n a l ) , o n e h a d an o r c h i o p e x y , a n d o n e h a d b i l a t e r a l m y r i n g o t o m y a n d i n s e r t i o n o f tubes as w e l l as an excision of a lipoma on a lower limb. The Hospitalization A l l o f the c h i l d r e n w h o s e parents p a r t i c i p a t e d i n this study w e r e a d m i t t e d to h o s p i t a l the m o r n i n g o f their surgery.  T h e y spent an average o f 28 m i n u t e s i n the  o p e r a t i n g r o o m (range: 13 to 4 2 m i n . ) a n d 53 m i n u t e s i n the post-anesthesic r e c o v e r y r o o m (range: 3 2 to 7 2 m i n . ) .  T h e average total length o f t i m e spent i n the d a y care  surgery u n i t w a s three h o u r s a n d 13 m i n u t e s (range: 2 hrs. 15 m i n . to 4 hrs. 35 m i n . ) . A s i s consistent w i t h the d a y care surgery e x p e r i e n c e , the parents o f the p r e - o p e r a t i v e c h i l d r e n w e r e t e l e p h o n e d b y the d a y c a r e u n i t " p r e a d m i s s i o n n u r s e " the d a y b e f o r e surgery to c o l l e c t s o m e basic d e m o g r a p h i c i n f o r m a t i o n about the c h i l d , h i s / h e r c o n d i t i o n a n d health h i s t o r y , a n d a l s o to i d e n t i f y any parental c o n c e r n s .  Three  o f the eight m o t h e r s contacted v o i c e d p r e - o p e r a t i v e c o n c e r n s to the n u r s e w h o telephoned them.  T h e c o n c e r n s w e r e d o c u m e n t e d b y the nurse as f o l l o w s :  "mother  n e r v o u s , needs e m o t i o n a l support"; " m o t h e r s l i g h t l y a p p r e h e n s i v e , c o n c e r n e d re: separation, w o u l d l i k e to be i n P A R " ; a n d " m o t h e r c o n c e r n e d r e : c h i l d ' s c o l d " .  A  r e v i e w o f the p a t i e n t s ' charts f o l l o w i n g h o s p i t a l d i s c h a r g e f a i l e d to r e v e a l any w r i t t e n d o c u m e n t a t i o n d e s c r i b i n g f o l l o w - u p o f these c o n c e r n s b y the d a y care u n i t staff. T h e eight c h i l d r e n w e r e d i s c h a r g e d h o m e to the care o f their parent(s) o n the d a y o f their s u r g i c a l p r o c e d u r e s .  A l l o f the parents r e c a l l e d r e c e i v i n g v e r b a l a n d  w r i t t e n i n s t r u c t i o n s f r o m the d a y care staff p r i o r to their h o s p i t a l d i s c h a r g e a n d , a l t h o u g h not s p e c i f i c a l l y a s k e d b y the researcher, three m e n t i o n e d r e c e i v i n g f o l l o w - u p telephone c a l l s f r o m a d a y care u n i t nurse o n their c h i l d ' s first p o s t - o p e r a t i v e d a y . T h e Parents' Accounts of Their Experience and Discussion A s w a s p r e v i o u s l y stated, the p a r e n t s ' accounts o f their d a y care surgery experiences—their thoughts, f e e l i n g s , reactions, a n d explanations—were w o v e n i n t o m a j o r c o n c e p t s a n d themes w h i c h , a l o n g w i t h the structure o f a three phase e x p e r i e n c e , f o r m e d the a n a l y t i c f r a m e w o r k f o r presentation o f this s t u d y ' s f i n d i n g s .  The major  c o n c e p t o f the a n a l y t i c f r a m e w o r k w a s parental stress a n d the f o u r m a j o r themes i d e n t i f i e d w e r e : parental r e s p o n s i b i l i t y , r o l e strain, c o p i n g , a n d s o c i a l support.  The  p a r e n t s ' a c c o u n t s w i l l be presented a c c o r d i n g to the three c h r o n o l o g i c a l phases o f their experience: pre-hospitalization, hospitalization, and post-hospitalization.  A s w i l l be  i l l u s t r a t e d i n the p a r e n t s ' accounts, the f i v e m a j o r concepts o f the a n a l y t i c  framework  v a r i e d i n i m p o r t a n c e a n d intensity d u r i n g the three different c h r o n o l o g i c a l phases o f the experience.  T h e presentation o f the p a r e n t s ' accounts a c c o r d i n g to the three phases  a l l o w s the reader to c o m p a r e a n d contrast the m e a n i n g the e x p e r i e n c e h e l d f o r t h e m at  64 different c h r o n o l o g i c a l points a n d its i m p a c t o n their e v e r y d a y l i v e s . s e c t i o n o f the chapter w i l l be a n integration o f relevant, current  I n c l u d e d i n this  literature.  V e r b a t i m accounts f r o m parent i n t e r v i e w s w i l l be u s e d e x t e n s i v e l y f o r  illustrative  p u r p o s e s a n d to demonstrate to the reader h o w the researcher interpreted and e v o l v e d constructs d i r e c t l y f r o m the data ( A n d e r s o n & C h u n g , 1982).  T h e quotations serve to  represent not o n l y the c o m m o n a l i t i e s but a l s o the e x c e p t i o n s to the c o n c e p t s , themes, a n d sub-themes i d e n t i f i e d i n data a n a l y s i s . T h e a b b r e v i a t i o n s u s e d i n this chapter to i d e n t i f y the speakers b e i n g q u o t e d are as f o l l o w s :  M : M o t h e r , F : Father, a n d R : R e s e a r c h e r .  A l l other i n d i v i d u a l s w h o have  been p e r s o n a l l y n a m e d i n the text o f the c o n v e r s a t i o n s w i l l be i d e n t i f i e d o n l y b y their p o s i t i o n o r r e l a t i o n s h i p to o n e o f the speakers.  T h i s i n f o r m a t i o n w i l l be p l a c e d i n  square b r a c k e t s , f o r e x a m p l e [ c h i l d ] . T h e P r e - h o s p i t a l i z a t i o n Phase T h e p r e - h o s p i t a l i z a t i o n phase o f the parents' e x p e r i e n c e b e g a n w i t h the parents' r e a l i z a t i o n that s o m e t h i n g w a s " w r o n g " w i t h their c h i l d a n d e n d e d w i t h the c h i l d ' s a d m i s s i o n to h o s p i t a l to u n d e r g o c o r r e c t i v e surgery.  D u r i n g this phase the parents  r e a d i e d t h e m s e l v e s a n d their f a m i l i e s e m o t i o n a l l y a n d p h y s i c a l l y f o r the d a y care surgery event.  T h i s phase w a s t y p i c a l l y a p e r i o d o f d e c i s i o n m a k i n g , uncertainty, a n d  a n t i c i p a t i o n that lasted f o r a p e r i o d o f w e e k s to years. T h e r e w e r e p a r t i c u l a r aspects o f this phase o f the e x p e r i e n c e that contributed to the p a r e n t s ' interpretation o r a p p r a i s a l o f their c h i l d ' s d a y care surgery as " t h r e a t e n i n g " , r e s u l t i n g i n f e e l i n g s o f a n x i e t y , w o r r y , a n d fear.  Parents h e l d the v i e w  that their y o u n g c h i l d r e n were p a r t i c u l a r l y v u l n e r a b l e to the negative effects o f a n operative procedure.  Parents also p e r c e i v e d that r e s p o n s i b i l i t i e s related to  65 d e c i s i o n - m a k i n g a n d pre-operative preparation f o r their y o u n g c h i l d r e n w e r e a d d e d to the u s u a l p a r e n t i n g r e s p o n s i b i l i t i e s .  T h e n e w , extra r e s p o n s i b i l i t i e s r e q u i r e d r o l e  adjustments i n o r d e r to enact t h e m .  G i v e n that the study parents h a d not h a d p r e v i o u s  e x p e r i e n c e e n a c t i n g s u c h r o l e s , the result w a s " r o l e s t r a i n " c h a r a c t e r i z e d b y feelings o f w o r r y , a n x i e t y , a n d g u i l t ( N y e , 1976). O t h e r d i m e n s i o n s o f this phase o f the e x p e r i e n c e that c o n t r i b u t e d to the appraisal o f the situation as threatening w a s "event u n c e r t a i n t y " ( L a z a r u s a n d F o l k m a n , 1984), o r not k n o w i n g w h a t to e x p e c t d u r i n g o r as a n o u t c o m e o f the e x p e r i e n c e .  O n e mother  stated it this w a y : " T h i s w a s the first t i m e , so it w a s r e a l l y h a r d to understand it, I guess." W a i t i n g d u r i n g this phase o f the e x p e r i e n c e w a s a l s o p a r t i c u l a r l y stressful f o r parents a n d , as the d a y o f surgery a p p r o a c h e d , " t e m p o r a l i m m i n e n c e " ( L a z a r u s a n d F o l k m a n , 1984) a d d e d to f e e l i n g s o f a n x i e t y , fear, a n d w o r r y .  F o r e x a m p l e , one  m o t h e r r e c a l l e d it this w a y : " L e a d i n g up to it [the d a y o f surgery] I w a s r e a l l y a n x i o u s f o r w e e k s , but p a r t i c u l a r l y the last f e w d a y s " . P a r e n t s ' attempts to m a n a g e this phase o f their e x p e r i e n c e w i t h i n the context o f their e v e r y d a y l i v e s resulted i n concrete c h a n g e s i n their r e g u l a r patterns o f routines and activities.  S o c i a l supports e n h a n c e d their d e c i s i o n m a k i n g a b i l i t y .  A variety of  c o p i n g strategies w e r e u s e d to m i n i m i z e the stresses o f this phase o f the e x p e r i e n c e . T h e p a r e n t s ' accounts r e v e a l e d that it w a s w i t h the i n i t i a l " d i s c o v e r y " that s o m e t h i n g w a s w r o n g w i t h their c h i l d that their u n d e r s t a n d i n g a n d interpretation o f their d a y care s u r g e r y e x p e r i e n c e b e g a n .  F o r seven o f the n i n e parents, the process o f  parental d e c i s i o n m a k i n g r e l a t i n g to the c h i l d ' s actual s u r g i c a l p r o c e d u r e w a s a  66 s i g n i f i c a n t c o m p o n e n t o f the p r e - h o s p i t a l i z a t i o n phase o f the d a y care surgery experience. A s w i l l be illustrated i n the quotations later i n this s e c t i o n , the r e s p o n s i b i l i t y f o r d e c i s i o n m a k i n g rests s o l e l y w i t h the mothers a n d fathers.  In three o f the eight  f a m i l i e s w h o p a r t i c i p a t e d i n this study, the mothers d e s c r i b e d that both they a n d their h u s b a n d s w e r e a c t i v e l y i n v o l v e d i n m a k i n g the d e c i s i o n related to the p r o p o s e d surgery. T h e s e three sets o f parents attended the d o c t o r s ' appointments together a n d spent c o n s i d e r a b l e t i m e d i s c u s s i n g o p t i o n s and t i m i n g f o r the event. In the f a m i l i e s w h e r e fathers d i d not attend d o c t o r s ' a p p o i n t m e n t s , m a n y o f the m o t h e r s s a w it as part o f their r o l e to " a s k the r i g h t q u e s t i o n s " a n d o b t a i n sufficient i n f o r m a t i o n i n o r d e r f o r the c o u p l e to m a k e an i n f o r m e d d e c i s i o n .  M o t h e r s reported  that their h u s b a n d s r e l i e d u p o n their o p i n i o n s but i n the e n d w e r e not a l w a y s satisfied: "I get frustrated w h e n he asks m e a l l the hundreds questions w h e n I c o m e f r o m the d o c t o r , I s a y , ' W h y d o n ' t y o u g o , i f y o u ' r e not s a t i s f i e d ? ' " In f i v e f a m i l i e s , it w a s the mothers w h o attended d o c t o r s ' appointments b y t h e m s e l v e s a n d m a d e the d e c i s i o n to p r o c e e d w i t h the c h i l d ' s surgery after o n l y b r i e f c o n s u l t a t i o n w i t h their h u s b a n d s .  O v e r a l l , it w a s the mothers i n this group w h o tended  to a s s u m e a m o r e p r i m a r y r o l e related to the d e c i s i o n m a k i n g p r o c e s s related to the d a y care s u r g e r y .  D e p e n d i n g u p o n c i r c u m s t a n c e s , the p r o c e s s l e a d i n g up to the d e c i s i o n to  p r o c e e d w i t h the s u r g i c a l p r o c e d u r e t o o k d a y s , w e e k s , o r e v e n m o n t h s to c o m p l e t e . F o r three o f the parents the " d i s c o v e r y " o f the c h i l d ' s p o t e n t i a l p r o b l e m w a s apparent at b i r t h : " W h e n he w a s b o r n he h a d a h e r n i a " .  F o r the r e m a i n i n g f i v e sets o f  parents, it w a s w i t h i n the c h i l d ' s first t w o years that a p r o b l e m b e c a m e suspect. M:  E v e r s i n c e she w a s s i x m o n t h s o l d I n o t i c e d her e y e . . . w e o n l y n o t i c e d  67 o n e e y e , w o u l d n ' t l o o k at y o u , it w o u l d l o o k out s o m e w h e r e else.  M:  T h e P u b l i c H e a l t h N u r s e n o t i c e d that he t i l t e d h i s h e a d a little bit to one side a n d she...suggested that I have it l o o k e d into.  T h e s e parents are r e c a l l i n g w h e n they first b e c a m e a w a r e that s o m e t h i n g m i g h t be " w r o n g " w i t h their c h i l d .  F e e l i n g s o f c o n c e r n l e d to a v i s i t to the f a m i l y practitioner to  seek i n f o r m a t i o n , a d v i c e , a n d p r o f e s s i o n a l v a l i d a t i o n a n d to f u l f i l their sense o f r e s p o n s i b i l i t y f o r their c h i l d ' s w e l l - b e i n g . M e d i c a l validation had two kinds o f immediate outcomes.  F o r s o m e parents, the  v a l i d a t i o n o f their o b s e r v a t i o n s c a m e as a " s h o c k " , w h i l e f o r others it w a s a c o n f i r m a t i o n o f w h a t they already k n e w .  T h e f o l l o w i n g quotations illustrate parental  reactions o f s h o c k a n d surprise to the m e d i c a l c o n f i r m a t i o n that s o m e t h i n g i s w r o n g w i t h their c h i l d : M:  It w a s a bit o f a s h o c k a c t u a l l y , because the p e d i a t r i c i a n h a d b e e n s o , u m m , definite that it w a s n ' t an e y e p r o b l e m , a n d a l l o f a s u d d e n I h a d a n e y e specialist t e l l i n g m e it w a s a n e y e p r o b l e m that needed surgery, I w a s quite c o n c e r n e d , so I a c t u a l l y got a s e c o n d o p i n i o n .  T h i s p a r e n t ' s c o n c e r n r e g a r d i n g the o p i n i o n o f the s p e c i a l i s t illustrates h o w h e a v i l y the r e s p o n s i b i l i t y f o r d e c i s i o n m a k i n g i s seen to rest w i t h the m o t h e r a n d / o r father. S e e k i n g a s e c o n d o p i n i o n w a s this m o t h e r ' s w a y o f f u l f i l l i n g her sense o f r e s p o n s i b i l i t y f o r m a k i n g the best i n f o r m e d d e c i s i o n f o r her c h i l d ' s w e l l - b e i n g . M:  W h e n I m e n t i o n e d it to [ f a m i l y doctor] a n d he s a i d h e ' d refer m e to [pediatric surgeon] I w a s sort o f i n s h o c k f o r a w h i l e ' c a u s e I h e ' d say " O h , d o n ' t w o r r y about  it".  thought  68 T h i s m o t h e r has a c k n o w l e d g e d that she w a s v i s i t i n g the p h y s i c i a n to seek reassurance that her o b s e r v a t i o n s o f her c h i l d w e r e not significant.  T h e response she r e c e i v e d w a s  not the one she e x p e c t e d o r " w i s h e d f o r " . A s w a s p r e v i o u s l y stated, not a l l parents w e r e s h o c k e d b y the n e w s .  The  f o l l o w i n g quotations illustrate the c o m m o n responses o f parents w h o h a d anticipated that their c h i l d m i g h t require a s u r g i c a l p r o c e d u r e later i n l i f e : M:  It w a s n ' t a surprise.  B e f o r e I went to [pediatric surgeon] I k n o w he  [ c h i l d ] n e e d the o p e r a t i o n .  M:  I k n e w about it, I m e a n I k n e w w h e n it c a m e to the t i m e o f h a v i n g it d o n e that he [child] w a s g o i n g to h a v e it d o n e y o u k n o w , it w a s n ' t a s h o c k to m e .  E v e n f o l l o w i n g v a l i d a t i o n o f the c o n d i t i o n a n d r e c o m m e n d a t i o n s f o r s u r g i c a l i n t e r v e n t i o n , f i v e sets o f parents r e m a i n e d h o p e f u l that surgery m i g h t not be necessary. M:  In the m e a n t i m e , a c t u a l l y , m y h u s b a n d a n d I n o t i c e d his n e c k got better, that h i s tilt w a s n o t i c e a b l y i m p r o v e d , a n d so w e b e g a n to w o n d e r i f it w a s s o m e t h i n g that w a s c o r r e c t i n g itself.  M:  S o m e t i m e s y o u d o n ' t see it [condition].  Y o u d o n ' t see it a l l the t i m e .  A n d so, I n e v e r k n o w whether it [surgery] w a s n e c e s s a r y . T h e s e t w o parents w e r e hesitant to p r o c e e d w i t h the surgery unless " a b s o l u t e l y " necessary.  T h i s w a s r e l a t e d to their p e r c e p t i o n o f the d a y care surgery event as  threatening to their c h i l d ' s w e l l - b e i n g as w e l l as their l a c k o f k n o w l e d g e about their  69 child's condition.  B o t h o f these facts c o n t r i b u t e d to their f e e l i n g s o f uncertainty a n d  anxiety. A n o t h e r set o f parents a c t u a l l y d e l a y e d a d e c i s i o n to p r o c e e d w i t h their c h i l d ' s surgery because o f their h o p e that it m i g h t not be necessary.  T h e d e c i s i o n to d e l a y  c h a n g e d their situation a n d t e m p o r a r i l y e l i m i n a t e d the stresses a s s o c i a t e d w i t h p r o c e e d i n g w i t h their c h i l d ' s surgery.  P e a r l i n a n d S c h o o l e r (1978) i d e n t i f y c h a n g i n g a  situation as o n e type o f f u n c t i o n a l m e t h o d o f c o p i n g w i t h a stressful situation. W i t h o n l y o n e e x c e p t i o n , a l l o f the study parents m a d e their d e c i s i o n to p r o c e e d w i t h the surgery w i t h some f e e l i n g s o f d o u b t a n d a m b i v a l e n c e . o b l i g a t i o n to f u l f i l their e x p e c t e d p a r e n t i n g r e s p o n s i b i l i t i e s  Their primary  (ensuring the safety,  p r o t e c t i o n a n d w e l l - b e i n g o f their c h i l d ) w a s w e i g h e d against s u b j e c t i n g their c h i l d to a surgical procedure with k n o w n risks, discomforts, and pain—usually for a more long term gain.  A s the f o l l o w i n g q u o t a t i o n demonstrates, the d e c i s i o n m a k i n g p r o c e s s  w e i g h e d h e a v i l y u p o n s o m e parents, c o n t r i b u t e d to their a p p r a i s a l o f the situation as " t h r e a t e n i n g " , a n d resulted i n f e e l i n g s o f fear, guilt, a n d a n x i e t y : M:  Y o u k n o w , i f y o u are m a k i n g y o u r d e c i s i o n y o u ' r e r e s p o n s i b l e f o r h i m , a n d y o u ' r e m a k i n g a d e c i s i o n that e v e n b a s e d o n w h a t other p r o f e s s i o n a l p e o p l e t o l d y o u , that he has to g o i n f o r surgery a n d u h , y o u k n o w , I guess ' c a u s e h e ' s s u c h a little g u y that y o u think...it's a b i g r e s p o n s i b i l i t y a n d y o u f e e l sort o f g u i l t y f o r h a v i n g put h i m t h r o u g h s o m e t h i n g that's quite traumatic f o r h i m , r e a l l y p r o b a b l y not as traumatic f o r h i m as it i s f o r us [laughter] but that i s h o w w e p e r c e i v e it a n y w a y as b e i n g .  70 T h i s quote illustrates the sense o f a m b i v a l e n c e that parents f e e l as they f u l f i l their r e s p o n s i b i l i t y f o r the d e c i s i o n m a k i n g p r o c e s s .  T h e p e r c e i v e d v u l n e r a b i l i t y o f the  y o u n g c h i l d a n d f e e l i n g s o f parental guilt are o b v i o u s factors i n the a m b i v a l e n c e . A l t h o u g h this m o t h e r h a d to struggle s o m e w h a t to get her ideas c l e a r , she i n d i c a t e s a strong parental r e l i a n c e o n p r o f e s s i o n a l o p i n i o n s d u r i n g the d e c i s i o n m a k i n g process a n d parental needs f o r support at this  time.  A n o t h e r m o t h e r e x p r e s s e d her sense o f r e s p o n s i b i l i t y f o r m a k i n g a d e c i s i o n f o r her c h i l d this w a y : M:  W h e n y o u h a v e to m a k e a d e c i s i o n that affects s o m e o n e f o r the rest o f their l i v e s o r e v e n l i k e [ c h i l d ] , f o r a f e w w e e k s , o r e v e n i f this d r a w s o n for a couple o f months.  It's g o i n g to affect her, y o u k n o w .  F o r this m o t h e r e v e n the fact that the c o n s e q u e n c e s o f her d e c i s i o n m a y o n l y affect her c h i l d f o r a short p e r i o d o f t i m e d i d not m a k e a d i f f e r e n c e i n the w a y she a p p r o a c h e d her d e c i s i o n m a k i n g . foremost concern.  H e r sense o f r e s p o n s i b i l i t y f o r her c h i l d ' s w e l l - b e i n g w a s her  T h i s same m o t h e r w e n t o n to state h o w h e a v i l y b u r d e n e d she felt  b y h a v i n g to m a k e this d e c i s i o n a n d c o m p a r e d her p e r s p e c t i v e to that o f health professionals: M:  T o the nurses, i t ' s p r o b a b l y routine.  T h i s is m y thought.  They probably  d o n ' t f e e l l i k e i t ' s a m a j o r d e c i s i o n . . . o r e v e n [pediatric surgeon]. W h e r e a s to m e , i t ' s s o m e t h i n g I t h i n k about a l l the t i m e . A g a i n , this m o t h e r i s e x p r e s s i n g h o w " m a j o r " the d e c i s i o n m a k i n g p r o c e s s related to her c h i l d ' s d a y care surgery i s f o r her. In contrast to the a b o v e quotations, the C h i n e s e f a m i l y w h o p a r t i c i p a t e d i n the study a p p r o a c h e d the d e c i s i o n to p r o c e e d w i t h the surgery i n a v e r y matter o f f a c t w a y ,  71 w i t h o u t the a m b i v a l e n c e that other parents h a d e x p r e s s e d : M:  ' C a u s e w e k n o w f o r us i s n o n e e d to m a k e , n o n e e d to talk, d i s c u s s about the d e c i s i o n .  W e h a v e to d o it, y o u k n o w , so n o t h i n g to try,  n o t h i n g to a n x i o u s , n o t h i n g to w o r r y . T h e d e c i s i o n m a k i n g p r o c e s s f o r this f a m i l y w a s v e r y straight f o r w a r d , b a s e d u p o n their o b s e r v a t i o n s o f their c h i l d ' s c o n d i t i o n a n d their p h y s i c i a n ' s r e c o m m e n d a t i o n s w i t h o u t the a n x i e t y a n d g u i l t e x p r e s s e d b y other parents.  G o u l d - M a r t i n a n d N g i n (1981) i n  their study o f the m e d i c a l practices o f C h i n e s e - A m e r i c a n s f o u n d that i m m i g r a n t s w e r e u s u a l l y p r o m p t s e e k i n g W e s t e r n m e d i c a l c a r e f o r c o n d i t i o n s r e q u i r i n g surgery. A n d e r s o n & C h u n g (1982) f o u n d that i n C h i n e s e i m m i g r a n t f a m i l i e s the contentment a n d h a p p i n e s s o f an i l l c h i l d i s o f p r i m a r y c o n c e r n . T h e f i n d i n g s o f the current study r e v e a l e d that parents w e r e m u c h m o r e a m b i v a l e n t about surgery that w a s o f a c o s m e t i c rather than a f u n c t i o n a l nature.  In  these cases, the a d d e d r e s p o n s i b i l i t i e s related to d e c i s i o n m a k i n g w e r e seen a l m o s t as a burden.  B e c a u s e o f the u n k n o w n o u t c o m e o f their c h i l d ' s surgery the parents felt less  secure about their d e c i s i o n to p r o c e e d w i t h the surgery: M:  It w i l l n e v e r affect her v i s i o n , her v i s i o n w a s a l w a y s f i n e , but it w a s a c o s m e t i c type thing. S o , to put her through a l l o f this, y o u k n o w , w e h a d to be sure that w e w a n t e d to, a n d the surgery i s n ' t a l w a y s 100 percent.  T h i s m o t h e r i s r e c o u n t i n g h o w she s t r u g g l e d w i t h a d e c i s i o n that, i n her p e r c e p t i o n , h a d an u n c e r t a i n l o n g - t e r m o u t c o m e a n d w o u l d result i n short t e r m " t r a u m a " f o r h e r c h i l d . T h e n o t i o n that parental a c t i o n taken n o w w i l l be b e n e f i c i a l f o r the c h i l d i n h i s / h e r later years has been d i s c u s s e d b y others as a n e x a m p l e o f p a r e n t s ' e n a c t i n g r e s p o n s i b i l i t i e s to attain o p t i m a l p h y s i c a l appearance o r " n o r m a l i z a t i o n " f o r their  72 c h i l d r e n ( A n d e r s o n & C h u n g , 1982). T h e f o l l o w i n g q u o t a t i o n illustrates another m o t h e r ' s uncertainty about surgery that w a s p r i m a r i l y c o s m e t i c i n nature a l o n g w i t h her c o n s i d e r a t i o n s f o r her d a u g h t e r ' s future p h y s i c a l appearance: M:  W e thought about l e a v i n g it, but then w h e n she got o l d e r she m i g h t c o m e to us a n d say " W e l l , w h y d i d n ' t y o u get m y feet f i x e d w h e n I w a s younger?"  T h e parents w h o p a r t i c i p a t e d i n this study h a d not h a d p r e v i o u s e x p e r i e n c e w i t h a c h i l d w h o h a d u n d e r g o n e d a y care surgery (see s e l e c t i o n c r i t e r i a , C h a p t e r 3 , p. 35). A s a result, the study parents brought o n l y l i m i t e d k n o w l e d g e r e g a r d i n g d a y care surgery w i t h t h e m to the e x p e r i e n c e a n d w e r e unsure o f w h a t n e w needs a n d d e m a n d s their y o u n g c h i l d m i g h t h a v e .  A l t h o u g h a l l parents w e r e t o l d i n a d v a n c e b y health  p r o f e s s i o n a l s s o m e o f w h a t to expect f r o m the e x p e r i e n c e , they s t i l l e x p r e s s e d f e e l i n g at least p a r t i a l l y u n p r e p a r e d f o r the it. F o u r o f the study parents articulated that f e e l i n g s o f uncertainty l e a d to the a n t i c i p a t i o n o f a v e r y n e g a t i v e , unpleasant s c e n a r i o .  