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

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T H E P O S T 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 P A R E N T S 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 B y P A M E L A J O A N O T T E R M A N B . S . N . , T h e Un ive rs i t y o f B r i t i sh C o l u m b i a , 1978 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F S C I E N C E I N N U R S I N G in T H E F A C U L T Y O F G R A D U A T E S T U D I E S (The S c h o o l o f Nurs ing ) W e accept this thesis as con fo rm ing to the requ i red standard T H E 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 December 1988 © P a m e l a Joan Ot terman, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of NURSING  The University of British Columbia Vancouver, Canada Date JANUARY 11. 1989  DE-6 (2/88) Abst rac t i i T h e Post D a y Care Surgery Exper ience  F o r Parents o f Todd le rs and Preschoolers T h i s study was des igned to explore the parents ' perspect ive and personal interpretat ions o f the mean ing o f their ch i ld rens ' f i rst t ime day care surgery exper ience w i t h i n the context o f their everyday l i ves . T h e phenomeno log ica l method was used to gu ide data co l lec t ion for this qual i tat ive study. Da ta were co l lec ted through a series o f 16 in-depth in terv iews w i th n ine parents whose young ch i ld ren underwent a day care surg ica l procedure. T h e average age o f the ch i ld ren was 23.8 months. Samp le select ion was gu ided by a purpos ive sampl ing technique. A semi-structured guide o f open-ended quest ions was used for parent in terv iews. A n a l y s i s o f the verba t im transcript ions was accomp l i shed us ing the technique o f constant comparat ive analys is . Informants gave detai led accounts o f their exper ience and descr ibed the meanings and interpretations they assigned to it. T h e parents ' accounts were synthesized in to a descr ip t ive f ramework o f their exper ience w h i c h descr ibed three dist inct ch rono log ica l phases: the pre-hospi ta l izat ion or preparatory phase, the hospi ta l izat ion o r operat ive phase, and the post-hospi ta l izat ion or readjustment phase. It was apparent that the parents ' exper ience extended w e l l beyond the few hours they actual ly spent in the hospi ta l sett ing. T h e s tudy 's f ind ings revea led that parents perce ived their exper ience as a stressful event i n their everyday l i ves . N e w responsib i l i t ies were added to the usual tasks o f parent ing a toddler or preschooler resul t ing i n parental ro le strain and an increased need for parental support. Parents reported feel ings o f fear, wo r r y , and anxiety i n va ry ing intensi ty throughout the three phases o f their exper ience. T h e y used a var ie ty o f cop ing strategies to manage the stresses o f their exper ience. T h e study f ind ings were d iscussed i n compar ison to other authors ' pub l i shed works , p lac ing these un ique f ind ings in context o f the current l i terature. Impl ica t ions fo r nurs ing pract ice, educat ion, and research were presented. i v Tab le o f Contents Abs t rac t i i T ab le o f Contents i v A c k n o w l e d g e m e n t s • v i C H A P T E R 1: Introduct ion 1 B a c k g r o u n d to the Study 2 Concep tua l F ramework 5 Statement o f the P r o b l e m 8 Int roduct ion to the M e t h o d o l o g y 8 De f i n i t i on o f Te rms 9 Assumpt ions 10 L im i t a t i on 11 S u m m a r y 11 C H A P T E R 2 : R e v i e w o f Se lected Li terature 13 Parenta l R o l e and Respons ib i l i t y Changes W h e n C a r i n g fo r A S i c k C h i l d . . : 14 T h e Ef fec ts Ma te rna l A n x i e t y on the Hosp i t a l i zed C h i l d 17 Parental At t i tudes Towards Pediatr ic D a y C a r e Surgery . . . . . 21 T h e Ef fec ts o f Short T e r m Hosp i ta l i za t ion on Todd le rs and Preschoolers 24 S u m m a r y 31 C H A P T E R 3: M e t h o d o l o g y 33 Research D e s i g n 33 Se lec t ion o f Part ic ipants 35 Cr i te r i a fo r Se lec t ion 35 Set t ing 36 Implementat ion Procedures 36 Da ta Co l l ec t i on 38 D a t a A n a l y s i s 41 E t h i c a l Cons iderat ions 43 Research C learance Procedures 43 In fo rmed Consen t 43 P r i v a c y 44 S u m m a r y 44 V C H A P T E R 4: Presentat ion and D i scuss ion o f F i nd ings 45 T h e S tudy ' s A n a l y t i c F r a m e w o r k 46 D a y Care Surgery as a Stressfu l Exper ience 49 Parenta l Respons ib i l i t y 52 R o l e St ra in 54 C o p i n g 56 S o c i a l Suppor t 57 Desc r ip t i on o f Par t ic ipant Fam i l i es 60 T h e F a m i l i e s 61 T h e C h i l d r e n 62 T h e Hosp i ta l i za t ion 62 T h e Parents ' Accoun ts o f The i r Exper ience and D i s c u s s i o n . . . . 63 T h e Pre-hosp i ta l iza t ion Phase 64 T h e Hosp i ta l i za t ion Phase 84 T h e Post -hosp i ta l iza t ion Phase 97 S u m m a r y I l l C H A P T E R 5: S u m m a r y , Conc lus ions , and Impl icat ions for N u r s i n g 114 S u m m a r y o f the Study 114 Conc lus i ons 119 Impl ica t ions fo r N u r s i n g Pract ice 120 Impl ica t ions fo r N u r s i n g Educa t i on 128 Impl ica t ions fo r N u r s i n g Research 130 References 133 A p p e n d i c e s 142 A p p e n d i x A : Research A p p r o v a l Cert i f icate f r o m the Un ive rs i t y o f B r i t i sh C o l u m b i a B e h a v i o u r a l Sc iences Screen ing Commi t tee fo r Research and Other Studies Invo l v ing H u m a n Sub jec ts . . . . 143 A p p e n d i x B : Research A p p r o v a l Let ter f r o m B r i t i sh C o l u m b i a ' s Ch i l d rens ' Hosp i t a l In -Hosp i ta l Research R e v i e w Commi t t ee 144 A p p e n d i x C : In format ion Let ter for Phys ic ians and Dent is ts . . . 145 A p p e n d i x D : Part ic ipant In format ion Let ter 146 A p p e n d i x E : Part ic ipant Consent F o r m 148 A p p e n d i x F : In i t ia l Interv iew G u i d e 149 v i Acknow ledgemen ts I w o u l d l i ke to thank the members o f m y thesis commi t tee , J i nny H a y e s (chair person) and Judy L y n a m , for their un fa i l i ng encouragement and guidance in comple t ion o f this research project. I a m espec ia l ly grateful to J i nny fo r her pat ience and understanding w h i c h extended beyond the usual bounds o f a facul ty-student re lat ionship. There were several other persons w h o supported me throughout this process. M y parents, and m y sister and brother- in- law, l ov i ng l y gave o f their t ime, energy, and resources to support this project. In addi t ion to m y f am i l y , there were several dear f r iends whose support was a lways there to encourage m e to "keep go ing " . M o s t impor tant ly , I w i s h to thank m y husband G e r a l d , w h o shared a l l o f the h ighs and the l o w s o f this exper ience, and wi thout whose love , pat ience, personal sacr i f ices, and fa i th i n m y abi l i ty , this project w o u l d not have been comple ted. I w o u l d also l i ke to acknow ledge m y son , M a r k , whose ar r iva l hera lded the beg inn ing o f one major under tak ing wh i l e c o i n c i d i n g w i th the comp le t ion o f another. F i n a l l y , I w o u l d l i ke to express m y thanks to the n ine parents w h o part ic ipated i n this study. T h e y w i l l i n g l y gave o f their t ime and the benefi t o f their exper ience to make the research poss ib le . C H A P T E R 1 1 Introduction T h i s is the report o f a study des igned to answer the quest ion: W h a t is the parents ' exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery? It is this author 's op in ion , based upon personal exper ience w o r k i n g as a pediat r ic nurse, that nurses l ack know ledge about parents ' o w n percept ions o f the post -hospi ta l izat ion pediatr ic day care surgery exper ience and h o w they manage at home f o l l o w i n g their c h i l d ' s surgery. T h e on ly w a y to t ru ly understand this exper ience is to have parents descr ibe h o w the event has affected their day to day l i ves . T h i s wr i ter has been unable to ga in ins ight into this important parental exper ience f r o m any l i terature rev iewed to date. Parents o f toddlers and preschoolers were selected for this study because it is k n o w n that ch i ld ren i n these age groups are par t icu lar ly vu lnerable to the real and imag ined threats o f hosp i ta l iza t ion and surgery ( D o r n , 1984; Redpath & Rogers , 1984; Rober tson , 1970; V e r n o n , S c h u l m a n & F o l e y , 1966). It is a lso k n o w n that parents c o m m o n l y fee l anx ious and concerned throughout their c h i l d ' s post -hospi ta l izat ion pe r iod (Droske , 1978). It was therefore ant ic ipated that parents o f toddlers and preschoolers m a y have part icular needs f o l l o w i n g their c h i l d ' s day care surgery. The l i terature rev iewed fo r this study was unable to offer ins ight in to what these needs m igh t be. Nurses w o r k i n g i n both hospi ta l and commun i t y settings have opportuni t ies to interact w i th and are i n post ions to in f luence the exper ience o f parents whose young 2 ch i ld ren have undergone day care surg ica l procedures. T h e f ind ings o f this study offer a theoret ical base f r o m w h i c h appropriate and ef fect ive nurs ing care fo r such parents m a y be p lanned and car r ied out. In order to in t roduce this research study, the remainder o f this chapter w i l l present the background to the p rob lem, the conceptual f ramework gu id ing the research, and the methodo log ica l perspect ive chosen to explore the spec i f ic research quest ion. B a c k g r o u n d to the S tudy Ped ia t r ic day care is w i d e l y recogn ized as a v iab le alternative to the tradi t ional two to three day hospi ta l stay fo r ch i ld ren undergo ing m ino r surg ica l procedures (E l -Sha f i e & Shap i ro , 1977; Johnson , 1983; L a w r i e , 1964; Shah , R o b i n s o n , K i n n i s , & Davenpor t , 1972; Shah , 1980). The phys i ca l and psycho -soc ia l benef i ts it of fers fo r the f a m i l y unit , as w e l l as the f inanc ia l savings for the Canad ian Hea l th Care Sys tem, have been w e l l documented ( A t w e l l , B u r n , D e w a r , & F reeman , 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; Othersen & C la twor thy , 1968; Shah , 1980; Schowal te r , 1977). T h e f i rst reported cases o f pediatr ic day care surgery were d iscussed i n the l i terature b y N i c o l l i n 1909. In a ten year pe r iod pr io r to 1909 he successfu l ly per fo rmed day surgery on an est imated 9,000 infants and ch i ld ren i n G l a s g o w , Scot land. B y 1910, the pract ice o f pediatr ic day care surgery began i n Canada at To ron to ' s H o s p i t a l fo r S i c k C h i l d r e n (Shah, 1980). S ince a pediatr ic day care surgery p rogram was first in t roduced i n Vancouve r , B r i t i s h C o l u m b i a i n 1967, the numbers o f ch i ld ren and their fami l ies rece iv ing this serv ice have cont inued to g row steadi ly each year (Shah, 1980). T h e growth o f this p rog ram is i n keep ing w i th the be l ie f that up to one ha l f o f a l l surg ica l procedures for 3 N o r t h A m e r i c a n ch i ld ren c o u l d be done on a day care basis (B rown lee , 1977; Shah , 1980). D u r i n g the 1984/85 f i sca l per iod , the number o f p r imary (first t ime on ly ) pediat r ic day care surg ica l procedures per fo rmed at B r i t i sh 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 was 4,792 (Br i t i sh C o l u m b i a M i n i s t r y o f Hea l th , 1985). T h i s represented over 4 0 % o f the total number o f surg ica l procedures per fo rmed on ch i ld ren at this center. T h i s number is 14 .4% above the p rov inc ia l average for day care surg ica l procedures (Br i t i sh C o l u m b i a M i n i s t r y o f Hea l th , 1985). In V a n c o u v e r i n 1986, the ever increas ing demand for pediatr ic day care surgery resul ted i n major renovat ions to the ex is t ing day care fac i l i t ies 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 ' Hosp i t a l . T h e new ly expanded P a y Care U n i t is more than doub le the o r ig ina l s ize and n o w inc ludes fac i l i t ies fo r med ica l as w e l l as surg ica l day care patients. T h i s expanded M e d i c a l / S u r g i c a l D a y Care U n i t accommodates an average o f 29 patients per day ( B . L a i r d , personal commun ica t i on , A p r i l 3, 1987). W h e n a surg ica l procedure is carr ied out i n a D a y Care Un i t , the parent(s) and c h i l d spend a re la t ive ly short per iod o f t ime, usual ly about s ix to eight hours, i n the hospi ta l sett ing. Exper ience has shown that the success o f any pediatr ic day care surgery p rog ram is h igh l y dependent upon the f u l l co-operat ion o f parents w h o , upon their c h i l d ' s d ischarge f r o m hospi ta l , are both w i l l i n g and able to assume the ro le o f p r imary careg iver (E l -Sha f i e & Shap i ro , 1977; Schowal te r , 1977). The acceptance o f this " n e w " careg iver ro le p laces increased demands on usual parent ing ro les. It requires that parents take over responsib i l i t ies and dec is ion m a k i n g that was , i n the past, left to the judgement o f health care professionals. It is this author 's op in ion that by con fe r r ing these n e w careg iv ing responsib i l i t ies on the parents o f pediatr ic day care 4 surgery pat ients, heal th profess ionals have made assumpt ions about the parents ' exper iences once they leave the hospi ta l and also about their abi l i t ies to manage the post-operat ive care o f their c h i l d w i th in the context o f their everyday l i ves . O n e o f the p r imary funct ions the f a m i l y uni t serves w i th in our society is i n re la t ion to the management o f health and med ica l care for its members (L i tman , 1974). F r i e d m a n (1986) ident i f ied the "p rov is ion and a l locat ion o f phys i ca l necessit ies and health care" (p. 59) as one o f f i ve basic f a m i l y funct ions. In both Western and non-Weste rn societ ies 7 0 % to 9 0 % o f a l l s ickness is managed so le ly w i th in the soc ia l ne twork o f the f am i l y and the commun i t y wi thout pro fess iona l consul ta t ion ( K l e i n m a n , 1978). Parents then, are quite accustomed to u t i l i z ing their o w n resources to manage a c h i l d ' s m i n o r i l lness w i th in their f am i l y unit . Th i s is an acceptable pract ice and w e l l w i t h i n the scope o f a parents ' no rma l responsib i l i t ies. W h e n a new situat ion arises w i th in the f a m i l y unit , however , such as one when a c h i l d must undergo day care surgery, the f irst t ime exper ience o f hospi ta l izat ion and a surg ica l procedure can be very anxiety p r o v o k i n g for both parent and ch i l d . S u c h anxiety m a y cont inue dur ing the post-hospi ta l izat ion pe r iod (Droske , 1978; M a h a f f y , 1965). Pro fess iona ls may f o r m their o w n op in ions about the nature o f the parents ' exper ience w h e n they leave the hosp i ta l . H o w e v e r , i t has been shown that there w i l l be d iscrepancies and inconsis tencies i n the ways i n w h i c h profess ionals and lay persons v i e w the same health care si tuat ion ( K l e i n m a n , 1978; K n o x & H a y e s , 1983). T h i s study was des igned to exp lore i n depth parents ' thoughts, feel ings and react ions w h e n car ing for their young c h i l d at home f o l l o w i n g day care surgery i n order to contr ibute to nurs ing know ledge about this important parental exper ience. T h e understanding ga ined f r o m focus ing on the parents ' po in t o f v i e w enhances health 5 p ro fess iona ls ' abi l i t ies to communica te w i th parents i n a mean ing fu l w a y (Anderson & C h u n g , 1982; K n o x & H a y e s , 1983). A n indepth understanding o f the parents ' exper ience prov ides nurses w i th c lear d i rect ion for assessment, p lann ing and imp lementa t ion o f appropriate nurs ing care both dur ing the young c h i l d ' s pre-hospi ta l izat ion and their post-hospi ta l izat ion per iods. T h e know ledge ga ined f rom this study a lso adds c lar i ty and va l id i t y to aspects o f nurs ing care present ly imp lemen ted by hospi ta l D a y Care U n i t nurses fo r the parents o f pediatr ic day care surgery patients. Concep tua l F r a m e w o r k T h e conceptua l f ramework w h i c h gu ided the development o f this study was deve loped by K l e i n m a n , E isenberg , and G o o d (1978). T h e K l e i n m a n et a l . (1978) f ramework adheres to two fundamenta l not ions: The f irst is a d is t inc t ion between the concepts o f "d isease" , " i l l ness " and "s i ckness" , and the second is a conceptua l izat ion o f a health care system w i th three dif ferent but interact ing soc ia l "arenas" . T h e f ramework ho lds that a c lear understanding o f the percept ions and explanatory mode ls o f i nd iv idua ls i n each o f the arenas i n the health care system w i l l l ead to improvement i n the areas o f patient commun ica t i on , comp l iance , and sat isfact ion. K l e i n m a n et a l . (1978) descr ibe "d isease" as a b io log i ca l ma l func t ion , and " i l l ness " as a persona l , interpersonal , and cul tura l react ion to the disease (p. 252) . S i m p l y put, diseases are treated and i l lnesses are exper ienced. S ickness is def ined as a c o m p l e x human phenomenon encompass ing both disease and i l lness. T h e human exper ience o f s ickness has interact ing b io log i ca l , psycho log i ca l , and soc iocu l tura l components . It i s the s ickness exper ience and the resul t ing d i f f icu l t ies it br ings to aspects o f da i l y l i v i n g that is o f p r imary concern to patients i n the heal th care system. 6 K l e i n m a n (1978) mainta ins that i n order to overcome s ickness, o r to success fu l l y comple te the hea l ing process, there must be a resolut ion o f both the b io log i ca l disease and the i l lness exper ience. T h e three soc ia l arenas o f K l e i n m a n ' s health care sys tem are referred to as the popu lar , p ro fess iona l , and fo l k arenas. T h e three arenas serve to soc ia l l y leg i t im ize s ickness and health care fo r the ind iv idua ls they represent. In health care relat ionships transactions occur between ind iv idua ls i n each o f these three arenas. T h e popu la r arena is compr i sed o f ind iv idua ls , farr i i l ies, and soc ia l / commun i t y networks. T h e major i ty o f heal th care act iv i t ies take p lace i n this arena. T h e pro fess iona l arena inc ludes sc ient i f ic med ic ine and ind igenous hea l ing tradi t ions, wh i l e the f o l k arena inc ludes non-pro fess iona l hea l ing special ists. E a c h o f these arenas "possesses its o w n explanatory systems, soc ia l ro les , interact ion sett ings, and inst i tu t ions" ( K l e i n m a n et a l . , 1978, p. 254) . T h e f o l l o w i n g f igure depicts K l e i n m a n ' s (1978) health care system. Popular Sector L - Points of Interaction Entrance and Exit F igu re 1. K l e i n m a n ' s Hea l th Care Sys tem (1978) 7 In each o f these three arenas, explanatory mode ls can be e l i c i ted f r o m ind iv idua ls to exp la in and def ine part icular s ickness episodes. Ind iv idua ls use personal explanatory mode ls to determine and descr ibe what is w rong w i th them or others, and a lso to r ecommend what steps shou ld be taken for successfu l treatment. Exp lana to ry mode ls are constructed or shaped by an i nd i v idua l ' s cul ture, society, know ledge base, be l ie fs , va lues, and past exper iences. Because ind iv idua ls f r o m dif ferent arenas w i l l have dif ferent explanatory mode ls for the same health care si tuat ions, the result is often "d iscrepant expectat ions and m i scommun i ca t i on " ( K l e i n m a n , 1978, p. 88). A c o m m o n examp le o f this type o f d iscrepancy is that i n most situations i n the profess ional arena, s ickness is const rued as "d isease" wh i l e the i n the popu lar arena it i s most of ten v i e w e d as " i l l ness " . A c c o r d i n g to the K l e i n m a n et a l . (1978) f ramework , i f nurses are to improve the care p rov ided to parents, they must be concerned w i th the w a y s i n w h i c h parents v i e w their ch i l d ren ' s i l lnesses s ince interpretation o f a si tuat ion may be made very d i f ferent ly by parents and profess ionals . In general , parents o f pediatr ic day care surgery patients are f a m i l y members represent ing the popu lar arena. T h e parents ' explanatory mode ls fo r the post day care surgery exper ience can be understood by e l i c i t ing their percept ions and explanat ions about this exper ience. A n understanding o f the parents ' explanatory mode ls w i l l p rov ide a so l id basis for c lear commun ica t i on between the nurse and the parents and help to faci l i tate ef fect ive nurs ing intervent ion. Others have prev ious ly demonstrated the re levance o f this f ramework i n nurs ing research and appl icat ions to nurs ing 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; Tho rne , 1983). 8 Statement o f the P r o b l e m T h e general p rob lem that this study addresses is a lack o f nurs ing know ledge about the parents ' exper ience at home f o l l o w i n g their c h i l d ' s short term hospi ta l stay fo r day care surgery and the mean ing assigned to this exper ience f r o m the parents ' perspect ive. Therefore, this study was des igned to ga in an understanding o f parents ' f i rst t ime exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery. T h e results p rov ide ins ight in to the subject ive mean ing o f the post-operat ive pediat r ic day care surgery exper ience by e luc ida t ing the parents ' personal explanat ions, percept ions, and def in i t ions o f their s i tuat ion, and also the ways i n w h i c h they desire to be he lped. H e n c e , the study addressed the f o l l o w i n g quest ion: W h a t is the parents ' exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery? Introduct ion to T h e M e t h o d o l o g y T h e qual i tat ive research method o f phenomeno logy was selected to address the research quest ion posed by this study. Phenomeno logy is not just a research method but is a lso a ph i l osophy and an approach (Oi ler , 1982). Cons ide red to be a v iab le and va luab le qual i tat ive methodo logy , it was chosen because it emp loys descr ip t ion to ident i fy and understand phenomena (Omery , 1983). A s R i s t (1979) stated, this type o f research method "enables a comprehens ion o f human behav ior i n greater depth than is poss ib le f r o m the study o f surface behavior , f r o m paper and penc i l tests, and f r o m standardized in te rv iews" (p. 20). Phenomeno logy represents an effort to descr ibe the human exper ience as it is l i v e d by the ind iv idua ls be ing studied. A l l phenomena, i nc lud ing the i nd i v idua l ' s percept ions o f the human exper ience and their effect on h im/her , are invest igated and descr ibed (Omery , 1983). A l l data g iven by the subjects are deemed to be relevant. 9 A researcher us ing the phenomeno log ica l method must approach the research encounter na ive ly and w i th an "open m i n d " (Omery , 1983). T h e researcher must recogn ize h is /her o w n p reconce ived ideas and attempt to set them aside (Oi le r , 1981). T h e researcher accepts the generated data as subject ive descr ipt ions o f the mean ing the exper ience has for the ind iv idua ls be ing studied, and he/she does not attempt to mod i f y it to f i t a p reconce ived def in i t ion o f the phenomenon (Omery , 1983). Phenomeno logy is an appropriate method to study the parents ' exper ience at home f o l l o w i n g their c h i l d ' s day care surgery because it str ives to understand a l l data i n the exper ience f r o m the perspect ive o f the parents themselves. In add i t ion , the phenomeno log ica l method is congruent w i th K l e i n m a n ' s f r amework (1978), as both approaches emphas ize that ind iv idua ls g ive subject ive mean ing to the situations they exper ience i n everyday l i fe . De f i n i t i on o f Te rms T h e f o l l o w i n g terms are de f ined in order to c lar i fy their use i n this study: D a y Care Surgery : an e lect ive surg ica l procedure car r ied out i n a spec ia l hospi ta l uni t where the patient is admit ted and d ischarged f r o m hospi ta l on the same day (Davenpor t , Shah , & R o b i n s o n , 1971). F a m i l y : two o r more persons l i v i n g together j o i ned by mutua l consent and bonds o f b l ood , marr iage, or adopt ion. These persons share a c o m m o n culture and assume soc ia l l y recogn ized roles such as mother and father, sister and brother, son and daughter (F r iedman, 1986). Parent : an adult person w h o fu l f i l s the p r imary caretak ing ro le for a ch i l d . T h i s person may be the c h i l d ' s b io log i ca l , adopt ive, step, or foster parent. 10 Parents ' Exper ience : parents ' react ions, thoughts and fee l ings, and the personal mean ing that they ho ld for them, w h i c h together compr ise the parent 's response to ca r ing for a c h i l d at home f o l l o w i n g day care surgery. Post -hosp i ta l iza t ion P e r i o d : that per iod o f t ime w h i c h commences when the parent and c h i l d leave the hospi ta l setting unaccompan ied by any hospi ta l personnel , and ends w h e n the c h i l d has recovered phys i ca l l y and emot iona l l y f r o m the surgery and a l l f a m i l y members have returned to their regular patterns and act iv i t ies o f da i l y l i v i ng . Preschoo ler : a c h i l d whose current age at the t ime o f the day care surgery is w i t h in the range o f three to f i ve years. Shor t - term C o n d i t i o n or I l lness: a non-chron ic , non-recurrent, disease or a i lment w h i c h is se l f - l im i t ing i n nature but requires surg ica l in tervent ion i n order to obta in cor rec t ion o r reso lu t ion. Todd le r : a c h i l d whose current age at the t ime o f day care surgery is w i th in the age range o f one to three years. Assumpt ions T h e assumpt ions that gu ided this study are as f o l l ows : 1. T h e const ruct ion o f an exper ience by the ind iv idua ls i n v o l v e d i n it i s a v a l i d representat ion o f the exper ience and can promote further understanding o f the phenomenon (Omery , 1983). 2. Parents ' exper iences f o l l ow ing their c h i l d ' s day care surgery, and the mean ings they assign to these exper iences w i th in the context o f their s i tuat ion, can be perce ived and understood by the researcher us ing a phenomeno log ica l method. 3. T h e researcher act ive ly part ic ipates i n the const i tut ion o f the actual research data by v i r tue o f open d ia logue w i th part ic ipants and a focus on their subject ive 11 exper iences ( G i o r g i , 1975a). 4 . Parents o f ch i ld ren aged one to f i ve years w h o were selected to part ic ipate i n this study of fered comprehens ive , relevant and re l iab le in fo rmat ion to the researcher (Mo rse , 1986). L im i t a t i on T h e f o l l o w i n g study l imi ta t ion was ident i f ied: 1. T h e real i ty o f an exper ience constructed by parents i n interact ion w i th the researcher is in f luenced by the soc ia l , cu l tura l , env i ronmenta l , and personal contexts o f the si tuat ion. Genera l i zab i l i t y o f f ind ings based on this type o f research is l im i ted to s im i la r meanings found i n the data (Omery , 1983) s ince every qual i tat ive research si tuat ion is "u l t imate ly about a part icular researcher i n interact ion w i th a par t icu lar subject i n a par t icu lar context" (Sande lowsk i , 1986, p. 31). T h e data therefore represent the exper iences o f on l y those parents w h o part ic ipated i n the study. S u m m a r y A g row ing number o f fami l ies are exper ienc ing day care surgery as an alternat ive to more t radi t ional fo rms o f health care de l ivery for young ch i ld ren . D u r i n g the post -hospi ta l izat ion pe r iod f o l l o w i n g a m ino r surg ica l procedure, parents ' attitudes and abi l i t ies to cope have been shown to have a p ro found effect o n a young c h i l d ' s we l l - be ing and recovery (Prugh, Staub, Sands, K i r s c h b a u m , & L e n i h a n , 1953; Rober t son , 1970). T h i s study is des igned to exp lore in-depth the parents ' percept ions and personal interpretat ions o f the post day care surgery exper ience w i th in the context o f their every day l i ves . K l e i n m a n (1978) purports, and other authors have demonstrated, that e l i c i t i ng c l ien ts ' explanatory mode ls enhances health pro fess iona ls ' understanding o f i l lness as a persona l , soc ia l and cul tura l exper ience and faci l i tates the p rov i s ion o f care that is mutua l l y sat is fy ing (Anderson , 1981; Ande rson & C h u n g , 1982; K n o x & Hayes , 1983). T h e results o f this research address the l ack o f emp i r i ca l know ledge concern ing this impor tant parental exper ience. T h e f ind ings o f this study direct nurses to p lan and p rov ide empath ic nurs ing care w h i c h ref lects the nature and mean ing o f the post day care surgery exper ience fo r this c l ient group. Chapter 2 prov ides a rev i ew o f the l i terature pert inent to this invest igat ion. C H A P T E R 2 13 Review of Selected Literature T h i s chapter presents a rev iew o f the l iterature pert inent to this s tudy 's research p rob lem. T h e intent o f the rev iew is to establ ish a background for what is understood to date about the post -hospi ta l izat ion exper ience fo r parents whose ch i ld ren have undergone a day care surgery procedure and to locate this study w i th in the context o f re lated pro fess iona l l i terature. O n searching l i terature f r o m nurs ing and other d i sc ip l i nes , this author was unable to locate a study that d iscusses parents ' percept ions o f the post -hospi ta l izat ion pediatr ic day care surgery exper ience nor their abi l i ty to manage at home dur ing this t ime. T h e pauc i ty o f l i terature about the post day care surgery exper ience f r o m the parents ' perspect ive h igh l ights a need for further invest igat ion. T h i s selected rev iew o f l i terature w i l l inc lude both exper ient ia l ly and research-based pub l ica t ions f r o m four relevant subject areas i n order to establ ish a background o f in fo rmat ion about the s tudy 's research quest ion. These four subject areas exp lore the more general impact o f a ch i l d ' s i l lness , hosp i ta l iza t ion and/or surgery on the c h i l d and h is /her parents. T h e f irst subject area examines parental ro le and respons ib i l i t y changes when a c h i l d becomes i l l o r requires hospi ta l izat ion. T h e second subject area relates spec i f i ca l l y to the effects o f maternal anx iety on the hosp i ta l ized c h i l d . T h e th i rd subject area, d i rect ly related to the issue in quest ion, explores parental attitudes towards pediatr ic day care surgery. A n d f ina l l y , the fourth subject area examines short term hospi ta l izat ion o f toddlers and preschoolers and resul t ing 14 post -hosp i ta l iza t ion behav ior changes. A l t h o u g h the l i terature rev iewed here is related to the research quest ion, it is not meant to generate a m i n d set about the nature and mean ing o f the post day care surgery exper ience fo r parents. T h i s is consistent w i th the conceptua l f ramework and the phenomeno log i ca l methodo logy . T h e remainder o f the chapter is o rgan ized into sections cor respond ing w i th the selected subject areas. Re la ted theory and research w i l l be examined again i n Chapter 4 , w h e n the f ind ings o f this study are presented and d iscussed. Parenta l R o l e and Respons ib i l i t y Changes W h e n C a r i n g fo r A S i c k C h i l d T h e l i terature supports that a parent 's ro le changes when a c h i l d becomes i l l ( H y m o v i c h , 1976, 1981; L i t m a n , 1974; P rugh et a l . , 1953). Parents o f young ch i ld ren are par t icu lar ly suscept ible to such changes because they re ly on their ch i l d rens ' responses and behaviors to help def ine their parental ro le. Conve rse l y , young ch i ld ren re ly a lmost exc lus i ve l y on their parents to interpret their env i ronment and translate it i n a mean ing fu l w a y to them (Fr iedman, 1986). L i t m a n , i n h is 1974 study o f the fam i l y as a basic unit i n health and med ica l care, showed that the f am i l y " in one w a y or another tends to be i n v o l v e d i n the dec i s i on -mak ing and the therapeutic process at every stage o f m e m b e r ' s i l lness , f r o m d iagnos is to treatment and recuperat ion" (p. 501). T h i s is par t icu lar ly true when the i l lness affects a ch i l d . H e emphas ized the impor tance o f the f a m i l y ' s response (especia l ly the wi fe-mother) to any member ' s i l lness and noted that i n addi t ion to be ing the "centra l agent o f cure and care" (p. 505) she a lso may exhib i t cons iderable var iat ion i n her "ab i l i ty to recogn ize d iscomfor t or i l lness i n a f am i l y member " (p. 505) . L i t m a n (1974) a lso f ound that because o f the demands o f her usual ro le , a mother often found 15 it d i f f i cu l t to f u l f i l her ob l igat ions to a l l members o f the househo ld w h e n one member was i l l . B a s e d on observat ion and exper ience, H y m o v i c h (1976) descr ibed i n deta i l the needs o f parents w h e n their c h i l d is s ick. She states that: "whether the i l lness is acute, ch ron ic , or fatal , treated at home o r in the hospi ta l , it w i l l have some impact on a l l members o f the f a m i l y , not just the i l l c h i l d " (p. 9) . P rugh et a l . (1953) a lso documented that when a c h i l d becomes i l l a change takes p lace in the parent -ch i ld re la t ionship. I f the c h i l d ' s i l lness necessitates hospi ta l izat ion, changes occur i n parental ro les and i n their everyday responsib i l i t ies . D u r i n g the c h i l d ' s hospi ta l izat ion most parents, a l though w i l l i n g to part ic ipate i n their ch i l d ' s care, are unsure o f their ro le i n the hospi ta l sett ing (A lg ren , 1985; K n o x & Hayes , 1983; M e r r o w & Johnson , 1968). A l g r e n (1985) revealed that parents rece ive m i n i m a l d i rect ion f r o m nurs ing staff to c la r i f y their ro le uncertainty. T h e hosp i ta l iza t ion o f a c h i l d results i n parental separat ion and re l inqu ishment o f the c h i l d ' s care to persons u n k n o w n at a time when parent and c h i l d have a greater need fo r one another ( G o f m a n , B u c k m a n & Schade, 1957). Parents become vulnerable and need spec ia l reassurance and explanat ion (Keane , Gar ra lda , & K e e n , 1986; K n o x & H a y e s , 1983; W i l k e n s o n , 1978). D u r i n g this t ime parents exper ience feel ings o f fear, gui l t , f rustrat ion and anxiety (Droske , 1978; G o f m a n et a l . , 1957; Smi therman, 1979; W h a l e y & W o n g , 1987; W o l f e r & V is in ta iner , 1975). A s these emot ions increase in intensi ty , judgement and memory can be impa i red and learn ing responses become less ef fect ive. 16 A sma l l amount o f l i terature exists w h i c h supports the premise that the post -hosp i ta l iza t ion per iod may also be par t icu lar ly d i f f i cu l t fo r parents (Droske , 1978; F r iebe rg , 1972; W i l k e n s o n , 1978). P rugh et a l . (1953) par t ia l ly attr ibuted parents ' pre-operat ive anxiety to concerns about dea l ing w i th the c h i l d once he/she returned home. U y e r (1986) descr ibed a study o f 200 young mothers w h o brought their s i ck ch i ld ren to an Out-pat ient C l i n i c for treatment o f a var ie ty o f m ino r i l lnesses. U y e r (1986) bel ieves that i n order to understand and manage her c h i l d ' s i l l ness , a mother must accurately interpret the facts concern ing the c h i l d ' s d iagnos is , treatment, care, and f o l l ow-up . T h i s author found that 7 2 % o f the mothers left the C l i n i c w i th incorrect or incomple te in fo rmat ion regard ing the necessary care fo r their i l l c h i l d . A n average o f 4 4 % also had inadequate in format ion regard ing treatment and fo l l ow-up . U y e r found that the implementa t ion o f an exper imenta l "nurs ing approach" w i th the exper imenta l group o f mothers s ign i f icant ly imp roved their comprehens ion o f their s ick ch i ld ren 's treatment and care thus demonstrat ing the va lue o f nurs ing intervent ion i n i m p r o v i n g patient commun ica t i on and educat ion. U y e r ' s (1986) study re inforces the fact that mothers do not a lways remember or va lue the in fo rmat ion that heal th