F o r e x a m p l e , despite h a v i n g been  g i v e n p r e - o p e r a t i v e i n f o r m a t i o n , o n e m o t h e r stated that it " D o e s n ' t register...until y o u are a c t u a l l y there [in the D a y C a r e U n i t ] , because y o u h a v e set i n y o u r m i n d the w a y y o u t h i n k things are g o i n g to b e . " certain w a y .  S h e c l e a r l y anticipated her e x p e r i e n c e to e v o l v e i n a  A n o t h e r m o t h e r stated that despite b e i n g t o l d w h a t to expect, she w a s  sure that " m y k i d ' s g o i n g to be different".  B o t h these mothers w e n t o n to d e s c r i b e  h o w they anticipated their e x p e r i e n c e to be " m u c h w o r s e " than it a c t u a l l y w a s . F o u r other study parents r e v e a l e d that they anticipated c h a n g e s i n their c h i l d r e n , but w e r e u n a b l e to p r e d i c t w h a t these c h a n g e s w o u l d be o r s p e c i f i c a l l y w h a t the c o u r s e o f their c h i l d ' s d a y care surgery m i g h t be l i k e .  F e e l i n g unsure o f w h a t to e x p e c t , o r  73 a n t i c i p a t i n g a negative e x p e r i e n c e , contributed to the stress o f their e x p e r i e n c e a n d r e s u l t e d i n f e e l i n g s o f fear, w o r r y , and a n x i e t y . M:  I w a s a f r a i d f o r her [ c h i l d ] .  O n e m o t h e r d e s c r i b e d it this w a y :  I t h i n k that's it. I d o n ' t k n o w a n y b o d y  w h o ' s ever h a d surgery, n o one i n o u r f a m i l y . . . n o o n e c l o s e .  N o one has  e v e r been i n the h o s p i t a l , e v e n grandparents, y o u k n o w , n o o n e has h a d anything.  S o , it w a s r e a l l y scary.  N o t e h o w this m o t h e r articulates her l a c k o f p r e v i o u s e x p e r i e n c e related to any type o f h o s p i t a l i z a t i o n o r s u r g i c a l p r o c e d u r e as c o n t r i b u t i n g to her a p p r a i s a l o f her d a u g h t e r ' s d a y care surgery as threatening a n d resulted i n f e e l i n g s o f a n x i e t y a n d fear related to an u n k n o w n o u t c o m e . E v e n t h o u g h parents h a v e b e e n t o l d that s p e c i f i c p r o c e d u r e s are c o n s i d e r e d to be m i n o r f r o m the m e d i c a l v i e w p o i n t , fears o f the u n k n o w n a n d / o r p r e c o n c e i v e d notions c o n t r i b u t e d to their p e r c e p t i o n s o f d a y care surgery as a " m a j o r " event.  O n e mother  e x p r e s s e d her fears this w a y : M:  W e l l , I t h i n k , a c t u a l l y [pediatric surgeon] w a s v e r y g o o d , I m e a n she kept e m p h a s i z i n g that it w a s m i n o r surgery and w o u l d o n l y take about thirty m i n u t e s , a n d that he w o u l d r e a l l y o n l y h a v e a little d i s c o m f o r t i n h i s o w n w a y . S o it w a s if, it w a s l o w - k e y y o u k n o w , n o b i g d e a l here, but I t h i n k that w e m a d e it a b i g d e a l , y o u k n o w , o u r s e l v e s , p r o b a b l y just because, i t ' s p r o b a b l y not k n o w i n g w h a t to e x p e c t , so that a l l o f these things g o through y o u r m i n d : "Is this g o i n g to h a p p e n ? Is this g o i n g to happen?"  T h i s parent i s n o t i n g that " e v e n a little d i s c o m f o r t " i s a " b i g d e a l " to the m o t h e r o f a y o u n g c h i l d as she feels r e s p o n s i b l e to protect her c h i l d f r o m h a r m .  T h i s m o t h e r is  74 a l s o s a y i n g that because o f her l a c k o f e x p e r i e n c e , the uncertainty o f not k n o w i n g what to e x p e c t r e l a t e d to her s o n ' s d a y care surgery c o n t r i b u t e d to her interpretation o f the event as a " b i g d e a l " despite assurances that f r o m a m e d i c a l standpoint it w a s c o n s i d e r e d quite " m i n o r " . o f her physician.  H e r interpretation o f this event i s c l e a r l y different f r o m that  T h i s f i n d i n g i s consistent w i t h the f r a m e w o r k o f K l e i n m a n (1978)  w h o states that l a y p e r s o n s a n d health p r o f e s s i o n a l s h a v e different e x p l a n a t o r y m o d e l s f o r the same h e a l t h care situation.  T h i s f i n d i n g has also b e e n m a d e b y other n u r s i n g  authors ( A n d e r s o n , 1 9 8 1 ; D u n n , 1 9 8 5 ; K n o x & H a y e s , 1 9 8 3 ; R o b i n s o n , 1983). T h i s same m o t h e r w e n t o n to e m p h a s i z e h o w a l a c k o f i n f o r m a t i o n about the i m p e n d i n g p r o c e d u r e a n d her c h i l d ' s response to it a l s o c o n t r i b u t e d to her a n x i e t y . her, i n f o r m a t i o n i s p e r c e i v e d as a support f o r her a b i l i t y to c o p e .  To  A l s o note that she is  e x p r e s s i n g that she felt that there w a s n o o p p o r t u n i t y to o b t a i n the i n f o r m a t i o n that w o u l d h a v e d e c r e a s e d her a n x i e t y related to the u p c o m i n g event.  T h e larger i s s u e  related to the d e c i s i o n to p r o c e e d w i t h the surgery s e e m e d to o v e r s h a d o w the i n f o r m a t i o n this m o t h e r n e e d e d to c o p e w i t h this e x p e r i e n c e i n her e v e r y d a y l i f e .  She  a l s o p o i n t e d out that h e r " l i t d e q u e s t i o n s " are a "bother" to the d o c t o r i n her e s t i m a t i o n : M:  Y o u d o n ' t w a n t to ask the d o c t o r e v e r y little q u e s t i o n .  P l u s there w a s n ' t  a n o p p o r t u n i t y to ask a l l those little questions, y o u k n o w , y o u w e r e c o n c e r n e d w i t h w h e t h e r o r not [child] r e a l l y n e e d e d the surgery a n d w a s it a g o o d time to d o it i n terms o f his age, o r w a s it better to w a i t  until  later, a n d those k i n d o f sort o f m o r e m a j o r questions than the little things.  S o I think p r o b a b l y , it w a s p r o b a b l y j u s t i g n o r a n c e that m a d e us  sort o f b u i l d it up i n o u r m i n d s into this t h i n g that w a s g o i n g to be m u c h w o r s e , n o better than it w a s .  75 A n o t h e r m o t h e r d e s c r i b e d h e r n e e d f o r i n f o r m a t i o n i n the d a y s p r i o r to the d a y o f her c h i l d ' s d a y care surgery this w a y , "I h a d 5 0 , 0 0 0 questions [about the surgery] a n d n o w h e r e to ask t h e m " .  In a d d i t i o n to e x p r e s s i n g her n e e d f o r i n f o r m a t i o n this  m o t h e r a l s o felt she d i d not h a v e any resources to a c q u i r e the i n f o r m a t i o n she w a n t e d . S h e a l s o w e n t o n to m e n t i o n that she d i d not want to " b o t h e r the d o c t o r " i n o r d e r to seek the a n s w e r s to her questions. It i s e v i d e n t that parents i n this study h a d a p r o m i n e n t n e e d f o r d u r i n g the p r e - h o s p i t a l i z a t i o n phases o f their e x p e r i e n c e .  information  T e r r y (1987) c o n d u c t e d a  study w i t h 2 2 parents o f c h i l d r e n aged three to 10 years h o s p i t a l i z e d f o r a p e r i o d o f 14 to 3 0 d a y s .  Parents c l e a r l y i d e n t i f i e d that their m o s t p r o m i n e n t n e e d w a s f o r  i n f o r m a t i o n , p a r t i c u l a r l y i n f o r m a t i o n about w h a t w a s w r o n g w i t h their c h i l d a n d w h a t w o u l d h a p p e n to their c h i l d .  O t h e r authors h a v e also d o c u m e n t e d that parents n e e d  i n f o r m a t i o n i n o r d e r to c o p e e f f e c t i v e l y w i t h their c h i l d ' s h o s p i t a l i z a t i o n a n d d i s c e r n their r o l e s as parents o f s i c k c h i l d r e n ( F r i e b e r g , 1 9 7 2 ; H a y e s & K n o x , 1 9 8 4 ; H y m o v i c h , 1 9 7 6 ; S m i t h e r m a n , 1979). T h e p e r c e i v e d v u l n e r a b i l i t y o f the y o u n g c h i l d b y the parents i s apparent i n the b l o c k q u o t a t i o n o n p a g e 7 4 as w e l l as i n the f o l l o w i n g a c c o u n t : M:  I w a s n ' t r e a l l y a n e r v o u s w r e c k u n t i l the w e e k b e f o r e a n d then I started to t h i n k about it...you k n o w , j u s t things l i k e , y o u k n o w , first c h i l d y o u h a d , a n d g o i n g i n t o an o p e r a t i o n , e v e n a little m i n o r o p e r a t i o n , s t i l l i t ' s h a r d to take.  It w a s n ' t d e p r e s s i n g , it w a s j u s t h a r d i n a w a y to  take because h e ' s so y o u n g a n d he w a s b y h i m s e l f . A g a i n , the m o t h e r q u o t e d a b o v e i s p o i n t i n g out that her interpretation o f " m i n o r " i s m u c h different than health p r o f e s s i o n a l s ' .  S h e f e e l s a strong r e s p o n s i b i l i t y to protect  76 her c h i l d due to h i s y o u n g age.  H e r i n a b i l i t y to be p h y s i c a l l y present to protect  d u r i n g h i s surgery i s a source o f anxiety f o r her.  him  T h i s q u o t a t i o n a l s o illustrates the  effect o f " t e m p o r a l i m m i n e n c e " ( L a z a r u s & F o l k m a n , 1984), as the t i m e f o r the event d r a w s c l o s e r , the stress associated w i t h it rises.  In separate studies, S k i p p e r (1966) and  S k i p p e r , L e o n a r d , a n d R h y m e s (1968) e a c h f o u n d a p p r o x i m a t e l y 6 0 p e r cent o f parents o f h o s p i t a l i z e d c h i l d r e n rated their fears as " i n t e n s e " o n the day before their c h i l d ' s surgery. In a n attempt to c o p e to the best o f her k n o w l e d g e w i t h a n e w e x p e r i e n c e , one study m o t h e r a c t u a l l y " i m p o s e d quarantine" o n herself a n d her c h i l d o v e r a p e r i o d o f s e v e r a l w e e k s p r i o r to the s u r g i c a l event.  T h i s w a s her w a y o f m i n i m i z i n g h e r c h i l d ' s  p o t e n t i a l r i s k o f a c q u i r i n g a c o l d o r i n f e c t i o n p r i o r to the s c h e d u l e d date f o r the surgery, M:  W e j u s t thought m a y b e w e s h o u l d k e e p h i m [child] a w a y f r o m other b a b i e s a n d , y o u k n o w , s h o p p i n g m a l l s a n d stuff l i k e that, to sort o f try to k e e p h i m healthy as p o s s i b l e .  T h i s s e l f - i m p o s e d f o r m o f i s o l a t i o n affected a l l m e m b e r s o f the f a m i l y . R:  S o , f o r the last c o u p l e o f w e e k s then, y o u h a v e n ' t b e e n g o i n g out as m u c h as u s u a l , y o u ' v e r e a l l y b e e n sort o f h o m e b o u n d .  M:  S o has m y h u s b a n d to a certain extent.  Because, you know, we would  d o things o n the w e e k e n d w i t h h i m together a n d , y o u k n o w , w h e n m y h u s b a n d c a m e h o m e f r o m w o r k a n d things l i k e that.  S o , you k n o w , it's  h a d m o r e o f an effect o n m e , but c e r t a i n l y o n h i m as w e l l . N e e d l e s s to say, the w e e k s p r i o r to the c h i l d ' s s u r g i c a l p r o c e d u r e w e r e "out-of-the-ordinary"  f o r this f a m i l y .  T h e i r lack o f knowledge and understanding o f  77 necessary a n d p r a c t i c a l preparation f o r d a y care surgery l e d t h e m to i m p l e m e n t this f o r m o f s e l f - i m p o s e d , temporary i s o l a t i o n . O t h e r parents a l s o e x p r e s s e d that the w e e k s o f w a i t i n g p r i o r to the actual s u r g i c a l p r o c e d u r e c o n t r i b u t e d to i n c r e a s e d a n x i e t y about their c h i l d ' s w e l l - b e i n g . e x a m p l e , o n e m o t h e r r e c a l l e d that " y o u w i s h the three w e e k s surgery] w o u l d be o v e r " .  For  [preceding the d a y o f  D e s p i t e stating that she w a s n ' t " s c a r e d i n any w a y " this  m o t h e r d i d express that the w a i t i n g p e r i o d w a s h a r d f o r her. D u r i n g the p r e - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e parents a n t i c i p a t e d s o m e o f the concrete c h a n g e s they w e r e g o i n g to h a v e to m a k e i n their d a y to d a y l i v e s i n o r d e r to c o p e w i t h the needs o f the post-operative c h i l d .  Parents c o m m u n i c a t e d that  they a n t i c i p a t e d these c h a n g e s to h a v e a negative i m p a c t o n their f a m i l y l i f e , a n d s u c h a n t i c i p a t i o n w a s a source o f a n x i e t y f o r t h e m . M:  For example:  F o r her, the fact that she e n j o y s h a v i n g baths a n d g o i n g i n the water so m u c h a n d that she w o u l d n ' t be able to d o this f o r , y o u k n o w , a c o u p l e o f m o n t h s a n d I d o n ' t k n o w , j u s t the sheer nuisance w i t h h a v i n g it a l l o n top o f a l l the adjustments w e w e r e g o i n g to h a v e to m a k e a n d h o w she w a s g o i n g to react to that.  T h i s m o t h e r w a s a n t i c i p a t i n g h o w she w o u l d c o p e w i t h the a d d e d parental r e s p o n s i b i l i t i e s related to post-operative care (cast care) w i t h i n the c o n t e x t o f her e v e r y day life.  S h e w a s a n t i c i p a t i n g a negative p o s t - h o s p i t a l i z a t i o n e x p e r i e n c e .  Another  m o t h e r s i m p l y stated: "I thought, a h h , s h e ' s [daughter] g o i n g to b e i m p o s s i b l e " . In their efforts to enact n e w r e s p o n s i b i l i t i e s as part o f their parental r o l e , the study parents e x p e r i e n c e d r o l e strain d u r i n g the p r e - h o s p i t a l i z a t i o n phase o f this experience.  T h e a d d e d r e s p o n s i b i l i t i e s o f p r e p a r i n g their c h i l d f o r the operative  p r o c e d u r e w e r e seen as a b u r d e n a n d i n c o n f l i c t w i t h n o r m a l p a r e n t i n g r e s p o n s i b i l i t i e s . Parents w h o p a r t i c i p a t e d i n this study s a w it as their p r i m a r y r e s p o n s i b i l i t y to nurture their c h i l d , not c a r r y out b e h a v i o r s that i n their o p i n i o n s , c o n t r i b u t e d to the c h i l d ' s discomfort.  T h e result o f r o l e strain i s often f e e l i n g s o f w o r r y , a n x i e t y , o r g u i l t ( N y e ,  1976) as i s illustrated i n the f o l l o w i n g : M:  I guess I j u s t w a s n ' t l o o k i n g f o r w a r d to h a v i n g , first o f a l l , I thought he w a s g o i n g t h r o u g h this h o r r i b l e e x p e r i e n c e a n d , y o u k n o w , the d a y o f the surgery, I d i d n ' t r e a l l y w a n t to be part o f c o n t r i b u t i n g to any a n x i e t y o r a n y t h i n g o n h i s part e a r l i e r i n the d a y , I thought, g i v e h i m to s o m e b o d y else a n d let t h e m h a v e h i m f o r a w h i l e , u m m , so I d o n ' t h a v e to l o o k the b i g m e a n y that's s ta rv i ng h i m a n d p u t t i n g h i m t h r o u g h the b l o o d test a n d a l l that.  R:  Y o u d i d n ' t w a n t to be associated w i t h a l l that.  M:  No.  R:  T h a t puts a lot o f r e s p o n s i b i l i t y o n y o u as M o m .  M:  W e l l , that's it.  A n d I t h i n k y o u just want to get r i d o f it, a n d y o u just  f e e l , I think, y o u ' v e m a d e a d e c i s i o n f o r y o u r c h i l d , that's h e ' s got to h a v e surgery a n d that's e n o u g h to t h i n k about, y o u d o n ' t w a n t a l l the other stuff as w e l l . T h i s m o t h e r i s e x p r e s s i n g that the a d d e d r e s p o n s i b i l i t i e s related to p r e p a r i n g her c h i l d f o r s u r g e r y w e r e a n x i e t y p r o v o k i n g f o r h e r - s h e felt l i k e a " b i g m e a n y " .  She is also  p o i n t i n g out that she anticipates the e x p e r i e n c e to be " h o r r i b l e " a n d she w i l l be u n a b l e to protect her y o u n g c h i l d f r o m h a r m .  A t h i r d e m p h a s i s i s apparent i n her c o m m e n t  about the effect o f h a v i n g d e c i d e d to p r o c e e d w i t h the surgery.  C l e a r l y this m o t h e r  79 f e e l s a m b i v a l e n t about the n e w r e s p o n s i b i l i t i e s related to her c h i l d ' s d a y care surgery. W y c k o f f a n d E r i c k s o n (1987) studied the effects o f stress o n 120 mothers o f c h i l d r e n h o s p i t a l i z e d f o r an average o f n i n e d a y s .  T h e s e authors i d e n t i f i e d that the  c h i l d ' s age w a s a factor i n p a r e n t s ' a b i l i t y to c o p e w i t h the c h i l d ' s h o s p i t a l i z a t i o n . " D i f f e r e n c e s i n parental c o p i n g i n r e l a t i o n to the c h i l d ' s age m a y b e related to d i f f e r e n c e s i n r e a c t i o n s to h o s p i t a l i z a t i o n , dependent o n the c h i l d ' s d e v e l o p m e n t a l stage" ( W y c k o f f & E r i c k s o n , 1 9 8 7 , p. 5). T h e c o m m o n p r a c t i c e o f w i t h h o l d i n g f o o d a n d f l u i d s f r o m the pre-operative c h i l d i n p r e p a r a t i o n f o r surgery w a s a s i g n i f i c a n t factor c o n t r i b u t i n g to parental r o l e strain.  T h e p r o v i s i o n o f f o o d a n d f l u i d s to y o u n g c h i l d r e n i s central to s o c i a l n o r m s  f o r parental r o l e b e h a v i o r ( H a n d e l , 1 9 7 0 ; F r i e d m a n , 1986).  H e r e the average age o f the  c h i l d r e n (23.8 m o n t h s ) w h o s e parents p a r t i c i p a t e d i n this study w a s a s i g n i f i c a n t factor i n the p a r e n t s ' f e e l i n g s o f r o l e strain.  W i t h h o l d i n g food and fluids was particularly  d i f f i c u l t f o r the parents i n this study w h o s e c h i l d r e n w e r e u n a b l e to c o m p r e h e n d w h y this p r e p a r a t i o n w a s necessary. F o r e x a m p l e : M:  O f course y o u feel guilty 'cause, y o u k n o w , y o u felt bad.  ' C a u s e the  c h i l d d o e s n ' t understand w h y y o u ' r e not g i v i n g h i m a n y t h i n g to eat.  You  k n o w , y o u c a n ' t t e l l h i m u n l e s s o f c o u r s e h e ' s o l d e n o u g h to understand, but [child] i s not.  S o , y o u k n o w , i t ' s r e a l l y h a r d to s a y , " W e l l , y o u c a n ' t  eat, i t ' s f o r y o u r o w n g o o d , y o u k n o w " .  A n d h e ' s too y o u n g to  understand that a n d it bothered h i m , a n d it bothered m e . P a r e n t a l g u i l t a n d anxiety i s c l e a r l y evident i n the p r e v i o u s q u o t a t i o n .  Parents  c o m m u n i c a t e d to the researcher that w h i l e c a r r y i n g out the p r e - o p e r a t i v e d a y c a r e surgery i n s t r u c t i o n s , they felt they w e r e l i t e r a l l y " s t a r v i n g " their c h i l d r e n :  80 M:  I d i d n ' t w a n t h i m to get upset, y o u k n o w . T h e hardest part w a s k e e p i n g h i m h a p p y , y o u k n o w , f r o m that t i m e [breakfast] o n ' t i l w e left [for the hospital].  It w a s d i f f i c u l t , y o u k n o w , ' c a u s e he c o u l d n ' t d r i n k , he  c o u l d n ' t eat, he w a s l o o k i n g a l l o v e r h i s p l a y p e n , y o u k n o w , e v e r y t h i n g ~ I v a c u u m e d e v e r y t h i n g so he c o u l d n ' t f i n d a s i n g l e c r u m b , a n d he w a s l o o k i n g f o r c r u m b s , it w a s j u s t terrible, y o u k n o w , p o o r c h i l d w a s s t a r v i n g a n d it w a s m y fault, I c o u l d n ' t d o a n y t h i n g about it. A s i s n o t e d a b o v e , parents i n this study c o m p l i e d "to the letter" w i t h the pre-operative i n s t r u c t i o n s f o r restriction o f f o o d a n d f l u i d s .  T h i s mother's feelings of guilt and  helplessness r e g a r d i n g not f u l f i l l i n g her u s u a l n u r t u r i n g r o l e f o r her c h i l d are evident i n the a b o v e quote. A l t h o u g h parents e x p r e s s e d that they k n e w s u c h p r o c e d u r e s w e r e i n the best interest o f their c h i l d ' s w e l l - b e i n g i n l i g h t o f the i m p e n d i n g surgery, the f o l l o w i n g q u o t a t i o n illustrates h o w o n e m o t h e r d i d not f e e l u n d e r s t o o d o r s u p p o r t e d , i n r e l a t i o n to the d i f f i c u l t y that s u c h a task p o s e d to her: M:  I f s o m e b o d y h a d j u s t r e c o g n i z e d that I h a d a r i g h t to be upset about it, that to t h e m it w a s n ' t a n y t h i n g m a y b e , but it w a s to m e , it r e a l l y w a s , that m y little b o y w a s g o i n g to h a v e to d o w i t h o u t s o m e t h i n g to d r i n k , s o m e t h i n g to eat, a n d w a s g o i n g to h a v e that [surgery] d o n e .  A n d I was  m o r e upset w i t h h o w I w a s g o i n g to c o p e w i t h h i m not eating a n d d r i n k i n g than a n y t h i n g else. C o p i n g w i t h the w i t h h o l d i n g o f f o o d and f l u i d s p o s e d a m a j o r task f o r this m o t h e r and resulted i n feelings o f anxiety.  D u r i n g the p r e - h o s p i t a l i z a t i o n phase o f their e x p e r i e n c e parents r e c e i v e d b o t h s o l i c i t e d a n d u n s o l i c i t e d o p i n i o n s a n d a d v i c e about the p r o p o s e d surgery, a p a r t i c u l a r p h y s i c i a n / s u r g e o n , a n d / o r a p a r t i c u l a r health care a g e n c y .  S u c h o p i n i o n s often  s i g n i f i c a n t l y i n f l u e n c e d parents' trust a n d c o n f i d e n c e i n the m e d i c a l i n f o r m a t i o n a n d r e c o m m e n d a t i o n s they r e c e i v e d .  A s might be expected, favourable opinions were  p e r c e i v e d as s u p p o r t i v e a n d v i c e v e r s a . confidence. M:  N e g a t i v e o p i n i o n s often e r o d e d the p a r e n t s '  For example: I t a l k e d to other p e o p l e , m y m o m , [laughs] a n d she g a v e m e other ideas a n d , gee, she s a i d there i s s o m e d o c t o r f r o m O r e g o n . . . s a y i n g that the scar tissue w i l l be left a n d i f it [the p r o p o s e d surgery] d o e s n ' t w o r k , then the e y e has to f i g h t against the scar tissue, a n d so o n , a n d so f o r t h , a n d , y o u k n o w , that put negative thoughts i n m y m i n d a n d I t h i n k , gee, a m I d o i n g the r i g h t t h i n g , o r w h a t e v e r ?  M:  I c o n s i d e r e d p o s t p o n i n g it [the surgery] u n t i l the F a l l , m y f r i e n d s w o u l d say " O h , i t ' s so hot i n the s u m m e r a n d the casts are g o i n g to bother h e r " , a n d " s h e ' s g o i n g to be i t c h y , a n d whatnot."  B o t h o f the a b o v e parental c o m m e n t s i n d i c a t e that w h e n parents are m a k i n g d e c i s i o n s r e l a t e d to their c h i l d ' s d a y care surgery, c o m m e n t s f r o m f a m i l y m e m b e r s a n d friends that are not i n agreement w i t h their stance m a y be r e a d i l y interpreted as sources o f d o u b t o r as n o n - s u p p o r t i v e .  T h i s latter f i n d i n g is c o n g r u e n t w i t h that o f L y n a m (1987)  i n an e x a m i n a t i o n o f the parent support n e t w o r k i n a p e d i a t r i c o n c o l o g y setting. o b s e r v a t i o n s w e r e part o f a larger study o n h o s p i t a l related stress ( K n o x & 1983).  Her  Hayes,  A l t h o u g h she reported o n parent support n e t w o r k s a m o n g parents o f c h i l d r e n  82 h o s p i t a l i z e d w i t h l o n g t e r m c o n d i t i o n s , she states that the data from this qualitative study i n d i c a t e that certain types o f parent r e l a t i o n s h i p s " c a n contribute to the stresses associated w i t h the h o s p i t a l i z a t i o n o f c h i l d r e n " ( L y n a m , 1 9 8 7 , p. 7). Parents a l s o r e c e i v e d input f r o m friends a n d relatives that h a d a v e r y p o s i t i v e effect o n their a n t i c i p a t i o n o f the s u r g i c a l event. M:  For example:  N o o n e w a s against it [the surgery] o r a n y t h i n g , i n fact, e v e r y o n e that I t a l k e d to that h a d h a d it o r whatever, o r I m e n t i o n e d it to, felt that it w a s the best.  It k i n d o f helps to k n o w that other p e o p l e f e e l l i k e it i s  g o o d , too, to h a v e it [the surgery]. K n o w i n g that friends a n d f a m i l y supported the p a r e n t s ' d e c i s i o n to p r o c e e d w i t h the surgery w a s an i m p o r t a n t aspect o f the e x p e r i e n c e f o r m o s t f a m i l i e s i n this study. For example: R:  S o y o u f e l t a l o t better when—  M:  A f t e r I h a d f a m i l y support, y e s , after m y m o m agreed [ w i t h the d e c i s i o n to p r o c e e d w i t h the surgery].  T h e literature o n s o c i a l support agrees w i t h this f i n d i n g that f r i e n d s a n d f a m i l y c a n h e l p i n areas that require agreement a n d p o s i t i v e affect ( P i l i s u k & F r o l a n d , 1978). O n e f a m i l y w h o p a r t i c i p a t e d i n this study w a s a notable e x c e p t i o n to the r e l i a n c e o n the support o f f a m i l y a n d f r i e n d s , p a r t i c u l a r l y i n the p r o c e s s o f d e c i s i o n m a k i n g about the c h i l d ' s surgery.  