profess ionals deem to be " important" . In certain cases, it i s poss ib le that the we l l -be ing and recovery o f the c h i l d may be at r isk i f recommendat ions are not f o l l owed . In summary , the l iterature supports that parents have unique needs and roles w h e n a c h i l d becomes i l l and/or hosp i ta l ized. A c h i l d ' s i l lness and the parental react ions to i t m a y affect the funct ion ing o f an entire f am i l y unit . Parenta l support i s c ruc ia l to the phys i ca l and psychosoc ia l recovery o f a c h i l d , and yet a c h i l d ' s 17 hospi ta l iza t ion may be ext remely anxiety p rovok ing for parents, espec ia l l y mothers. M u c h is s t i l l not k n o w n about the parents ' exper ience at home f o l l o w i n g a c h i l d ' s hosp i ta l iza t ion: H o w do parents cope w i th new responsib i l i t ies and their increased need for in format ion? H o w do they adjust to ro le changes dur ing the post -hospi ta l izat ion per iod? W h e n do they readjust to fo rmer ro les and regular patterns o f da i l y l i v i n g after the c h i l d has been d ischarged f r o m hospi ta l? Because the percept ion o f an event is more s igni f icant than the actual c i rcumstances (Wha ley & W o n g , 1987), it is necessary to learn about an exper ience as it actual ly l i v e d by the persons i nvo l ved i n it. It was thought that a study such as this one invest igat ing the post day care surgery per iod w o u l d p rov ide ins ight in to h o w we can better prepare parents for the transit ions they must face dur ing this t ime. T h e Ef fects o f Ma te rna l A n x i e t y on the Hosp i t a l i zed C h i l d There have been several studies w h i c h have demonstrated the degree and effects o f maternal anxiety dur ing a c h i l d ' s pre- and post-operat ive hospi ta l iza t ion per iod . In the three studies to be examined here, a l l o f the ch i ld ren underwent m ino r e lect ive surg ica l procedures wh i l e hosp i ta l i zed for short per iods o f time. These studies are s ign i f icant because, by 1988 standards, most o f the surg ica l procedures descr ibed in them w o u l d be cons idered suitable pediatr ic day care surgery cases. T h e f ind ings o f these studies, document ing leve ls o f maternal anxiety, m a y be general izable to the react ions o f mothers when their ch i ld ren undergo these same types o f procedures on a day care surgery basis. M a h a f f y (1965) studied a sample o f 43 randomly selected ch i ld ren aged two to ten years w h o were admit ted for tons i l lec tomy and adenoidectomy. These ch i ld ren had no p rev ious hospi ta l izat ions. M a h a f f y proposed that hosp i ta l iza t ion is an anxiety 18 p r o v o k i n g exper ience for both parent and c h i l d and that a "mother must be comfor tab le and secure" (p. 12) i n order to meet her c h i l d ' s needs. T h e researcher in t roduced an independent var iab le o f "suppor t ive nurs ing care" to mothers o f the 21 ch i ld ren i n the exper imenta l group i n order to test the hypothesis that reduc ing parental stress w o u l d measurab ly reduce distress i n the ch i l d both dur ing the hosp i ta l iza t ion and post -hospi ta l izat ion per iod . T h e s tudy 's f ind ings c lear ly supported the hypothesis , a l though genera l izab i l i ty o f M a h a f f y ' s (1965) f ind ings must be made w i t h caut ion as the study s ize was sma l l and not a l l dependent var iab les were cont ro l led . M a h a f f y revea led, by means o f a post -hospi ta l izat ion quest ionnaire, that a l l o f the ch i ld ren w h o part ic ipated i n the study showed behav iora l mani festat ions o f anxiety i n the post -hosp i ta l iza t ion per iod . There were, however , stat ist ical ly s ign i f icant d i f ferences between the cont ro l and exper imenta l groups i n the mani festat ion o f three types o f behavior . A greater number o f ch i ld ren in the cont ro l group (their mothers d i d not rece ive "support ive nurs ing care") exh ib i ted d isturbed sleep, fear o f med i ca l personne l , and an increased dependency on their mothers. T h e imp l i ca t ion o f this f i nd ing is that the exper imenta l nurs ing intervent ion used w i th the mothers m a y have had an effect on the c h i l d ' s behav ior upon returning home. T h i s f i nd ing can be exp lo red further by invest igat ing the post -hospi ta l izat ion pe r iod as descr ibed by the parents themselves, a task undertaken by the author o f this research report. In a s im i la r study, W o l f e r and V is in ta ine r (1975) hypothes ized that ch i ld ren and parents w h o rece ive specia l psycho log i ca l preparat ion and cont inued support ive care f r o m a C l i n i c a l Nu rse Spec ia l is t ( C N S ) w o u l d show less behav iora l upset and better c o p i n g abi l i t ies dur ing the hospi ta l izat ion per iod and fewer post -hospi ta l adjustment p rob lems. E igh t y ch i ld ren aged three to 14 years scheduled for m i n o r surgery and their 19 parents were randomly assigned to cont ro l and exper imenta l groups. T h e ch i ld ren had not been hosp i ta l i zed i n the prev ious year and were admit ted fo r procedures such as tons i l lec tomy, adenoidectomy, myr ingo tomy , and ingu ina l or u m b i l i c a l herniorrhaphy. A s w i th M a h a f f y ' s (1965) study, there was ev idence o f anxiety i n both the cont ro l and exper imenta l groups. Parents i n the latter group (wi th C N S support) however , had s ign i f icant ly l owe r self rat ings o f anxiety , h igher rat ings o f adequacy o f i n fo rmat ion p rov ided , and greater sat isfact ion w i th the care g iven . T h e ch i ld ren in the exper imenta l group showed s igni f icant phys io log i ca l ev idence o f reduced anxiety wh i le i n hospi ta l (eg., l o w e r b l ood pressure readings, reduced inc idence o f c r y i n g & vomi t i ng , etc.) and a lso obta ined s ign i f i candy lower post-hospi ta l adjustment scores on the Posthosp i ta l B e h a v i o r Quest ionnai re (Ve rnon , S c h u l m a n , & F o l e y , 1966). These f ind ings add support to the premise that nurs ing intervent ion p lays a ro le i n reduc ing anxiety i n hosp i ta l i zed parents and ch i ld ren . O f further interest was W o l f e r and V is in ta ine r ' s (1975) f i nd ing that the anxiety rat ings i n both parental groups p roved to be s ign i f icant ly h igher for parents o f young ch i ld ren . In add i t ion , ch i ld ren whose ages were between three and s ix years consis tent ly demonstrated greater upset and less cooperat ion than those i n o lder age groups. These f ind ings support the need for an invest igat ion w h i c h focuses on the exper ience o f parents o f ch i ld ren under the age o f f i ve . It is important to note that the W o l f e r and V ins in ta ine r (1975) study had a number o f methodo log ica l p rob lems regard ing the poss ib le bias o f parents i n the exper imenta l group w i th w h o m the research nurse spent cons iderab ly more t ime than those parents i n the cont ro l group. In 1978, Va rda ro reported an invest igat ion designed to determine a re lat ionship between anx ie ty i n the preschoo l c h i l d and anxiety i n the parent p r io r to the c h i l d ' s 20 hosp i ta l iza t ion for e lect ive surgery. She studied 18 subjects aged 18 to 66 months and their mothers. T h e ch i ld ren had no prev ious hospi ta l izat ion exper ience o r preparat ion. V a r d a r o (1978) emp loyed three dif ferent instruments to measure anxiety: A ur ine test fo r 17-hydroxycor t icoster iod was done on samples co l lec ted f r om both mother and c h i l d ; the State-Trai t A n x i e t y Inventory Se l f -Eva lua t i on Quest ionnai re ( S T A I ) was g i ven to the mother ; and the Prehosp i ta l B e h a v i o r Quest ionna i re w a s g iven to the mother to f i l l out about her ch i l d . Stat is t ical analys is o f the data showed a h igh ly s igni f icant pos i t i ve corre la t ion between anxiety i n the mother about hospi ta l izat ion o f her p reschoo l c h i l d fo r e lect ive surgery and anxiety i n the p reschoo l ch i l d . A c c o r d i n g to the State Quest ionnai re o f the S T A I , e ighty-n ine per cent o f the mothers exper ienced m e d i u m or h igh anxiety when comp le t i ng the quest ionnaire at home two days pr ior to the hospi ta l admiss ion . O f interest was the f i nd ing that the leve l o f maternal anxiety was s ign i f icant ly h igher for mothers o f one c h i l d versus those mothers w i th more than one ch i l d . L im i ta t i ons o f this study inc lude the sma l l sample s ize , use o f a Prehospi ta l B e h a v i o r Quest ionnai re w h i c h l acked prev ious re l iab i l i t y and va l id i t y test ing, and us ing mothers w h o were exper ienc ing anxiety to rate the behav ior o f their o w n ch i l d . T h e f ind ings o f the three preced ing studies as w e l l as those done by Fr ieberg (1972), Sk ipper , L e o n a r d , and R h y m e s (1968) and Prugh et a l . (1953) p rov ide support fo r the "emot iona l contag ion hypothes is" w h i c h ho lds that a parent 's emot iona l state m a y be read i ly t ransmit ted to a young c h i l d (Wo l f e r and V is in ta iner , 1975). E m o t i o n a l l y upset parents are often unable to assist their ch i ld ren to cope w i th a stressful s i tuat ion, yet parental support and comfor t is essent ia l w h e n a young c h i l d is 21 fac ing any type o f new exper ience (Vardaro , 1978). Ma te rna l anxiety may effect the c h i l d ' s emot iona l responses both dur ing hosp i ta l iza t ion and i n the post-hospi ta l izat ion per iod . T h e l i terature a lso supports the premise that selected nurs ing intervent ions can have a s ign i f icant impac t on reduc ing parental anx iety dur ing a c h i l d ' s hospi ta l izat ion. In summary , the f ind ings d iscussed in this sect ion support an invest igat ion to exp lore the parents ' exper ience f r o m their perspect ive i n order to address parental needs. A s the f ind ings o f these studies revea led, i n seek ing to meet parental needs health profess ionals w i l l a lso ind i rec t ly meet the needs o f their pediatr ic patients w h o may be s ign i f icant ly af fected b y their parents ' percept ions o f the health care encounter. Parenta l At t i tudes Towards Pediat r ic D a y Care Surgery T h e l i terature searched fo r the purpose o f this report has not revealed any studies w h i c h spec i f i ca l l y examine parents ' exper ience i n the post -hospi ta l izat ion per iod f o l l o w i n g their young c h i l d ' s day care surgery. There are, however , three studies that addressed the attitudes and impress ions o f parents towards their c h i l d ' s day care surgery before it was undertaken. These are inc luded here because a l l three were conducted in the same c i ty as the current research. In 1969, p r io r to the establ ishment o f a pediatr ic day care fac i l i ty i n Vancouve r , B r i t i s h C o l u m b i a , Shah , Papag iorg is , R o b i n s o n , K i n n i s and Israels surveyed the attitudes o f a group o f 611 parents towards this alternative f o r m o f health care de l ivery . T h e ch i ld ren o f the part ic ipant parents ranged i n age f r o m in fancy to 18 years. The authors co l lec ted n o m i n a l l eve l data by the administ rat ion o f a quest ionnaire to selected parents f o l l o w i n g their c h i l d ' s convent iona l hospi ta l stay for a m i n o r e lect ive surg ica l procedure. T h e quanti tat ive quest ionnaire requ i red parental responses w h i c h ind icated 22 on l y agreement o r d isagreement w i th the statements presented. T h e major f i nd ing o f their study was that 4 5 . 3 % o f those parents w h o qua l i f ied fo r day care stated they w o u l d have preferred day care i f such an alternative had been ava i lab le at the t ime. In re lat ion to the quest ionnai re 's statements assessing leve l o f anxiety , the authors fa i l ed to revea l s ign i f icant d i f ferences between the responses o f the two parent groups (choos ing day care or convent iona l hospi ta l izat ion) . B o t h groups agreed that they were anx ious w h e n their ch i ld ren were i n the hospi ta l and also that their ch i ld ren were anx ious dur ing this t ime. O n e interest ing f i nd ing o f the study was that certain surg ica l procedures (ie., repai r o f hern ia o r squint) were associated w i th greater parental preference fo r convent iona l hospi ta l izat ion than others (ie., cast change o r r e m o v a l , cys toscopy) . The authors suggested that this d i f ference might be because "parents are more anx ious about procedures w h i c h result i n read i ly v i s ib le changes or effects o f procedures w h i c h are cons idered ser ious for adul ts" (p. 346). Unfor tunate ly , the authors use o f a structured, c lose-ended quest ionnaire d i d not a l l o w the study part ic ipants to open ly express op in ions or concerns such as those related to their fee l ings o f anxiety. T h e quest ionnaire fo rced parents to respond to the perce ived concerns o f the researchers rather than those ident i f ied by the parents themselves. A s a f o l l ow-up to the 1969 study, Shah et a l . (1972), undertook a cont ro l led study o f med i ca l compl ica t ions and parental attitudes f o l l o w i n g the day care surgery o f 318 ch i ld ren . T h e ch i ld ren were alternately ass igned to ei ther the cont ro l o r the exper imenta l groups and were matched for age, sex, type o f surgery and soc io -economic c lass. A l t h o u g h the authors fa i led to comment on the re l iab i l i t y and va l id i t y o f their 23 data co l l ec t ion tools, they reported that 56 percent o f the parents i n the study chose the day care opt ion for their c h i l d ' s surgery as opposed to hav ing the c h i l d stay i n hospi ta l overn ight . Shah et a l . (1972) conc luded that it was probab ly a h igher degree o f anxiety i n the parents car ing for their ch i ld ren at home w h i c h accounted for a s ign i f icant ly h igher number o f post-operat ive reports o f pa in and cough ing i n this group. T h e day care surgery parents also expressed a stronger preference for post -hospi ta l izat ion home v is i ts by a nurse and cons idered this v is i t to be important. T h e authors attr ibuted this f i nd ing to an increased need for reassurance. Despi te acknow ledg ing that the post-hospi ta l iza t ion pe r iod f o l l o w i n g a c h i l d ' s day care surgery can be an anx ious t ime for parents, these authors d i d not suggest further invest igat ion o f these f ind ings and in fact recommended that the one support that was avai lab le to the parents—the home v is i ts by the nurse—be d iscont inued i n l ight o f the few med ica l compl ica t ions i n the postoperat ive per iod . T h i s act ion fa i led to take in to account the impact o f the mother 's emot iona l we l l - be ing on that o f the postoperat ive ch i l d . In another bas ic l eve l descr ip t ive study, Davenpor t et a l . (1971) reported on a study popu la t ion o f 833 ch i ld ren w h o underwent day care surgery over a 27 month per iod . N ine t y - s i x percent o f the subjects had a hospi ta l stay o f eight hours o r less. D u r i n g the last three months o f their data co l lec t ion pe r iod fo r other research purposes, 184 study parents were contacted by telephone on the day after the c h i l d ' s operat ion and asked to respond w i th yes/no answers to eight attitude statements concern ing their exper ience w i t h the day care surgery p rogram. A large major i ty o f parents agreed that their c h i l d was both happier (94.6%) and safer (90.8%) at home than in hospi ta l f o l l o w i n g surgery. \ 24 In this study there was no home v is i t made by a nurse after d ischarge f r o m hosp i ta l . O v e r 9 0 % o f the parents responded " n o " to the statement that home v is i ts by a nurse w o u l d have been o f va lue. T h i s contrasts the f ind ings o f other authors and lends support to an invest igat ion o f the post-hospi ta l izat ion pe r i od to examine in detai l the parents ' perspect ives o f their exper iences. T h e authors o f this study stated that the parents ' attitude towards the home v is i t was " l og i ca l i n l ight o f the f e w and m i l d comp l i ca t ions f o l l o w i n g surgery" (p. 500). It is noteworthy that this conc lus ion does not concur w i th the f ind ings o f other studies rev iewed i n this sect ion w h i c h have c lear ly demonstrated the va lue o f nurs ing intervent ion i n decreasing anxiety i n the parent w i t h subsequent benef ic ia l effects for the ch i l d . A g a i n , this study d i d not a l l ow the parents an opportuni ty fo r open express ion regard ing their exper ience. In summary , parents support the concept o f day care surgery for their ch i ld ren . T h e f ind ings the studies presented i n this sub-sect ion d i d not exp lore the pediatr ic day care surgery exper ience f r o m the parents ' point o f v i e w and fa i l to p rov ide any insight in to the parental post day care surgery per iod exper ience. Because o f the strength o f the parent /ch i ld re lat ionship and the potent ial effect that one member o f the dyad cou ld have upon the other, l i terature descr ib ing the effects o f a short term hospi ta l izat ion on toddlers and preschoolers w i l l be rev iewed here. T h e Ef fec ts o f Short T e r m Hosp i ta l i za t ion on Todd lers and Preschoolers P ioneer ing research on the emot iona l s ign i f icance o f i l lness , hospi ta l izat ion, and surgery on young ch i ld ren was done i n the 1930s and 40s. Au tho rs such as B e v e r l y (1936), Jackson (1942), and L a n g f o r d (1948) descr ibed i n deta i l the psycho log i ca l and p h y s i o l o g i c a l impact o f parental separation and hospi ta l izat ion for ch i ld ren o f dif ferent ages. B o w l b y ' s 1952 report to the G e n e v a Conference o f the W o r l d Hea l th 25 Organ iza t ion brought further attention to the psycho log i ca l consequences o f hosp i ta l iz ing ch i ld ren . In 1953, P rugh et a l . pub l i shed what is n o w cons idered to be a c lass ic study invest igat ing the emot iona l react ions o f ch i ld ren and fami l ies to l o n g term hosp i ta l i za t ion . In 1958, Rober tson pub l i shed the f i rst ed i t ion o f h is insights in to the behav io r o f young ch i ld ren i