T h e C h i n e s e parents i n this study d e l i b e r a t e l y d i d not c o n s u l t o r  e v e n i n f o r m their parents o r f a m i l y m e m b e r s r e g a r d i n g the d e c i s i o n to p r o c e e d w i t h the surgery because they felt that n o n - m e d i c a l p e r s o n s d i d not h a v e s u f f i c i e n t k n o w l e d g e to o f f e r o p i n i o n s o n the matter.  T h e s e parents also m e n t i o n e d to the researcher that the  c h i l d ' s paternal g r a n d m o t h e r h a d not agreed w i t h the n e e d f o r s u r g i c a l c o r r e c t i o n o f the  child's condition. F:  It d o e s n ' t matter i f y o u got b i g surgery o r s m a l l surgery.  E v e n y o u ask  a n y b o d y , y o u r mother, y o u r father, y o u r f a m i l y , they c a n ' t h e l p y o u at all.  T h e y d o n ' t k n o w a n y t h i n g about that.  trust i s d o c t o r , n o b o d y else.  Is o n l y one t h i n g y o u c a n  Y o u tell t h e m this a n d that, w h a t c a n they  d o ? [laughs] E v e n they say " y e s " , o r they say " n o " , they m a y w r o n g . T h i s f i n d i n g i s i n c o n s i s t e n t w i t h the w o r k o f G o u l d - M a r t i n a n d N g i n (1981) w h o f o u n d that C h i n e s e - i m m i g r a n t f a m i l i e s w i l l m o s t l i k e l y turn to f a m i l y m e m b e r s f o r s y m p a t h y o r suggestions i n matters o f p h y s i c a l i l l n e s s .  H o w e v e r , A n d e r s o n a n d C h u n g (1982) i n  their study o f i m m i g r a n t C h i n e s e f a m i l i e s , f o u n d that i f parents d i s a g r e e d w i t h the attitude o f their s i g n i f i c a n t others i n r e l a t i o n to their c h i l d ' s m e d i c a l c o n d i t i o n a n d / o r treatment, their r e s p o n s e w a s to " l i m i t their contact w i t h these s i g n i f i c a n t others" (p. 47). In a d d i t i o n to the C h i n e s e i m m i g r a n t parents, f o u r other study parents also e x p r e s s e d a h i g h l e v e l o f trust a n d faith i n their p h y s i c i a n s , a l t h o u g h f o r these latter parents, c r i t e r i a f o r j u d g i n g the p h y s i c i a n / s u r g e o n i n c l u d e d the w a y the he/she interacted w i t h parent a n d c h i l d . M:  D o c t o r [pediatric surgeon] i s the o n e w h o t o o k care o f [ c h i l d ] . l o t o f f a i t h i n h i m , he s e e m e d to be a v e r y g o o d doctor. n i c e d o c t o r , so I felt v e r y at ease w i t h h i m .  I had a  H e is a very  S o , i t ' s not l i k e w h e n y o u  meet a d o c t o r a n d y o u got this strange f e e l i n g about h i m , y o u k n o w , I m e a n y o u ' r e w o n d e r i n g , y o u k n o w , y o u j u s t got strange f e e l i n g s about c e r t a i n d o c t o r s , and he gave m e a c o m f o r t a b l e f e e l i n g .  84 T h i s i s an e x a m p l e o f c o m m u n i c a t i o n o f p o s i t i v e affect as a c o m p o n e n t o f s o c i a l support a n d p r o m o t i n g parental c o n f i d e n c e .  Parents w e r e satisfied i f the health  p r o f e s s i o n a l s appeared to care about their c h i l d a n d t h e m s e l v e s .  Kupst, Dresser,  S c h u l m a n , a n d P a u l (1976) n o t e d i n their study o n i m p r o v i n g p h y s i c i a n - p a r e n t c o m m u n i c a t i o n that a f e e l i n g o f c a r i n g f r o m health p r o f e s s i o n a l s h e l p s e n o r m o u s l y i n maintaining communication. S e v e r a l o f the p h y s i c i a n s / s u r g e o n s w h o w e r e c o n s u l t e d b y the parents i n this study, w e r e h i g h l y r e c o m m e n d e d b y f a m i l y a n d f r i e n d s : M:  T h e f a c t m y g i r l f r i e n d [name], her little b o y , [pediatric surgeon] t o o k care o f h i m . . . a n d [female friend] w a s a b s o l u t e l y p l e a s e d w i t h h i m w h e n I t o l d her I w a s g o i n g to see h i m [pediatric surgeon].  She was just like " O h ,  y o u ' r e g o i n g to be so h a p p y w i t h h i m " . T h i s m o t h e r f e l t s u p p o r t e d t h r o u g h her f r i e n d ' s strong p o s i t i v e r e c o m m e n d a t i o n .  This  is a n another e x a m p l e o f the i m p o r t a n c e o f c o m m u n i c a t i o n o f p o s i t i v e affect as a c o m p o n e n t o f s o c i a l support f o r the parents i n this study. In s u m m a r y , parents w h o participated i n this study a p p r a i s e d their c h i l d ' s d a y care surgery to be stressful f o r t h e m d u r i n g the p r e - h o s p i t a l i z a t i o n phase o f their experience.  T h e d i m e n s i o n s o f their e x p e r i e n c e c o n t r i b u t i n g to this a p p r a i s a l i n c l u d i n g  d e c i s i o n m a k i n g , l a c k o f i n f o r m a t i o n , a n d a d d e d r e s p o n s i b i l i t i e s , w e r e r e p o r t e d i n this section.  T h e next section presents the s t u d y ' s f i n d i n g s related to the h o s p i t a l i z a t i o n  p h a s e o f their e x p e r i e n c e . T h e Hospitalization Phase T h e h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e refers to that p e r i o d o f t i m e that the parents a n d c h i l d w e r e a c t u a l l y i n the h o s p i t a l setting.  A s w a s p r e v i o u s l y n o t e d , the  85 average t i m e spent b y the f a m i l i e s i n this study i n the d a y care u n i t w a s three hours a n d 13 m i n u t e s .  D u r i n g this acute phase o f the encounter w i t h the health care s y s t e m ,  their c h i l d ' s f i n a l preparation f o r surgery w a s c o m p l e t e d a n d parents r e l i n q u i s h e d h i m o r h e r to the c a r e o f health care p r o f e s s i o n a l s i n o r d e r that the actual s u r g i c a l p r o c e d u r e c o u l d be p e r f o r m e d .  A l t h o u g h the span o f t i m e d u r i n g this phase o f the e x p e r i e n c e  w a s short, the p a r e n t s ' f e e l i n g s a n d e m o t i o n s d u r i n g this t i m e w e r e intense. T h e d i m e n s i o n s o f this phase o f the e x p e r i e n c e that c o n t r i b u t e d to the parents' interpretation o f their e x p e r i e n c e s as stressful w e r e p r i m a r i l y r e l a t e d to event u n c e r t a i n t y , o r not k n o w i n g w h a t to e x p e c t due to their l a c k o f p r e v i o u s e x p e r i e n c e . R o l e strain w a s a d o m i n a n t theme i n this phase p a r t i c u l a r l y w h e n parents w e r e p h y s i c a l l y separated f r o m their c h i l d d u r i n g the actual o p e r a t i o n . p e r i o d o f t i m e w a s v e r y d i f f i c u l t f o r parents.  W a i t i n g d u r i n g this  T h e r e w e r e p a r t i c u l a r aspects o f the d a y  care surgery environment—routines a n d c o m m u n i c a t i o n w i t h health care professionals—that a l s o c o n t r i b u t e d to parents f e e l i n g s o f fear, w o r r y , a n d a n x i e t y . D u r i n g this phase o f the e x p e r i e n c e , parents r e l i e d o n c o p i n g m e c h a n i s m s that f u n c t i o n e d to c o n t r o l o r m a n a g e the stressful f e e l i n g s ( P e a r l i n & S c h o o l e r , 1978).  As  a l l parents w e r e a s k e d to h a v e s o m e o n e a c c o m p a n y t h e m to the h o s p i t a l , s o c i a l support w a s a l s o a factor i n parental c o p i n g d u r i n g this phase o f the e x p e r i e n c e . B y the time the parents i n this study a r r i v e d at the h o s p i t a l , as p r e v i o u s l y r e p o r t e d , they w e r e already f e e l i n g a n x i o u s a n d g u i l t y as a result o f their a n t i c i p a t i o n o f a rather negative e x p e r i e n c e a n d their i n a b i l i t y to f e e d a n d c o m f o r t their y o u n g c h i l d r e n i n their u s u a l w a y s .  B e c a u s e o f the intensity o f their f e e l i n g s at this t i m e , d e l a y s i n  a d m i s s i o n p r o c e d u r e s o r i n the s c h e d u l e d t i m e f o r surgery a d d e d to their o f the event as stressful.  interpretation  86 A p a r t i c u l a r l y d i f f i c u l t t i m e f o r parents d u r i n g the h o s p i t a l i z a t i o n phase o f the d a y care surgery e x p e r i e n c e w a s w h e n they h a d to r e l i n q u i s h the c h i l d to the o p e r a t i n g r o o m staff i n order that the surgery c o u l d p r o c e e d .  T h r e e o f s e v e n mothers r e p o r t e d  b r e a k i n g d o w n a n d c r y i n g at the p o i n t o f separation f r o m their c h i l d .  Parents  c o m m u n i c a t e d i n i t i a l l y f e e l i n g r e l i e f that the event w a s a c t u a l l y p r o c e e d i n g , and anxiety because o f g i v i n g up c o n t r o l a n d their "protector" r o l e . M:  W e w a i t e d i n the p l a y area w i t h [child] w h i c h , I guess, w a s a little bit h a r d , that's w h e n I started to c r y , because, I guess, it [the surgery] w a s g o i n g ahead, a n d I w a s sort o f w o r r i e d .  M:  I w a s r e a l l y v e r y g o o d up u n t i l w h e n y o u s a w m e [researcher met w i t h parent] w h e n I started c r y i n g .  I h e l d up r i g h t u n t i l then, a n d then I  thought, o h , it w a s j u s t the release, y o u k n o w , because there she goes [to the o p e r a t i n g r o o m ] . T h e a m b i v a l e n c e a s s o c i a t e d w i t h this p o i n t o f the e x p e r i e n c e i s e v i d e n t f r o m the mothers q u o t e d a b o v e .  T h e s e mothers felt r e l i e f a n d fear s i m u l t a n e o u s l y .  C r y i n g was  a w a y o f r e l e a s i n g their f e e l i n g s o f f e a r i s an o b v i o u s i n d i c a t o r o f the acute n e e d f o r support at this t i m e .  F o r f o u r o f the parents, s o c i a l support w a s p r o v i d e d to t h e m b y  the p e r s o n that h a d a c c o m p a n i e d t h e m to the d a y care unit. A d d i t i o n a l factors that c o n t r i b u t e d to parents' a n x i e t y , fear, a n d w o r r y , w e r e l a c k o f k n o w l e d g e a n d situational c o n t r o l as i s e v i d e n c e d i n the f o l l o w i n g quotations: M:  It w a s d i f f i c u l t because, a g a i n , I think the t h i n g i s , y o u d o n ' t k n o w w h a t ' s g o i n g o n , and y o u d o n ' t h a v e a n y c o n t r o l .  N o t that y o u c o u l d d o  a n y t h i n g i f y o u w e r e there [in the operating r o o m ] a n y w a y , but s o m e h o w ,  87 y o u k n o w , y o u h a v e this sense that e v e n i f y o u c o u l d n ' t d o a n y t h i n g , i f y o u w e r e there, it w o u l d be m o r e r e a s s u r i n g , so I t h i n k i t ' s h a r d not k n o w i n g w h a t ' s g o i n g o n a n d h a v i n g a f e e l i n g that y o u d o n ' t h a v e c o n t r o l o v e r the situation a n d y o u aren't there to assist i f s o m e t h i n g goes wrong.  I guess y o u j u s t w a n t to k n o w w h a t ' s g o i n g o n , and y o u d o n ' t  k n o w w h a t ' s g o i n g o n , so it m a k e s y o u w o r r y m o r e ' c a u s e y o u d o n ' t k n o w what's going on.  M:  T h e c o n t r o l o f b e i n g there, a n d y o u are the o n e that's i n charge o f h i m , w h e r e a s w h e n he goes i n t o surgery a n d the d o c t o r ' s i n c h a r g e o f h i m , y o u h a v e n o say i n the matter o r a n y t h i n g , a n d y o u j u s t h a v e to sit there a n d w a i t patiently, a n d just w a i t ' t i l he c o m e s out.  N o t e that these t w o m o t h e r s are s a y i n g that d u r i n g the h o s p i t a l i z a t i o n phase o f the d a y care surgery e x p e r i e n c e , the u s u a l sense o f c o n t r o l they h a v e w h i c h enables t h e m at a l l t i m e s to care f o r a n d protect their c h i l d w a s g o n e w h e n they w e r e p h y s i c a l l y separated f r o m their c h i l d . their c h i l d .  " B e i n g there" s o m e h o w meant b e i n g able to f u l f i l l a r o l e to protect  N o t h a v i n g c o n t r o l o v e r their y o u n g c h i l d resulted i n intense f e e l i n g s o f  role strain, guilt and anxiety.  C l a r k e (1984) states that " p e r c e i v e d l a c k o f c o n t r o l  w h e r e c o p i n g i s important leads to negative e m o t i o n a n d this i s a s s o c i a t e d w i t h loss o f s e l f - e s t e e m " (p. 8). W i t h o u t e x c e p t i o n , a l l o f the parents i n this study e x p r e s s e d fears a n d c o n c e r n s about a l l o w i n g their c h i l d to u n d e r g o a general anesthetic.  Parental consent for what  they p e r c e i v e d to be a large r i s k f o r their c h i l d resulted i n f e e l i n g s o f c o n f l i c t a n d anxiety.  M:  I w a s c o n c e r n e d because he h a d the c o l d , but e v e n i f he h a d n ' t h a d the c o l d I w o u l d have been concerned.  Y o u k n o w , e a c h i n d i v i d u a l reacts  d i f f e r e n t l y a n d h e ' d n e v e r h a d o n e [operation] b e f o r e , a n d I w a s , quite f r a n k l y , m y b i g c o n c e r n w a s that s o m e t h i n g w a s g o i n g to h a p p e n w i t h the anesthetic a n d he w a s g o i n g to d i e , b r a i n d a m a g e o r s o m e t h i n g as a result.  I m e a n , that w a s m y b i g c o n c e r n , it r e a l l y w a s .  S o I w a s quite  p e t r i f i e d o f that, a n d I m e a n , I k n e w that it d o e s n ' t h a p p e n v e r y often but it w a s s t i l l i n the b a c k o f m y m i n d .  M:  T h a t ' s m a i n l y e v e r y p a r e n t ' s c o n c e r n i s the anesthetic, y o u k n o w . W o n d e r h o w i t ' s g o i n g to, y o u k n o w , affect.  Because y o u have heard a  lot o f g r u e s o m e stories about anesthetic s o , y o u k n o w , I ' m not r e a l l y too h a p p y about it. N o t e h o w these t w o m o t h e r s are forthright about the intensity o f their fears r e g a r d i n g an anesthetic f o r their c h i l d .  Parents s p e c i f i e d that the sources o f the " g r u e s o m e  stories" they h a d h e a r d w e r e p r i m a r i l y n e w s p a p e r a n d t e l e v i s i o n reports about m o r t a l i t y a n d m o r b i d i t y a s s o c i a t e d w i t h general anesthetics.  O n e m o t h e r c i t e d " n e w s reports i n  the b a c k o f m y m i n d " as the source o f her fears. T h e p e r i o d o f w a i t i n g w h i l e the c h i l d ' s surgery w a s a c t u a l l y t a k i n g p l a c e c o n t r i b u t e d to f e e l i n g s o f anxiety and w o r r y . M:  W e l l , y o u see, i t ' s r e a l l y h a r d to e x p l a i n ; i t ' s j u s t that y o u g o through different e m o t i o n s . Its l i k e y o u ' r e w o n d e r i n g i f y o u ' r e g o i n g to m a k e it, i f h e ' s g o i n g to sleep t h r o u g h the w h o l e , y o u k n o w .  I mean, if he's  g o i n g to w a k e up i n the m i d d l e o f it o r [pause], i t ' s s i l l y things, but y o u  89 d o g o t h r o u g h it, y o u k n o w .  Y o u d o t h i n k about it a n d i f h e ' s e v e r  g o i n g to w a k e up f r o m i t . . . . Y o u ' r e sitting there because y o u got a l l that t i m e to k i l l a n d , w h a t else w o u l d h a p p e n w h e n y o u h a v e n o t h i n g else to amuse yourself with?  Y o u k n o w , y o u r m i n d starts p l a y i n g games o n  y o u , y o u c a n r e a l l y get upset. In a d d i t i o n to e x p r e s s i n g h o w d i f f i c u l t the w a i t i n g p e r i o d i s w h i l e the c h i l d i s i n the o p e r a t i n g r o o m , this m o t h e r i s e x p r e s s i n g her c o n f u s i o n a n d fears r e l a t e d to her c h i l d ' s anesthetic.  A n o t h e r parent stated that the w a i t i n g w a s d i f f i c u l t because she w a s v e r y  a w a r e that " s o m e t h i n g freak c a n h a p p e n [ w h i l e c h i l d i s i n the o p e r a t i n g r o o m ] " . O n e o f the c o p i n g strategies parents u s e d d u r i n g the w a i t i n g p e r i o d f o r their c h i l d to return to the d a y care u n i t f r o m the r e c o v e r y r o o m w a s that o f " s o c i a l c o m p a r i s o n " ( P e a r l i n & S c h o o l e r , 1978).  T h i s strategy i n v o l v e s the c o m p a r i s o n o f  o n e ' s m i s f o r t u n e w i t h the m i s f o r t u n e o f others a n d i s p e r c e i v e d b y s o m e as a f o r m o f support. M:  F o r example, I w a s w a t c h i n g this l a d y i n f r o n t o f m e [in the w a i t i n g area].  H e r little  b o y w a s i n f o r an ear operation o r something...apparently her s o n ' s o p e r a t i o n took an h o u r . . . Y o u k n o w , f o r w h a t [child] w a s h a v i n g [surgical p r o c e d u r e ] , it d i d n ' t s e e m as terrible as what her little b o y w a s g o i n g through. B y c o m p a r i n g her p l i g h t to that o f other parents i n the w a i t i n g area this m o t h e r i s s a y i n g that her situation d i d n ' t s e e m as b a d as that o f other parents.  T h r o u g h use o f  the t e c h n i q u e o f " s o c i a l c o m p a r i s o n " this m o t h e r i s i n d i c a t i n g that she felt reassured. Parents i n this study h a d c l e a r ideas about h o w their c h i l d r e n w e r e g o i n g to appear a n d h o w they w o u l d b e h a v e i n 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 .  For  90 example, M:  I thought, g e n e r a l anesthesia a n d e v e r y t h i n g , g o h o m e r i g h t after a c o u p l e h o u r s , I w a s a bit c o n c e r n e d , but not w h e n I s a w h i m .  W h e n he c a m e  out a n d e v e r y t h i n g , there w a s a c t u a l l y n o p r o b l e m . I w a s v e r y h a p p y w h e n they t o l d m e I c o u l d take h i m h o m e . T h i s m o t h e r i s e x p r e s s i n g h o w she h a d not r e a l l y b e l i e v e d that her son w o u l d be w e l l e n o u g h to g o h o m e w i t h i n a f e w h o u r s o f h i s surgery.  W h a t c h a n g e d her o p i n i o n w a s  her s o n ' s actual p h y s i c a l appearance w h e n he r e t u r n e d f r o m the r e c o v e r y r o o m w h i c h , s h e ' s i m p l y i n g , w a s m o r e p o s i t i v e than she h a d thought it w o u l d be. O t h e r parents a l s o e x p r e s s e d that they d i d not e x p e c t the c h i l d to d o w e l l i n the post-operative period.  P a r e n t s ' negative expectations w e r e b a s e d o n their a p p r a i s a l o f  their s o n o r d a u g h t e r ' s d a y care surgery as an event that m a y i n v o l v e h a r m to their child.  F o r e x a m p l e , one parent d e s c r i b e d it this w a y , " S h e l o o k e d a lot better w h e n  she c a m e out [of the r e c o v e r y r o o m ] than I thought she w a s g o i n g to b e " .  A number  o f parents e c h o e d the f e e l i n g s o f o n e m o t h e r w h o s a i d , "I guess I e x p e c t e d h i m to be v e r y g r o g g y , y o u k n o w , v e r y s l e e p y f r o m the anesthetic. sleepy."  A c t u a l l y , he w a s n ' t that  T h e s e p a r e n t s ' e x p e r i e n c e i n 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 w a s m o r e  p o s i t i v e than they h a d e x p e c t e d .  T h e i r intense f e e l i n g s o f fear a n d w o r r y w e r e r e p l a c e d  w i t h ones o f relief. Parents r e p o r t e d that the m o m e n t o f r e u n i t i n g w i t h their c h i l d after r e t u r n i n g f r o m the r e c o v e r y area w a s a v e r y s p e c i a l o n e : "It w a s a v e r y s p e c i a l m o m e n t j u s t to see h i m .  I guess, y o u k n o w , j u s t g o a n d r u n up to h i m a n d g i v e h i m a b i g h u g " .  P h y s i c a l contact w i t h their c h i l d w a s v e r y i m p o r t a n t f o r the parents to k n o w that their c h i l d w a s alright a n d a l s o to r e n e w their parental r o l e o f p r o v i d i n g c o m f o r t and care.  91 A s o n e m o t h e r stated: " T h e m i n u t e I got h i m [child] i n m y a r m s , I k n e w he w a s n ' t [sick]".  A n o t h e r m o t h e r c o m m e n t e d o n her frustration o f not b e i n g able to p h y s i c a l l y  " r e u n i t e " w i t h her c h i l d because she w a s left a l o n e i m m e d i a t e l y after her c h i l d returned to the d a y care u n i t a n d she d i d not k n o w h o w to put siderails d o w n o n the h o s p i t a l c r i b therefore w a s u n a b l e to p h y s i c a l l y c o m f o r t her c h i l d . M:  She explained:  W h e r e they [nurses] d i s a p p e a r e d to a l l o f a s u d d e n I d o n ' t k n o w .  If they  w o u l d h a v e stayed w i t h m e j u s t f o r a s e c o n d u n t i l I c o u l d f i n d out what I could do.  Y o u k n o w , it w a s k i n d o f a matter of, " Y o u r d a u g h t e r ' s  b a c k " [ f r o m P A R ] , a n d I w e n t i n there [to the c u b i c l e ] , a n d they w e r e gone. T h i s m o t h e r w e n t o n to e m p h a s i z e the i m p o r t a n c e o f p h y s i c a l contact f o r her i n those f i r s t f e w m i n u t e s after the c h i l d returns from the r e c o v e r y r o o m .  She is also  c o m m e n t i n g o n h o w h e r r e u n i t i n g w i t h her c h i l d m i g h t h a v e been better h a n d l e d b y n u r s i n g staff. T h r e e other study parents c o m m e n t e d that they d i d not anticipate their c h i l d ' s a r r i v a l b a c k i n the d a y care u n i t at the t i m e that it o c c u r r e d a n d this c o n t r i b u t e d to their f e e l i n g s o f stress related to this phase o f their e x p e r i e n c e .  A l t h o u g h the parents  h a d b e e n i n f o r m e d o f an a p p r o x i m a t e t i m e f o r their c h i l d ' s return to the d a y care unit, parents r e c a l l e d f e e l i n g surprised u p o n the c h i l d ' s a c t u a l return a n d s o m e w h a t u n p r e p a r e d f o r the w a y their c h i l d ' s return w a s h a n d l e d .  O n e m o t h e r d e s c r i b e d her  c h i l d ' s return this w a y : M:  A l l o f a s u d d e n , y o u k n o w , w e h e a r d the d o o r s o p e n a n d then this l a d y , w h o w e d i d n ' t k n o w , c a m e out a n d s a i d , " W h o d o e s this o n e b e l o n g t o ? " A n d , u h h , so that w a s it a n d w e s a i d " W e l l , h e ' s o u r s " a n d she h a n d e d  92 h i m o v e r to us a n d that w a s it...I d i d n ' t t h i n k the w h o l e r e c o v e r y t h i n g w a s h a n d l e d v e r y w e l l f o r us.  Just, y o u k n o w , w e w e r e v e r y h a p p y a n d  reassured j u s t to h a v e h i m b a c k w i t h us. T h i s m o t h e r ' s c o m m e n t s reflect a l a c k o f k n o w l e d g e r e g a r d i n g b o t h w h e n a n d h o w her c h i l d w o u l d b e returned to her.  A l t h o u g h she i s e x p r e s s i n g r e l i e f at h a v i n g her c h i l d  b a c k w i t h her, she w o u l d l i k e to h a v e k n o w n i n a d v a n c e w h e n her c h i l d w a s returning f r o m the post-anesthetic r e c o v e r y r o o m a n d perhaps h a v e a m o r e p e r s o n a l a n d e m p a t h i c a p p r o a c h u s e d i n r e u n i t i n g her w i t h her post-operative c h i l d . A n o t h e r m o t h e r d e s c r i b e d a m u c h m o r e p o s i t i v e scenario related to the w a i t i n g p e r i o d p r i o r to her s o n ' s return f r o m the post-anesthetic r e c o v e r y r o o m .  In the  f o l l o w i n g q u o t a t i o n she i s e m p h a s i z i n g h o w important i n f o r m a t i o n a n d a c a r i n g attitude h e l p e d a l l a y her a n x i e t y d u r i n g the d i f f i c u l t w a i t i n g p e r i o d . M:  I w a s so c o n c e r n e d about, w a s he i n R e c o v e r y o r w h a t e v e r ?  And I  n e v e r e v e n h a d to ask t h e m . T h i s nurse c a m e up to m e a n d s a i d , "I j u s t thought I'd let y o u k n o w * I p h o n e d R e c o v e r y a n d y o u r s o n i s d o i n g j u s t fine".  Y o u k n o w , I d i d n ' t h a v e to ask, l i k e she d i d it.  T h e nurses a n t i c i p a t i o n o f this m o t h e r ' s needs h a d an o b v i o u s p o s i t i v e effect o n this parent. T h e h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e w a s d i f f i c u l t f o r parents because they e x p e r i e n c e d the fears a n d anxieties associated w i t h r o l e strain w h i l e w a i t i n g f o r their c h i l d to return f r o m the o p e r a t i n g r o o m .  A l l parents, as requested b y the d a y care unit  staff, h a d another p e r s o n w i t h t h e m at the h o s p i t a l . p e r s o n f o r support d u r i n g this t i m e . p r e s e n c e w i t h her that d a y :  M o s t r e l i e d h e a v i l y o n the other  O n e m o t h e r s a i d this r e g a r d i n g her h u s b a n d ' s  93 M:  I m e a n , he t o o k the d a y off, y o u k n o w , f r o m w o r k to c o m e a n d s p e n d , y o u k n o w , to g o to the h o s p i t a l w i t h m e , so that w a s v e r y s p e c i a l .  If it  w a s n ' t f o r h i m , I d o n ' t think I c o u l d r e a l l y h a v e g o n e t h r o u g h it as w e l l as I d i d . T h i s m o t h e r i s r e f e r r i n g to the c o m p o n e n t o f s o c i a l support others refer to as i n t e g r a t i o n ( D i m o n d & J o n e s , 1983).  S h e feels supported j u s t k n o w i n g that her  h u s b a n d w a s there to h e l p her i n t i m e o f her need. A n u m b e r o f parents adopted a p o s i t i v e attitude a n d u s e d p o s i t i v e " s e l f - t a l k " to support t h e m s e l v e s d u r i n g this t i m e . F o r e x a m p l e : M:  [It w a s m e ] t e l l i n g m y s e l f not to w o r r y about it, y o u k n o w . . . . N o t to w o r r y because [ c h i l d ] ' s i n g o o d hands...the d o c t o r ' s f i n e , the b a b y ' s g o i n g to be f i n e , i t ' s not a m a j o r o p e r a t i o n .  P e a r l i n a n d S c h o o l e r (1978) d e s c r i b e this c o p i n g strategy o f " s e l e c t i v e i g n o r i n g " as one that i s attained b y s e e k i n g s o m e p o s i t i v e attribute w i t h i n a stressful situation. T h r e e m o t h e r s stated that they f o u n d nurses to be s u p p o r t i v e d u r i n g their w a i t i n g p e r i o d after the c h i l d h a d g o n e to the o p e r a t i n g r o o m .  O n e mother i n particular  r e m e m b e r e d it this w a y : M:  I r e m e m b e r w h e n I w a s r e a l l y upset, w h e n he [child] w e n t i n t o the t h i n g [the operating r o o m ] . A n d then I c a m e b a c k a n d sat d o w n , and this nurse c a m e o v e r , a n d k n e e l i n g d o w n , l i k e t a l k i n g to m e o n e y e l e v e l , a n d just, y o u k n o w , t a l k i n g to m e about it.  I d o n ' t r e m e m b e r what she s a i d e v e n ,  j u s t t a l k i n g to m e , I r e m e m b e r that ' c a u s e that got m e u n d e r c o n t r o l . A n d , I guess, it w a s that I felt that they c a r e d - t h e y c a r e d about they d i d n ' t k n o w h i m . . . a n d they c a r e d about m e .  [child],  I guess that i s what it  r e a l l y c a m e out as, a n d it w a s important. T h e f e e l i n g that the d e s c r i b e d nurse c a r e d about t h e m w a s a n i m p o r t a n t c r i t e r i o n o f support d u r i n g a d i f f i c u l t  time.  F o r these study parents, trust a n d faith i n health p r o f e s s i o n a l s w a s e x t e n d e d to a b e l i e f that they w o u l d a l w a y s act w i t h the c h i l d ' s best interest i n m i n d .  F o r example,  parents c o m m u n i c a t e d that they w e r e c o n f i d e n t that health p r o f e s s i o n a l s w o u l d ensure that they r e c e i v e d the appropriate i n f o r m a t i o n about c a r i n g f o r the p r e - a n d postoperative c h i l d . M:  I m e a n , i f it w a s s o m e t h i n g that i s r e a l l y sort o f a p r e s s i n g q u e s t i o n , y o u k n o w , I d o n ' t t h i n k I w o u l d hesitate to ask it.  B u t , w h e n t h e y ' r e sort o f  little t h i n g s , that y o u t h i n k " O h m y g o o d n e s s , w e l l , that's p r o b a b l y a d u m b t h i n g to ask because i f it w a s an important t h i n g , they w o u l d h a v e m e n t i o n e d it," o r s o m e t h i n g l i k e that.  Y o u tend not to ask those things.  T h i s m o t h e r i s u n d e r the a s s u m p t i o n that the health care p r o f e s s i o n a l k n o w s a n d understands w h a t i n f o r m a t i o n i s important to her i n order f o r her to m a n a g e her c h i l d ' s care w i t h i n the c o n t e x t o f her e v e r y d a y l i f e .  S u c h a f i n d i n g c o r r e s p o n d s to the  r e s e a r c h d o n e b y R o b i n s o n a n d T h o r n e (1984) w h o i d e n t i f i e d o n e phase i n the d e v e l o p m e n t o f r e l a t i o n s h i p s between c o n s u m e r s a n d health care w o r k e r s as  "naive  trust", w h e r e f a m i l i e s " w a i t p a s s i v e l y f o r the p r o f e s s i o n a l health care p r o v i d e r s to f u l f i l their r e s p o n s i b i l i t i e s " (p. 5 9 9 ) .  O n e parent w h o p a r t i c i p a t e d i n the current study  d e s c r i b e d h e r f e e l i n g s this w a y : " Y o u tend to put a lot o f trust i n p e o p l e i n the h o s p i t a l I think.  A n d y o u k n o w , y o u f i g u r e , w e l l , this i s the w a y i t ' s d o n e . " Interactions w i t h health care p r o f e s s i o n a l s w e r e not a l w a y s p e r c e i v e d to be  helpful or supportive.  In s e v e r a l instances, inconsistent i n f o r m a t i o n about what parents  95 s h o u l d e x p e c t i n terms o f contact w i t h the c h i l d ' s surgeon c o n t r i b u t e d to i n c r e a s e d anxiety and worry.  T h e m a j o r i t y o f study parents w e r e a n x i o u s l y " w a i t i n g to get the  n e w s , to hear that y e s , h e ' s [child] out o f there [ O . R . ] a n d y e s , h e ' s O . K . " .  One  m o t h e r d e s c r i b e d her e x p e r i e n c e this w a y : M:  W e l l , i t ' s p r o b a b l y j u s t s i l l y t h i n g s , but the nurse s a i d the d o c t o r w a s g o i n g to c o m e r i g h t out after the cast.  H e d i d n ' t , either he d i d n ' t o r w e  m i s s e d h i m , w e n t d o w n to h a v e l u n c h o r s o m e t h i n g .  S o w e thought he  w a s s t i l l i n there d o i n g cast a n d a l l , a n d a l l o f a s u d d e n [child] appeared a n d she w a s f i n i s h e d [soft l a u g h ] .  S o , I, y o u k n o w , I b a c k i n m y m i n d I  k n e w there w a s p r o b a b l y n o t h i n g w r o n g , but y o u k n o w these little doubts y o u have. T h i s m o t h e r i s s a y i n g that w h e n the surgeon d i d not c o m e out to talk to her as she h a d b e e n l e d to e x p e c t , it i n t r o d u c e d a strong f e e l i n g o f doubt that s o m e t h i n g h a d gone w r o n g w i t h her d a u g h t e r ' s p r o c e d u r e . T h i s c o n t r i b u t e d to h e r fears a n d a n x i e t y about her c h i l d ' s w e l l - b e i n g . M:  A n o t h e r parent d e s c r i b e d it this w a y :  I u n d e r s t o o d that he [pediatric surgeon] w o u l d c o m e out o n c e he f i n i s h e d [the s u r g e r y ] , he w o u l d talk to m e about it.  A n d then I thought " W h a t ' s  g o i n g o n ? " y o u k n o w , " W h y i s n ' t he c o m i n g ? " R:  Y e a h , a n d then y o u start to w o r r y .  M:  Y o u start to w o r r y , y e a h .  B u t I thought, i f there w a s s o m e t h i n g terribly  w r o n g h e ' d c o m e out a n d tell m e , y o u k n o w , if, if, they w o u l d just tell m e that i f I lost h i m R:  [child].  S o y o u sort o f h a d that i n the b a c k o f y o u r m i n d .  96 M:  W e l l , i f it takes longer...than y o u e x p e c t , I t h i n k e v e r y n o r m a l m o t h e r does that, p r a y f o r n o t h i n g [to happen].  A n d it c a n h a p p e n , y o u k n o w , it  c a n h a p p e n i f the anesthesia o r s o m e t h i n g goes w r o n g .  A n d sometimes I  t h i n k there i s n o t h i n g p e o p l e c a n d o . T h e s e p a r e n t s ' are d e s c r i b i n g their acute sense o f t i m e w h i l e they are separated f r o m their c h i l d as w e l l as a their sense o f helplessness. T h e y are e x p r e s s i n g that d i s c r e p a n c i e s i n w h a t they h a v e b e e n l e d to e x p e c t i n terms o f c o m m u n i c a t i o n w i t h their p h y s i c i a n s i s p a r t i c u l a r l y stressful i f not f o l l o w e d t h r o u g h .  O n e m o t h e r stated,  "I  t h i n k i t ' s r e a l l y n i c e i f he [surgeon] m a k e s sure he sees the parents r i g h t afterwards [after the surgery is p e r f o r m e d ] . "  O t h e r authors ( H a y e s & K n o x , 1984; T e r r y , 1987)  h a v e d o c u m e n t e d that parents w a n t i n f o r m a t i o n d i r e c t l y f r o m their p h y s i c i a n s w h o they see as p r i m a r y s o u r c e s o f i n f o r m a t i o n r e g a r d i n g their c h i l d ' s d i a g n o s i s , treatment regime, and expected outcome. In s u m m a r y , there w e r e several d i m e n s i o n s o f this phase o f the e x p e r i e n c e that c o n t r i b u t e d to the parents' interpretation o f their e x p e r i e n c e as stressful.  These were  related to event uncertainty a n d r e l i n q u i s h i n g the r e s p o n s i b i l i t y f o r c o n t r o l a n d p r o t e c t i o n o f their c h i l d to health p r o f e s s i o n a l s r e s u l t i n g i n r o l e strain a n d a n x i e t y . Parents d e s c r i b e d p a r t i c u l a r aspects o f the d a y care surgery e n v i r o n m e n t — w a i t i n g , fears o f a g e n e r a l anesthetic, r e u n i t i n g w i t h the post-operative c h i l d , a n d c o m m u n i c a t i o n w i t h health care professionals—that c o n t r i b u t e d to their f e e l i n g s o f fear, w o r r y , a n d a n x i e t y . D u r i n g this p h a s e o f the e x p e r i e n c e parents r e l i e d o n c o p i n g m e c h a n i s m s that f u n c t i o n to c o n t r o l o r m a n a g e the stressful f e e l i n g s ( P e a r l i n & S c h o o l e r , 1978).  A s a l l parents  b r o u g h t s o m e o n e w i t h t h e m to the h o s p i t a l , s o c i a l support w a s one s u c h factor i n parental c o p i n g d u r i n g this phase o f the e x p e r i e n c e .  97 T h e n e x t s e c t i o n presents the f i n d i n g s related to the p o s t - h o s p i t a l i z a t i o n phase o f the d a y care surgery e x p e r i e n c e f o r parents. T h e Post-Hospitalization Phase T h e p o s t - h o s p i t a l i z a t i o n phase b e g a n w h e n the c h i l d a n d parent(s) w e r e d i s c h a r g e d f r o m h o s p i t a l a n d c o n t i n u e d u n t i l the c h i l d h a d r e c o v e r e d p h y s i c a l l y a n d e m o t i o n a l l y f r o m the surgery a n d a l l f a m i l y m e m b e r s h a d returned to their regular patterns a n d activities o f d a i l y l i v i n g .  A l t h o u g h the parents' i n d i v i d u a l e x p e r i e n c e s  dictated the rate at w h i c h they m o v e d t h r o u g h the phases o f their e x p e r i e n c e s , f i v e f a m i l i e s i n this study c l e a r l y i d e n t i f i e d w h e n the r e c o v e r y phase o f their e x p e r i e n c e had e n d e d , u s u a l l y w i t h i n a w e e k to 10 d a y s o f the actual s u r g i c a l p r o c e d u r e .  D u e to  uncertainty about the effectiveness o f the s u r g i c a l p r o c e d u r e , o n e parent w h e n i n t e r v i e w e d f o r the s e c o n d t i m e , w a s s t i l l unable to articulate w h e n she felt this phase of her experience w o u l d actually end. L i k e the p r e - h o s p i t a l i z a t i o n a n d h o s p i t a l i z a t i o n phases o f the p a r e n t s ' e x p e r i e n c e , the p o s t - h o s p i t a l i z a t i o n phase w a s a l s o stressful f o r parents. w o r r i e d a n d a n x i o u s d u r i n g this t i m e .  Parents reported f e e l i n g  D i m e n s i o n s o f the p o s t - h o s p i t a l i z a t i o n p e r i o d  that c o n t r i b u t e d to p a r e n t s ' interpretations o f the events as stressful i n c l u d e d n e w r e s p o n s i b i l i t i e s f o r the care a n d s u p e r v i s i o n o f the post-operative c h i l d , changes i n the c h i l d ' s b e h a v i o r a n d patterns o f a c t i v i t y , and changes i n f a m i l y activities a n d routines. A l a c k o f i n f o r m a t i o n r e g a r d i n g these d i m e n s i o n s o f the p o s t - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e w a s i d e n t i f i e d b y the parents as c o n t r i b u t i n g to the stressful nature o f this p h a s e o f the e x p e r i e n c e .  Parents i m p l e m e n t e d s e v e r a l c o p i n g strategies a n d u t i l i z e d  s o c i a l support to m a n a g e this phase o f their e x p e r i e n c e .  98 D e s p i t e h a v i n g r e c e i v e d i n f o r m a t i o n a n d instructions f r o m d a y care unit staff, the f o l l o w i n g q u o t a t i o n r e v e a l s one m o t h e r ' s c o n c e r n s r e g a r d i n g her n e w r e s p o n s i b i l i t i e s i n the p o s t - h o s p i t a l i z a t i o n phase.  S h e describes a l a c k o f i n f o r m a t i o n r e g a r d i n g her  " m i n o r " c o n c e r n s o n c e she has returned h o m e a n d her n e e d f o r support at this t i m e . M:  M a y b e w h a t happens i s , y o u k n o w , right after the surgery y o u h a v e c e r t a i n m a i n c o n c e r n s l i k e , w e l l , i s [child] b a c k to n o r m a l , y o u k n o w ? he r e c o v e r e d f r o m the anesthetic?  Is  W h i c h w a s o n e o f the m a j o r things.  S o that a l l o f those other things y o u forget about t h e m f o r a w h i l e .  And  then i t ' s not u n t i l y o u get h o m e , a n d those m a j o r c o n c e r n s h a v e k i n d o f settled d o w n , but then the m i n o r c o n c e r n s b e c o m e m o r e o b v i o u s , o r y o u start to w o r r y . T h i s m o t h e r i n d i c a t e s that at h o m e the parents' p e r c e p t i o n a n d a p p r a i s a l o f their situation c h a n g e s .  T h e m a j o r issues b e c o m e less o f a source o f stress, but these are  r e p l a c e d w i t h i m m e d i a t e issues related to c a r i n g f o r a post-operative c h i l d at h o m e . K u p s t , D r e s s e r , S c h u l m a n , a n d P a u l (1976) i n their study o n i m p r o v i n g p a r e n t - p h y s i c i a n c o m m u n i c a t i o n , f o u n d that parents tend to f o c u s their attention o n areas w h e r e they, as parents, are d i r e c t l y r e s p o n s i b l e s u c h as instructions about m e d i c a t i o n s a n d p h y s i c a l activities.  T h e s e authors a l s o n o t e d that parents often think o f questions f o r health care  practitioners after they l e a v e the h o s p i t a l .  T h i s w a s a l s o the case f o r parents w h o  p a r t i c i p a t e d i n this study. In their attempts to f u l f i l parental r e s p o n s i b i l i t i e s f o r the c a r e , p r o t e c t i o n , and nurturance o f their post-operative c h i l d , parents i m p l e m e n t e d a pattern o f "protective b e h a v i o r s " p a r t i c u l a r l y i n the first 2 4 to 48 hours after r e t u r n i n g h o m e .  The  i m p l e m e n t a t i o n o f p r o t e c t i v e b e h a v i o r s o n the part o f the parents s e r v e d to c o m p l y w i t h  99 p a r e n t a l r o l e expectations a n d decrease r o l e strain.  Parents r e p o r t e d that the first o r  s e c o n d night at h o m e w a s often the m o s t d i f f i c u l t f o r the c h i l d a n d the parent: M:  T h e f i r s t night, y e a h , he w a s f u s s y about that.  ' C o u r s e I w a s f u s s y too.  I w a s a l w a y s m a k i n g sure e v e r y t h i n g w a s f i n e , y o u k n o w .  M:  N a t u r a l l y as a m o t h e r y o u get up a c o u p l e o f t i m e s to c h e c k , "Is he alright?"  N o t e h o w these m o t h e r s c o p e w i t h the n e w r e s p o n s i b i l i t i e s o f their p a r e n t i n g r o l e b y i n c r e a s i n g the f r e q u e n c y o f their p h y s i c a l c h e c k s o n the p o s t - o p e r a t i v e c h i l d . A l l study parents a c k n o w l e d g e d s o m e degree o f " o v e r - p r o t e c t i v e n e s s " d u r i n g the initial post-operative period.  C a r l s o n , S i m a c e k , H e n r y , a n d M a r t i n s o n (1985) i n their  d e s c r i p t i o n o f a h o m e care p r o g r a m f o r t e r m i n a l l y i l l c h i l d r e n state that h o m e care o f a n i l l c h i l d i s stressful a n d "potential sources o f stress i n c l u d e uncertainty about what to e x p e c t a n d about h o w to care f o r the c h i l d a n d the a s s u m p t i o n o f f u l l r e s p o n s i b i l i t y f o r the c h i l d ' s c o m f o r t " ( C a r l s o n et a l . , 1 9 8 3 , p. 115).  Parents w h o p a r t i c i p a t e d i n the  current study a l s o e x p r e s s e d uncertainty about c a r i n g f o r their c h i l d d u r i n g the p o s t - o p e r a t i v e d a y care surgery p e r i o d . I n a s s u m i n g the r e s p o n s i b i l i t y f o r the care o f their c h i l d d u r i n g this phase o f their e x p e r i e n c e , m o s t parents c a r r i e d out post-operative instructions "to the letter".  For  example, M:  I w o u l d n ' t let h i m [four year old] w a l k a n y w h e r e yesterday [day o f surgery] w i t h o u t h o l d i n g m y h a n d because he [doctor] t o l d m e he [child] c o u l d get d i z z y a n d f a l l , and I d i d n ' t w a n t to take a c h a n c e .  100 M:  A l l he [child] d i d w a s c r y f o r s o m e t h i n g to eat a n d s o m e t h i n g to d r i n k a l l the w a y h o m e [ f r o m the hospital]...they [day care staff] t o l d m e not to f e e d h i m f o r f o u r hours y o u see.  S o I didn't.  I g a v e i n 15 m i n u t e s  before the f o u r h o u r s a n d let h i m h a v e a c o u p l e o f c r a c k e r s . T h e s e m o t h e r s are d e s c r i b i n g h o w v i g i l a n t they w e r e i n their a p p r o a c h to i m p l e m e n t i n g p o s t - o p e r a t i v e instructions f o r their c h i l d ' s care.  T h i s m o t h e r a l s o i n d i c a t e s her l i m i t e d  k n o w l e d g e a n d e x p e r i e n c e w i t h post-operative care w h i c h does not a l l o w her to interpret the p o s t - o p e r a t i v e instructions w i t h a n y degree o f  flexibility.  Parents r e p o r t e d that i n the w e e k f o l l o w i n g the d a y care surgery they n o t i c e d b e h a v i o r c h a n g e s i n their post-operative c h i l d r e n .  T h e s e b e h a v i o r c h a n g e s often  i n f l u e n c e d u s u a l patterns o f a c t i v i t y a n d as a result, c o n t r i b u t e d to the stresses o f this phase o f the e x p e r i e n c e . M:  F o r example:  S h e ' s r e a l l y g o o d a r o u n d h o m e , but w h e n w e ' r e out s o m e p l a c e s h o p p i n g o r s o m e t h i n g , she w o n ' t w a l k . S h e wants m e to c a r r y her...she j u s t seems r e a l l y unsure o f herself.  M:  H e hangs o n m o r e to m e , y o u k n o w .  H e c r i e d so h a r d w h e n I left, a n d  e v e n o n M o n d a y a n d T u e s d a y he w o u l d n ' t let g o o f m e , a n d c r i e d and cried. B e h a v i o r c h a n g e s i n v o l v i n g fear o f separation f r o m m o t h e r r e q u i r e d e x t r a t i m e , energy, a n d p l a n n i n g o n the part o f mothers d u r i n g the first w e e k at h o m e .  O t h e r parents  d e s c r i b e d i n c r e a s e d aggressiveness a n d i r r i t a b i l i t y that w a s not characteristic o f their child.  F o r example: M:  H e ' d try to get a w a y w i t h m o r e things.  101  M:  H e w a s j u s t m i s e r a b l e to get a l o n g w i t h . . . y o u k n o w w h a t he acted l i k e ? L i k e he w a s o v e r - t i r e d .  B u t he h a d h a d e n o u g h sleep.  Parents w e r e o f t e n p u z z l e d b y the c h a n g e s , " H e w a s j u s t terrible...and I d o n ' t know why!"  Parents c o p e d w i t h their c h i l d r e n ' s b e h a v i o r c h a n g e s b y i n c r e a s i n g  parental attention, p e r m i s s i v e n e s s , d i s c i p l i n e , a n d / o r a f f e c t i o n . T h e s e f i n d i n g s that i n d i c a t e a change i n the c h i l d r e n ' s b e h a v i o r f o l l o w i n g day care surgery are consistent w i t h the f i n d i n g s o f other authors w h o stated that b e h a v i o r c h a n g e s s u c h as i n c r e a s e d separation a n x i e t y , i n c r e a s e d sleep a n x i e t y , a n d i n c r e a s e d a g g r e s s i o n f o l l o w i n g surgery a n d a general anesthetic are c o m m o n ( B r o w n , 1 9 7 9 ; H a n n a l l a h & R o s a l e s , 1 9 8 3 ; S i p o w i c z & V e r n o n , 1 9 6 5 ; V e r n o n et a l . , 1966). O n e o f the m o s t p r o m i n e n t d i m e n s i o n s o f the p o s t - h o s p i t a l i z a t i o n p e r i o d , i d e n t i f i e d b y a l l the study parents as c o n t r i b u t i n g to their interpretations o f this phase as stressful, w e r e c h a n g e s i n f a m i l y routines a n d a c t i v i t i e s . f a m i l y m e m b e r s not j u s t the post-operative c h i l d .  T h e s e c h a n g e s affected a l l  T h e c h a n g e s w e r e dictated b y the  c h i l d ' s treatment, the c h i l d ' s r e a c t i o n to treatment, a n d / o r b y the p a r e n t s ' attempts to m a n a g e the e x p e r i e n c e w i t h i n the context o f their e v e r y d a y l i v e s .  M o s t o f the changes  w e r e c o n c r e t e i n nature a n d related to the post-operative c h i l d ' s activities such as bathing and sleeping.  F a m i l y m e m b e r s w e r e affected b y c h a n g e s i n the f r e q u e n c y a n d  nature o f f a m i l y o u t i n g s a n d activities.  Parental management of changes i n family  a c t i v i t i e s a n d routines often l e d to creative a n d f l e x i b l e c o p i n g strategies o n their part w h i c h s e r v e d to a l l o w t h e m to f u l f i l their r e s p o n s i b i l i t i e s a n d m i n i m i z e r o l e strain. B a t h i n g the post-operative c h i l d w a s a m a j o r c h a n g e c o m m o n to a l l f a m i l i e s i n the study.  T h e r e g u l a r bath time r o u t i n e f o r a l m o s t a l l the c h i l d r e n w a s c h a n g e d to  102 sponge b a t h i n g at least f o r the first f e w p o s t - o p e r a t i v e d a y s .  T h i s was a significant  c h a n g e i n an a c t i v i t y that w a s c o n s i d e r e d to be a " s p e c i a l t i m e " f o r these c h i l d r e n . M:  H e j u s t l o v e s h i s b a t h , y o u k n o w . . . a n d h e ' s not a l l o w e d to. d o e s n ' t understand that n o w .  A n d he  N o t yet, I d o n ' t think...he c l i m b e d i n the  bathtub a l l d a y [ p o s t - o p e r a t i v e l y ] , i n a n d out, n o w a t e r i n there. T h i s m o t h e r i s d e s c r i b i n g h o w the age o f her c h i l d m a k e s it d i f f i c u l t to e x p l a i n the c h a n g e related to b a t h i n g r o u t i n e , a n d h o w this i n f l u e n c e d her c h i l d ' s b e h a v i o r .  She is  a l s o e x p r e s s i n g her frustration w i t h this c h a n g e i n routine. O n e parent c l e a r l y a c k n o w l e d g e d the i n c o n v e n i e n c e o f the c h a n g e i n the c h i l d ' s bathing routine: M:  I've a l w a y s k i n d o f e n j o y e d b a t h i n g little k i d s i n the tub.  So, you know,  f o r m e it w a s k i n d o f the i n c o n v e n i e n c e o f h a v i n g to start s p o n g e bathing over again. S o m e o f the b a t h i n g changes w e r e f o r o b v i o u s reasons s u c h as casts o r bandages.  O t h e r parents b a s e d their rationale o n their interpretation o f the c h i l d ' s  c o n d i t i o n , a n d the r i s k s they p e r c e i v e d to be associated w i t h tub b a t h i n g . M:  F o r example:  I d i d n ' t g i v e h i m a bath f o r a f e w d a y s because I w a s w o r r i e d about w a t e r getting i n h i s eye a n d getting i n f e c t e d a n d stuff.  I just gave h i m  o n e o f those sponge baths ' c a u s e he tends to s p l a s h a lot. I n o r d e r to decrease the stresses associated w i t h this s i g n i f i c a n t c h a n g e i n r o u t i n e , alternate f o r m s o f a c t i v i t y w e r e i m p l e m e n t e d i n m a n y f a m i l i e s to take the p l a c e o f bath t i m e .  T h e f o l l o w i n g quotations illustrate the i m p a c t o f this c h a n g e i n f a m i l y  r o u t i n e as w e l l as the i n v o l v e m e n t o f b o t h parents i n i m p l e m e n t i n g alternative activities.  103 M:  W e ' v e d e c i d e d that w e ' r e g o i n g to h a v e s o m e sort o f entertainment  after  d i n n e r [laugh] to take the p l a c e o f bath time because that's the t i m e she really enjoys.  S o , w e ' r e p l a n n i n g o n t a k i n g l o t s o f l o n g w a l k s o u t s i d e to  try to o c c u p y the e v e n i n g s a little bit d i f f e r e n t l y than w e h a v e been.  M:  W h e n he c o u l d n ' t h a v e his bath f o r a w e e k , b o y , w e w e n t through  times  w h e r e , y o u k n o w , l i k e it w a s after d i n n e r f o r i n s t a n c e , he a l w a y s has his bath, a n d m y h u s b a n d w o u l d g o h a v e his s h o w e r , a n d [child] w o u l d hear the water a n d g o try r u n n i n g after it, a n d g o i n t o the b a t h r o o m a n d have h i s bath. R:  N o t b e i n g able to h a v e the bath t i m e w a s r e a l l y quite a c h a n g e i n his routine.  M:  W h a t k i n d s o f things d i d y o u d o to m a k e that t i m e easier?  I really don't k n o w .  W e p l a y e d a lot w i t h h i m , a n d let h i m r u n a r o u n d  m o r e than w e u s u a l l y d o , kept h i m o c c u p i e d , a n d I g a v e h i m sponge baths, but he hated sponge baths.  B u t s o m e t i m e s h e d i d n ' t m i n d it, there  w a s water, so I let h i m p l a y w i t h the d i s h .  