n hospi ta l . B y 1965, V e r n o n , F o l e y , S i p o w i c z , and Schu lman presented a rev iew o f over 200 pub l ica t ions that dealt w i th the effects o f hospi ta l izat ion and i l lness on ch i ld ren . These ear ly works made s igni f icant contr ibut ions to our present understanding o f the emot iona l react ions o f ch i ld ren to the exper iences o f i l lness, hosp i ta l iza t ion, and surgery. Desp i te an abundance o f l i terature di rect ly concern ing the hospi ta l iza t ion o f ch i ld ren , there has been less attention pa id to the psycho log i ca l consequences o f the exper ience once the c h i l d has returned home. C h i l d r e n often exh ib i t some degree o f behav io ra l change f o l l o w i n g any type o f i l lness, not just one i n v o l v i n g hospi ta l izat ion o r surgery ( W i l k e n s o n , 1978). T h e term "psycho log i ca l upset" has been used here to refer to any adverse behav iora l change observed in ch i ld ren f o l l o w i n g the exper ience o f i l l ness , hosp i ta l iza t ion and/or surgery. T h e remainder o f this sect ion w i l l d iscuss the f ind ings o f severa l researchers w h o have examined psycho log i ca l upset i n ch i ld ren f o l l o w i n g their hospi ta l izat ion. T h i s rev iew is inc luded here because it was felt that the nature o f the c h i l d ' s exper ience may affect the parent 's exper ience du r ing the post-hosp i ta l iza t ion per iod . V e r n o n et a l . (1966) were forerunners i n examin ing post -hospi ta l izat ion behavior changes in young ch i ld ren . In the ear ly 1960 's they deve loped the Posthospi ta l izat ion B e h a v i o r Quest ionnai re . T h e quest ionnaire is a 28 i tem instrument w h i c h has since been used w i d e l y i n the f i e ld o f post-hospi ta l behav ior changes i n ch i ld ren and has extensive re l iab i l i t y and va l id i t y ( B r o w n , 1979; Hanna l l ah & Rosa les , 1983; M a h a f f y , 1965; S i p o w i c z & V e r n o n , 1965; 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 & V is in ta iner , 1975). F o r each o f the 28 i tems i n the quest ionnaire, the parent compares the c h i l d ' s t yp ica l behav ior before hospi ta l izat ion w i th his/her behav ior dur ing the f irst week after hosp i ta l iza t ion. T h e f i rst pub l i shed study u t i l i z ing the Posthospi ta l iza t ion B e h a v i o r Quest ionnaire ( P B Q ) was conducted by S i p o w i c z and V e r n o n (1965). T h e y conducted a comparat ive study o f 24 sets o f tw ins , where one o f each set was not hosp i ta l i zed and one was hosp i ta l i zed fo r med i ca l o r surg ica l in tervent ion. T h e range o f the hospi ta l stay was one to more than twenty-one days. T h e P B Q was ma i l ed to each mother s ix days after d ischarge. T h e results showed that the major i ty o f the hosp i ta l i zed tw ins , par t icu lar ly those aged 6 months to 4 years, showed more psycho log i ca l upset upon return home than the non-hosp i ta l i zed tw in . A l t h o u g h the number o f subjects was sma l l , this s tudy 's strength l ies i n the fact that the methodo logy inc luded a w e l l matched cont ro l group. V e r n o n et a l . (1966) studied the post hospi ta l izat ion behav ior o f 387 ch i ld ren aged one month to 16 years w h o were hosp i ta l i zed fo r a var ie ty o f surg ica l and med ica l cond i t ions. T h e mean durat ion o f their hospi ta l stay was 8.8 days. In this study the P B Q was ma i l ed to each set o f parents s ix days after d ischarge therefore on ly parents w h o were mot iva ted to do so returned the quest ionnaire. T h e researchers acknow ledged that even though not a l l i tems on the quest ionnaire were suitable for a l l o f the age groups i n the study, a l l the i tems were scored. Fac to r analys is o f the quest ionnaire responses revea led s ix categories o f post -hospi ta l izat ion behav ior 27 disturbances. These were: general anxiety and regression, separat ion anxiety , sleep anx ie ty , eat ing disturbances, aggression, and apathy-wi thdrawl . T h e invest igators e x a m i n e d their f ind ings i n l ight o f several var iab les: gender, pr ior hosp i ta l iza t ion, degree o f pa in exper ienced dur ing hospi ta l izat ion, bir th order, age, durat ion o f hosp i ta l iza t ion, and parental occupat iona l status. O n l y the latter three var iab les were shown to be s ign i f icant ly related to one or more o f the post -hospi ta l izat ion behav ior d isturbances. T h e authors o f this study conc luded that ch i ld ren between the ages o f s ix months and four years were most l i ke l y to demonstrate psycho log i ca l upset i n the post -hospi ta l izat ion per iod . T h e behaviors mani fested by this age group w o u l d be: increased sleep and separat ion anxiety, and increased aggression towards authori ty. S u c h f ind ings support an invest igat ion o f the exper ience o f parents o f toddlers and preschoolers dur ing the post-hospi ta l izat ion per iod as the parental exper ience c o u l d be s ign i f icant ly af fected by the c h i l d ' s psycho log i ca l upset. U s i n g an exper imenta l des ign, Davenpor t and W e r r y (1970) invest igated the post -hospi ta l izat ion effects o f br ief hospi ta l izat ion, m ino r surgery, and general anesthesia on 145 ch i ld ren aged one to 15 years w h o were hospi ta l ized fo r less than 48 hours. Th i r t y percent o f the subjects i n their study were aged s ix months to four years. T h e ch i ld ren were selected f r o m two dif ferent hospi tals and matched w i th a cor responding non-hosp i ta l i zed cont ro l group. T h e cont ro l groups were compr i sed o f s ib l ings o f the part ic ipants or ch i ld ren w h o attended a pediatr ic Out-Pat ient C l i n i c fo r a rout ine phys i ca l examina t ion . T h e Posthosp i ta l iza t ion B e h a v i o r Quest ionnai re was verba l l y admin is tered by a research assistant to the mother o f each c h i l d on the day o f her c h i l d ' s admiss ion and 28 again two weeks after hospi ta l d ischarge. Davenpor t and W e r r y fa i l ed to f i n d stat ist ical ly s ign i f icant ev idence o f res idual post -hospi ta l izat ion psycho log i ca l upset i n ei ther the exper imenta l o r contro l groups o f their subjects as rated by the subjects ' mothers. T h i s f i nd ing is inconsistent w i th that o f other researchers us ing the same instrument. T h i s incons is tency i n f ind ings lends support to an invest igat ion designed to exp lo re the nature o f the post -hospi ta l izat ion per iod f r o m the parents perspect ive. B r o w n (1979) studied the post-hospi ta l izat ion behav ior o f 4 0 ch i ld ren whose ages ranged between three and s i x years. E a c h c h i l d was hosp i ta l i zed fo r f i ve days for a tons i l lec tomy and adenoidectomy. B r o w n conducted three in terv iews w i t h each mother us ing the categor ies i n the Posthospi ta l izat ion B e h a v i o r Quest ionnai re (Ve rnon et a l . , 1966). A l l in terv iews were conducted in the c h i l d ' s home. She found that there were four categories o f behav ior w h i c h were descr ibed by parents as "wo rse " at one month post -hospi ta l izat ion but " i m p r o v e d " at s ix months. These categories were: general anx ie ty , separat ion anxiety, aggression, and sleep disturbances. T h e researcher found that instances o f psycho log i ca l upset decreased w i th the durat ion o f the post-hospi ta l iza t ion per iod . A l t h o u g h age, length o f hospi ta l izat ion and type o f surgery were inc luded i n the study des ign, other potent ia l ly in f luenc ing var iab les were not ment ioned. B r o w n ' s f ind ings agree w i th those o f V e r n o n et a l . (1966) and point to a need to further invest igate the post-hospi ta l izat ion pe r iod f r o m the parents ' perspect ive. Hanna l l ah and Rosa les (1983) undertook a study to examine the effects o f e l im ina t ing parent -ch i ld separation dur ing anaesthesia induc t ion for p reschoo l ch i ld ren undergo ing day care surgery. T h e purpose o f their study was to determine whether or not it was safe and feasib le to a l l ow parents o f young ch i ld ren to be present dur ing the anesthesia induc t ion o f their ch i l d . The ch i ld ren , aged one to f i ve years, were admit ted 29 fo r a var ie ty o f day care surg ica l procedures such as dental wo rk , hern ia repairs, c i r c u m c i s i o n , and eye surgery. F i f t y ch i ld ren had parents present dur ing anesthesia induc t ion and f i f ty d i d not. A notable f i nd ing o f this study was re lated to the results o f the Posthosp i ta l iza t ion B e h a v i o r Quest ionnaire ( V e m o n et a l . 1966) comple ted by parents through an in terv iew two weeks after their c h i l d ' s surgery w h i c h revealed a s ign i f icant number o f post-hospi ta l izat ion behav ior disturbances. O v e r 6 0 % o f the ch i ld ren in the exper imenta l and cont ro l groups mani fested behaviors related to sleep anxiety , ove r 4 5 % demonstrated separation anxiety, and over 3 4 % showed increased signs o f aggress ion. T h e authors fa i led to acknowledge the h igh inc idences o f these post day care surgery behav iora l disturbances or d iscuss the parents ' react ions to them. T h e preced ing studies have invest igated the occurrence o f post -hospi ta l izat ion p s y c h o l o g i c a l upset i n young ch i ld ren . A s many o f the researchers acknowledge , it is a d i f f i cu l t area to study because psycho log i ca l upset i n the post -hospi ta l izat ion per iod is i n f l uenced by numerous var iab les related to the c h i l d , the f a m i l y , and the actual hosp i ta l iza t ion exper ience. K n o w n var iab les that affect the exper ience inc lude : age o f the c h i l d , pre-hospi ta l personal i ty , past exper ience w i th hosp i ta l iza t ion, parental separat ion, qual i ty o f the parenta l -ch i ld re la t ionship, l e ve l o f maternal anx ie ty , status o f f a m i l y equ i l i b r i um , length o f hospi ta l izat ion, reason for hospi ta l izat ion, and preparat ion for hosp i ta l iza t ion (Be lmont , 1970; V e r n o n et a l . , 1966; W i l k i n s o n , 1978). A def in i te weakness i n the des ign o f most o f the studies rev iewed here is the m i n i m a l contro l exerted over these var iab les dur ing the research. In order to quant i fy psycho log i ca l upset i n the post -hospi ta l izat ion per iod , most researchers used the Posthospi ta l izat ion B e h a v i o r Quest ionnai re (Ve rnon et a l . , 1966). P u b l i s h e d reports o f re l iab i l i ty and va l id i t y o f this instrument have been made by 30 several authors (Ve rnon et a l . , 1966; V e r n o n , F o l e y , and S c h u l m a n , 1967). A l t h o u g h the quest ionnaire was apparent ly des igned to be adminis tered w i th in one week after d ischarge f r o m hosp i ta l , some invest igators have used it up to s ix months f o l l o w i n g hospi ta l d ischarge ( B r o w n , 1979). A l s o contrary to i ts o r ig ina l intent, it has been admin is tered to parents o f non-hosp i ta l i zed ch i ld ren (Davenpor t & W e r r y , 1970) and to parents o f ch i ld ren w h o fe l l outs ide o f the age groups to w h i c h some o f the questions app ly (Ve rnon et a l . , 1966). O f the studies rev iewed here, a l l but one (Davenport & W e r r y , 1970) reported that subjects exh ib i ted behav ior dur ing the post -hospi ta l izat ion pe r iod that was dif ferent f r o m their pre-hospi ta l izat ion behavior . T h e ch i ld ren 's behav ior changes were interpreted to be as a result o f the hospi ta l izat ion/surg ica l exper ience and consequent ly w o u l d l i k e l y affect the parent 's percept ions and exper ience du r ing the post -hospi ta l izat ion per iod . In 1981 F le tcher rev iewed the avai lab le l i terature related to psycho log i ca l upset i n post -hosp i ta l ized ch i ld ren . H e conc luded that the ident i f icat ion o f psycho log i ca l upset is cons iderab ly more comp lex than " focus ing on the hosp i ta l i zed c h i l d and compar i ng pre- and post-hospi ta l izat ion behav ior " (p. 193). T h i s wr i ter was unable to locate any studies examin ing post-hospi ta l izat ion behav ior changes in ch i ld ren us ing a qual i tat ive methodo logy . Y e t this perspect ive w o u l d add m u c h needed descr ip t ion and depth to this comp l i ca ted issue as w e l l as p rov ide some insight in to h o w the parents m igh t respond to these changes i n the c h i l d dur ing the post-hospi ta l izat ion per iod . In summary , the rev iew o f this sect ion o f l i terature appears to support the statement that "the comb ina t ion o f hospi ta l izat ion and i l lness is psycho log i ca l l y upset t ing to ch i ld ren i n general , even in the case o f br ie f hosp i ta l iza t ion for rout ine 31 i l l ness " ( S i p o w i c z & V e r n o n , 1965, p. 230). C h i l d r e n between the ages o f s ix months and f i ve years are par t icu lar ly suscept ible to "psycho log i ca l upset" f o l l o w i n g hosp i ta l iza t ion and surgery because o f their l eve l o f cogn i t i ve deve lopment and cop ing mechan isms (Do rn , 1984). P s y c h o l o g i c a l upset i n this age group mani fests i tse l f most c o m m o n l y as sleep disturbances, separation anxiety, and aggression. Because such behaviors can be re in forced and in tens i f ied by parental anx iety , nurses must exp lore the mean ing parents ass ign to these changes i n their c h i l d ' s behav ior , and ascertain h o w the parent 's post -hospi ta l izat ion exper ience may be in f luenced by changes. S u m m a r y T h i s chapter has rev iewed selected l i terature related to four major subject areas i n order to establ ish what is k n o w n about the post day care surgery exper ience fo r parents o f young ch i ld ren . T h i s author was unable to locate a study w h i c h spec i f i ca l l y invest igates the post day care surgery exper ience f r o m the parent 's po in t o f v i e w o r even descr ibes the impact o f this type o f health care encounter on the parent. T h i s l i terature rev i ew therefore exp lo red the more general impact o f a c h i l d ' s hospi ta l izat ion and surgery o n the parents, and on the ch i ld ren themselves. T h e current pub l i shed research does not p rov ide an indepth understanding o f the parents ' exper ience i n the post -hospi ta l izat ion pe r iod f o l l o w i n g their c h i l d ' s day care surgery. In 1972, Shah et a l . came to the f o l l o w i n g conc lus ion after s tudy ing med i ca l comp l i ca t ions and parental attitudes towards day care surgery for ch i ld ren : W h i l e it is necessary to sample the attitudes and op in ions o f consumers o f health serv ices concern ing changes in care, this study shows that when the expert prov iders endorse change i n the pattern o f de l ivery o f care, patients w i l l accept expert adv ice and judgement, (p. 48) T o - d a y , many parents have in fact "accepted" day care surgery as an alternative to the t radi t ional overn ight stay i n hospi ta l fo r their ch i l d ren . Desp i te this apparent parental acceptance there is st i l l stress and anxiety associated w i th this exper ience. A s heal th profess ionals it i s important that we do not assume to k n o w the parents ' perspect ive on this f o r m o f health care de l ivery . Nurses w o r k i n g i n both day care surgery units and commun i t y health settings need to understand the exper ience o f parents i n order to p rov ide appropriate preparat ion, support, in fo rmat ion , and guidance. T h i s study was therefore undertaken fo r the purpose o f e l i c i t i ng parents ' perspect ive on the post day care surgery exper ience and its impact on their day to day l i ves . T h e results o f this wr i te r ' s invest igat ion are a s ign i f icant addi t ion to current know ledge . T h e next chapter out l ines the implementat ion o f the selected methodo logy fo r this study. 