It w e n t a l l o v e r the f l o o r ,  but at least he w a s h a p p y , y o u k n o w . T h e s e parents are s a y i n g that they h a d to m a k e m o d i f i c a t i o n s to their routines i n order to p l e a s e their c h i l d a n d meet d e v e l o p m e n t a l needs.  T h e increase i n parental  p e r m i s s i v e n e s s e v i d e n t i n the a b o v e quotation w a s e x e m p l a r y o f attempts to m i n i m i z e parental r o l e strain.  T h a t i s , w h i l e restricting s o m e a c t i v i t i e s , parents t o o k advantage o f  a n y other a v a i l a b l e opportunities to k e e p their c h i l d r e n h a p p y a n d content. T h e c h i l d r e n ' s s l e e p i n g a n d n a p p i n g routines w e r e a l s o c h a n g e d .  T h e s e changes  a f f e c t e d the parents' a b i l i t y to p l a n a n d i m p l e m e n t their o w n d a y - t o - d a y activities.  104 M:  T u e s d a y [the sixth post-operative day] w a s the first d a y he settled d o w n f o r b o t h naps.  R:  S o that w o u l d r e a l l y c h a n g e y o u r activity i n the d a y .  M:  U h h u h , f o r a m o r e e x h a u s t i n g d a y [laughs]. harder to get things d o n e a n d e v e r y t h i n g .  B u t , y e a h , it d i d m a k e it  A n d y o u can't predict when  h e ' s g o i n g to g o to sleep, o r i f h e ' s g o i n g to g o to s l e e p , ' c a u s e u s u a l l y I c a n count o n an h o u r i n the m o r n i n g a n d an h o u r i n the afternoon type t h i n g , a n d u s u a l l y a r o u n d the same t i m e . A s this m o t h e r e x p r e s s e d , c h a n g e s i n f a m i l y activities a n d routines as a result o f the c h i l d ' s d a y care surgery w e r e , at times, " e x h a u s t i n g " .  S u c h changes d e m a n d e d m o r e  e n e r g y a n d f l e x i b i l i t y o n the part o f the parents a n d are e x e m p l a r y o f the stresses parents f e l t d u r i n g this phase o f their e x p e r i e n c e . A n o t h e r e x a m p l e o f c h a n g e i n f a m i l y routines w a s a decrease i n the f r e q u e n c y o f activities o u t s i d e the h o m e s u c h as s h o p p i n g a n d v i s i t i n g .  T h i s curtailment o f  o u t s i d e a c t i v i t i e s o c c u r r e d d u r i n g b o t h the p r e - a n d p o s t - h o s p i t a l i z a t i o n phases o f the e x p e r i e n c e a n d l a s t e d f r o m a f e w d a y s up to several w e e k s . M:  For example:  W e sort o f stayed i n o n the w e e k e n d , a l t h o u g h I w e n t out, I left h i m [child] w i t h m y m o m , a n d I w e n t out a n d tried to d o s o m e s h o p p i n g . D i d n ' t get m u c h d o n e but, other than that I d i d n ' t take h i m out i n t o any o f the stores o r a n y t h i n g ' c a u s e I w a s s t i l l sort o f w o r r i e d about h i m . S o , b y M o n d a y b o t h o f us w e r e b a c k to n o r m a l .  T h i s q u o t a t i o n illustrates the c a r r y - o v e r o f w o r r y a n d anxiety to the p o s t - h o s p i t a l i z a t i o n phase.  P a r e n t a l adjustments i n u s u a l routines, s u c h as not t a k i n g the c h i l d s h o p p i n g ,  r e f l e c t s the r e s p o n s i b i l i t y theme f o r d o i n g w h a t w a s interpreted to be i n the best interest  105 o f the c h i l d . M:  It's k i n d o f c u r t a i l e d o u r activities a little bit...I d o n ' t take her s h o p p i n g as m u c h .  I d o n ' t t h i n k w e ' v e been out as m u c h , I d o n ' t k n o w w h a t  the r e a s o n i s . E v e n t h o u g h the m o t h e r q u o t e d a b o v e w a s unable to articulate her r a t i o n a l e f o r adjusting f a m i l y a c t i v i t i e s , she nonetheless c h a n g e d her d a i l y r o u t i n e , s i m i l a r to other parents i n the study w h o i d e n t i f i e d that such b e h a v i o r w a s "better" f o r the post-operative c h i l d . Parents i d e n t i f i e d that s i b l i n g s o f the c h i l d w h o u n d e r w e n t the s u r g i c a l p r o c e d u r e w e r e a l s o affected b y the changes i n f a m i l y activities a n d routines.  F o r e x a m p l e , the  c h a n g e i n b a t h i n g routine f o r the post-operative c h i l d a l s o affected the b a t h i n g r o u t i n e for siblings: M:  W e d o n ' t bath [sibling] i n the e v e n i n g any m o r e w h e n [child] is a r o u n d . W e w a i t ' t i l she [child] goes to b e d a n d then bath [ s i b l i n g ] .  I guess i t ' s  pretty m u c h the same except that w e h a v e to h a v e activities to f i l l that spot. N o t e h o w the c h a n g e i n routine f o r the post-operative c h i l d affected the routines o f the sibling.  S u c h c h a n g e s r e q u i r e d m o r e creativity o n the part o f the parents to c o m e up  w i t h " a c t i v i t i e s " to f i l l the t i m e u s u a l l y u s e d b y b a t h i n g . S o m e a c t i v i t y c h a n g e s w e r e s p e c i f i c a l l y related to seasonal opportunities.  For  e x a m p l e , i n f o u r f a m i l i e s , s u m m e r activities w e r e c u r t a i l e d f o r a l l the c h i l d r e n , not just the p o s t - o p e r a t i v e c h i l d . M:  I w a s g o i n g to put t h e m [ c h i l d & s i b l i n g ] both i n s w i m m i n g l e s s o n s , but n o w , I guess I w o n ' t put either one o f t h e m i n s w i m m i n g lessons.  106 T h i s m o t h e r i s c i t i n g another e x a m p l e o f c h a n g e s i n routine a n d activities r e q u i r e d b y the p o s t - o p e r a t i v e c h i l d that a l s o s i g n i f i c a n t l y affected the a c t i v i t i e s o f the s i b l i n g .  This  d e c i s i o n w a s m a d e b y the m o t h e r because she felt it w o u l d b e "too h a r d " o n the p o s t - o p e r a t i v e c h i l d i f her s i b l i n g w a s i n s w i m m i n g l e s s o n s a n d she w a s not. O t h e r c h a n g e s d e s c r i b e d b y parents that o c c u r r e d w i t h i n the f a m i l y u n i t d u r i n g the p o s t - h o s p i t a l i z a t i o n p h a s e i n c l u d e d protective b e h a v i o r patterns o n the part o f o l d e r siblings. M:  I t h i n k h e ' s [sibling] been a little m o r e , u m m , c o n c e r n e d about her than he u s u a l l y i s , i n a w a y , not quite as q u i c k to p u s h her o v e r , w h i c h i s nice.  M:  I guess he [sibling] j u s t a c c e p t e d it but, u m m , a c t u a l l y he seems quite p r o t e c t i v e o f her r i g h t n o w .  H e k n o w s there i s s o m e t h i n g w r o n g w i t h  her, so h e ' s b e e n pretty g o o d about it.  B u t I t h i n k it w i l l bother h i m  e v e n t u a l l y , b e c a u s e s h e ' s g o i n g to take m o r e t i m e . In a d d i t i o n to c o m m e n t i n g o n the s i b l i n g ' s p r o t e c t i v e b e h a v i o r s , this latter parent is also e x p r e s s i n g c o n c e r n that the extra t i m e r e q u i r e d to care f o r the p o s t - o p e r a t i v e c h i l d m i g h t b e p e r c e i v e d b y the s i b l i n g i n a negative f a s h i o n . T h e theme o f s o c i a l support w a s p r o m i n e n t d u r i n g the p o s t - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e .  Parents p e r c e i v e d their p r i m a r y sources o f support to be f a m i l y  members and friends.  A g a i n , k n o w i n g that there w e r e others w h o c a r e d about the  p a r e n t s ' situation a n d e x p e r i e n c e a n d h a v i n g s o m e o n e a v a i l a b l e to l i s t e n w e r e i mportant c o m p o n e n t s o f support.  F o r example:  107 R:  It s o u n d s l i k e y o u ' v e h a d a lot o f f a m i l y support a n d i n p u t f r o m y o u r friends.  M:  O h yeah, a lot  o f support f r o m m y f a m i l y .  E s p e c i a l l y m y f a m i l y and  [husband]'s f a m i l y , y o u k n o w , b o t h o u r f a m i l i e s . support, a n d f r i e n d s , a lot o f f r i e n d s , too. w o r r y about it, a n d e v e r y t h i n g l i k e that. them a call. cares.  W e ' v e h a d a lot o f  A l w a y s t e l l i n g m e not to A n d i f I n e e d h e l p just g i v e  Y o u k n o w , things l i k e that. It's n i c e to k n o w that e v e r y o n e  Y o u understand f a m i l y a l w a y s cares but f r i e n d s , y o u k n o w , i t ' s  n i c e to k n o w that y o u h a v e f r i e n d s that c a r e .  M:  O h y e a h , it [friends c a l l i n g ] g i v e s y o u this great f e e l i n g , s o m e b o d y else is c o n c e r n e d a n d cares about y o u , that's the r i g h t w o r d , cares about y o u .  A s i s consistent w i t h the literature ( H e l l e r , 1979), helpers w e r e rated h i g h l y w h e n they e n g a g e d i n a c t i v i t i e s i n v o l v i n g affective support (eg. c o m f o r t i n g ) . R:  W h o w a s there, w h o d i d y o u r e l y o n to h e l p y o u w o r k t h r o u g h those f e e l i n g s w h e n y o u w e r e so upset o n F r i d a y [due to u n s u c c e s s f u l s u r g i c a l procedure]?  M:  O h , j u s t f r i e n d s , because m y h u s b a n d h a d other things o n h i s m i n d , too...he w a s upset...so I c o u l d n ' t r e a l l y talk to him....I t o l d the g i r l s at w o r k a n d then I felt better.  T h i s m o t h e r , l i k e others i n the study, sought support f r o m f r i e n d s a n d c o l l e a g u e s as o p p o s e d to her h u s b a n d .  l i n g e r a n d P o w e l l (1980) i n their d e s c r i p t i o n s o f the r o l e o f  s o c i a l n e t w o r k s i n s u p p o r t i n g f a m i l i e s under stress, stated that support m a y be situation s p e c i f i c that i s , " c o - w o r k e r s m a y support e a c h other e x c l u s i v e l y at w o r k " (p. 5 7 0 ) .  108 T h i s w a s the case f o r the m o t h e r q u o t e d a b o v e . A s w a s p r e v i o u s l y stated, f i v e f a m i l i e s i n this study c l e a r l y i d e n t i f i e d w h e n the p o s t - h o s p i t a l i z a t i o n o r r e c o v e r y phase o f their e x p e r i e n c e h a d e n d e d .  T h e s e parents  e x p r e s s e d satisfaction w i t h their e x p e r i e n c e a n d v i e w e d it as " f a i t - a c c o m p l i " w i t h i n a p p r o x i m a t e l y ten d a y s o f the surgery.  Parents often d e s c r i b e d a sense o f r e l i e f f r o m  the stressful f e e l i n g s o f w o r r y a n d anxiety w h e n their e x p e r i e n c e h a d e n d e d . M:  O h y e a h , it i s a n i c e f e e l i n g , I ' m g l a d i t ' s o v e r w i t h , d o n e w i t h , f i n i s h e d , n o t h i n g to w o r r y about a g a i n .  M:  [I'm  g l a d it's] r e a l l y b e h i n d m e [the surgery e x p e r i e n c e ] .  I think on  F r i d a y [fourth post-operative d a y ] , y o u k n o w , he w a s r u n n i n g a r o u n d and s c r e a m i n g , a n d c l i m b i n g l i k e n o t h i n g else h a p p e n e d .  I thought, " W e l l , it  r e a l l y d o e s n ' t hurt h i m o r h e ' d be c r y i n g m o r e , o r d o i n g s o m e t h i n g e l s e . " S o I thought, " T h a t ' s i t - i t ' s g o n e . " In a d d i t i o n to e x p r e s s i n g her f e e l i n g s o f r e l i e f , this m o t h e r i s s a y i n g that it w a s her c h i l d ' s r e s p o n s e to the surgery that a l l o w e d her to c o n c l u d e that the e x p e r i e n c e f o r her was "over".  O t h e r parents a l s o c o m m e n t e d o n the p o s t - o p e r a t i v e c h i l d ' s l e v e l o f  a c t i v i t y as a n i n d i c a t o r that the e x p e r i e n c e w a s o v e r . O t h e r parents w h o p a r t i c i p a t e d i n the study w e r e not as definite i n c o n c l u d i n g that their e x p e r i e n c e w a s " o v e r " .  F o r t w o study parents, the c h a n g e d p h y s i c a l  appearance o f their c h i l d i n the p o s t - h o s p i t a l i z a t i o n p e r i o d c o n t r i b u t e d to the stressful nature o f their e x p e r i e n c e a n d l e d to c o n t i n u e d f e e l i n g s o f a n x i e t y a n d w o r r y r e g a r d i n g p o s s i b l e f a i l u r e o f the a n t i c i p a t e d o u t c o m e f o r the surgery.  For example:  109 M:  T h e n I s a w her this m o r n i n g and her e y e w a s a l l r e d . A n d then I a g a i n h a d m y doubts, gee, a m I d o i n g the r i g h t t h i n g ?  It j u s t l o o k e d a w f u l .  F o r this m o t h e r , the p h y s i c a l appearance o f h e r daughter w a s a factor d e t e r m i n i n g her s a t i s f a c t i o n w i t h the e x p e r i e n c e and the t i m i n g o f her sense o f c o m p l e t i o n . T h r e e parents i n the study v i e w e d the s u r g e o n ' s o p i n i o n about the c h i l d ' s p o s t - o p e r a t i v e p r o g r e s s as a k e y p o i n t i n b e i n g able to f e e l satisfied w i t h their e x p e r i e n c e a n d b e i n g able to c o n c l u d e that this f i n a l phase w a s o v e r .  D u r i n g the  w a i t i n g p e r i o d p r i o r to o b t a i n i n g the s u r g e o n ' s o p i n i o n , parental f e e l i n g s o f a n x i e t y , fear, a n d w o r r y that h a d t y p i f i e d the pre-operative phase c o n t i n u e d to b e present. R:  W o u l d y o u say at this p o i n t that things are b a c k to n o r m a l ?  M:  Y e a h , I guess s o , y e a h .  R:  Y o u s o u n d a little hesitant.  M:  W e l l , I guess the o n l y t h i n g i s I t h i n k i n m y o w n m i n d , things w i l l r e a l l y be b a c k to n o r m a l w h e n he goes b a c k to another v i s i t to the e y e d o c t o r a n d she says e v e r y t h i n g i s O . K . T h e n I guess I'll  f e e l that things are  b a c k to n o r m a l w h e n I h a v e s o m e reassurance that, y o u k n o w , the o p e r a t i o n has r e a l l y d o n e the trick. R:  S o that w i l l a l l a y some o f the things y o u are s t i l l w o r r i e d about i n the b a c k o f y o u r m i n d there.  S o , y o u are s t i l l w o n d e r i n g , has this  w h o l e thing...? M:  W e l l , i t ' s j u s t that, y e a h .  It's v e r y , v e r y  e n c o u r a g i n g f o r m e that h e ' s  w a l k i n g that, y o u k n o w , the other m o m s s a i d h o w straight h i s h e a d looked.  B u t , I s t i l l , y o u k n o w , I guess I j u s t w a n t to hear it f r o m a  d o c t o r , "It's great, it r e a l l y w o r k e d . "  S o , f o r m e , n o , things w o n ' t be  110 b a c k to n o r m a l c o m p l e t e l y ' t i l I see her [pediatric surgeon]. T h i s m o t h e r i s e m p h a s i z i n g the i m p o r t a n c e o f the r o l e o f the p h y s i c i a n i n p r o v i d i n g her w i t h i n f o r m a t i o n a n d reassurance r e g a r d i n g the results o f her c h i l d ' s surgery.  F o r her,  it w a s not u n t i l she r e c e i v e d such i n f o r m a t i o n a n d reassurance that her f e e l i n g s o f a n x i e t y a n d w o r r y w e r e r e l i e v e d a n d she w a s able to c o n c l u d e that this f i n a l phase o f her e x p e r i e n c e w a s " o v e r " . A l t h o u g h the p o s t - h o s p i t a l i z a t i o n phase o f the parents' e x p e r i e n c e w a s t y p i f i e d b y c h a n g e s i n b e h a v i o r patterns a n d f a m i l y routines as w e l l as f e e l i n g s o f w o r r y a n d a n x i e t y , parents d i d report that, i n g e n e r a l , this phase o f the e x p e r i e n c e w a s m o r e p o s i t i v e than they h a d anticipated.  In fact, the m a j o r i t y o f the parents w e r e p l e a s a n t l y  s u r p r i s e d b y their c h i l d ' s r e a c t i o n to the s u r g i c a l event. M:  For example:  I r e a l l y e x p e c t e d m o r e c r y i n g a n d I w a s g o i n g to c a r r y h i m a r o u n d a l l d a y , a n d he w o u l d n ' t w a n t to w a l k , y o u k n o w . A n d h a v i n g p r o b l e m s l i k e that, but he surprised m e [laughs]. It's a g o o d f e e l i n g , y o u k n o w .  M:  I w o u l d n ' t h a v e anticipated that she w o u l d d o that w e l l .  I mean, people  t o l d m e she w o u l d , but I c o u l d n ' t quite p i c t u r e it.  M:  B u t afterwards, he [child] w a s  fine.  It w a s n ' t n e a r l y as b a d as I  thought  it w a s g o i n g to be. It i s e v i d e n t f r o m the a b o v e quotations that parents h a d i m a g i n e d expectations r e g a r d i n g their c h i l d ' s b e h a v i o r a l reactions to this event.  T h e parents' l a c k o f p r e v i o u s  e x p e r i e n c e c o n t r i b u t e d to their a n t i c i p a t i o n o f a m o r e negative p o s t - o p e r a t i v e c o u r s e . O n e m o t h e r stated, "It [day care surgery] w o u l d n ' t bother m e as m u c h the s e c o n d  Ill time...I w o u l d understand it m o r e , y o u k n o w . " T h i s section has d i s c u s s e d the parents' e x p e r i e n c e s d u r i n g the p o s t - h o s p i t a l i z a t i o n p h a s e o f their c h i l d ' s d a y care surgery.  D i m e n s i o n s o f this phase that contributed to  p a r e n t s ' interpretation o f the event as stressful i n c l u d e d n e w r e s p o n s i b i l i t i e s f o r the care a n d s u p e r v i s i o n o f the post-operative c h i l d , changes i n the c h i l d ' s b e h a v i o r a n d patterns o f a c t i v i t y , a n d changes i n f a m i l y activities a n d routines. r e g a r d i n g these d i m e n s i o n s  A lack of  information  o f the p o s t - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e w a s also  i d e n t i f i e d b y the parents as c o n t r i b u t i n g to the stressful nature o f this phase o f the experience.  A l t h o u g h parents h a d anticipated a rather negative p o s t - o p e r a t i v e c o u r s e , i n  g e n e r a l , they w e r e p l e a s e d w i t h their c h i l d ' s response to the s u r g i c a l p r o c e d u r e . Parents i m p l e m e n t e d several c o p i n g strategies to m a n a g e this phase o f their e x p e r i e n c e . Summary T h i s chapter has presented the theory generated i n  a n s w e r to the research  q u e s t i o n : w h a t i s the parents' e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery?  T h e a c c o u n t s presented i n this chapter represent a  synthesis o f this s t u d y ' s data i n t o a d e s c r i p t i o n that p r o v i d e s a b a s i s f o r understanding h o w p a r t i c i p a n t parents interpreted a n d a s s i g n e d m e a n i n g to the d a y care surgery e x p e r i e n c e a n d c o p e d w i t h it i n their e v e r y d a y l i v e s . A s c a n be seen f r o m the presentation o f the p a r e n t s ' accounts, the e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery w a s o n l y one aspect o f the p a r e n t s ' m u c h broader e x p e r i e n c e o f h a v i n g their son o r daughter u n d e r g o a d a y care s u r g i c a l p r o c e d u r e .  T h e t i m e span o f this b r o a d e r e x p e r i e n c e extended far  b e y o n d the f e w short hours the parents actually spent i n the d a y care unit. f i n d i n g s o f this study r e v e a l e d that the n i n e participant parents interpreted  The major their  112 e x p e r i e n c e as a stressful o n e a n d that they a n d their f a m i l i e s w e r e s i g n i f i c a n t l y affected b y their c h i l d ' s d a y care surgery. T h e chapter b e g a n w i t h an i n t r o d u c t i o n to the s t u d y ' s a n a l y t i c f r a m e w o r k .  Next,  the c o n c e p t s a n d themes w h i c h f o r m e d the theory d e v e l o p e d f r o m the p a r e n t s ' accounts w e r e presented a n d d i s c u s s e d i n r e l a t i o n to theory e x i s t i n g i n the literature.  There was  a d e t a i l e d d e s c r i p t i o n o f the participant f a m i l i e s a n d f i n a l l y a presentation o f the parents' a c c o u n t s o f their e x p e r i e n c e s a c c o r d i n g to the structure o f the a n a l y t i c framework. T h e f o u r m a j o r themes w h i c h c h a r a c t e r i z e d the p a r e n t s ' e x p e r i e n c e s , a n d f o r m e d the structure o f the s t u d y ' s a n a l y t i c f r a m e w o r k , represented d i m e n s i o n s that either c o n t r i b u t e d to the nature o f the stressful e x p e r i e n c e o r e n h a n c e d parents' a b i l i t y to m a n a g e the stresses. s o c i a l support.  T h e themes w e r e : parental r e s p o n s i b i l i t y , r o l e strain, c o p i n g , a n d  R e l a t e d literature w a s used throughout the chapter to d i s c u s s the  s p e c i f i c f i n d i n g s o f this study a n d o f f e r e v i d e n c e to either support o r contrast t h e m . T h e theory generated f r o m the parents' accounts i s b a s e d o n the f i n d i n g that parents that it i s stressful f o r t h e m to h a v e a c h i l d u n d e r g o d a y care surgery—more stressful than health p r o f e s s i o n a l s m a y p e r c e i v e o r understand.  O n e mother, w h o was  e m p l o y e d as a t e c h n i c i a n i n an acute care h o s p i t a l , c o m p a r e d her p e r s p e c t i v e as both a parent a n d a health care p r o f e s s i o n a l w h i l e u n d e r g o i n g the e x p e r i e n c e o f her c h i l d ' s day care surgery.  T h i s p a r t i c u l a r m o t h e r stated that as a health c a r e p r o f e s s i o n a l she k n e w  " i t ' s so routine...it's n o t h i n g , i t ' s n o b i g d e a l " , a n d yet w h e n her o w n daughter had to u n d e r g o a s u r g i c a l p r o c e d u r e , she d e s c r i b e d h e r s e l f as j u s t another "upset parent".  This  m o t h e r ' s p e r s o n a l e x p e r i e n c e h i g h l i g h t s the stressful nature o f this e x p e r i e n c e as w e l l as the d i s c r e p a n c i e s b e t w e e n the e x p l a n a t o r y m o d e l s h e l d b y parents a n d health  113 p r o f e s s i o n a l s f o r the s a m e health care situation.  S u c h d i f f e r e n c e s o f t e n result i n  m i s u n d e r s t a n d i n g s a n d d i s s a t i s f a c t i o n w i t h care ( K l e i n m a n et a l . , 1978). Three-quarters o f the parents w h o participated i n this study d e s c r i b e d , i n retrospect, that the o v e r a l l p e d i a t r i c d a y care surgery e x p e r i e n c e w a s m u c h m o r e p o s i t i v e than they h a d thought it w o u l d be.  A s o n e parent stated, "I guess o v e r a l l the  w h o l e t h i n g w a s not as b a d as I h a d a n t i c i p a t e d " i n essence h i g h l i g h t i n g that the a n t i c i p a t i o n o f it w a s w o r s e than the actual event itself. C h a p t e r 5 offers further d i s c u s s i o n o f the s t u d y ' s f i n d i n g s , s u m m a r i z e s the study, draws conclusions, and identifies nursing implications for practice, education, and research.  114 CHAPTER 5  Summary, Conclusions, and Implications for Nursing  T h i s chapter b e g i n s w i t h a s u m m a r y o f the study w h i c h a n s w e r e d the r e s e a r c h q u e s t i o n : w h a t i s the p a r e n t s ' e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery?  F o l l o w i n g this, the c o n c l u s i o n s , i m p l i c a t i o n s ,  a n d r e c o m m e n d a t i o n s f o r n u r s i n g p r a c t i c e , e d u c a t i o n , a n d research are presented. A l t h o u g h the c o r e f i n d i n g s o f this study are r i c h i n b o t h the general a n d s p e c i f i c i m p l i c a t i o n s a n d d i r e c t i o n s they o f f e r f o r n u r s i n g p r a c t i c e , o n l y the m a j o r c o n c l u s i o n s a n d i m p l i c a t i o n s f o r n u r s i n g are b r i e f l y s u m m a r i z e d i n this chapter. S u m m a r y o f the S t u d y T h i s study has p r o v i d e d an a n s w e r to the q u e s t i o n : W h a t is the parents' e x p e r i e n c e o f h a v i n g a t o d d l e r o r p r e s c h o o l e r at h o m e f o l l o w i n g d a y care surgery? U s i n g a p h e n o m e n o l o g i c a l m e t h o d , the study e x p l o r e d i n - d e p t h the p a r e n t s ' b r o a d p e r s p e c t i v e a n d p e r s o n a l interpretations o f their c h i l d ' s first time d a y care surgery e x p e r i e n c e w i t h i n the context o f e v e r y d a y f a m i l y l i f e . A l t h o u g h there i s m u c h d o c u m e n t a t i o n that p e d i a t r i c d a y care surgery offers b o t h p s y c h o - s o c i a l benefits f o r the f a m i l y unit as w e l l as f i n a n c i a l s a v i n g s f o r the C a n a d i a n H e a l t h C a r e S y s t e m ( A t w e l l et a l . , 1 9 7 3 ; C l o u d et a l . , 1 9 7 2 ; J o h n s o n , 1 9 8 3 ; L a w r i e , 1 9 6 4 ; S h a h , 1980) there is a l a c k o f e m p i r i c a l k n o w l e d g e a d d r e s s i n g this t o p i c f r o m the p a r e n t s ' p e r s p e c t i v e .  B e c a u s e parents are the p r i m a r y caretakers  f o r p r e - a n d post-treatment c h i l d r e n , i t w a s argued b y the researcher that it w a s m u t u a l l y b e n e f i c i a l to t r u l y understand the p a r e n t s ' perceptions a n d p e r s o n a l  115 interpretations o f the d a y care surgery e x p e r i e n c e w i t h i n the context o f their e v e r y day lives.  Parents o f toddlers a n d p r e s c h o o l e r s w e r e selected f o r this study because  it i s k n o w n that parents are a n x i o u s a n d c o n c e r n e d about their c h i l d r e n ' s i l l n e s s e s a n d h o s p i t a l i z a t i o n s , a n d a l s o because c h i l d r e n i n these age g r o u p s are p a r t i c u l a r l y v u l n e r a b l e to the r e a l and i m a g i n e d threats o f h o s p i t a l i z a t i o n a n d surgery. T h e n u m b e r o f c h i l d r e n a n d f a m i l i e s r e c e i v i n g treatment i n m e d i c a l a n d s u r g i c a l D a y C a r e U n i t s i s g r o w i n g steadily e v e r y year ( S h a h , 1 9 8 0 ; B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l , 1987).  Nurses w o r k i n g i n both hospital and  c o m m u n i t y settings h a v e opportunities to i n f l u e n c e the e x p e r i e n c e s o f parents w h o s e y o u n g c h i l d r e n u n d e r g o d a y care surgery, b o t h before a n d after the event. T h e c o n c e p t u a l f r a m e w o r k f o r the study w a s based u p o n the w o r k o f K l e i n m a n a n d h i s c o l l e g u e s (1978).  K l e i n m a n ' s m o d e l adheres to t w o f u n d a m e n t a l  n o t i o n s : the f i r s t i s a d i s t i n c t i o n b e t w e e n the c o n c e p t s o f " d i s e a s e " , " i l l n e s s " a n d " s i c k n e s s " , a n d the s e c o n d i s a c o n c e p t u a l i z a t i o n o f a  health care s y s t e m w i t h three  different but i n t e r a c t i n g s o c i a l " a r e n a s " : p o p u l a r , p r o f e s s i o n a l , a n d f o l k .  T h e s e three  arenas serve to s o c i a l l y l e g i t i m i z e s i c k n e s s a n d health care f o r the i n d i v i d u a l s they represent.  W i t h i n the  are e x p e r i e n c e d .  c o n t e x t o f this f r a m e w o r k , diseases are treated a n d i l l n e s s e s  S i c k n e s s i s d e f i n e d as a c o m p l e x h u m a n p h e n o m e n o n  e n c o m p a s s i n g b o t h disease a n d i l l n e s s .  I n d i v i d u a l s represented b y e a c h o f the three  s o c i a l arenas use different e x p l a n a t o r y m o d e l s to e x p l a i n a n d d e f i n e p a r t i c u l a r sickness episodes. K l e i n m a n (1978) directs health care p r o f e s s i o n a l s to e l i c i t the c l i e n t s ' e x p l a n a t o r y m o d e l s i n order to enhance health p r o f e s s i o n a l s ' u n d e r s t a n d i n g o f i l l n e s s as a p e r s o n a l , s o c i a l , and c u l t u r a l e x p e r i e n c e a n d , i n d o i n g s o , facilitate the  116 p r o v i s i o n o f n u r s i n g care that i s m u t u a l l y s a t i s f y i n g .  T h e parents, represented b y  the " p o p u l a r " arena o f K l e i n m a n ' s H e a l t h C a r e S y s t e m , h a v e e x p l a n a t o r y m o d e l s f o r the post d a y care surgery e x p e r i e n c e that h a v e been shaped b y their k n o w l e d g e , b e l i e f s , v a l u e s , c u l t u r e , a n d past e x p e r i e n c e s .  T h e parents' explanatory models can  o n l y b e f u l l y u n d e r s t o o d b y e l i c i t i n g their perceptions a n d e x p l a n a t i o n s about their experience. T h e i n v e s t i g a t o r selected the p h e n o m e n o l o g i c a l m e t h o d o f q u a l i t a t i v e research to g u i d e the i n v e s t i g a t i o n because it e m p h a s i z e s l i f e i n the e v e r y d a y w o r l d as it is u n d e r s t o o d a n d interpreted b y o n e l i v i n g t h r o u g h the situation ( G i o r g i , 1975a). P h e n o m e n o l o g y a l l o w s the r e a l i t y o f the  p a r t i c i p a n t ' s e x p e r i e n c e to be f u l l y  e x p r e s s e d a n d , t h r o u g h a p r o c e s s o f e x h a u s t i v e d e s c r i p t i o n , the researcher c a n d e v e l o p an u n d e r s t a n d i n g o f the p h e n o m e n o n u n d e r study ( R a y , 1 9 8 5 ; L y n c h - S a u e r , 1985).  U s i n g this m e t h o d , the author w a s able to l e a r n h o w the parents interpreted  a n d g a v e m e a n i n g to their e x p e r i e n c e o f h a v i n g their y o u n g c h i l d u n d e r g o a s u r g i c a l d a y care surgery p r o c e d u r e . In o r d e r to substantiate the n e e d f o r r e s e a r c h o n the s p e c i f i c t o p i c o f p a r e n t s ' e x p e r i e n c e w i t h their y o u n g c h i l d r e n s ' d a y care surgery, a n d to establish a b a c k g r o u n d o f i n f o r m a t i o n about w h a t w a s g e n e r a l l y k n o w n about f a m i l i e s w i t h c h i l d r e n w h o u n d e r g o h o s p i t a l i z a t i o n f o r a short-term i l l n e s s , a b o d y o f related literature w a s r e v i e w e d .  T h e p a u c i t y o f literature about p a r e n t s ' e x p e r i e n c e w i t h  p e d i a t r i c d a y care surgery l e a d to a r e v i e w o f several subject areas e x p l o r i n g i n g e n e r a l the i m p a c t o f p e d i a t r i c h o s p i t a l i z a t i o n a n d surgery o n c h i l d r e n a n d their parents.  117 T h e literature r e v i e w d o c u m e n t e d that: parental r o l e s a n d r e s p o n s i b i l i t i e s c h a n g e w h e n a c h i l d b e c o m e s i l l o r requires h o s p i t a l i z a t i o n e v e n o n a short t e r m b a s i s ; m a t e r n a l a n x i e t y affects the c h i l d ' s l e v e l o f a n x i e t y d u r i n g h o s p i t a l i z a t i o n ; a n d the short t e r m h o s p i t a l i z a t i o n o f toddlers a n d p r e s c h o o l e r s results i n post-hospitalization behavior changes.  It w a s apparent that the current p u b l i s h e d  literature d i d not p r o v i d e a n i n - d e p t h u n d e r s t a n d i n g o f the parents' o w n e x p e r i e n c e i n the p o s t - h o s p i t a l i z a t i o n p e r i o d f o l l o w i n g their c h i l d ' s d a y c a r e surgery. T h e data w e r e c o l l e c t e d b y m e a n s o f 16 i n - d e p t h i n t e r v i e w s w i t h n i n e parents o f post-operative toddlers a n d p r e s c h o o l e r s w h o u n d e r w e n t a v a r i e t y o f p e d i a t r i c d a y care surgery p r o c e d u r e s . transcribed verbatim. ducted.  T h e i n t e r v i e w s w e r e a u d i o t a p e d a n d then  E i g h t first i n t e r v i e w s a n d eight s e c o n d i n t e r v i e w s w e r e c o n -  T h e i n t e r v i e w s w e r e semi-structured a n d an i n t e r v i e w g u i d e ( A p p e n d i x F ,  p. 149) w a s u s e d d u r i n g the first i n t e r v i e w s to h e l p e l i c i t the p a r e n t s ' d e s c r i p t i o n s o f their e x p e r i e n c e .  T h e content o f the s e c o n d i n t e r v i e w s w a s d r a w n f r o m a n a l y s i s  o f the m a t e r i a l d i s c u s s e d d u r i n g the first i n t e r v i e w s a n d f r o m i n t e r v i e w s w i t h other parents.  D u r i n g e a c h o f the i n t e r v i e w s , the researcher e x p l o r e d a n d c l a r i f i e d the  m e a n i n g the parents a s s i g n e d to their c h i l d ' s d a y care surgery e x p e r i e n c e . T h e p r o c e s s o f a n a l y z i n g data b e g a n w i t h the onset o f data c o l l e c t i o n a n d c o n t i n u e d c o n c u r r e n t l y throughout this phase o f the research p r o c e s s .  Following  c o m p l e t i o n o f a l l o f the i n t e r v i e w s , data a n a l y s i s c o n t i n u e d u n t i l the p a r e n t s ' accounts w e r e s y n t h e s i z e d i n t o a d e s c r i p t i v e f r a m e w o r k o f their e x p e r i e n c e w i t h a t o d d l e r o r p r e s c h o o l e r ' s day care surgery.  In the presentation o f the p a r e n t s '  a c c o u n t s , v e r b a t i m quotations f r o m parent i n t e r v i e w s w e r e u s e d e x t e n s i v e l y f o r illustrative purposes.  118 T h e s t u d y ' s a n a l y t i c f r a m e w o r k represented the r e s e a r c h e r ' s c o n c e p t u a l i z a t i o n a n d interpretation o f the s i m i l a r i t i e s a n d shared aspects o f the p a r e n t ' s accounts o f their e x p e r i e n c e s as r e v e a l e d b y i n - d e p t h a n a l y s i s .  T h e study's analytic  framework  w a s b a s e d o n a c o r e c o n c e p t o f stress a n d w a s o r g a n i z e d a c c o r d i n g to a c h r o n o l o g i c a l structure c o n s i s t i n g o f three distinct phases d e s c r i b e d b y the parents. T h e s e three c h r o n o l o g i c a l phases w e r e n a m e d the p r e - h o s p i t a l i z a t i o n o r preparatory p h a s e , the h o s p i t a l i z a t i o n o r operative p h a s e , a n d the p o s t - h o s p i t a l i z a t i o n o r readjustment phase.  T h e m a j o r themes i d e n t i f i e d i n data a n a l y s i s represented  d i m e n s i o n s o f the parents' e x p e r i e n c e s that c o n t r i b u t e d to their interpretation o f the event as stressful.  A d d i t i o n a l themes f r o m the parents' accounts a l s o r e v e a l e d  aspects o f their e x p e r i e n c e that e n h a n c e d o r i n h i b i t e d their a b i l i t y to m a n a g e w i t h i n the c o n t e x t o f their e v e r y d a y l i v e s .  T h e concepts a n d themes w h i c h f o r m e d this  s t u d y ' s a n a l y t i c f r a m e w o r k w e r e presented a n d d i s c u s s e d i n C h a p t e r 4 i n r e l a t i o n to e x i s t i n g theory i n the literature. A c c o r d i n g to the study participants, this "first t i m e " e x p e r i e n c e w a s p e r c e i v e d as a stressful event i n their e v e r y d a y l i v e s .  D e s p i t e h a v i n g r e c e i v e d assurances  f r o m health care p r o f e s s i o n a l s that pediatric d a y care surgery w a s not o n l y safe, but a l s o c o n s i d e r e d m i n o r a n d routine, the parents i n this study w e r e u n a b l e to v i e w it as s u c h f o r their c h i l d .  T h e events, o c c u r r e n c e s , a n d d e c i s i o n s inherent i n the  e x p e r i e n c e i n t e n s i f i e d parental f e e l i n g s o f r e s p o n s i b i l i t y f o r their c h i l d ' s present a n d future w e l l - b e i n g .  T h r o u g h o u t the c o u r s e o f the e x p e r i e n c e , n e w r e s p o n s i b i l i t i e s  s u c h as m o n i t o r i n g the c h i l d ' s post-operative c o u r s e a n d a s s e s s i n g the n e e d f o r a n a l g e s i a , w e r e a d d e d to the u s u a l tasks o f p a r e n t i n g a t o d d l e r o r p r e s c h o o l e r .  The  a d d i t i o n o f n e w r e s p o n s i b i l i t i e s resulted i n the p a r e n t s ' r e p o r t i n g f e e l i n g s o f r o l e  119 strain at p a r t i c u l a r p o i n t s o f the e x p e r i e n c e , s u c h as w h e n they w e r e r e q u i r e d to w i t h h o l d f o o d a n d f l u i d s f r o m the pre-operative c h i l d .  A s parents c o p e d w i t h the  e x p e r i e n c e o f their c h i l d ' s d a y care surgery, they m a d e concrete c h a n g e s to their e s t a b l i s h e d patterns a n d activities o f d a i l y l i v i n g .  F o r e x a m p l e , i n a l l o f the  p a r t i c i p a n t f a m i l i e s the o p e r a t i v e c h i l d ' s b a t h i n g routine w a s c h a n g e d f r o m a tub bath to a s p o n g e bath f o r at least several d a y s p o s t - o p e r a t i v e l y . T h r o u g h o u t the three phases o f their e x p e r i e n c e , the p a r e n t s ' thoughts, f e e l i n g s , b e h a v i o r s , a n d reactions c h a n g e d a n d v a r i e d i n intensity a n d parents e x p r e s s e d f e e l i n g s o f fear, w o r r y , a n d a n x i e t y .  Parents u s e d a v a r i e t y o f c o p i n g  strategies, i n c l u d i n g s o c i a l support, i n o r d e r to m a n a g e the stresses o f their experience.  R e t r o s p e c t i v e l y , the m a j o r i t y o f the study parents r e f l e c t e d o n their  e x p e r i e n c e w i t h their y o u n g c h i l d ' s d a y care surgery as b e i n g m o r e p o s i t i v e than they h a d anticipated. F o r d i s c u s s i o n p u r p o s e s , the f i n d i n g s o f this study w e r e c o m p a r e d w i t h the f i n d i n g s o f n u m e r o u s other studies.  A l t h o u g h there h a v e not been a n y other studies  e x p l o r i n g this e x p e r i e n c e f r o m the p a r e n t s ' p e r s p e c t i v e , the literature r e v i e w e d does o f f e r support f o r this w r i t e r ' s f i n d i n g s a n d v i c e v e r s a . Conclusions T h e m a j o r c o n c l u s i o n s d r a w n f r o m the f i n d i n g s o f this study are: 1.  Parents o f toddlers a n d p r e s c h o o l e r s v i e w the d a y care surgery e x p e r i e n c e  as o n e w h i c h o c c u r s o v e r a span o f t i m e m u c h greater than the f e w h o u r s a c t u a l l y spent i n the h o s p i t a l setting. 2.  Parents interpret a n d a s s i g n m e a n i n g to their e x p e r i e n c e o n l y w i t h i n the  c o n t e x t o f a l l three phases ( p r e - h o s p i t a l i z a t i o n , h o s p i t a l i z a t i o n , a n d post-  120 h o s p i t a l i z a t i o n ) o f their e x p e r i e n c e . 3.  Parents o f toddlers a n d p r e s c h o o l e r s interpret this first time e x p e r i e n c e as  stressful a n d i d e n t i f y p a r t i c u l a r d i m e n s i o n s o f the e x p e r i e n c e that contribute to their interpretations. 4.  Parents o f toddlers a n d p r e s c h o o l e r s v i e w this e x p e r i e n c e w i t h i n the  b r o a d c o n t e x t o f e v e r y d a y f a m i l y l i f e a n d d e s c r i b e s i g n i f i c a n t c h a n g e s that take p l a c e i n f a m i l y l i f e as a result o f the event. 5.  T h e r e are s p e c i f i c a p p l i c a t i o n s o f the theory generated f r o m these  p a r e n t s ' accounts w h i c h c o u l d be a p p l i e d to i m p r o v e the q u a l i t y o f n u r s i n g care to p e d i a t r i c d a y care surgery f a m i l i e s .  A s e l e c t i o n o f these f o l l o w :  Implications for Nursing Practice A l t h o u g h the f i n d i n g s a n d c o n c l u s i o n s o f this study suggest i m p l i c a t i o n s f o r nurses i n v o l v e d i n the assessment, p l a n n i n g , i m p l e m e n t a t i o n , a n d e v a l u a t i o n o f n u r s i n g care f o r parents w h o s e y o u n g c h i l d r e n u n d e r g o d a y care surgery, it i s " i m p o r t a n t to p o i n t out that the a p p l i c a t i o n o f r e s e a r c h to p r a c t i c e i s t y p i c a l l y not a s t r a i g h t f o r w a r d p r o c e s s " ( K n a f l , C a v a l l a r i , & D i x o n , 1 9 8 8 , p. 2 9 7 ) .  T h e nurses w h o  p r o v i d e c a r e f o r p e d i a t r i c d a y care surgery f a m i l i e s m a y b e e m p l o y e d i n M e d i c a l / S u r g i c a l D a y C a r e U n i t s , c o m m u n i t y health care a g e n c i e s , o r d o c t o r s ' o f f i c e s , a n d m a y c o m e i n t o contact w i t h parents at different phases o f this experience. T h e c o n c l u s i o n s d r a w n f r o m this study reflect the f i n d i n g that parents h a v e their o w n u n i q u e e x p l a n a t i o n s o f their i l l n e s s e x p e r i e n c e w h i c h are constructed f r o m the p e r s o n a l m e a n i n g s o f the e x p e r i e n c e h e l d w i t h i n the i n d i v i d u a l s ' p e r s o n a l , s o c i a l , and cultural contexts.  T h i s i s consistent w i t h the w o r k o f K l e i n m a n et a l . (1978)  121 w h o argue that health p r o f e s s i o n a l s h o l d e x p l a n a t o r y m o d e l s that d i f f e r f r o m those h e l d b y i n d i v i d u a l s i n the p o p u l a r culture s y s t e m or, s i m p l y put, these p a r e n t s ' v i e w s o f the d a y care surgery e x p e r i e n c e d i f f e r f r o m those h e l d b y health professionals. D i s c r e p a n c i e s b e t w e e n the e x p l a n a t o r y m o d e l s u t i l i z e d b y parents a n d health p r o f e s s i o n a l s often result i n m i s u n d e r s t a n d i n g s a n d d i s s a t i s f a c t i o n w i t h care.  It i s  therefore i m p l i e d that i n order to p r o v i d e care that i s m u t u a l l y s a t i s f y i n g a n d s u p p o r t i v e to parents d u r i n g the first t i m e e x p e r i e n c e o f their t o d d l e r o r p r e s c h o o l e r s ' d a y care surgery, nurses m u s t e l i c i t p a r e n t s ' p e r s p e c t i v e s a n d a c k n o w l e d g e the p a r e n t s ' interpretation o f the event.  A s a result o f e x p l o r a t i o n o f  the p a r e n t s ' e x p l a n a t o r y m o d e l s f o r their d a y care surgery e x p e r i e n c e , the f i n d i n g s o f this study h a v e e m p h a s i z e d the i m p o r t a n c e o f a n t i c i p a t i n g parental needs, c o n c e r n s , a n d responses i n o r d e r to p r o v i d e e m p a t h i c parent care a n d m i n i m i z e the stresses parents associate w i t h this e x p e r i e n c e . In a d d i t i o n to e x p l o r i n g the parents' e x p l a n a t o r y m o d e l s , nurses a l s o n e e d to e x a m i n e their o w n e x p l a n a t o r y m o d e l s , v a l u e s , a n d attitudes about p a r e n t s ' e x p e r i e n c e o f their c h i l d ' s d a y care surgery.  B y d o i n g this, nurses w i l l ensure that  they d o not a s s u m e to k n o w w h a t parents need a n d understand about the e x p e r i e n c e . N u r s e s w i l l b e g i n to establish the " g r o u n d o f c o m m o n u n d e r s t a n d i n g " ( K l e i n m a n et a l . , 1978) b e t w e e n themselves a n d the patient that is essential i n order to negotiate a m u t u a l l y acceptable p l a n o f care.  If a p e d i a t r i c h e a l t h care a g e n c y adheres to a  p h i l o s o p h y o f f a m i l y centered patient care, the n e e d f o r m u t u a l u n d e r s t a n d i n g b e t w e e n parents a n d m e m b e r s o f the health care t e a m i s further e m p h a s i z e d . K n a f l , C a v a l l a r i , a n d D i x o n (1988) o b s e r v e d ,  As  122 T o be f a m i l y centered i m p l i e s that consistent, systematic efforts are m a d e to understand one another's v i e w p o i n t s a n d that o p e n n e g o t i a t i o n between f a m i l y m e m b e r s a n d nurses i s e n c o u r a g e d a n d valued.  F a m i l y centered n u r s i n g care requires that nurses a n d f a m i l y  m e m b e r s w o r k together as equals i n d e f i n i n g a n d m a n a g i n g the p e d i a t r i c h o s p i t a l i z a t i o n e x p e r i e n c e (p. 3 0 0 - 3 0 1 ) . T h e c o n c l u s i o n s d r a w n f r o m the f i n d i n g s o f this study r e v e a l that pediatric d a y care surgery i s v i e w e d b y parents as a threatening, stressful e x p e r i e n c e o c c u r r i n g o v e r a span o f t i m e b e g i n n i n g w i t h the r e a l i z a t i o n o f a p r o b l e m , a n d e x t e n d i n g to w h e n the parent(s) d e c i d e s the e x p e r i e n c e i s o v e r .  T h e parental  e x p e r i e n c e i s m u c h l o n g e r than the f e w h o u r s a c t u a l l y spent i n the h o s p i t a l setting a n d i s v i e w e d i n the b r o a d context o f e v e r y d a y l i f e as an i m p o r t a n t f a m i l y event. T h e i m p l i c a t i o n s f o r nurses are t w o f o l d .  F i r s t , nurses m u s t e x a m i n e their  current p r a c t i c e s a n d address the f i n d i n g that parental needs f o r n u r s i n g care e x t e n d b e y o n d the p a r e n t s ' stay i n the p e d i a t r i c M e d i c a l / S u r g i c a l D a y C a r e U n i t .  Second,  nurses m u s t c o n s i s t e n t l y a p p l y the f o u r steps o f the n u r s i n g p r o c e s s at e a c h o f the three t e m p o r a l phases o f the parents' e x p e r i e n c e . I n r e l a t i o n to a p p l i c a t i o n o f the n u r s i n g p r o c e s s , the n e e d f o r o n g o i n g assessment i s i m p e r a t i v e i n order to ascertain the d i m e n s i o n s o f the p a r e n t s ' e x p e r i e n c e s that contribute to f e e l i n g s o f stress.  Planning and nursing intervention  w i l l v a r y a c c o r d i n g to the i n d i v i d u a l needs o f the c l i e n t a n d the phase o f their experience.  In g e n e r a l , n u r s i n g interventions w i l l be d i r e c t e d t o w a r d s e n h a n c i n g  p a r e n t s ' c o p i n g strategies to m a n a g e stress.  E v a l u a t i o n , the essential f o u r t h step o f  the n u r s i n g p r o c e s s , w i l l ensure that n u r s i n g g o a l s f o r parent care c o n t i n u e to be  123 m e t o n an o n g o i n g basis. E x a m p l e s o f s p e c i f i c i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e w i l l be presented here a c c o r d i n g to the f r a m e w o r k o f the three c h r o n o l o g i c a l phases: p r e - h o s p i t a l i z a t i o n , h o s p i t a l i z a t i o n , and p o s t - h o s p i t a l i z a t i o n .  It i s e x p e c t e d that these e x a m p l e s m a y  assist nurses w o r k i n g i n v a r i o u s settings to i d e n t i f y c o m m o n c o n c e r n s w h i c h s h o u l d be a n t i c i p a t e d b y health p r o f e s s i o n a l s w h e n p l a n n i n g care f o r the parents o f toddlers a n d p r e s c h o o l e r w h o u n d e r g o a d a y care surgery p r o c e d u r e . T h e p r e - h o s p i t a l i z a t i o n o r preparatory phase o f the parents' e x p e r i e n c e b e g a n w i t h the p a r e n t s ' r e a l i z a t i o n that s o m e t h i n g w a s " w r o n g " w i t h their c h i l d a n d e n d e d w i t h the c h i l d ' s a d m i s s i o n to h o s p i t a l to u n d e r g o c o r r e c t i v e surgery.  D u r i n g this  p h a s e parents r e a d i e d themselves a n d their f a m i l i e s e m o t i o n a l l y a n d p h y s i c a l l y f o r the d a y care surgery event. D u r i n g the p r e - h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e the nurse m u s t assess the p a r e n t s ' interpretation, u n d e r s t a n d i n g , a n d expectations o f the event.  In  p a r t i c u l a r , gaps a n d misinterpretations o f i n f o r m a t i o n , as w e l l as p o t e n t i a l sources o f stress, s h o u l d be i d e n t i f i e d .  T h e parents' u s u a l m e t h o d s o f c o p i n g w i t h stressful  situations a n d sources o f s o c i a l support, s h o u l d a l s o be assessed i n o r d e r that these m a y be strengthened a n d e n h a n c e d as n e e d e d . A n e x a m p l e o f a s p e c i f i c i m p l i c a t i o n f o r n u r s i n g p r a c t i c e d u r i n g this phase i s the p r o v i s i o n o f a n t i c i p a t o r y g u i d a n c e r e g a r d i n g the p o s s i b l e factors c o n t r i b u t i n g to the stresses o f this e x p e r i e n c e .  T h i s n u r s i n g i n t e r v e n t i o n m a y i n c l u d e parental  g u i d a n c e r e l a t e d to: d e c i s i o n - m a k i n g r e g a r d i n g the actual s u r g i c a l p r o c e d u r e ; i n c r e a s i n g a n x i e t y a n d uncertainty as the event a p p r o a c h e s ; a n d / o r parental f e e l i n g s o f g u i l t a n d w o r r y d u e to a d d e d r e s p o n s i b i l i t i e s (particularly w i t h h o l d i n g f o o d a n d  124 fluids). A t the present t i m e , i n the a g e n c y w h e r e the study w a s c o n d u c t e d ( B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l ) , the opportunities to assess parents d u r i n g the p r e - h o s p i t a l i z a t i o n phase o f their e x p e r i e n c e are l i m i t e d .  W h e n the surgery is  a c t u a l l y b o o k e d b y the p h y s i c i a n , the parents m a y o r m a y not be seen b y a nurse, h o w e v e r , they d o r e c e i v e a d e t a i l e d i n f o r m a t i o n p a m p h l e t " G e t t i n g R e a d y f o r D a y Care" (British C o l u m b i a ' s Childrens' Hospital).  In a d d i t i o n to p r o v i d i n g i m p o r t a n t  a n d essential i n f o r m a t i o n , the p a m p h l e t addresses c o n c e r n s related to the c h i l d ' s r e a c t i o n to the surgery.  A l t h o u g h an e x c e l l e n t source o f i n f o r m a t i o n f o r parents, the  p a m p h l e t does not address parental fears related to the a n t i c i p a t i o n o f d a y care surgery event o r the r e s u l t i n g i m p a c t o f the event o n f a m i l y l i f e .  A  pamphlet  cannot be c o n s i d e r e d a substitute f o r systematic n u r s i n g assessment a n d i n t e r v e n t i o n , a n d i n f o r m a t i o n o f f e r e d to parents s h o u l d , w h e n e v e r p o s s i b l e , reflect an i n d i v i d u a l assessment. In a d d i t i o n to the p a m p h l e t , there is a preparatory v i d e o t a p e a v a i l a b l e f o r v i e w i n g b y parents a n d c h i l d r e n p r i o r to the c h i l d ' s d a y care surgery.  T h e r e i s also  a n e x p e r i e n c e d d a y care nurse a v a i l a b l e f o r o n e h o u r p e r w e e k to address parental c o n c e r n s r e g a r d i n g preparation o f the c h i l d .  