33 C H A P T E R 3 M e t h o d o l o g y T h i s chapter descr ibes the app l ica t ion o f the phenomeno log i ca l method o f inqu i ry i n a study o f the parents ' exper ience o f hav ing a toddler o r preschooler at home f o l l o w i n g day care surgery. A br ie f in t roduct ion to phenomeno logy was in t roduced i n Chapter 1. T h e purpose o f this chapter is to rev iew the des ign o f this methodo logy i n further deta i l and d iscuss the implementat ion o f phenomeno logy i n re lat ion to this s tudy 's : se lect ion o f part ic ipants, sett ing, implementat ion procedures, data co l lec t ion , data analys is , and eth ica l considerat ions. Research D e s i g n " T h e phenomeno log ica l method is an induct ive , descr ip t ive research method. " (Omery , 1983, p. 50) . The or ig ins o f phenomeno logy began w i th the w o r k o f the Eu ropean ph i losopher , E d m u n d Husse r l , w h o be l ieved that "the study o f ph i l osophy shou ld have not on l y ' r igor ' but a lso a new h u m a n i s m " (Ray , 1985, p. 83). Phenomeno log is ts be l ieve that human beings act in accordance w i th the w a y they construct meanings for the situations they face (Dav is , 1978). Phenomenolog is ts emphas ize the " l i ved context" o f phenomena—li fe i n the everyday w o r l d as it is understood and interpreted by one l i v i n g through the situation (G io rg i , 1975a). "Phenomeno logy accepts exper ience as it exists i n the consc iousness o f the i nd i v i dua l " (F i e l d & M o r s e , 1985, p. 28) . It is the phenomeno log is t ' s task to ensure that the subject 's v iewpo in t o f the si tuat ion under study is revealed through descr ip t ion i n an unbiased w a y (G io rg i , • 34 1975b). It is the subject 's po in t o f v i e w that prov ides the " r i ch data w h i c h must be ob ta ined" ( G i o r g i , 1975a, p. 100). Because language is the major means o f commun ica t i on i n everyday l i fe , phenomeno logy depends a lmost exc lus i ve l y on language to obta in a descr ip t ion o f the exper ience under study. A n y t h i n g that the subject feels is wor thy o f ment ion ing is registered as data. T h i s a l l ows the real i ty o f the subject 's exper ience to be fu l l y expressed (Ray , 1985). It is through this process o f exhaust ive descr ip t ion that one deve lops an understanding o f the phenomenon under study (Lynch -Sauer , 1985). C r i t i c a l to the researcher 's approach in a phenomeno log ica l study is a heightened awareness o f the part ic ipant, the sett ing, and a m i n i m u m o f preconcept ions about the exper ience under study (Dav is , 1978). A truly presupposi t ionless descr ip t ion o f a phenomenon is imposs ib le because a researcher w i l l presuppose imp l i c i t l y i n the quest ions and answers o f an open-ended d ia logue accord ing to the intent ions and a ims o f h is /her research (Dav is , 1978; G i o r g i , 1975a). W h a t is suspended by the researcher, however , are assumpt ions w h i c h extend beyond h is /her in i t ia l quest ions. T h e researcher accepts the data as they appear wi thout t ry ing to mod i f y them to f i t a p reconce ived def in i t ion o f the phenomenon (Omery , 1983). T h e goa l o f the phenomeno log ica l method is to der ive consensual ly va l idated know ledge f r o m a systematic examinat ion o f human exper ience (Lynch-Sauer , 1985). V a l i d i t y i n the phenomeno log ica l method is " formulated in l ight o f a c l ien t ' s concept ion o f h i m s e l f o r hersel f i n the w o r l d " (Ray , 1985, p. 89). Descr ip t ions o f an exper ience shou ld be recogn ized as true by those w h o l i ve the exper ience. C o n t r o l i n phenomeno log ica l research comes not f r o m an expectat ion fo r dupl icate behav ior f r o m dupl icate data but rather f r o m the researcher 's perspect ive o f 35 the data. T h e key cr i ter ion is not whether another pos i t ion w i th respect to the data c o u l d be adopted, but whether a reader, adopt ing the same v iewpo in t and si tuat ion o f the researcher, c o u l d a lso seen what the researcher saw, whether o r not he/she agrees w i th it ( G i o r g i , 1975a; S a n d e l o w s k i , 1986). Se lec t ion o f Part ic ipants In a phenomeno log ica l study, the part ic ipants must have l i v e d or be l i v i n g the exper ience under invest igat ion. T h e y must a lso be interested i n understanding and express ing the feel ings w h i c h accompany their exper ience (Omery , 1983). Consis tent w i th the phenomeno log ica l method and the purpose o f this study, the part ic ipants sought were parents w h o cared for toddlers and preschoolers at home after the c h i l d ' s surgery because they c o u l d p rov ide the data to " i l luminate the phenomenon be ing s tud ied" (Sande lowsk i , 1986, p. 31). A purpos ive samp l ing technique was u t i l i zed to select study part ic ipants (D iers , 1979; M o r s e , 1986). U s i n g this nonprobabi l i ty method, parents were selected on the basis o f spec i f i c character ist ics w h i c h w o u l d enable the researcher to co l lec t the in-depth data requ i red to answer this s tudy 's research quest ion. B o t h mothers and fathers were approached to part ic ipate i n the study. A l l o f the parents w h o agreed to part ic ipate were selected f r o m the D a y Care U n i t o f a tertiary leve l pediatr ic hospi ta l i n V a n c o u v e r , B r i t i sh C o l u m b i a . Cr i t e r i a fo r Se lec t ion T h e spec i f i c cr i ter ia establ ished to select the fami l ies for par t ic ipat ion in this study were that: 1. T h e age o f the c h i l d at the t ime o f surgery ranged between one and f i ve years. , 36 2. T h e c h i l d res ided w i th h is/her parent(s). 3. T h e c h i l d had not had prev ious day care surgery o r overn ight hospi ta l admiss ions . 4 . T h e c h i l d w a s admit ted fo r e lect ive surg ica l cor rect ion o f a short-term cond i t ion or i l lness. 5. T h e c h i l d was d ischarged home to the care o f h is/her parent(s) on the same day o f hosp i ta l admiss ion . 6. T h e parent(s) assumed the care o f the c h i l d dur ing the post-hospi ta l izat ion per iod . 7. T h e parent(s) were able to understand, speak, and read E n g l i s h , regardless o f ethnic background. 8. T h e parent(s) had not had prev ious exper ience w i th a c h i l d w h o underwent day care surgery. 9. T h e f a m i l y res ided i n the V a n c o u v e r Met ropo l i tan area. Sett ing T h e sett ing chosen for the data co l lec t ion process was the parents ' o w n homes. T h e parents ' home env i ronment was chosen in order to ensure p r i vacy and to promote their comfor t and ease when descr ib ing personal exper iences. W h e n us ing the phenomeno log ica l method " a re laxed atmosphere and suf f ic ient t ime to express the fee l ing or exper ience are essent ia l " (Omery , 1983, p. 56). Implementat ion Procedures T h e f o l l o w i n g steps were f o l l o w e d in order to imp lement this study: 1. A f t e r pe rmiss ion to conduct the study was obta ined f r o m the appropriate screening commit tees (Append ices A & B , pp. 143 & 144), the researcher met w i th the 37 H e a d Nu rse o f the D a y Care U n i t to i n f o rm her about the nature o f the p roposed study and seek her co-operat ion in car ry ing it out. A s requested by the H e a d Nurse , a summary o f the research p roposa l was prepared and made ava i lab le to a l l o f the nurs ing staff on the unit. 2. A l l o f the phys ic ians and dentists w h o admit ted ch i ld ren to the D a y Care U n i t rece ived a letter f r o m the researcher i n fo rm ing them about the nature and purpose o f the study (Append i x C , p. 145). Fur ther detai ls o f the research project w o u l d be p rov ided i f they w ished to contact the researcher d i rect ly . T h e researcher d i d not rece ive any inqu i r ies about the project f r o m this group o f profess ionals . 3. In order to select parents w h o met the establ ished select ion cr i ter ia , the researcher v is i ted the D a y Care U n i t on the even ing before a regular surg ica l day to r ev i ew the operat ing r o o m schedule and the patient charts fo r the f o l l o w i n g day. 4 . O n the day o f surgery, the researcher persona l ly contacted the potent ia l study part ic ipants i n the D a y Care U n i t after their c h i l d had been taken to the operat ing r o o m (the rat ionale fo r this approach is d iscussed under E th i ca l Cons idera t ions p. 43) . T h e researcher in t roduced hersel f and of fered a br ief verba l exp lanat ion about the study. A f t e r de termin ing i f the parent(s) met the select ion cr i ter ia, the researcher o f fered a wr i t ten letter o f in fo rmat ion w h i c h exp la ined the purpose, nature, r i sks , and benefi ts o f the p roposed study (Append i x D , p. 146). It was suggested to parents that they might read the researcher 's in fo rmat ion letter dur ing the wa i t ing per iod pr io r to their ch i l d ' s return to the D a y Care U n i t f r o m the post-anesthetic recovery r o o m ( P A R R ) . 5. A f t e r consul ta t ion w i th the nurs ing staff i n the D a y C a r e U n i t , the researcher returned to see the parents after their c h i l d returned f r o m P A R R i n order to address any quest ions o r concerns regard ing the study in format ion letter. T h i s method o f approach 38 was used w i th the f irst three part ic ipant fami l ies , and it was found that parents ' in terest /wi l l ingness to part ic ipate i n the study was q u i c k l y establ ished dur ing their f irst contact w i t h the researcher. It was also found that parents were o c c u p i e d w i th concerns re lated to the we l l - be ing o f their c h i l d after h is/her return f r o m P A R R . Therefore i n order to be sensi t ive to parental needs at this time, it was dec ided that for the remainder o f the part ic ipant select ion process the researcher w o u l d not return to see the parents a second t ime in the D a y Care Un i t . 6. I f the parents agreed to be so contacted, the researcher te lephoned them at home the f o l l o w i n g morn ing to ascertain o r c o n f i r m their w i l l i ngness to part ic ipate i n the study and, as appropriate, arrange a convenient t ime to v is i t . T h e parent 's verba l agreement and release o f their telephone number to the researcher const i tuted pe rm iss ion for further contact. 7. In fo rmed wr i t ten consent f r o m the part ic ipants was obta ined by the researcher at the f irst home v is i t and pr io r to c o m m e n c i n g an in terv iew (Append i x E , p. 148). Subsequent in terv iews were arranged on a date and t ime convenient fo r the parent(s). Da ta C o l l e c t i o n " T h e goa l o f phenomeno logy is to descr ibe 'accurately the exper ience o f the phenomenon under study" (F i e l d & M o r s e , 1985, p. 28). In order to answer the research quest ion posed by this study, the data co l lec t ion process cons is ted o f in-depth in te rv iews conducted by the researcher. A total o f 16 in terv iews were car r ied out w i th n ine parents o f post-operat ive toddlers and preschoolers over a s ix month per iod . E igh t f i rst in terv iews and eight second in terv iews were conducted. 39 P r i o r to arranging each o f the in terv iews it was made c lear that both parents were inv i ted to part ic ipate. In a l l cases except one however , the in terv iews were conducted w i t h the mother alone. In the case o f one f am i l y , mother and father were present fo r the f irst and second in terv iews. T h e parent 's i nd i v i dua l dec is ion to part ic ipate i n the in terv iews, even i f their spouse d i d not choose to do so, is consistent w i th this s tudy 's methodo logy . T h e in terv iews were des igned to explore "the mean ing o f that exper ience as it un fo lds for the part ic ipants" (Omery , 1983, p. 54) . T h e in terv iews were semi^-structured i n nature and ranged i n length f r o m 45 to 105 minutes. A n in terv iew guide (Append ix F , p. 149) was used dur ing the f irst in terv iew to faci l i tate the exp lora t ion o f general content areas and help e l ic i t the parents ' descr ipt ions o f their exper ience. T h e guide cons is ted o f several open-ended quest ions w h i c h had evo l ved f r o m the s tudy 's theoret ical f ramework and the rev iew o f relevant l i terature. Open-ended quest ions are des igned to create a conversat iona l atmosphere and a l l ow for free express ion (D iers , 1979). Cons is tent w i th the analyt ic method, the content o f the second in terv iews was d rawn f r o m analys is o f the mater ia l d iscussed dur ing the f i rst in terv iews and f r o m in terv iews w i t h other parents. D u r i n g the second in terv iew the researcher sought c la r i f i ca t ion and a deeper understanding o f issues in i t ia l l y ra ised. T h e second in terv iews a lso gave opportuni ty to attend to new topics that were ra ised b y the parent. T h i r d in te rv iews, a l though an opt ion , were not deemed to be necessary for further c la r i f i ca t ion o f data. F o r s i x o f the eight fami l ies the f irst in terv iews were conducted on the c h i l d ' s f i rst post-operat ive day. D u e to d i f f icu l t ies co-ord inat ing the researcher 's schedule w i th 40 the f a m i l y ' s schedule, two fami l ies were seen for the f irst t ime on the c h i l d ' s second post-operat ive day. T h e second in terv iews were conducted between the c h i l d ' s seventh and tenth post-operat ive day. These t ime per iods were chosen i n order to e l ic i t parents ' immed ia te responses to the exper ience and as w e l l to g ive them some t ime to assimi late its impact . Severa l invest igators (Droske , 1978; F r ieberg , 1972; Rober tson , 1970) have documented an increased parental concern regard ing post -hospi ta l izat ion behav ior changes, such as sleep anxiety and increased dependency, i n toddlers and preschoolers one to two weeks after hospi ta l d ischarge. A s was agreed to by the part ic ipants, a l l o f the in terv iews were audio- recorded i n order to obta in accurate verba t im accounts o f the in te rv iewee 's responses. The tape record ings were t ranscr ibed either by the researcher or a qua l i f i ed dicta-typist . F o l l o w i n g t ranscr ipt ion, the in terv iew data was then ana lyzed by the researcher. A s an addendum to the taped in terv iews, the researcher kept wr i t ten f i e ld notes o f telephone conversat ions and d iscuss ions w i th the parents that were not aud io- recorded (Anderson , 1981; L o f l a n d & L o f l a n d , 1984). Spec i f i c data related to the character ist ics o f the parents and fami l i es , and general observat ions about the in te rv iew process were also c o m p i l e d as f i e l d notes. It was necessary on two occas ions , due to fa i lure o f the audio-recorder, to record por t ions o f the parent in terv iews as f i e ld notes. These notes were made f r o m the researcher 's m e m o r y immedia te ly after leav ing the f a m i l y ' s home. T h e approach to data co l lec t ion as descr ibed i n this sect ion is i n keep ing w i th the f ramework and methodo logy chosen for this study as it a l l ows for exp lora t ion and c la r i f i ca t ion o f issues related to a part icular exper ience. T h e f ie ld notes and the ve rba t im transcripts o f the taped in terv iews compr ised the data for this study. 41 Da ta A n a l y s i s In a qual i tat ive research methodo logy , data co l lec t ion and data analys is are not d ist inct phases o f the research project. A c c o r d i n g to M o r s e (1986), i n a qual i tat ive methodo logy , data co l lec t ion and analys is do not cease unt i l "the theory is complete , does not have gaps, makes sense, and has been con f i rmed" (p. 184). T h e process o f co l l ec t ing , c o d i n g and ana lyz ing data began at onset o f this study and cont inued after comp le t i on o f a l l the in terv iews unt i l the parents ' accounts were synthes ized into a descr ip t ive f ramework o f their exper ience w i th a toddler o r preschooler after the c h i l d ' s day care surgery. F o r the purposes o f this research project the data were ana lyzed accord ing to the f i ve step me thod proposed by G i o r g i (1975a; 1975b): 1) F o l l o w i n g transcr ipt ion o f a taped in terv iew w i th a parent(s), the researcher read the entire descr ip t ion through i n order to get a sense o f the who le . 2) N e x t the transcript was reread s l ow l y and del ineated each t ime that a t ransi t ion i n mean ing was perce ived w i th respect to the post day care surgery exper ience for parents o f toddlers and preschoolers. T h e resul t o f this procedure was the ident i f ica t ion o f a series o f "mean ing uni ts" . F o r example , one o f the mean ing units ident i f ied after read ing and rereading several transcripts was the fear and anxiety fel t by parents du r ing the pre-hospi ta l izat ion pe r iod and related to the u n k n o w n outcome o f their c h i l d ' s surg ica l and/or anesthetic procedure. L o f l a n d and L o f l a n d (1984) state that meanings are " consc ious l y s ing led out as impor tant aspects o f rea l i ty" (p. 71). M e a n i n g units i n qual i tat ive data analys is are descr ibed as " t ransbehav iora l " ( Lo f l and & L o f l a n d , 1984, p. 72)-- they not on l y descr ibe behav io r but a lso def ine, jus t i fy , and interpret it. 42 3) In the th i rd step, the ident i f ied mean ing units were compared to each other and to the sense o f the who le . Redundanc ies were e l iminated and rema in ing units were c la r i f i ed and elaborated. T h i s comparat ive analys is cont inued w i th in the i nd i v i dua l transcript, between transcripts f r o m the same parents, and among transcripts f r o m other parents. There was cont inua l movement back and for th between the transcripts. 4) N e x t the researcher "systemat ica l ly interrogated" ( G i o r g i , 1975b, p. 75) each o f the ident i f ied mean ing units i n order to revea l its contr ibut ion to the post day care surgery exper ience for parents o f toddlers and preschoolers. M a n y o f the mean ing units were c o m m o n across the parents ' accounts o f their exper ience. T h e mean ing units were then t ransformed f r o m the everyday language o f the part ic ipants in to the language o f nurs ing sc ience. F o r example , one mean ing unit ident i f ied was an increase in the f requency o f parental observat ions o f the c h i l d dur ing the in i t ia l post-operat ive per iod . T h i s f i nd ing was t ransformed into a concrete c lass i f i ca t ion ca l l ed "protect ive behav iors" . 5) In the f i f th step, the researcher integrated and synthesized the mean ing units d rawn f r o m the parents ' accounts into c o m m o n themes and concepts f o rm ing a descr ip t ive f ramework o f the mean ing o f the post day care surgery exper ience for parents o f toddlers and preschoolers. T h e final po int o f the phenomeno log ica l approach is commun ica t i on o f the f ind ings to other researchers for the purpose o f conf i rmat ion or c r i t i c i sm. A s was p rev ious ly stated, these steps were not car r ied out sequent ia l ly but rather f o rmed the basis o f the analyt ic process that was ongo ing dur ing and after the data co l l ec t ion for this project. The f ina l result o f the process is a synthesis o f the parents ' accounts o f their exper ience w i t h a post day care surgery toddler or preschoo ler into the f ramework descr ibed i n Chapter 4. 43 E th i ca l Cons iderat ions In order to ensure that the r ights o f the parents w h o part ic ipated i n this study were protected, certain eth ica l recommendat ions were f o l l o w e d (Canada C o u n c i l , 1977; D i e r s , 1979). These were: Research C learance Procedures. A p p r o v a l to carry out the p roposed research was sought and rece ived f r o m both the Un ive rs i t y o f B r i t i sh C o l u m b i a Behav iou ra l Sc iences Sc reen ing Commi t tee for Research and Other Studies I nvo l v i ng H u m a n Subjects and 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 ' Hosp i ta l In -Hosp i ta l Research R e v i e w Commi t t ee (Append ices A & B , pp. 143 & 144). In fo rmed Consent . Potent ia l part ic ipants w h o met the study cr i ter ia were contacted i n person by the researcher and rece ived verba l and wr i t ten in fo rmat ion about the purpose, nature, imp l i ca t ions , r i sks , and benefi ts o f the study (Append i x D , p. 146). D u e to the method used fo r book ing ch i ld ren for day care surgery procedures at B r i t i sh C o l u m b i a ' s C h i l d r e n s ' Hosp i t a l at the t ime the study was conducted, there was no pract ica l oppor tun i ty to contact parents by m a i l i n advance o f their a r r iva l at the D a y C a r e U n i t on the day o f the c h i l d ' s surgery. There was no co l l us ion o r decept ion by the researcher i n her approach to potent ia l study part ic ipants. T h e r ight to refuse to part ic ipate or w i thdraw f r o m the study at any time wi thout pre jud ice to current or future heal th care for their ch i ld ren , was exp la ined verba l l y and i n wr i t i ng to a l l part ic ipants. T h e r ight to refuse to answer any quest ions, o r to dec l ine the use o f a tape recorder was also made clear. T h e part ic ipants were asked to read and s ign a consent f o r m (Append i x E , p. 148) i n the presence o f the researcher after she had ensured a l l quest ions had been answered to the parent 's sat isfact ion, and pr ior to c o m m e n c i n g data co l lec t ion . 44 P r i v a c y . In order to ensure conf ident ia l i ty and anonymi ty , par t ic ipant 's were assured that their names and a l l other ident i fy ing in format ion d i d not appear o n any in terv iew tapes or transcripts. A code, k n o w n on ly to the researcher, w a s used to ident i fy the transcripts. A c c e s s to the coded data was restr icted to the researcher, the two members o f her thesis commi t tee, and the typist (the latter two i n on l y a l im i ted manner) . T h e data were stored i n a l o c k e d f i l i ng cabinet. T h e data co l lec ted were used for the stated research object ives on ly . Par t ic ipants w i l l not be personal ly ident i f ied ei ther d i rect ly or ind i rec t ly i n any pub l i ca t ion re lated to this study. Ar rangements were made to erase the tapes and shred the transcr ipts, the f i e l d notes, and the study consent fo rms w i th in three to f i ve years of the study. A br ie f summary o f the s tudy 's f ind ings was submit ted to the c l i n i ca l agency and also to those parents w h o had p rev ious ly ind icated their w i s h to be so in fo rmed. S u m m a r y T h i s chapter d iscussed the implementat ion o f the phenomeno log ica l method to study parents ' post -hospi ta l izat ion exper ience w i th toddlers and preschoolers w h o underwent day care surgery. N i n e parents part ic ipated in the study and 16 in-depth in terv iews were conducted. T h e researcher assumed the ro le o f faci l i tator i n the exp lora t ion o f the mean ing o f this parental exper ience and contr ibuted to the const ruct ion o f the accounts. Da ta co l lec t ion and analys is were in ter twined. Chapter 4 represents the researcher 's interpretat ion and synthesis o f the par t ic ipants ' accounts into a descr ip t ion o f the mean ing o f the post day care surgery exper ience for parents o f toddlers and preschoolers. Chapter 4 a lso discusses and interprets the s tudy 's f ind ings w i t h i n the context o f current, related l i terature. V 45 C H A P T E R 4 Presentation and Discussion of Findings W h a t is the parents ' exper ience o f hav ing a toddler or preschoo ler at home f o l l o w i n g day care surgery? T h e f ind ings o f the study des igned to answer this quest ion are presented i n this chapter. These f ind ings prov ide ins ight in to the parents ' b road perspect ive o f the pediatr ic day care surgery exper ience w i th in the context o f their everyday l i ves . A l t h o u g h it was the researcher 's o r ig ina l intent to descr ibe the "post" day care surgery exper ience for parents o f toddlers and preschoolers, it soon became apparent du r ing the data co l lec t ion process that the post-hospi ta l izat ion exper ience was on l y mean ing fu l w h e n v i e w e d w i th in the context o f the events and occurrences that had l ed up to it. Parents art iculated that the total exper ience began w i th their rea l iza t ion that someth ing was " w r o n g " w i th their c h i l d and ended on ly w h e n the c h i l d ' s behav ior and appearance, as w e l l as the act iv i t ies and rout ines o f a l l f am i l y members , had returned to acceptable patterns. Th i s " large p ic ture" p rov ided the context fo r the exper ience o f hav ing a toddler or preschooler undergo day care surgery. T h e parents ' b road v i e w o f their pediatr ic day care surgery exper ince contrasts w i t h the nar rower perspect ive he ld by many health care profess ionals . U n l i k e parents, w h o descr ibe their exper ience as occur r ing over a span o f time rang ing f r o m weeks to years, heal th care profess ionals tend to v i e w the parents ' exper ience p r imar i l y w i th in the context o f the immedia te preoperat ive, operat ive, and in i t ia l post-operat ive surg ica l days (Davenpor t , Shah , & R o b i n s o n , 1971). Parents w h o part ic ipated i n this study were 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, wil l 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 conceptuali-zation 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 synthes ized and o rgan ized in to concepts, themes, and sub-themes and three temporal phases. T h i s conceptua l structure fo rms the theory generated f r o m this study. A l t h o u g h it i s the author 's intent to present data w h i c h enhance the reader 's understanding o f the shared aspects o f the parents ' exper iences, it remains important to recogn ize the un ique nature o f the exper iences o f the i nd i v i dua l parents w h o par t ic ipated i n this study. Because the parents ' percept ions o f the exper ience and the intensi ty o f their react ions and responses to it changed over the span o f their total exper ience, the concept o f t ime is important i n an examinat ion o f this s tudy 's f ind ings . D u r i n g ana lys is o f the parents ' accounts, i t became apparent to the researcher that the parents ' were descr ib ing three dist inct , ch rono log ica l stages to their exper ience. T h e wr i ter has named these three temporal phases and, us ing parameters descr ibed by the part ic ipants, de f ined their boundar ies and their character ist ics. T h e three phases o f the parents ' exper ience were: a pre-hospi ta l izat ion o r preparatory phase, a hospi ta l izat ion or operat ive phase, and a post -hospi ta l izat ion or readjustment phase. T h e three phases w i l l be br ie f ly in t roduced to the reader here and w i l l be descr ibed i n deta i l later i n this chapter. T h e pre-hospi ta l izat ion o r preparatory phase began w i t h the parents ' rea l izat ion that someth ing was " w r o n g " w i th their c h i l d and ended w i th the c h i l d ' s admiss ion to hospi ta l to undergo correct ive surgery. D u r i n g this phase the parents readied themselves and their fami l ies emot iona l l y and phys ica l l y fo r the day care surgery event. The hospi ta l izat ion o r operat ive phase occur red dur ing the three to s ix hours that the parent(s) and c h i l d were actual ly i n the hospi ta l sett ing. T h i s was a h i gh l y emot iona l , intense phase o f the exper ience as the f ina l preparat ions fo r surgery were made and the parent(s) re l inqu ished their c h i l d to the care o f health 48 care pro fess iona ls i n order that the surgery cou ld be per formed. T h e post-hosp i ta l iza t ion or readjustment phase began upon hospi ta l d ischarge and cont inued unt i l the c h i l d had recovered phys i ca l l y and emot iona l ly f r o m the surgery and a l l f am i l y members had returned to acceptable patterns o f da i l y l i v i n g . It was the parents ' i nd i v i dua l exper iences that dictated the rate at w h i c h they m o v e d through these three phases. T h e ident i f icat ion o f the three phases o f the parents ' exper ience not on l y ref lects a c o m m o n thread i n the parents ' accounts o f their exper iences, but a lso serves to p rov ide a structure fo r the ana ly t ica l f ramework i n order to examine and contrast the parents ' thoughts, fee l ings , behaviors , and react ions as the events o f the exper ience e v o l v e d i n sequence over time. Throughout the three phases o f the exper ience parents exper ienced di f ferent feel ings and emot ions i n va ry i ng intensit ies. Parents a lso used a var ie ty o f c o p i n g mechan isms and soc ia l supports to manage dur ing the var ious phases o f their exper ience. T h e core concept that emerged f r o m an analys is o f the s tudy 's data was stress—parents w h o part ic ipated i n this study perce ived their exper ience as a stressful event i n their everyday l i ves resul t ing i n feel ings o f fear, wor ry , and anxiety throughout the three conceptua l phases o f the exper ience. T h e core concept o f stress is the basis o f the s tudy 's analy t ic f ramework and encompasses under l y ing themes, and sub-themes deve loped f r o m analys is o f the data. T h e major themes ident i f ied i n data analys is represent d imens ions o f the parents' exper iences that contr ibuted to their interpretation o f the event as stressful . These were increased parental respons ib i l i t y and ro le strain. A d d i t i o n a l themes f r o m the parents ' accounts a lso reveal d imens ions o f their exper ience that enhanced or inh ib i ted their 49 ab i l i ty to manage w i th in the context o f their everyday l i ves . These themes have been ident i f ied as c o p i n g strategies and soc ia l support. T h e s tudy 's conceptual f ramework is therefore based on a core theme o f stress and is o rgan ized accord ing to a ch rono log ica l structure cons is t ing o f three dist inct phases. T h e components o f the f ramework , a long w i th under ly ing themes and sub-themes, are s igni f icant i n terms o f how the parents understand and exp la in their exper ience w i th their c h i l d ' s day care surgery and w i l l be in t roduced to the reader here. D a y C a r e Surgery as a Stressfu l Exper ience T h e l i terature abounds w i th references to the hospi ta l izat ion o f a c h i l d as a stressful event fo r the parents (Fre iberg, 1972; G o f m a n , B u c k m a n , & Schade, 1957; K n o x & H a y e s , 1983; P r u g h et a l . , 1953; Te r ry , 1987; W o l f e r & V is in ta ine r , 1975). A l t h o u g h these aforement ioned studies were conducted p r imar i l y w i t h parents o f ch i ld ren w h o were hosp i ta l i zed for per iods longer than those associated w i th day care surgery, the f ind ings o f the current study revea l that the parents ' exper ience w i th a c h i l d ' s short term hospi ta l izat ion for a day care surgery procedure is a lso stressful . O n e mother descr ibed her exper ience w i th her daughter 's day care surgery as someth ing that "changed her l i fe for a l i t t le wh i l e . " A l t h o u g h the concept o f stress has been def ined in the l i terature as both a s t imulus and a response, fo r the purposes o f this study stress is de f ined as a " t ransact ion between the i nd i v idua l and his internal or external env i ronment " (C la rke , 1984, p. 4) . T h i s interact ional or phenomeno log ica l def in i t ion o f stress is based upon the w o r k o f Laza rus and col leagues (Lazarus, 1966; Laza rus , A v e r i l l , & Op ton , 1974; Lararus & F o l k m a n , 1984; Lazarus & Laun ie r , 1978). These authors adhere to the v i e w that stress is a personal exper ience that ref lects a def ic i t between the w a y an 50 i nd i v i dua l perceives a demand made by the env i ronment and the person 's ab i l i ty to manage o r tolerate the demand. T h e theoret ical perspect ive o f stress and cop ing deve loped by the aforement ioned authors p rov ides a basis for understanding h o w parents w h o part ic ipated i n this study interpreted and assigned mean ing to the day care surgery exper ience and coped w i th it i n their everyday l i ves . A c c o r d i n g to Laza rus and co l leagues, each si tuat ion or demand i n the env i ronment is cogn i t i ve ly appraised o r evaluated by the i nd i v i dua l accord ing to its mean ing or s ign i f i cance for the person 's we l l -be ing . It is the mean ing that the si tuat ion ho lds for the i nd i v i dua l that determines i f the si tuat ion is appraised as i r re levant, ben ign-pos i t ive , o r stressful (Lazarus & F o l k m a n , 1984). T h i s theoret ical perspect ive w a s par t icu lar ly he lp fu l because it ho lds that stress is an interact ive phenomenon and takes into account one 's ab i l i ty to act on the envi ronment . T h e parents w h o part ic ipated i n this study appraised the si tuat ion o f their c h i l d ' s day care surgery as a stressful one. Th i s was par t icu lar ly apparent w h e n parents were unable to cope i n usual ways to meet the demands o f their new si tuat ion. F o r examp le , one mother descr ibed the stress she exper ienced the morn ing o f surgery due to her inab i l i t y to meet her c h i l d ' s demands in usua l ways : I was concerned a l i t t le bit how I was go ing to keep h i m happy for a f ew hours before h is surgery because, you k n o w , I cou ldn ' t feed h i m and I thought, " O h , this l i t t le g u y ' s go ing to be hungry and c ranky . It 's go ing to be horr ib le . " I f a si tuat ion is appraised by i nd i v idua l as be ing stressful , the transaction is further appraised as cha l leng ing , threatening, and/or i nvo l v i ng ha rm or loss (Lazarus & F o l k m a n , 1984). Threat is exper ienced i f a situation is appraised as phys i ca l l y or 51 psycho log i ca l l y hazardous. "Threat concerns harms or losses that have not yet taken p lace but are ant ic ipated" (Lazarus & F o l k m a n , 1984, p. 32) . Threat appraisal can be consc ious or can occur outs ide the rea lm o f awareness. F o r the parents w h o par t ic ipated i n this study, their c h i l d ' s day care surgery represented a major event in their l i ves . T h e parents expressed that the surg ica l event he ld serious imp l i ca t ions for the c h i l d ' s present and future we l l - be ing as w e l l as a potent ia l ly fatal ou tcome. O n e mother was ve ry f rank about her fears: " M y b i g concern was that . .he [chi ld] was go ing to d ie . " H o w an i nd i v i dua l appraises o r perceives a si tuat ion depends upon a number o f i n f l uenc ing factors. Lazarus and F o l k m a n (1984) d iscuss eight propert ies o f situations that m a y contr ibute to their apprasia l o f be ing ha rmfu l , dangerous, or threatening to the i nd i v i dua l . T w o o f these properties—event uncertainty and tempora l i inminence—were f ound to contr ibute to this s tudy 's par t ic ipants ' percept ions o f their ch i l d ren ' s day care surgery si tuat ion as " threatening". Parents a lso reported exper ienc ing emot ions o f fear, wor ry , and anxiety. These emot ions have been descr ibed in the l i terature as consequences o f a "threat" appraisal (Lazarus & F o l k m a n , 1984). It has been acknow ledged that stressful situations are an expected component o f f a m i l y l i f e and that there are many maturat ional o r deve lopmenta l stressors associated w i th parent ing young ch i ld ren (Agu i l e ra and M e s s i c k , 1978; F r i e d m a n , 1986; M i l l e r & S o l l i e , 1986). A g u i l e r a and M e s s i c k (1978) c lass i fy the hospi ta l izat ion o f a c h i l d as a s i tuat ional stressor—"a random stress event not related to the deve lopmenta l stage o f the f a m i l y " ( M i l e s , Sp icher , & Hassane in , 1984, p. 334) . In the exper iences o f the fami l ies w h o par t ic ipated i n this study, the stress associated w i th their c h i l d ' s day care surgery was super imposed on the stress associated w i th parent ing a young c h i l d in everyday l i fe . Parents w h o part ic ipated in this study a lso descr ibed increased parental respons ib i l i t ies and ro le strain as factors contr ibut ing to the stressful nature o f their exper ience. In order to understand h o w addi t ional parent ing responsib i l i t ies contr ibuted to the stresses associated w i t h this exper ience i t i s necessary to examine some o f the l i terature re lated to norma l o r usua l parent ing responsib i l i t ies. Parenta l Respons ib i l i t y Parenthood is a pos i t ion f i rm ly embedded i n our soc ia l structure and one that is bes towed w i th the p r inc ipa l task o f prepar ing ch i ld ren to become adult members o f society (Hande l , 1970). Parent ing responsib i l i t ies beg in du r ing the prenatal pe r iod , are in tens i f ied w i th the b i r th o f the f irst c h i l d , and cont inue 24 hours per day throughout in fancy , ch i l dhood and somet imes beyond (F r iedman, 1986). L e v i n e (1974) descr ibes three categories o f parent ing responsib i l i t ies : 1) to promote the health and phys i ca l su rv iva l o f the c h i l d to ensure that the c h i l d l i ves l o n g enough to produce ch i ld ren o f their o w n ; 2) to foster the sk i l l s and abi l i t ies that the c h i l d w i l l need fo r economic and sel f -maintenance as a adult; and 3) to foster the capabi l i t ies fo r m a x i m i z i n g cu l tura l bel ie fs and va lues . Other authors have documented extensive l ists o f spec i f ic parent ing responsib i l i t ies ( A r n o l d , 1978; H a n d e l , 1970) w h i c h cou ld be encompassed w i th in L e v i n ' s (1974) categories. T h e responsib i l i t ies for parent ing a young c h i l d are ever constant. A young c h i l d ' s need for surg ica l intervent ion to correct a short- term cond i t ion o r i l lness heightens a parent 's awareness o f h is/her responsib i l i t ies to ensure the health and p h y s i c a l safety o f a son/daughter. One mother descr ibed her feel ings o f responsib i l i ty to protect her son f r o m the pa in and d iscomfor t she associated w i t h surgery this way : 53 " Y o u don ' t want anyth ing to hurt your l i t t le baby [four years o ld ] . H e c o u l d fa l l d o w n on the street and probab ly get hurt more...but i t ' s di f ferent [surgery]. I just can ' t exp la in it. I t 's di f ferent." B y v i r tue o f the nature o f the exper ience, day care surgery a lso adds responsib i l i t ies for the preparat ion and care o f the operat ive c h i l d over and above usual parent ing. These added responsib i l i t ies , inherent i n what is pe rce ived to be a potent ia l ly ser ious event, contr ibute to the stresses o f this exper ience. Parenta l responsib i l i t ies change over the years as the c h i l d matures and parents adapt to their ch i l d ren ' s deve lopmenta l needs. D u r i n g the