T h e a v a i l a b i l i t y o f b o t h o f these  resources i s a p o s i t i v e factor i n the preparation o f f a m i l i e s f o r d a y care surgery. T h e " G e t t i n g R e a d y f o r D a y C a r e " p a m p h l e t c l e a r l y states that parents m a y c a l l the D a y C a r e U n i t i f they h a v e any questions o r c o n c e r n s about their c h i l d ' s i m p e n d i n g surgery.  It i s i m p o r t a n t to note, h o w e v e r , that based o n the f i n d i n g s o f  this study a n d others ( K n a f l , C a v a l l a r i , & D i x o n , 1988; R o b i n s o n & T h o r n e , 1984), f i r s t t i m e parents a s s u m e that health p r o f e s s i o n a l s t e l l t h e m e v e r y t h i n g they n e e d to  125 k n o w a n d are often v e r y reluctant a n d a f r a i d to m a k e requests f o r further information.  Parents i n the current study stated that they thought their questions are  " d u m b " , that they s h o u l d already k n o w the a n s w e r s , o r their c o n c e r n s w e r e t o o i n s i g n i f i c a n t to " b o t h e r " a health p r o f e s s i o n a l w i t h .  H e a l t h p r o f e s s i o n a l s w h o are  not a w a r e that parents h o l d this p e r s p e c t i v e m a y inadvertently r e i n f o r c e to parents that they t h i n k parental c o n c e r n s are i n s i g n i f i c a n t . A t B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l , o n e o r t w o d a y s p r i o r to the a c t u a l d a y care surgery a p r e a d m i s s i o n nurse f r o m the D a y C a r e U n i t p h o n e s the parent to o b t a i n s o m e b a s i c d e m o g r a p h i c i n f o r m a t i o n about the c h i l d , " a n s w e r any questions a n d r e m i n d parents o f f a s t i n g i n s t r u c t i o n s " ( B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l , 1 9 8 6 , p.3).  U n f o r t u n a t e l y , between the time that the c h i l d ' s surgery i s  b o o k e d a n d p r i o r to the n u r s e ' s telephone c a l l , there i s a s i g n i f i c a n t gap i n contact w i t h the d a y c a r e surgery f a m i l i e s .  C o m m u n i t y health nurses o r nurses e m p l o y e d i n  d o c t o r ' s o f f i c e s m a y c o m e i n t o contact w i t h these f a m i l i e s d u r i n g the p r e h o s p i t a l i z a t i o n p h a s e o f their e x p e r i e n c e a n d m a y h a v e an o p p o r t u n i t y to assess their p e r c e p t i o n s o f the event, o f f e r reassurance r e g a r d i n g the v a l i d i t y o f their c o n c e r n s , and answer questions. T h e p r e a d m i s s i o n n u r s e ' s telephone c a l l to the parent one o r t w o d a y s p r i o r to the c h i l d ' s surgery i s t i m e l y because it i s k n o w n that the p a r e n t s ' a n x i e t y about their c h i l d ' s d a y care surgery increases as the event approaches.  If time permits,  this telephone c a l l i s an e x c e l l e n t o p p o r t u n i t y to d i s c u s s parental anxieties a n d address parental c o n c e r n s i n an e m p a t h i c m a n n e r . p o i n t are r e a l .  P a r e n t a l w o r r i e s a n d fears at this  I f parents are t o l d that they h a v e " n o t h i n g to w o r r y a b o u t " , it o n l y  serves to r e i n f o r c e the d i f f e r e n c e s b e t w e e n the p a r e n t ' s p e r s p e c t i v e o f the event a n d  126 that o f the health p r o f e s s i o n a l ( K n o x & H a y e s , 1983). T h e h o s p i t a l i z a t i o n o r operative phase o c c u r r e d d u r i n g the three to s i x hours that the parent(s) a n d c h i l d w e r e a c t u a l l y i n the h o s p i t a l setting.  T h i s is a highly  e m o t i o n a l , intense phase o f the e x p e r i e n c e as the f i n a l preparations f o r surgery are m a d e a n d the parent(s) r e l i n q u i s h their c h i l d to the care o f health care p r o f e s s i o n a l s i n o r d e r that the surgery c a n be p e r f o r m e d .  T h e f i n d i n g s o f this study r e v e a l that  parents a r r i v e d at the D a y C a r e U n i t f e e l i n g a n x i o u s as a result o f b e i n g u n a b l e to c o m f o r t their c h i l d r e n i n u s u a l w a y s a n d f e e l i n g uncertain about the i m p e n d i n g event a n d its o u t c o m e .  R e l i n q u i s h i n g the c h i l d , w a i t i n g f o r the c h i l d ' s r e t u r n , a n d  then r e u n i t i n g w i t h h i m / h e r w e r e a l l stressful points o f this phase o f the e x p e r i e n c e f o r parents.  A t these p o i n t s , nurses h a v e an i m p o r t a n t r o l e to p l a y i n d e m o n s t r a t i n g  s e n s i t i v i t y to the p a r e n t s ' needs b y p r o v i d i n g relevant i n f o r m a t i o n , r e a s s u r a n c e , a n d support.  F o r e x a m p l e , w h e n parents felt p r e p a r e d f o r their c h i l d ' s return to the D a y  C a r e U n i t f r o m the R e c o v e r y R o o m , it h a d a v e r y p o s i t i v e effect o n the parent a n d h i s / h e r f e e l i n g s about their d a y care surgery e x p e r i e n c e . A p a r t i c u l a r l y stressful time f o r parents w a s d u r i n g the w a i t i n g p e r i o d f o r t h e m i n the D a y C a r e U n i t after their c h i l d h a d left f o r the o p e r a t i n g r o o m .  Parents  e x p r e s s e d acute fears related to their c h i l d r e n ' s m o r b i d i t y a n d m o r t a l i t y e s p e c i a l l y related to the r i s k s inherent i n r e c e i v i n g a g e n e r a l anesthetic.  Appropriate nursing  i n t e r v e n t i o n s at this t i m e s h o u l d i n c l u d e not o n l y reassurance but an empathetic a c k n o w l e d g e m e n t o f the intensity o f parental fears.  N u r s i n g i n t e r v e n t i o n s to  e n h a n c e parental c o p i n g strategies at this t i m e w o u l d a l s o be appropriate.  T h e fact  that a l l parents are a s k e d to h a v e another adult a c c o m p a n y t h e m to the D a y C a r e U n i t i s i m p o r t a n t i n the p r o v i s i o n o f s o c i a l support at this t i m e .  127 W h i l e i n the D a y C a r e U n i t , m o s t parents r e m a i n f o c u s e d o n the c h i l d ' s i m m e d i a t e p r e - a n d post-operative needs.  It i s often not u n t i l they return h o m e that  the m o r e m i n o r issues affecting their d a y to d a y l i v e s b e c o m e apparent.  D u r i n g the  h o s p i t a l i z a t i o n p h a s e , nurses n e e d to o f f e r anticipatory g u i d a n c e that i s relevant to p a r e n t s ' needs a n d perspectives i n o r d e r to a i d i n their transition to the p o s t - h o s p i t a l i z a t i o n phase o f their e x p e r i e n c e . P o s t - o p e r a t i v e i n s t r u c t i o n p a m p h l e t s a n d v e r b a l post-operative t e a c h i n g h e l p to b r i d g e the gap b e t w e e n h o s p i t a l a n d h o m e .  P a m p h l e t s , h o w e v e r h e l p f u l , are b y  nature f o r c e d to be s o m e w h a t general therefore c a n n o t address the c o n c e r n s o f a l l parents a n d s h o u l d not b e c o n s i d e r e d a substitute f o r i n d i v i d u a l i z e d n u r s i n g interventions.  D u r i n g the h o s p i t a l i z a t i o n phase o f the e x p e r i e n c e parents m a y f a i l to  "take i n " a l l o f the i n f o r m a t i o n that has been o f f e r e d to t h e m .  Their lack of  p r e v i o u s e x p e r i e n c e a n d their f a i t h i n their care p r o v i d e r s , often prevents t h e m f r o m a s k i n g pertinent questions.  T h i s h i g h l i g h t s the n e e d f o r nurses to p r o v i d e  appropriate a n d r e l e v a n t anticipatory g u i d a n c e , rather than w a i t f o r these parents to ask q u e s t i o n s . T h e p o s t - h o s p i t a l i z a t i o n o r re-adjustment phase b e g a n u p o n h o s p i t a l d i s c h a r g e a n d c o n t i n u e d u n t i l the c h i l d h a d r e c o v e r e d p h y s i c a l l y a n d e m o t i o n a l l y  from  the  surgery a n d a l l f a m i l y m e m b e r s h a d returned to acceptable patterns o f d a i l y l i v i n g . T h e telephone c a l l that parents r e c e i v e from a nurse i n the D a y C a r e U n i t (at B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l ) o n the c h i l d ' s first p o s t - o p e r a t i v e d a y i s a v e r y t i m e l y o p p o r t u n i t y to address s o m e o f the parental c o n c e r n s that m a y h a v e arisen s i n c e the a r r i v a l h o m e .  S p e c i f i c n u r s i n g i m p l i c a t i o n s f o r this phase o f the  p a r e n t s ' e x p e r i e n c e relate to e n h a n c i n g c r e a t i v i t y a n d f l e x i b i l i t y i n parental c o p i n g  128 abilities.  P r o v i d i n g i n f o r m a t i o n a n d support w i l l assist parents w i t h the concrete  c h a n g e s they f a c e i n their d a i l y routines a n d activities. In a d d i t i o n , this f o l l o w - u p telephone c a l l is a n e x c e l l e n t o p p o r t u n i t y to b e g i n the e v a l u a t i o n phase o f the n u r s i n g p r o c e s s .  A "flow-through" nursing care p l a n ,  w h i c h c o u l d be i n i t i a t e d b y the p r e a d m i s s i o n d a y care n u r s e , a d d e d to b y the nurses c a r i n g f o r the f a m i l y d u r i n g the h o s p i t a l i z a t i o n phase, a n d c o m p l e t e d b y the d a y care nurse m a k i n g the f o l l o w - u p telephone c a l l , w o u l d facilitate a p p l i c a t i o n o f the n u r s i n g p r o c e s s a n d ensure c o n t i n u i t y o f n u r s i n g care f o r these f a m i l i e s . s h o u l d be m a d e f o r further f o l l o w - u p o f f a m i l i e s i f n e e d e d .  Provision  R e f e r r a l s to c o m m u n i t y  h e a l t h a n d h o m e care nurses to p r o v i d e f o l l o w - u p h o m e v i s i t s m a y be appropriate i n s o m e situations. T h e f i n d i n g s o f this study not o n l y r e v e a l i m p l i c a t i o n s f o r n u r s i n g practice but a l s o s h o w that parents are r e s o u r c e f u l i n the m a n a g e m e n t o f their c h i l d ' s care d u r i n g the d a y care surgery e x p e r i e n c e .  In g e n e r a l , parents r e f l e c t that this first  t i m e e x p e r i e n c e w a s m o r e p o s i t i v e than they h a d anticipated. N u r s e s h a v e a s i g n i f i c a n t r o l e to p l a y i n the care o f f a m i l i e s w i t h y o u n g c h i l d r e n w h o u n d e r g o d a y care surgery. D i x o n ( 1 9 8 8 ) , the  A s w a s stated b y K n a f l , C a v a l l a r i ,  &  " u n i q u e n e s s o f the p e d i a t r i c n u r s e ' s w o r k rests i n the fact that  she p r a c t i c e s her n u r s i n g s k i l l s o n c h i l d r e n a n d m u s t take the parents i n t o a c c o u n t as she p r o v i d e s c a r e " (p.272).  In the f o l l o w i n g s e c t i o n , i m p l i c a t i o n s f o r n u r s i n g  e d u c a t i o n w i l l be d i s c u s s e d . Implications for Nursing Education T h e f i n d i n g s and c o n c l u s i o n s f r o m this study p o i n t to s e v e r a l i m p l i c a t i o n s f o r nursing education.  F i r s t , i f nurses are to p r o v i d e r e s p o n s i b l e , s u p p o r t i v e , and  129 e f f e c t i v e health c a r e , they m u s t d e v e l o p the c o m m u n i c a t i o n s k i l l s n e e d e d to e x p l o r e c l i e n t s ' e x p l a n a t o r y m o d e l s f o r their i l l n e s s e x p e r i e n c e s .  Inservice educational  opportunities w i t h i n agencies, continuing nursing education courses, and opportunities i n f o r m a l n u r s i n g e d u c a t i o n p r o g r a m s s h o u l d b e m a d e a v a i l a b l e to support the d e v e l o p m e n t o f s u c h s k i l l s . A s nurses a n d n u r s i n g students l e a r n to enlist c l i e n t s ' e x p l a n a t o r y m o d e l s , they m u s t also c a r e f u l l y e x a m i n e their o w n a s s u m p t i o n s , v a l u e s , a n d b e l i e f s , a n d l e a r n to i n c o r p o r a t e this u n d e r s t a n d i n g a n d awareness i n t o c l i n i c a l p r a c t i c e ( A n d e r s o n , 1987).  A s the f i n d i n g s o f this study i n d i c a t e , an u n d e r s t a n d i n g o f the  p a r e n t s ' e x p e r i e n c e f r o m the parents' p o i n t o f v i e w w o u l d e n a b l e nurses to i n c o r p o r a t e this k n o w l e d g e i n t o a m u t u a l l y s a t i s f y i n g p l a n o f care. A n o t h e r i m p l i c a t i o n f r o m this study relates to the care o f the c l i e n t outside the acute care setting.  N u r s i n g c u r r i c u l a , w i t h their p r o m i n e n t acute care f o c i , often  f a i l to e m p h a s i z e the care o f the c l i e n t outside the h o s p i t a l e n v i r o n m e n t .  Client  p r e p a r a t i o n f o r h o s p i t a l i z a t i o n a n d p l a n n i n g f o r d i s c h a r g e are often not e m p h a s i z e d i n n u r s i n g c o u r s e content.  A s the f i n d i n g s o f this study i n d i c a t e , the h o s p i t a l i z a t i o n  phase o f the p a r e n t s ' e x p e r i e n c e s w a s o n l y one aspect o f the total i l l n e s s e x p e r i e n c e . It it therefore i m p l i e d that n u r s i n g e d u c a t i o n e m p h a s i z i n g the needs o f the c l i e n t s i n the p r e - and post- h o s p i t a l i z a t i o n phases o f their i l l n e s s m a y better prepare nurses w h o p r a c t i c e o u t s i d e the h o s p i t a l setting to p r o v i d e q u a l i t y care to p a r t i c u l a r c l i e n t groups.  It m a y a l s o sensitize the nurses w h o w o r k i n acute care settings to the  needs o f their c l i e n t s before a n d after h o s p i t a l i z a t i o n . A t h i r d i m p l i c a t i o n f o r n u r s i n g e d u c a t i o n is related to f a m i l y centered n u r s i n g care i n a p e d i a t r i c setting.  A s i s w e l l d o c u m e n t e d b y other authors  ( H y m o v i c h , 1976 &  1 9 8 1 ; L i t m a n , 1974), a c h i l d ' s i l l n e s s i n v o l v e s a n d affects a l l  m e m b e r s o f the f a m i l y , e s p e c i a l l y parents a n d s i b l i n g s .  A s n u r s i n g m o d e l s often  f o c u s care o n the c l i e n t as an i n d i v i d u a l , n u r s i n g educators must c o n t i n u e to e m p h a s i z e the n e e d f o r f a m i l y centered care. F a m i l y c e n t e r e d care i n the acute care setting has often b e e n equated w i t h c e r t a i n p o l i c i e s s u c h as o p e n v i s i t i n g hours a n d i n c r e a s e d parental p a r t i c i p a t i o n i n care.  In the a p p l i c a t i o n o f research f i n d i n g s to p r a c t i c e a n d e d u c a t i o n nurses must  be a w a r e that "too o f t e n p r o g r a m s o f f a m i l y - c e n t e r e d care reflect w h a t p r o f e s s i o n a l s t h i n k f a m i l i e s s h o u l d w a n t as o p p o s e d to w h a t f a m i l i e s a c t u a l l y m a y w a n t " C a v a l l a r i , & D i x o n , 1 9 8 8 , p. 2 9 9 ) .  (Knafl,  It i s therefore essential that p a r e n t s ' p e r s p e c t i v e  o f their health care encounters be i n c l u d e d i n n u r s i n g c u r r i c u l a .  In the  following  s e c t i o n , i m p l i c a t i o n s f o r n u r s i n g research w i l l be d i s c u s s e d . Implications for Nursing Research D u r i n g the p r o c e s s o f the current study, the researcher b e c a m e aware o f i m p l i c a t i o n s f o r further research i n the area o f parent care a n d pediatric d a y care surgery.  First,  a l t h o u g h the current study e x p l o r e d the p a r e n t s ' first  time  e x p e r i e n c e w i t h y o u n g c h i l d r e n u n d e r g o i n g a d a y care s u r g i c a l p r o c e d u r e , a large p r o p o r t i o n o f d a y care p r o c e d u r e s p e r f o r m e d are s e c o n d o r subsequent procedures. W i t h a h i g h percentage o f f a m i l i e s e x p e r i e n c i n g repeat procedures o n their c h i l d r e n , it w o u l d be v a l u a b l e f o r nurses to learn h o w the parents' p e r s p e c t i v e o f the e x p e r i e n c e c h a n g e s w i t h subsequent h o s p i t a l a d m i s s i o n s .  T h e results o f s u c h a  study w o u l d o f f e r nurses g u i d e l i n e s as to h o w they c o u l d best assess, p l a n , i m p l e m e n t , a n d evaluate care f o r parents returning to the D a y C a r e U n i t f o r repeat admissions.  131 T h e current study e x a m i n e d the e x p e r i e n c e s o f parents o f toddlers a n d preschoolers only.  A v a l u a b l e a d d i t i o n to current k n o w l e d g e w o u l d result  from  an  e x a m i n a t i o n o f the p e r s p e c t i v e s o f parents o f y o u n g e r or o l d e r c h i l d r e n w h o u n d e r g o d a y c a r e surgery.  I n a d d i t i o n , a study i n c o r p o r a t i n g the p e r s p e c t i v e s o f a greater  n u m b e r o f fathers as w e l l as s i b l i n g s w o u l d a d d a f a m i l y p e r s p e c t i v e to this important experience. A further i m p l i c a t i o n f o r n u r s i n g research w o u l d be to use a r e l i a b l e a n d v a l i d m e a s u r e m e n t t o o l to m e a s u r e the l e v e l s o f stress parents f e e l at v a r i o u s points o f their e x p e r i e n c e .  T h e f i n d i n g s o f s u c h a study w o u l d d o c u m e n t i n a q u a n t i f i e d  m a n n e r the n e e d f o r i n t e r v e n t i o n at p a r t i c u l a r p o i n t s o f the p a r e n t s ' e x p e r i e n c e . A l o g i c a l f o l l o w - u p to the current study w o u l d be a c o m b i n e d q u a l i t a t i v e and quantitative research project d e s i g n e d to evaluate a n d c o m p a r e the effect o f n u r s i n g i n t e r v e n t i o n s o n the e x p e r i e n c e s o f t w o g r o u p s o f parents u n d e r g o i n g their s o n o r d a u g h t e r ' s d a y care surgery f o r the first t i m e .  T h e e x p e r i m e n t a l group o f parents  w o u l d r e c e i v e n u r s i n g i n t e r v e n t i o n d i r e c t e d at r e d u c i n g the stresses inherent i n this experience.  T h e c o n t r o l g r o u p w o u l d be w e l l - m a t c h e d subjects w h o w o u l d r e c e i v e  o n l y standard n u r s i n g care.  T h e intent o f s u c h a study w o u l d b e to support o r  reject the v a l u e o f s p e c i f i c n u r s i n g interventions i n i m p r o v i n g the q u a l i t y o f care o f f e r e d to these f a m i l i e s . It i s e v i d e n t f r o m the suggestions presented here that parent care i n p e d i a t r i c d a y c a r e surgery requires c o n t i n u e d i n v e s t i g a t i o n .  T h e n e e d f o r further research i n  this i m p o r t a n t area i s e m p h a s i z e d b y R o b i n s o n (1972) w h o o b s e r v e d that " m u c h i s k n o w n a n d w r i t t e n about c h i l d patients, their b e h a v i o u r , their needs a n d their treatment, v e r y little i s k n o w n s y s t e m a t i c a l l y about the attitudes a n d b e h a v i o u r o f  132  their parents" (p. 447). In conclusion, the nine parents who participated in this study contributed an abundance of rich data about their first time experience with their childrens' pediatric day care surgery. From the data collected, the writer developed a theory which significantly contributes to health professionals' current knowledge about the parents' perspective of this experience. The findings of this study suggest that understanding the parents' perspective is necessary in order to positively intervene in their illness experience and improve the quality of nursing care offered to this large group of health care consumers.  133  References A d a m s , E . & S a r a s o n , I. G . (1963). R e l a t i o n s h i p s B e t w e e n A n x i e t y i n C h i l d r e n a n d T h e i r Parents. C h i l d D e v e l o p m e n t . 3 4 , 2 3 7 - 2 4 6 . A g u i l e r a , D . C . & M e s s i c k , J . M . (1978). C r i s i s i n t e r v e n t i o n : M e t h o d o l o g y (3rd ed.). St. L o u i s : M o s b y .  Theory and  A l g r e n , C . (1985). R o l e p e r c e p t i o n o f mothers w h o h a v e h o s p i t a l i z e d c h i l d r e n . C h i l d r e n ' s H e a l t h C a r e . 14(1), 6 - 9 . A n d e r s o n , J . (1981). A n interpretive a p p r o a c h to c l i n i c a l n u r s i n g r e s e a r c h . Papers. 13(4), 6-12.  Nursing  A n d e r s o n , J . M . ( 1 9 8 7 ) . M i g r a t i o n a n d health: P e r s p e c t i v e s o n i m m i g r a n t w o m e n . S o c i o l o g y o f H e a l t h and I l l n e s s : A J o u r n a l o f M e d i c a l S o c i o l o g y . 9(4), 410-438. A n d e r s o n , J . & C h u n g , J . (1982). C u l t u r e a n d i l l n e s s : p a r e n t s ' preceptions o f thenc h i l d ' s l o n g t e r m i l l n e s s . N u r s i n g P a p e r s . 14(4). 4 0 - 5 1 . A r n o l d , L . E . ( E d . ) . (1978). H e l p i n g parents h e l p their c h i l d r e n . N e w Y o r k : Brunne/Mazel. A t w e l l , J . D . , B u r n , J . M . B . , D e w a r , A . K . , & F r e e m a n , N . V . (1973). D a y - C a s e S u r g e r y . T h e L a n c e t . 1, 8 9 5 - 9 7 .  Pediatric  B e l m o n t , H . S . (1970). H o s p i t a l i z a t i o n a n d its effect u p o n the total c h i l d . Pediatrics. 9, 472-483. B e v e r l y , B . I. ( 1 9 3 6 ) . E f f e c t o f i l l n e s s o n e m o t i o n a l d e v e l o p m e n t . P e d i a t r i c s . 8, 5 3 3 - 5 3 6 .  Clinical  Journal o f  B o u l t o n , M . G . (1983). O n b e i n g a mother: A study o f w o m e n w i t h p r e s c h o o l children. L o n d o n : Tavistock. B o w l b y , J . ( 1 9 5 1 ) . M a t e r n a l care a n d c h i l d health. M o n o g r a p h S e r i e s . ( N o . 2).  W o r l d Health Organization  B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l (1987). A n n u a l report 1 9 8 6 / 8 7 . V a n c o u v e r , B C : Author. British  C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l (1986). G o i n g h o m e sooner w i t h m e d i c a l / s u r g i c a l d a y care. S p e a k i n g o f C h i l d r e n . 1-3.  11(2),  B r i t i s h C o l u m b i a ' s C h i l d r e n s ' H o s p i t a l . G e t t i n g R e a d y f o r D a y C a r e (pamphlet). Vancouver, B C : Author.  B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h H o s p i t a l P r o g r a m s R e s e a r c h D i v i s i o n (1985). Report o n D a y Care Surgery. V i c t o r i a , B C : Author. B r o w n , B . (1979). B e y o n d separation: S o m e n e w e v i d e n c e o n the i m p a c t o f b r i e f h o s p i t a l i z a t i o n o n y o u n g c h i l d r e n . In D . H a l l & M . S t a c e y ( E d s . ) , B e y o n d separation: F u r t h e r studies o f c h i l d r e n i n h o s p i t a l (pp. 18-53). L o n d o n : Routledge & Kegan Paul. B r o w n l e e , R . C . (1977). T h e case f o r d a y - c a r e surgery (Letter to the editor). P e d i a t r i c s . 60_, 6 5 0 - 5 1 . C a n a d a C o u n c i l , (1977). E t h i c s : R e p o r t o f the c o n s u l t a t i v e group o n ethics. Ottawa, O N T : Author. C a p l a n , G . ( 1 9 7 6 ) . T h e f a m i l y as a support s y s t e m . In G . C a p l a n & M . K i l l i l e a ( E d s . ) , S u p p o r t systems a n d m u t u a l h e l p : M u l t i d i s c i p l i n a r y e x p l o r a t i o n s . N e w Y o r k : G r u n e & Stratton. C a r l s o n , P . , S i m a c e k , M . , H e n r y , W . F . , & M a r t i n s o n , I. M . ( 1 9 8 5 ) . H e l p i n g parents c o p e : A m o d e l h o m e - c a r e p r o g r a m f o r the d y i n g c h i l d . Issues i n C o m p r e h e n s i v e P e d i a t r i c N u r s i n g . 8, 1 1 3 - 1 2 7 . C a s s e l , J . ( 1 9 7 6 ) . T h e c o n t r i b u t i o n o f the s o c i a l e n v i r o n m e n t to host resistance. A m e r i c a n J o u r n a l o f E p i d e m i o l o g y . 104. 1 0 7 - 1 2 3 . C l a r k e , M . ( 1 9 8 4 ) . Stress a n d c o p i n g : C o n s t r u c t s f o r n u r s i n g . N u r s i n g . 9, 3-13.  Journal of Advanced  C l o u d , D . T., Reed, W . A . , F o r d , J . L., Linkner, L. M . , Trump, D. S., & Dorman, G . W . (1972). T h e surgi-center: A fresh c o n c e p t i n outpatient p e d i a t r i c surgery. J o u r n a l o f P e d i a t r i c S u r g e r y . 7 , 2 0 6 - 2 1 1 . C o b b , S . ( 1 9 7 6 ) . S o c i a l support as a m o d e r a t o r o f l i f e stress. P s y c h o s o m a t i c Medicine. 38, 300-314. C o h e n , F . (1985). Stress a n d b o d i l y i l l n e s s . In A . M o n a t & R . S . L a z a r u s ( E d s . ) , Stress a n d c o p i n g : A n a n t h o l o g y ( 2 n d ed.) (pp. 4 0 - 5 4 ) . N e w Y o r k : C o l u m b i a U n i v e r s i t y Press. D a v e n p o r t , H . T . , & W e r r y , J . S . (1970). T h e effect o f general anesthesia, surgery a n d h o s p i t a l i z a t i o n u p o n the b e h a v i o r o f c h i l d r e n . A m e r i c a n J o u r n a l o f Orthopsychiatry. 40, 806-824. D a v e n p o r t , H . T . , S h a h , C . P . , & R o b i n s o n , G . C . (1971). D a y surgery f o r children. C a n a d i a n M e d i c a l A s s o c i a t i o n Journal. 105. 