toddler and preschooler years, parental responsib i l i t ies are focused on caretak ing, protect ion, l im i t sett ing, nur tur ing, and the foster ing o f soc ia l and independent behaviors . Feed ing , bath ing, toi let t ra in ing, d i sc ip l i n i ng , ma in ta in ing c lose phys i ca l contact, and p rov id i ng for a safe env i ronment (F r iedman, 1986; H a n d e l 1970) are spec i f ic behaviors parents carry out to f u l f i l the responsib i l i t ies o f their parent ing ro le for young ch i ld ren . A s the average age o f the ch i l d ren whose parents par t ic ipated i n this study was 23.8 months, the study part ic ipants were accustomed to car ry ing out the p rev ious ly ment ioned parent ing behav iors to ensure their ch i l d ren 's we l l -be ing . Kes tenberg (1970) offers a theoret ical perspect ive o f parents ' i nvo lvement w i th , and respons ib i l i t y for, the c h i l d f r o m bir th to schoo l age. H e refers to parent ing the c h i l d f i ve years o f age o r younger as "total parenthood" . A c c o r d i n g l y , parents are he ld accountable for their ch i l d ren 's we l l -be ing at a l l t imes and therefore must take direct respons ib i l i t y fo r the c h i l d at a l l times or ensure that someone else does (Bou l ton , 1983). A l o n g w i th this responsib i l i ty comes an element o f " con t ro l " over the ch i l d and h is /her env i ronment . T h e parents w h o part ic ipated i n this study were accustomed to 54 hav ing the respons ib i l i t y o f parental "su rve i l l ance" and cont ro l ove r their c h i l d and h is /her " w o r l d " . D u r i n g the hospi ta l izat ion phase o f day care surgery parents were requ i red to re l inqu ish this contro l to health care profess ionals . O n e mother descr ibed it this w a y , " Y o u ' r e put t ing h i m into someone e lse 's hands and , y o u k n o w , i t ' s just comple te ly out o f you r cont ro l f r o m then on . " Soc ie ty p laces expectat ions for the fu l f i l lment o f responsib i l i t ies on ro les (Johnson, 1979). Respons ib i l i t i es guide the parent i n when , where , and h o w to per fo rm or enact their ro le . W h e n parents are unable to fu l f i l their parent ing responsib i l i t ies through the implementa t ion o f their parent ro le , the result is ro le strain. R o l e strain is another o f the major themes ident i f ied f r o m an analys is o f this s tudy 's data and w i l l be d iscussed next. R o l e St ra in Adequate ro le func t ion ing is c ruc ia l fo r a f a m i l y ' s successfu l func t ion ing (F r iedman, 1986). R o l e is de f ined as a "more o r less homogeneous sets o f behaviors w h i c h are normat ive ly de f ined and expected o f an occupant o f a g i ven soc ia l pos i t i on " ( N y e , 1976, p. 7). R o l e s are based on ro le responsib i l i t ies or expectat ions and are learned through past exper iences and cu l tura l upbr ing ing. E v e r y ro le has a partner o r a "re levant other" (Johnson, 1979, p. 320). F o r parents, their mother/ father ro le is comp l imen ta ry to the c h i l d ' s ro le. Parents enact their ro le expectat ions or respons ib i l i t ies for parent ing a young c h i l d through behaviors such as feed ing, bath ing, and ensur ing contentment and safety. G o o d e (1960) def ines ro le strain as the stress generated w i th in a person when one either cannot c o m p l y o r has d i f f i cu l ty c o m p l y i n g w i th the expectat ions o f a ro le or sets o f ro les. In other words , the ind iv idua l has d i f f i cu l ty i n attempting to fu l f i l l ro le 55 respons ib i l i t ies or ob l igat ions (Fr iedman, 1986). Parents i n this study exper ienced ro le strain w h e n they were unable to f u l f i l l no rma l ro le expectat ions. A t certain points du r ing the exper ience, comp l iance w i th surg ica l standards/ instruct ions interfered w i th parents ' ab i l i ty to f u l f i l l their no rma l ro les o f nur tur ing, ca r ing , and protect ing the operat ive c h i l d . Th i s was par t icu lar ly apparent fo r the parents i n this study dur ing the pre-hospi ta l izat ion and hospi ta l izat ion phases o f their exper ience. Fee l ings o f wor ry , anx ie ty , and gui l t of ten resul t f r o m the stress o f ro le strain ( N y e , 1976) because ind iv idua ls fee l that they are inadequate i n their enactment o f the responsib i l i t ies o f their n e w ro le (F r iedman, 1986). A s one mother stated in reference to her c h i l d ' s day care surgery, " Y o u tend to, w h e n y o u don ' t k n o w , y o u tend to wo r r y about every l i t t le th ing, I th ink." W h e n a f am i l y member becomes i l l , roles among the f a m i l y members change (Johnson, 1979). W h e n a c h i l d has to undergo a day care surg ica l procedure, the parents must assume ro le behaviors related to pre and post-operat ive expectat ions for care o f the ch i l d . " Lea rn i ng a new ro le o r chang ing a ro le can be very st ressfu l" even i n no rma l c i rcumstances (Johnson, 1979, p. 321). Because it was their f irst t ime exper ience w i t h pediat r ic day care surgery, the parents i n this study had l i t t le opportuni ty to learn the ro le associated w i th car ing fo r the surg ica l ch i l d . F o r example , one mother descr ibed fee l ing very unsure o f what was appropriate to take w i th her to the hospi ta l and h o w she shou ld dress her ch i l d . She actual ly phoned the hospi ta l , spoke to a nurse and sa id , " W e l l , this is p robab ly a d u m b quest ion, but what should [chi ld] wea r? " T h e result o f not k n o w i n g h o w to fu l f i l her new ro le was ro le strain. In order to manage the stresses associated w i th ro le strain and other aspects o f their exper ience, parents coped i n a var iety o f ways . T h e f o l l o w i n g sect ion w i l l 56 descr ibe the theme o f cop ing and how it was used by the parents i n this study. C o p i n g C o p i n g is def ined as a process o f p rob lem so lv ing (thoughts and act ions) d i rected toward meet ing the demands o f the si tuat ion and/or cont ro l o f the emot iona l fee l ings engendered b y it (Lazarus & Laun ie r , 1978; Laza rus , A v e r i l l , & Op ton , 1974). Fundamenta l to the concept o f cop ing is the assumpt ion that i nd iv idua ls are act ive ly respons ive to forces that imp inge upon them (Pear l in & Schoo le r , 1978). Th rough patterns o f da i l y l i v i n g the i nd i v idua l learns to use many methods to cope w i th stress and decrease anxiety. Lazarus and col leagues descr ibe a secondary appra isa l process used by ind iv idua ls to assess avai lab le cop ing opt ions i n l ight o f a par t icu lar situation appraisal . A n i nd i v i dua l ' s select ion o f a response is based upon act ions that have successfu l ly re l i eved anxiety and tension i n the past (Agu i l e ra & M e s s i c k , 1978). A s parents coped w i th the exper ience o f their c h i l d ' s day care surgery w i th in the context o f their everyday l i ves , they made concrete changes to their establ ished patterns and act iv i t ies o f da i l y l i v i n g . S o m e o f these changes were a direct result o f the nature o f the surg ica l procedure (eg., casts, bandages) whereas others were a result o f the parents ' interpretat ion o f their si tuation and their best cho ice for management. Parents i n this study used both direct and indirect cop ing strategies (C la rke , 1984) throughout their exper ience i n efforts to meet the demands o f their si tuation and cope w i t h the stress they exper ienced. T h e parents ' use o f cop ing strategies enabled them to act as "key f igures i n m i n i m i z i n g the sequelea resul t ing f r o m stressor events" ( M i l e s , Car ter , Sp icher , & Hassane in , 1984, p. 334) . D i rec t cop ing i nvo l ves act ion that w i l l affect the demand o f the si tuat ion in some way . F o r example , one mother was creat ive i n her attempts to distract her hungry c h i l d i n the per iod just pr ior to the actual 57 surg ica l procedure: "It took us on l y two toys. O n e toy got us [ f rom home to 2/3 o f the w a y to the hospital ] and the other toy f r o m [there] r ight up to just before they ca l l ed h i m for the surgery. H e was gett ing real f idgety and hungry then." Indirect cop ing consists o f "strategies w h i c h do not alter the demand i n real i ty but alter the w a y the i nd i v i dua l exper iences the demand or his o w n cop ing , or bo th " (C la rke , 1984, p. 11). T w o mothers i n this study descr ibed a c o p i n g strategy o f " th ink ing pos i t i ve " as a w a y o f cop ing w i th "unknowns " that contr ibuted to their fee l ings o f stress. F o r example , one mother stated: I a lways l ook on the pos i t ive . I k n e w it [surgery] had to be done, so wha t ' s the point o f m a k i n g such a b i g th ing out o f i t? It has to be done, that 's it, y o u k n o w . Desp i te the stressful nature o f the parents ' exper ience, the part ic ipants expressed that they felt they were able to cope ef fect ive ly w i th their c h i l d ' s day care surgery exper ience. F o r example , " S o far, i t ' s on l y been a week [post-operat ively] , i t ' s been p leasant ly surpr is ing I guess, that h o w easy i t ' s been. " It was ev ident for the fami l ies w h o part ic ipated in this study, soc ia l support was a factor cont r ibut ing to their abi l i ty to cope ef fect ive ly throughout the exper ience. One mother stated that fo r her the key to cop ing w i th her son 's day care surgery was her " [Husband] be ing there and a l l the support I 've had f r o m everybody . " T h i s f ina l theme o f soc ia l support, deve loped f r o m analys is o f the data, w i l l be d iscussed next. S o c i a l Suppor t T h e d imens ions o f the theme o f soc ia l support became apparent as parents shared aspects o f their exper iences w h i c h they perce ived as both support ive and non-suppor t ive . S u c h aspects inc luded interact ions w i th f a m i l y members , f r iends, and 58 health profess ionals throughout a l l phases o f the exper ience. F o r the parents w h o part ic ipated in this study, their needs fo r soc ia l support changed ove r the three phases o f their exper ience. Cer ta in types o f support were perce ived by the parents to be more appropriate at par t icu lar points o f their exper ience. F o r examp le , emot iona l support and in fo rmat ion to reduce anxiety and the distress of uncertainty were an obv ious need dur ing the pre-hospi ta l izat ion and hospi ta l izat ion phases o f this exper ience. Suppor t i n the f o r m o f in fo rmat ion and tangible assistance to assist the parent to manage a recommended treatment reg ime was most appropriate du r ing the post -hospi ta l izat ion phase o f the exper ience. S o c i a l support has been descr ibed as a major factor i n adaptation to stressful l i fe events ( C o b b , 1976; K a p l a n , C a s s e l , & G o r e , 1977). It is general ly agreed that "human beings need soc ia l support, that rece iv ing it contr ibutes to we l l -be ing and abi l i ty to wi ths tand stress, and that the need fo r soc ia l support persists throughout l i f e " ( D i m o n d & Jones, 1983, p. 238) . S o c i a l support is an interpersonal t ransact ion that funct ions to "buf fer" o r protect ind iv idua ls f r o m the effects o f many k inds o f l i fe stresses (Casse l , 1976; C o b b , 1976; C o h e n , 1985; P i l i suk & F ro land , 1978). In addi t ion, soc ia l support has " a med ia t ing effect that st imulates the deve lopment o f cop ing strategies" ( D i m o n d & Jones, 1983, p. 242) . In other words , peop le mob i l i ze needed support to cope w i th change (Rober ts , 1988). D i m o n d and Jones (1983) rev iewed the vast l i terature on soc ia l support, and p roposed a compos i te def in i t ion o f the concept o f soc ia l support emphas iz ing four ma in po ints : commun ica t i on o f pos i t ive affect, soc ia l integrat ion, inst rumental behavior , and rec ip roc i ty . C o m m u n i c a t i o n o f pos i t i ve affect i nvo lves feedback o f in fo rmat ion that encourages sel f-esteem and offers warmth , car ing and concern ( C o b b , 1976). S o c i a l in tegrat ion of fers support by v i r tue o f be long ing to a group, shar ing c o m m o n exper iences, and k n o w i n g that there are others w h o w i l l c o m e to one ' s a id i n t ime o f need (P i l i suk & F ro l and , 1978). Instrumental behav ior as a component o f support i nvo l ves the p rov i s i on o f mater ia l or tangible a id (Sussman, 1965). Rec ip roc i t y refers to mutua l i ty i n a re lat ionship and an exchange o f need grat i f icat ion between the parties i n v o l v e d (Cap lan , 1976). T h e structure o f a soc ia l network and its interact ional propert ies determine the adequacy and appropriateness o f soc ia l support i n t imes o f stress ( D i m o n d & Jones, 1983). M o s t of ten, soc ia l support der ives f r o m a network o f f a m i l y , f r iends, ne ighbours , and/or commun i t y groups (Ferrar i , 1986). "Ne ighbors can best handle immed ia te emergenc ies; k i n are most appropriate for long- te rm commi tments , and f r iends can help i n areas that require agreement and pos i t ive af fect" ( L i twak and S z e l e n y i , 1969). Profess iona ls and c le rgy are usefu l authori ty resources dur ing t imes o f uncertainty as they m a y of fer guidance ( D i m o n d & Jones, 1983). It is important to note that " a network structure that may assure ef fect ive soc ia l support i n one situation m a y not be ef fect ive i n a l l s i tuat ions" ( D i m o n d & Jones, 1983, p. 238) . Because soc ia l support is an interpersonal t ransact ion, there are t imes when interact ions are not pe rc ieved as support ive but rather are construed as stressful (He l le r , 1979). In summary , this s tudy 's analyt ic f ramework is grounded i n f i nd ing that the pediat r ic day care surgery exper ience was stressful for parents. T h e major themes ident i f ied i n data analys is represent d imens ions o f the parents ' exper iences that cont r ibuted to their interpretat ion o f the event as stressful. A s stated ear l ier, these were increased parental respons ib i l i t y and ro le strain. A d d i t i o n a l themes f r o m the parents ' accounts a lso revealed d imens ions o f their exper ience that enhanced o r inh ib i ted their 60 ab i l i ty to manage it w i th in the context o f their everyday l i ves , namely , cop ing strategies and soc ia l support. T h e f ramework presents the themes ident i f ied i n the data w i th in the context o f the tempora l phases o f the exper ience because the latter prov ides a ch rono log i ca l sequencing for the exper ience. Descr ip t ion o f Part ic ipant Fam i l i e s In order to fami l i a r i ze the reader w i th the fami l ies w h o part ic ipated i n this study, their general character ist ics and demograph ics w i l l be descr ibed here. Parents f r o m eight f am i l y groups part ic ipated in this exp lorat ion o f the parental exper ience. A total o f 16 in terv iews were carr ied out ove r a s ix month per iod w i th n ine parents o f post-operat ive toddlers and preschoolers. P r i o r to arranging each o f the in terv iews it was made c lear that both parents were inv i ted to part ic ipate. In a l l eases except one however , the in terv iews were conducted w i th the mother alone. In the case o f this one f a m i l y , mother and father were in terv iewed together. T h e parent 's i nd i v i dua l dec is ion to part ic ipate i n the in terv iews, even i f h is /her spouse d i d not choose to do so, is consistent w i th the phenomeno log ica l method. S i x parents w h o met the study cr i ter ia and in i t ia l l y expressed interest i n par t ic ipat ing, dec l ined to do so when contacted on the c h i l d ' s f irst post-operat ive day. T h e reasons they c i ted inc luded f am i l y commi tments ( lack o f t ime), parental i l lness, and exper ienc ing a " terr ible n ight" w i th the post-operat ive ch i l d . D u r i n g telephone conversat ions w i th most o f these parents, they ind icated they were fee l ing somewhat ove rwhe lmed w i th the responsib i l i t ies o f meet ing their usual f am i l y commi tments as w e l l as the needs o f the post-operat ive ch i l d . Th i s observat ion is consistent w i th the theme o f stress w h i c h was prominent throughout the accounts o f the par t ic ipat ing parents. T h e parents w h o chose not to part ic ipate made it c lear that an addi t ional 61 comirutrnent to part ic ipate i n the research study was s imp l y not feasib le fo r them. D e c l i n i n g to part ic ipate i n this study was a k n o w n var iab le parents ' cou ld c lear ly con t ro l i n their attempts to manage the exper ience w i th in the context o f the t ime and energy commi tments o f their everyday l ives . A l l o f the parents w h o d i d part ic ipate i n the study thanked the researcher for the v is i ts and stated they were p leased to have opportuni t ies to share their personal "s tor ies" and contr ibute to an understanding o f parents ' exper ience w i th pediatr ic day care surgery. T h e F a m i l i e s A l l e ight o f the part ic ipant fami l ies were dua l parent fami l ies a l though this was not one o f the study select ion cr i ter ia. Three fami l i es had on l y one c h i l d ; f i ve fami l ies had two ch i ld ren . A l l o f the husband/fathers were emp loyed fu l l t ime; four were profess ionals . O f the eight wi fe /mothers , three were emp loyed part t ime and one fu l l t ime. T w o had p rev ious ly been emp loyed on a seasonal basis but were not w o r k i n g at the t ime o f the c h i l d ' s surgery. Seven o f the eight fami l ies o w n e d their o w n homes. In s ix o f the eight fami l i es the parents were born and ra ised i n Canada . O n e set o f parents had immig ra ted to Canada f r o m a G e r m a n commun i t y i n South A m e r i c a ; one set o f parents had immigra ted f r om C h i n a . T h e latter parents had on ly a basic conversat iona l c o m m a n d o f the E n g l i s h language. A l t h o u g h this was inconsistent w i th the se lect ion cr i ter ia, it was dec ided to inc lude them i n this study because it was the researcher 's on ly opportuni ty to explore the post day care surgery exper ience f r o m a father 's perspect ive. It was also felt that the in