4 9 8 - 5 0 1 . D a v i s , A . J . (1978). T h e p h e n o m e n o l o g i c a l a p p r o a c h f o r n u r s i n g research. In N . L . C h a s k a ( E d . ) , T h e n u r s i n g p r o f e s s i o n : V i e w s t h r o u g h the m i s t (pp. 186-197). New York: McGraw-Hill.  135  D i e r s , D . (1979).  R e s e a r c h i n n u r s i n g practice.  Philadelphia:  Lippincott.  D i a m o n d , M . , & J o n e s , S . L . (1983). S o c i a l support: A r e v i e w a n d theoretical integration. In P . L . C h i n n ( E d . ) , A d v a n c e s i n n u r s i n g theory d e v e l o p m e n t (pp. 2 3 5 - 2 4 7 ) . R o c k v i l l e , M D : A s p e n . D o r n , L . (1984). C h i l d r e n ' s c o n c e p t s o f i l l n e s s : C l i n i c a l a p p l i c a t i o n s . N u r s i n g . 10, 3 2 5 - 3 2 7 .  Pediatric  D r o s k e , S . C . (1978). C h i l d r e n ' s b e h a v i o r a l changes f o l l o w i n g h o s p i t a l i z a t i o n H a v e w e p r e p a r e d the parents? J o u r n a l o f the A s s o c i a t i o n f o r the C a r e o f C h i l d r e n i n H o s p i t a l s . 7(2), 3 - 7 . D u n n , P . C . (1985). W o m e n ' s perceptions o f their i l l n e s s e x p e r i e n c e w i t h m y o c a r d i a l i n f a r c t i o n . U n p u b l i s h e d m a s t e r ' s thesis, U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, B . C . E c k e n h o f f , J . E . (1953). R e l a t i o n s h i p o f anesthesia to postoperative p e r s o n a l i t y c h a n g e s i n c h i l d r e n . A m e r i c a n J o u r n a l o f the D i s e a s e s o f C h i l d r e n . 8 6 . 587-91. E l - S h a f i e , M . , & S h a p i r o R . P . (1977). Outpatient pediatric surgery i n a d e v e l o p i n g country. Pediatrics. 60, 600-602. F e r r a r i , M . (1986). P e r c e p t i o n s o f s o c i a l support b y parents o f c h r o n i c a l l y i l l versus healthy c h i l d r e n . C h i l d r e n ' s H e a l t h C a r e . 15(1), 2 6 - 3 1 . F l e t c h e r , B . (1981). P s y c h o l o g i c a l upset i n p o s t h o s p i t a l i z e d c h i l d r e n : A r e v i e w o f the literature. M a t e r n a l - C h i l d N u r s i n g J o u r n a l . 10. 1 8 5 - 9 5 . F r i e b e r g , K . (1972). H o w parents react w h e n their c h i l d is h o s p i t a l i z e d . Journal of N u r s i n g . 72, 1270-1272.  American  F i e l d , P . A . , & M o r s e , J . M . (1985). N u r s i n g r e s e a r c h : T h e a p p l i c a t i o n o f q u a l i t a t i v e approaches. R o c k v i l l e , M D : A s p e n . F r i e d m a n , M . M . (1986). F a m i l y N u r s i n g T h e o r y and A s s e s s m e n t ( 2 n d ed.). N e w York: Appleton-Century-Crofts. G o f m a n , H . , B u c k m a n , W . , & S c h a d e , G . H . (1957). P a r e n t s ' e m o t i o n a l response to c h i l d ' s h o s p i t a l i z a t i o n . A m e r i c a n J o u r n a l o f the D i s e a s e s o f C h i l d r e n . 9 3 , 629-637. G o o d e , W . I . (1960). T h e o r y o f r o l e strain. A m e r i c a n S o c i o l o g i c a l R e v i e w . 2 5 . 488-496.  136 G i o r g i , A . (1975a). A n a p p l i c a t i o n o f p h e n o m e n o l o g i c a l m e t h o d i n p s y c h o l o g y . In A . G i o r g i , C . F i s c h e r , & E . M u r r a y ( E d s . ) , D u s q u e s n e studies i n p h e n o m e n o l o g i c a l p s y c h o l o g y . V o l u m e II (pp. 8 3 - 1 0 3 ) . P i t t s b u r g h : Dusquesne. G i o r g i , A . (1975b). C o n v e r g e n c e a n d d i v e r g e n c e o f qualitative a n d quantitative m e t h o d s i n p s y c h o l o g y . In A . G i o r g i , C . F i s c h e r , & E . M u r r a y ( E d s . ) , D u s q u e s n e studies i n p h e n o m e n o l o g i c a l p s y c h o l o g y . V o l u m e II (pp. 7 2 - 7 9 ) . Pittsburgh: Dusquesne. G o u l d - M a r t i n , K . , & N g i n , C . (1981). C h i n e s e A m e r i c a n s . In A . H a r w o o d ( E d . ) , E t h n i c i t y a n d M e d i c a l C a r e (pp. 142-170). C a m b r i d g e , M A : H a r v a r d University. H a n d e l , G . (1970). S o c i o l o g i c a l aspects o f p a r e n t h o o d . I n E . J . A n t h o n y & T . B e n e d e k ( E d s . ) , P a r e n t h o o d : It's p s y c h o l o g y a n d p s y c h o p a t h y (pp. 8 7 - 1 0 5 ) . Boston: Little, B r o w n , & C o . H a n n a l l a h , R . S . , & R o s a l e s , J . K . (1983). E x p e r i e n c e w i t h p a r e n t s ' presence d u r i n g anaesthesia i n d u c t i o n i n c h i l d r e n . C a n a d i a n A n a e s t h e t i s t s S o c i e t y Journal. 30, 286-289. H a y e s , V . E . & J . E . K n o x (1984). T h e e x p e r i e n c e o f stress i n parents o f c h i l d r e n hospitalized w i t h long-term disabilities. Journal o f A d v a n c e d N u r s i n g . 9, 333-341. H e l l e r , K . ( 1 9 7 0 ) . T h e effects o f s o c i a l support: P r e v e n t i o n a n d treatment i m p l i c a t i o n s . In A . P . G o l d s t e i n & F . H . K a n f e r ( E d s . ) , M a x i m i z i n g treatment gains: T r a n s f e r enhancement i n p s y c h o t h e r a p y (pp. 3 5 3 - 3 8 2 ) . N e w Y o r k : Academic. H e r z f e l d , G . (1938). H e r n i a i n infancy.  A m e r i c a n Journal of Surgery. 39, 422.  H y m o v i c h , D . P . (1976). Parents o f s i c k c h i l d r e n : T h e i r needs a n d tasks. N u r s i n g . 2(5), 9-13.  Pediatric  H y m o v i c h , D . P . (1981). A s s e s s i n g the i m p a c t o f c h r o n i c c h i l d h o o d i l l n e s s o n the f a m i l y a n d parent c o p i n g . Image. 13. 7 1 - 7 4 . H y m o v i c h , D . P . (1984). D e v e l o p m e n t o f the c h r o n i c i t y i m p a c t a n d c o p i n g i n s t r u m e n t : Parent questionnaire ( C I C L P Q ) . N u r s i n g R e s e a r c h . 33(4), 218-222. H y m o v i c h , D . P . , & C . D . B a k e r (1985). T h e needs, c o n c e r n s , a n d c o p i n g o f parents o f c h i l d r e n w i t h c y s t i c f i b r o s i s . F a m i l y R e l a t i o n s . 3 4 , 9 1 - 9 7 . J a c k s o n , E . B . (1942). T h e treatment o f the y o u n g c h i l d i n h o s p i t a l . J o u r n a l o f O r t h o p s y c h i a t r y . 12. 5 6 - 5 8 .  American  137 J o h n s o n , G . G . (1983). D a y care surgery f o r infants a n d c h i l d r e n . Anesthetists Society Journal. 30, 553-557.  Canadian  J o h n s o n , S . H . (1979). R o l e theory strategies. In S . H . J o h n s o n ( E d . ) H i g h r i s k p a r e n t i n g : N u r s i n g assessment and strategies f o r the f a m i l y at risk, (pp. 318-328). Toronto: Lippincott. K a p l a n , B . , C a s s e l , J . , & G o r e , S . (1977). S o c i a l support a n d health. 15, 4 7 - 5 8 .  M e d i c a l Care.  K e a n e , S . , G a r r a l d a , M . E . , & K e e n , J . H . (1986). R e s i d e n t parents d u r i n g p a e d i a t r i c a d m i s s i o n s . International J o u r n a l o f N u r s i n g S t u d i e s . 2 3 ( 3 ) , 247-253. K e s t e n b e r g , J . S . ( 1 9 7 0 ) . T h e effect o n parents o f the c h i l d ' s t r a n s i t i o n i n t o a n d out o f l a t e n c y . In E . J . A n t h o n y & T . B e n e d e k ( E d s . ) , P a r e n t h o o d : It's p s y c h o l o g y a n d p s y c h o p a t h y (pp. 2 8 9 - 3 0 6 ) . B o s t o n : L i t t l e , B r o w n , & C o . K l e i n m a n , A . (1978). C o n c e p t s a n d a m o d e l f o r c o m p a r i s o n o f m e d i c a l systems as c u l t u r a l systems. S o c i a l S c i e n c e a n d M e d i c i n e . 12. 8 5 - 9 3 . K l e i n m a n , A . , E i s e n b e r g , L . , & G o o d , B . (1978). C u l t u r e , i l l n e s s , a n d care: C l i n i c a l lessons f r o m a n t h r o p o l g y a n d c r o s s - c u l t u r a l research. A n n a l s o f Internal M e d i c i n e . 88, 251-218. K n a f l , K . A . , C a v a l l a r i , K . A . , & D i x o n , D . M . (1988). P e d i a t r i c h o s p i t a l i z a t i o n : F a m i l y a n d nurse p e r s p e c t i v e s . G l e n v i e w , I L : Scott, F o r e s m a n , & C o . Knox, J. E., & H a y e s , V . E . (1983). H o s p i t a l i z a t i o n o f a c h r o n i c a l l y i l l c h i l d : A stressful time f o r parents. Issues i n C o m p r e h e n s i v e P e d i a t r i c N u r s i n g . 6(4), 217-226. K u p s t , M . J . , D r e s s e r , K . , S c h u l m a n , J . L . , & P a u l , M . H . (1976). I m p r o v i n g p h y s i c i a n - p a r e n t c o m m u n i c a t i o n . J o u r n a l o f C l i n i c a l P e d i a t r i c s . 15(1), 2 7 - 3 0 . L a n g f o r d , W . S. (1948). P h y s i c a l illness and convalescence: child. Journal of Pediatrics. 33, 242-245. L a w r i e , R. (1964).  O p e r a t i n g o n c h i l d r e n as d a y - c a s e s .  T h e i r m e a n i n g to the  T h e Lancet. 2, 1289-92.  L a z a r u s , R . S . (1966). P s y c h o l o g i c a l stress a n d the c o p i n g p r o c e s s . N e w Y o r k : McGraw-Hill. L a z a r u s , R . S . , & F o l k m a n , S . ( 1 9 8 4 ) . Stress. A p p r a i s a l a n d C o p i n g . N e w Y o r k : Springer. L a z a r u s , R . S . & L a u n i e r , R . (1978). Stress related transactions b e t w e e n p e r s o n and e n v i r o n m e n t . In L . A . P e r v i n & M . L e w i s ( E d s ) . P e r s p e c t i v e s i n international p s y c h o l o g y (pp. 2 8 7 - 3 2 7 ) . N e w Y o r k : P l e n u m .  138 L a z a r u s , R . S . , A v e r i l l , J . R . , & O p t o n , E . M . (1974). T h e p s y c h o l o g y o f c o p i n g : Issues o f research a n d assessment. In G . V . C o e l h o , D . A . H a m b u r g , & J . E . A d a m s ( E d s ) . C o p i n g a n d A d a p t a t i o n (pp. 2 4 9 - 3 1 5 ) . N e w Y o r k : B a s i c B o o k s . L e V i n e , R . A . ( 1 9 7 4 ) . P a r e n t a l goals: A C r o s s - c u l t u r a l v i e w . T e a c h . C o l l . R e c . 7 6 . 266-239. L i t m a n , T . J . (1974). T h e f a m i l y as a b a s i c u n i t i n health a n d m e d i c a l care: A s o c i a l - b e h a v i o r a l o v e r v i e w . S o c i a l S c i e n c e a n d M e d i c i n e . 8, 4 9 5 - 5 1 9 . L i t w a k , E . & S z e l e n y i , I. (1969). P r i m a r y g r o u p structures a n d their f u n c t i o n s : K i n , n e i g h b o r s , a n d friends. A m e r i c a n J o u r n a l S o c i o l o g y R e v i e w . 3 4 . 4 6 5 - 4 7 8 . L o f l a n d , J . , & L o f l a n d , L . (1984). CA: Wadsworth.  A n a l y z i n g s o c i a l settings ( 2 n d ed.).  Belmont,  L y n a m , M . J . ( 1 9 8 7 ) . T h e parent support n e t w o r k i n o n c o l o g y : S u p p o r t i v e o r not? C a n c e r N u r s i n g . 10(4), 2 0 7 - 2 1 6 . L y n c h - S a u e r , J . (1985). U s i n g a p h e n o m e n o l o g i c a l research m e t h o d to study n u r s i n g p h e n o m e n a . In M . M . L e i n i n g e r ( E d . ) , Q u a l i t a t i v e research m e t h o d s i n n u r s i n g (pp. 9 3 - 1 0 7 ) . O r l a n d o , F L : G r u n e & Stratton. M a h a f f y , P . R . (1965). T h e effects o f h o s p i t a l i z a t i o n o n c h i l d r e n admitted tonsillectomy and adenoidectomy. N u r s i n g Research. 4 4 , 12-19.  for  M a t t s s o n , A . , a n d W e i s b e r g , I. (1970). B e h a v i o r a l reactions to m i n o r i l l n e s s i n preschool children. Pediatrics. 46. 604-610. M e r r o w , D . L . , & J o h n s o n , B . S . (1968). P e r c e p t i o n s o f the m o t h e r ' s r o l e w i t h her h o s p i t a l i z e d c h i l d . N u r s i n g R e s e a r c h . 17. 1 5 5 - 5 6 . M i l e s , M . S . , C a r t e r , M . C , S p i c h e r , C , & H a s s a n e i n , R . S . (1984). M a t e r n a l a n d p a t e r n a l stress reactions w h e n a c h i l d i s h o s p i t a l i z e d i n a p e d i a t r i c i n t e n s i v e care unit. Issues i n C o m p r e h e n s i v e P e d i a t r i c N u r s i n g . 7 , 3 3 3 - 3 4 2 . M i l l e r , B . C , & S o l l i e , D . L . (1986). N o r m a l stresses d u r i n g transition to p a r e n t h o o d . In R . H . M o o s ( E d . ) , C o p i n g w i t h l i f e c r i s e s : A n integrated a p p r o a c h (pp. 129-138). N e w Y o r k : P l e n u m . M o r s e , J . M . ( 1 9 8 6 ) . Quantitative a n d qualitative r e s e a r c h : Issues i n s a m p l i n g . In P . L . C h i n n ( E d . ) , N u r s i n g research m e t h o d o l o g y : Issues a n d i m p l e m e n t a t i o n (pp.181-93). R o c k v i l l e , M D : A s p e n . N i c o l l , J . H . (1909).  T h e surgery o f i n f a n c y .  British M e d i c a l Journal. 2, 753-754.  N y e , F.I. (1976). R o l e structure a n d a n a l y s i s o f the f a m i l y ( V o l . 2 4 ) . B e v e r l y H i l l s , C A : Sage.  139 O i l e r , C . (1982). T h e phenomenological approach in nursing research. Research. 3 1 , 178-181. O m e r y , A . (1983). Phenomenology: A M e t h o d for N u r s i n g Research. N u r s i n g S c i e n c e . 5(2), 4 9 - 6 3 .  Nursing  Advances in  O t h e r s e n , B . H . , & C l a t w o r t h y , H . W . (1968). Outpatient h e r n i o r r h a p h y f o r infants. A m e r i c a n J o u r n a l o f the D i s e a s e s o f C h i l d r e n . 116. 7 8 - 8 0 . P e a r l i n , L . I., & S c h o o l e r , C . (1978). T h e structure o f c o p i n g . J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r . 19(3), 2 - 2 1 . P i l i s u k , M . & F r o l a n d , C . (1978). K i n s h i p , s o c i a l n e t w o r k s , s o c i a l support a n d health. S o c i a l S c i e n c e a n d M e d i c i n e . 12, 2 7 3 - 2 8 0 . Prugh, D . G . , Staub, E . M . , Sands, H . H . , K i r s c h b a u m , R. M . , & L e n i h a n , E . A . (1953). A study o f the e m o t i o n a l reactions o f c h i l d r e n a n d f a m i l i e s to hospitalization and illness. A m e r i c a n Journal o f Orthopsychiatry. 32, 70-106. R a y , M . A . (1985). A p h i l o s o p h i c a l m e t h o d to study n u r s i n g p h e n o m e n a . In M . M . L e i n i n g e r ( E d . ) , Q u a l i t a t i v e research m e t h o d s i n n u r s i n g (pp. 8 1 - 9 1 ) . O r l a n d o , F L : G r u n e & Stratton. R e d p a t h , C . C , & R o g e r s , C . S . (1984). H e a l t h y y o u n g c h i l d r e n ' s c o n c e p t s o f h o s p i t a l s , m e d i c a l p e r s o n n e l , operations, a n d i l l n e s s . J o u r n a l o f P e d i a t r i c P s y c h o l o g y . 9(1), 2 9 - 3 9 . R i s t , R . C . (1979). O n the m e a n s o f k n o w i n g qualitative research i n e d u c a t i o n . N e w Y o r k University Education Quarterly. Summer. 17-21. R o b e r t s , S . (1988). S o c i a l support a n d h e l p s e e k i n g : R e v i e w o f the A d v a n c e s i n N u r s i n g S c i e n c e . 10. 1-11.  literature.  Robertson, J . (1970). Y o u n g children in hospital. L o n d o n : Tavistock. R o b i n s o n , C . (1983). T h e e x p e r i e n c e o f h o s p i t a l i z a t i o n f o r parents o f a c h r o n i c a l l y i l l c h i l d : A n interpretive study. U n p u b l i s h e d m a s t e r ' s thesis, U n i v e r s i t y o f British Columbia, Vancouver, B . C . R o b i n s o n , D . ( 1 9 7 2 ) . Illness b e h a v i o u r a n d c h i l d r e n ' s h o s p i t a l i z a t i o n : A s c h e m a o f p a r e n t s ' attitudes t o w a r d s authority. S o c i a l S c i e n c e a n d M e d i c i n e . 8, 4 4 7 - 4 6 8 . R o b i n s o n , C , & T h o r n e , S . (1984). Strengthening f a m i l y "interference". J o u r n a l o f A d v a n c e d N u r s i n g . 9, 5 9 7 - 6 0 2 . S a n d e l o w s k i , M . ( 1 9 8 6 ) . T h e p r o b l e m o f rigor i n qualitative research. N u r s i n g S c i e n c e . 8(3), 2 7 - 3 7 .  Advances in  140 S c h o w a l t e r , J . E . (1977). 60, 651-52.  " W e w o n ' t l e a v e y o u " (Letter to the editor).  Pediatrics.  S h a h , C . P . (1980). D a y - c a r e surgery i n C a n a d a : E v o l u t i o n , p o l i c y , a n d e x p e r i e n c e o f p r o v i n c e s . C a n a d i a n Anesthetists S o c i e t y J o u r n a l . 2 7 , 3 9 9 - 4 0 5 . S h a h , C . P . , P a p a g e o r g i s , D . , R o b i n s o n , G . C , K i n n i s , C , & Israels, S . ( 1 9 6 9 ) . A study o f the n e e d f o r alternative types o f health care f o r c h i l d r e n i n h o s p i t a l : P a r e n t a l attitudes t o w a r d d a y care. P e d i a t r i c s . 4 4 , 3 3 8 - 3 4 7 . S h a h , C . P . , R o b i n s o n , G . C , K i n n i s , C , & D a v e n p o r t , H . T . (1972). D a y care surgery f o r c h i l d r e n : A c o n t r o l l e d study o f m e d i c a l c o m p l i c a t i o n s a n d parental attitudes. M e d i c a l C a r e . 10, 4 3 7 - 4 4 9 . S i p o w i c z , R . , & V e r n o n , D . T . ( 1 9 6 5 ) . P s y c h o l o g i c a l responses o f c h i l d r e n to hospitalization: A comparison o f hospitalized and non-hospitalized twins. A m e r i c a n J o u r n a l o f the D i s e a s e s o f C h i l d r e n . 109. 2 2 8 - 2 3 1 . S k i p p e r , J . K . ( 1 9 6 6 ) . M o t h e r ' s distress o v e r their c h i l d r e n ' s h o s p i t a l i z a t i o n t o n s i l l e c t o m y . J o u r n a l o f M a r r i a g e a n d the F a m i l y , 2 8 . 1 4 5 - 1 5 1 .  for  S k i p p e r , J . , L e o n a r d , R . & R h y m e s , J . (1968). C h i l d h o s p i t a l i z a t i o n a n d s o c i a l i n t e r a c t i o n : A n e x p e r i m e n t a l study o f m o t h e r s ' f e e l i n g s a n d stress adaptation. M e d i c a l C a r e . 6, 4 9 6 - 5 0 6 . S m i t h e r m a n , C . ( 1 9 7 9 ) . Parents o f h o s p i t a l i z e d c h i l d r e n h a v e needs, too. A m e r i c a n Journal o f N u r s i n g . 79, 1423-1424. S u s s m a n , M . B . ( 1 9 6 5 ) . R e l a t i o n s h i p s o f adult c h i l d r e n w i t h their parents i n the U n i t e d States. In Shanas & S t r e i b ( E d s . ) , S o c i a l structure a n d the f a m i l y : G e n e r a t i o n a l relations (pp. 9 1 - 9 3 ) . N e w Jersey: P r e n t i c e - H a l l . T e r r y , D . G . (1987). T h e needs o f parents o f h o s p i t a l i z e d c h i l d r e n . C h i l d r e n ' s H e a l t h Care. 1 6 , 18-20. T h o r n e , S . (1983). T h e f a m i l y c a n c e r e x p e r i e n c e : A qualitative study o f f a m i l i e s i n w h i c h a n adult m e m b e r i s l i v i n g w i t h cancer. U n p u b l i s h e d m a s t e r ' s thesis, University of British Columbia, Vancouver, B . C . U n g e r , D . G . , & P o w e l l , D . R . (1980). S u p p o r t i n g f a m i l i e s under stress: T h e r o l e o f social networks. F a m i l y Relations. 29. 566-574. U y e r , G . ( 1 9 8 6 ) . E f f e c t o f n u r s i n g a p p r o a c h i n understanding o f p h y s i c i a n s ' d i r e c t i o n s , b y the mothers o f s i c k c h i l d r e n i n an out-patient c l i n i c . International J o u r n a l o f N u r s i n g S t u d i e s . 2 3 , 7 9 - 8 5 . V a r d a r o , J . A . (1978). P r e a d m i s s i o n a n x i e t y a n d m o t h e r - c h i l d r e l a t i o n s h i p s . o f the A s s o c i a t i o n f o r the C a r e o f C h i l d r e n In H o s p i t a l s . 7 ( 2 ) , 8 - 1 5 .  Journal  141  V e r n o n , D . T., F o l e y , J . M . , S i p o w i c z , R . R., & S c h u l m a n , J . L . (1965). T h e p s y c h o l o g i c a l responses o f c h i l d r e n to h o s p i t a l i z a t i o n a n d i l l n e s s . Springfield, IL: Thomas. V e r n o n , D . T . , S c h u l m a n , J . L . , & F o l e y , J . M . (1966). C h a n g e s i n c h i l d r e n ' s b e h a v i o r after h o s p i t a l i z a t i o n . A m e r i c a n J o u r n a l o f the D i s e a s e s o f C h i l d r e n . 111. 581-593. W h a l e y , L . F . , & W o n g , D . L . (1987). ed.). St. L o u i s : M o s b y .  N u r s i n g care o f infants a n d c h i l d r e n  (3rd  W i l k e n s o n , A . ( 1 9 7 8 ) . B e h a v i o r a l disturbances f o l l o w i n g short-term h o s p i t a l i z a t i o n . Issues i n C o m p r e h e n s i v e P e d i a t r i c N u r s i n g . 3(1), 11-18. W o l f e r , 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 p a t i e n t s ' a n d p a r e n t s ' stress responses a n d adjustment. N u r s i n g R e s e a r c h . 2 4 , 2 4 4 - 5 5 . W y c k o f f , P . M . & E r i c k s o n , M . T . (1987). M e d i a t i n g factors o f stress o n mothers o f seriously i l l , hospitalized children. Children's Health Care. 16(1), 4-12.  142  APPENDICES  146 APPENDIX D  Participant Information Letter D e a r Parent: M y n a m e i s P a m e l a O t t e r m a n a n d I a m a student i n the M a s t e r o f S c i e n c e i n N u r s i n g P r o g r a m at the U n i v e r s i t y o f B r i t i s h C o l u m b i a . I a m a l s o a pediatric nurse. I a m c o n d u c t i n g a study to l e a r n m o r e about w h a t parents e x p e r i e n c e w h e n their y o u n g c h i l d has b e e n h o s p i t a l i z e d f o r d a y care surgery. T h e r e i s v e r y little i n f o r m a t i o n a v a i l a b l e about w h a t parents think about this e x p e r i e n c e a n d h o w they m a n a g e at h o m e w i t h a c h i l d w h o has j u s t h a d a n o p e r a t i o n . T h i s letter i s to i n q u i r e i f y o u are interested i n p a r t i c i p a t i n g i n m y study. S h o u l d y o u agree t o participate, I w i l l talk w i t h y o u t w o o r three times i n y o u r o w n h o m e after y o u return f r o m h o s p i t a l w i t h y o u r c h i l d . T h e first i n t e r v i e w w i l l be the first o r s e c o n d d a y after y o u return h o m e , a n d the s e c o n d i n t e r v i e w w i l l be o n e to t w o w e e k s after y o u r c h i l d ' s operation. A t h i r d i n t e r v i e w m a y be arranged i f necessary. E a c h m e e t i n g w i l l be a p p r o x i m a t e l y o n e h o u r l o n g a n d w i l l be arranged at a t i m e m o s t c o n v e n i e n t f o r y o u a n d y o u r f a m i l y . W i t h y o u r p e r m i s s i o n , the i n t e r v i e w s w i l l be tape r e c o r d e d , t r a n s c r i b e d (typed), a n d a n a l y z e d after o u r v i s i t s . D u r i n g the i n t e r v i e w s , I a m interested i n l e a r n i n g about y o u r reactions to the d a y care surgery e x p e r i e n c e a n d h o w it affected y o u a n d the other m e m b e r s o f y o u r f a m i l y . A l l o f the i n f o r m a t i o n that y o u share w i t h m e w i l l b e kept strictly c o n f i d e n t i a l a n d y o u r identity w i l l n e v e r be r e v e a l e d i n a n y w a y whatsoever. T h e tape r e c o r d i n g s are so that I d o not h a v e to take w r i t t e n notes w h i l e w e talk. T h e y are f o r m y p e r s o n a l use a n d w i l l o n l y be shared w i t h t w o o f m y a d v i s o r s w h o are a l s o e x p e r i e n c e d pediatric nurses. I w i l l assume a l l r e s p o n s i b i l i t y f o r the tape r e c o r d i n g s a n d w i l l p e r s o n a l l y destroy then w h e n I h a v e c o m p l e t e d the project a n d a n y related p u b l i c a t i o n s (in g e n e r a l , this takes about three to f i v e years). I b e l i e v e that i f pediatric nurses learn m o r e about the e x p e r i e n c e s o f parents related to their c h i l d ' s d a y care surgery, w e c o u l d use the k n o w l e d g e to better prepare parents f o r c o p i n g w i t h a s i m i l a r e x p e r i e n c e . O t h e r parents w h o h a v e h a d an o p p o r t u n i t y to talk w i t h a nurse after their c h i l d ' s h o s p i t a l i z a t i o n h a v e i n d i c a t e d that they e n j o y e d a n d benefited f r o m the i n t e r v i e w s .  Y o u are u n d e r n o o b l i g a t i o n to participate i n this study. I f y o u s h o u l d d e c i d e to participate, y o u h a v e the r i g h t to c h a n g e y o u r m i n d a n d w i t h d r a w at a n y t i m e . Y o u a l s o h a v e the r i g h t to refuse to a n s w e r a n y questions that I m a y ask o r c o m m e n t o n a n y t o p i c d u r i n g the c o u r s e o f a n i n t e r v i e w . I f y o u s h o u l d d e c i d e not to participate, y o u r r e f u s a l w i l l not i n a n y w a y affect y o u r c h i l d ' s s c h e d u l e d surgery o r a n y subsequent n u r s i n g o r m e d i c a l care. W i t h y o u r p e r m i s s i o n , I w i l l c a l l y o u at h o m e t o m o r r o w to find out y o u r  149  APPENDIX F Initial Interview G u i d e  1.  W o u l d y o u d e s c r i b e y o u son/daughter's c o n d i t i o n f o r m e  please? 2. surgery?  H o w w o u l d y o u d e s c r i b e y o u r c h i l d ' s r e a c t i o n the his/her d a y care  3. H o w h a v e the d a y to d a y activities o f y o u r h o u s e h o l d c h a n g e d , i f at a l l ? 4. C o u l d y o u d e s c r i b e s o m e o f y o u r i m p r e s s i o n s o n the first n i g h t at h o m e after the surgery? 5. W h a t has it been l i k e f o r y o u l o o k i n g after ( c h i l d ' s name) since y o u a r r i v e d h o m e f r o m h o s p i t a l ? Is this w h a t y o u expected? 6. C a n y o u t h i n k o f a reason w h y the e x p e r i e n c e o f y o u r c h i l d ' s d a y care surgery has affected y o u the w a y it has? 7. W h a t / w h o m has b e e n m o s t h e l p f u l to y o u d u r i n g this t i m e ? W h a t w o u l d have been more helpful?  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0097414/manifest

Comment

Related Items