f luence o f the Ch inese coup le ' s cu l tura l backg round c o u l d add another d imens ion to the data. It is interest ing to note that G o u l d - M a r t i n and N g i n (1981), i n their study o f the med ica l pract ices o f immigran 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 med ica l in format ion and dec is ions are "very l i k e l y to i nvo l ve m e n " (p. 152). T h e C h i l d r e n T h e age range o f the ch i ld ren w h o underwent surg ica l procedures i n the D a y Care U n i t was f r o m 11 to 45 months. The i r average age was 23.8 months. In the group, seven were de f ined as toddlers and one as a preschooler . O n e 11 month o l d in fant was i nc luded i n the study because his parents met a l l o f the other select ion cr i ter ia and were ve ry interested in part ic ipat ing i n the study. F i v e o f the ch i ld ren were boys and three were g i r ls . T h e ch i ld ren underwent a var iety o f surg ica l day care procedures: T w o had correct ive eye surgery (uni lateral) , two had bi lateral manipu la t ions and easts for equ inovarus, two had hern ia repairs (one u m b i l i c a l , one ingu ina l ) , one had an o rch iopexy , and one had bi lateral my r i ngo tomy and insert ion o f tubes as w e l l as an exc i s i on o f a l i p o m a on a l ower l imb . T h e Hosp i ta l i za t i on A l l o f the ch i ld ren whose parents part ic ipated i n this study were admit ted to hospi ta l the morn ing o f their surgery. T h e y spent an average o f 28 minutes in the operat ing r o o m (range: 13 to 42 min. ) and 53 minutes in the post-anesthesic recovery r o o m (range: 32 to 7 2 min. ) . T h e average total length o f t ime spent i n the day care surgery uni t was three hours and 13 minutes (range: 2 hrs. 15 m i n . to 4 hrs. 35 min.) . A s is consistent w i th the day care surgery exper ience, the parents o f the pre-operat ive ch i ld ren were te lephoned by the day care unit "p readmiss ion nurse" the day before surgery to co l lec t some basic demograph ic in format ion about the ch i l d , h is /her cond i t i on and health h is tory, and a lso to ident i fy any parental concerns. Three o f the eight mothers contacted v o i c e d pre-operat ive concerns to the nurse w h o te lephoned them. T h e concerns were documented by the nurse as f o l l ows : "mother nervous, needs emot iona l support" ; "mother s l ight ly apprehensive, concerned re: separat ion, w o u l d l i ke to be i n P A R " ; and "mother concerned re: c h i l d ' s c o l d " . A rev i ew o f the pat ients ' charts f o l l o w i n g hospi ta l d ischarge fa i l ed to revea l any wr i t ten documentat ion descr ib ing fo l l ow-up o f these concerns by the day care unit staff. T h e eight ch i ld ren were d ischarged home to the care o f their parent(s) on the day o f their surg ica l procedures. A l l o f the parents reca l led rece iv ing verba l and wr i t ten instruct ions f r o m the day care staff p r io r to their hospi ta l d ischarge and, a l though not spec i f i ca l l y asked by the researcher, three ment ioned rece i v ing f o l l ow-up telephone ca l ls f r o m a day care unit nurse on their c h i l d ' s f i rst post-operat ive day. T h e Parents ' Accoun t s o f The i r Exper ience and D i scuss ion A s was p rev ious ly stated, the parents ' accounts o f their day care surgery experiences—their thoughts, fee l ings, react ions, and explanat ions—were w o v e n in to major concepts and themes w h i c h , a long w i th the structure o f a three phase exper ience, f o rmed the analy t ic f ramework for presentat ion o f this s tudy 's f ind ings . T h e ma jo r concept o f the analy t ic f ramework was parental stress and the four major themes ident i f ied were : parental respons ib i l i ty , ro le strain, cop ing , and soc ia l support. T h e parents ' accounts w i l l be presented accord ing to the three ch rono log ica l phases o f their exper ience: pre-hosp i ta l iza t ion, hosp i ta l iza t ion, and post -hospi ta l izat ion. A s w i l l be i l lustrated i n the parents ' accounts, the f i ve major concepts o f the analyt ic f ramework va r i ed i n impor tance and intensity dur ing the three dif ferent ch rono log ica l phases o f the exper ience. T h e presentation o f the parents ' accounts accord ing to the three phases a l l ows the reader to compare and contrast the mean ing the exper ience he ld for them at 64 dif ferent ch rono log i ca l points and its impact on their everyday l i ves . Inc luded in this sect ion o f the chapter w i l l be an integrat ion o f relevant, current l i terature. V e r b a t i m accounts f r o m parent in terv iews w i l l be used extens ive ly for i l lustrat ive purposes and to demonstrate to the reader h o w the researcher interpreted and evo l ved constructs d i rec t ly f r o m the data (Anderson & C h u n g , 1982). T h e quotat ions serve to represent not on l y the commona l i t i es but a lso the except ions to the concepts, themes, and sub-themes ident i f ied i n data analys is . T h e abbreviat ions used i n this chapter to ident i fy the speakers be ing quoted are as f o l l ows : M : Mo the r , F : Father, and R: Researcher . A l l other i nd iv idua ls w h o have been persona l ly named i n the text o f the conversat ions w i l l be ident i f ied on l y by their pos i t ion or re la t ionship to one o f the speakers. T h i s in format ion w i l l be p laced in square brackets, fo r examp le [chi ld] . T h e Pre-hosp i ta l i za t ion Phase T h e pre-hospi ta l izat ion phase o f the parents ' exper ience began w i th the parents ' rea l iza t ion that someth ing was " w r o n g " w i th their c h i l d and ended w i th the c h i l d ' s admiss ion to hosp i ta l to undergo correct ive surgery. D u r i n g this phase the parents read ied themselves and their fami l ies emot iona l l y and phys i ca l l y fo r the day care surgery event. T h i s phase was typ ica l l y a per iod o f dec is ion m a k i n g , uncertainty, and ant ic ipat ion that lasted for a per iod o f weeks to years. There were part icular aspects o f this phase o f the exper ience that contr ibuted to the parents ' interpretat ion or appraisal o f their c h i l d ' s day care surgery as " threatening" , resul t ing i n feel ings o f anxiety, wor ry , and fear. Parents he ld the v i e w that their young ch i ld ren were par t icu lar ly vu lnerable to the negat ive effects o f an operat ive procedure. Parents also perce ived that responsib i l i t ies related to 65 dec i s i on -mak ing and pre-operat ive preparat ion for their young ch i ld ren were added to the usual parent ing responsib i l i t ies. T h e new, extra responsib i l i t ies requ i red ro le adjustments i n order to enact them. G i v e n that the study parents had not had prev ious exper ience enact ing such ro les, the result was "ro le stra in" character ized by feel ings o f wor ry , anxiety , and gui l t (Nye , 1976). Other d imens ions o f this phase o f the exper ience that contr ibuted to the appraisal o f the si tuat ion as threatening was "event uncertainty" (Lazarus and F o l k m a n , 1984), or not k n o w i n g what to expect dur ing or as an ou tcome o f the exper ience. O n e mother stated it this way : " T h i s was the f irst t ime, so i t was rea l ly hard to understand it, I guess." W a i t i n g dur ing this phase o f the exper ience was also par t icu lar ly stressful for parents and, as the day o f surgery approached, " tempora l i m m i n e n c e " (Lazarus and F o l k m a n , 1984) added to feel ings o f anxiety, fear, and wor ry . F o r example , one mother reca l led it this way : " L e a d i n g up to it [the day o f surgery] I was rea l ly anx ious fo r weeks , but par t icu lar ly the last f ew days" . Parents ' attempts to manage this phase o f their exper ience w i th in the context o f their everyday l i ves resul ted i n concrete changes in their regular patterns o f rout ines and act iv i t ies. S o c i a l supports enhanced their dec is ion m a k i n g abi l i ty . A var iety o f c o p i n g strategies were used to m i n i m i z e the stresses o f this phase o f the exper ience. T h e parents ' accounts revealed that it was w i th the in i t ia l "d i scove ry " that someth ing was w rong w i th their c h i l d that their understanding and interpretat ion o f their day care surgery exper ience began. F o r seven o f the n ine parents, the process o f parental dec is ion m a k i n g re lat ing to the c h i l d ' s actual surg ica l procedure was a 66 s ign i f icant component o f the pre-hospi ta l izat ion phase o f the day care surgery exper ience. A s w i l l be i l lustrated in the quotat ions later i n this sect ion, the responsib i l i ty for dec is ion m a k i n g rests so le ly w i th the mothers and fathers. In three o f the eight fam i l i es w h o part ic ipated i n this study, the mothers descr ibed that both they and their husbands were act ive ly i n v o l v e d in m a k i n g the dec is ion related to the proposed surgery. These three sets o f parents attended the doctors ' appointments together and spent cons iderable t ime d iscuss ing opt ions and t im ing for the event. In the fami l ies where fathers d i d not attend doctors ' appointments, many o f the mothers saw it as part o f their ro le to "ask the r ight quest ions" and obta in suf f ic ient in fo rmat ion i n order for the coup le to make an i n fo rmed dec is ion . Mo the rs reported that their husbands re l ied upon their op in ions but i n the end were not a lways sat isf ied: "I get frustrated w h e n he asks me a l l the hundreds quest ions when I c o m e f r o m the doctor , I say, ' W h y don ' t y o u go, i f you ' r e not sa t i s f ied? ' " In f i ve fami l i es , it was the mothers w h o attended doc tors ' appointments by themselves and made the dec is ion to proceed w i th the c h i l d ' s surgery after on l y br ie f consul ta t ion w i th their husbands. O v e r a l l , i t was the mothers i n this group w h o tended to assume a more p r imary ro le related to the dec is ion m a k i n g process related to the day care surgery. Depend ing upon c i rcumstances, the process lead ing up to the dec is ion to p roceed w i th the surg ica l procedure took days, weeks , or even months to complete. F o r three o f the parents the "d i scove ry " o f the c h i l d ' s potent ia l p rob lem was apparent at b i r th: " W h e n he was born he had a hern ia" . F o r the rema in ing f i ve sets o f parents, it was w i th in the c h i l d ' s f i rst two years that a p rob lem became suspect. M : E v e r s ince she was s ix months o l d I not iced her eye. . .we on ly not iced 67 one eye, wou ldn ' t l ook at y o u , it w o u l d l ook out somewhere else. M : T h e P u b l i c Hea l th Nurse not iced that he t i l ted h is head a l i t t le bi t to one side and she...suggested that I have i t l ooked into. These parents are reca l l i ng when they f irst became aware that someth ing migh t be " w r o n g " w i th their ch i l d . Fee l ings o f concern led to a v is i t to the f am i l y pract i t ioner to seek in fo rmat ion , adv ice , and profess ional va l ida t ion and to f u l f i l their sense o f respons ib i l i t y fo r their c h i l d ' s we l l -be ing . M e d i c a l va l ida t ion had two k inds o f immediate outcomes. F o r some parents, the va l ida t ion o f their observat ions came as a "shock " , wh i l e fo r others it was a con f i rmat ion o f what they already knew. T h e f o l l o w i n g quotat ions i l lustrate parental react ions o f shock and surprise to the med ica l conf i rmat ion that someth ing is w rong w i th their c h i l d : M : It was a bit o f a shock actual ly , because the pediat r ic ian had been so, u m m , def in i te that it wasn ' t an eye p rob lem, and a l l o f a sudden I had an eye special ist te l l ing me it was an eye p rob lem that needed surgery, I was quite concerned, so I actual ly got a second op in ion . T h i s parent 's concern regard ing the op in ion o f the specia l is t i l lustrates h o w heav i l y the respons ib i l i t y fo r dec is ion m a k i n g is seen to rest w i th the mother and/or father. S e e k i n g a second op in i on was this mother 's w a y o f f u l f i l l i ng her sense o f responsib i l i ty fo r m a k i n g the best i n fo rmed dec is ion fo r her c h i l d ' s we l l -be ing . M : W h e n I ment ioned it to [ fami ly doctor] and he sa id h e ' d refer me to [pediatric surgeon] I was sort o f i n shock for a wh i l e 'cause I thought h e ' d say " O h , don ' t wor ry about i t". 68 T h i s mother has acknow ledged that she was v i s i t i ng the phys i c ian to seek reassurance that her observat ions o f her c h i l d were not s igni f icant. T h e response she rece ived was not the one she expected or "w i shed for" . A s was p rev ious ly stated, not a l l parents were shocked by the news. T h e f o l l o w i n g quotat ions i l lustrate the c o m m o n responses o f parents w h o had ant ic ipated that their c h i l d m igh t require a surg ica l procedure later i n l i fe : M : It wasn ' t a surprise. Be fo re I went to [pediatr ic surgeon] I k n o w he [chi ld] need the operat ion. M : I k n e w about it, I mean I knew w h e n it came to the t ime o f hav ing it done that he [chi ld] was go ing to have it done y o u k n o w , it wasn ' t a shock to me. E v e n f o l l o w i n g va l ida t ion o f the cond i t ion and recommendat ions for surg ica l in tervent ion, f i ve sets o f parents remained hopefu l that surgery migh t not be necessary. M : In the meant ime, actual ly , m y husband and I not iced his neck got better, that h is t i l t was not iceably imp roved , and so we began to wonder i f it was someth ing that was correct ing itself. M : Somet imes y o u don ' t see it [condi t ion] . Y o u don ' t see it a l l the t ime. A n d so, I never k n o w whether it [surgery] was necessary. These two parents were hesitant to proceed w i th the surgery unless "abso lu te ly" necessary. T h i s was re lated to their percept ion o f the day care surgery event as threatening to their c h i l d ' s we l l -be ing as w e l l as their l ack o f know ledge about their 69 c h i l d ' s cond i t ion . B o t h o f these facts contr ibuted to their fee l ings o f uncertainty and anxiety. Ano the r set o f parents actual ly de layed a dec is ion to proceed w i th their c h i l d ' s surgery because o f their hope that it m ight not be necessary. T h e dec is ion to delay changed their s i tuat ion and temporar i ly e l im inated the stresses associated w i th proceed ing w i th their c h i l d ' s surgery. Pear l i n and Schoo le r (1978) ident i fy chang ing a si tuat ion as one type o f funct iona l method o f cop ing w i th a stressful s i tuat ion. W i t h on l y one except ion , a l l o f the study parents made their dec is ion to proceed w i t h the surgery w i th some feel ings o f doubt and ambiva lence . The i r p r imary ob l iga t ion to fu l f i l their expected parent ing responsib i l i t ies (ensur ing the safety, protect ion and we l l - be ing o f their ch i ld ) was we ighed against subject ing their c h i l d to a surg ica l procedure w i th k n o w n r i sks , d iscomfor ts , and pain—usual ly for a more l ong term ga in . A s the f o l l o w i n g quotat ion demonstrates, the dec is ion m a k i n g process we ighed heav i l y upon some parents, contr ibuted to their appra isa l o f the si tuat ion as " threatening" , and resul ted i n feel ings o f fear, gui l t , and anxiety: M : Y o u k n o w , i f you are m a k i n g you r dec is ion you ' r e responsib le for h i m , and you ' r e m a k i n g a dec is ion that even based on what other profess ional people to ld you , that he has to go in for surgery and uh , you k n o w , I guess 'cause he ' s such a l i t t le guy that y o u think. . . i t 's a b i g responsib i l i ty and y o u fee l sort o f gu i l ty for hav ing put h i m through someth ing that 's qui te traumatic for h i m , rea l ly p robab ly not as traumatic for h i m as it is fo r us [laughter] but that is h o w we perce ive it anyway as be ing . 70 T h i s quote i l lustrates the sense o f ambiva lence that parents fee l as they fu l f i l their respons ib i l i t y fo r the dec is ion m a k i n g process. T h e perce ived vu lnerab i l i t y o f the y o u n g c h i l d and fee l ings o f parental gui l t are obv ious factors i n the ambiva lence. A l t h o u g h this mother had to struggle somewhat to get her ideas c lear, she indicates a strong parental re l iance on profess ional op in ions dur ing the dec is ion m a k i n g process and parental needs fo r support at this time. Ano the r mother expressed her sense o f responsib i l i ty fo r m a k i n g a dec is ion for her c h i l d this w a y : M : W h e n y o u have to make a dec is ion that affects someone fo r the rest o f their l i ves or even l i ke [chi ld ] , fo r a few weeks , or even i f this draws on fo r a coup le o f months. It 's go ing to affect her, y o u k n o w . F o r this mother even the fact that the consequences o f her dec is ion may on ly affect her c h i l d for a short per iod o f t ime d i d not make a d i f ference i n the w a y she approached her dec is ion m a k i n g . H e r sense o f responsib i l i ty fo r her c h i l d ' s we l l -be ing was her foremost concern . T h i s same mother went on to state h o w heav i l y burdened she felt by hav ing to make this dec is ion and compared her perspect ive to that o f health pro fess iona ls : M : T o the nurses, i t ' s p robab ly rout ine. Th i s is m y thought. T h e y probably don ' t fee l l i ke i t ' s a major decis ion. . .or even [pediatric surgeon]. Whereas to me , i t ' s someth ing I th ink about a l l the t ime. A g a i n , this mother is express ing how "major " the dec is ion m a k i n g process related to her c h i l d ' s day care surgery is fo r her. In contrast to the above quotat ions, the Ch inese f am i l y w h o part ic ipated in the study approached the dec is ion to proceed w i th the surgery i n a very matter o f fact way , 71 wi thout the ambiva lence that other parents had expressed: M : ' C a u s e we k n o w for us is no need to make , no need to talk, d iscuss about the dec is ion . W e have to do it, y o u k n o w , so noth ing to try, no th ing to anx ious , noth ing to wor ry . T h e dec is ion m a k i n g process fo r this f a m i l y was very straight fo rward , based upon their observat ions o f their c h i l d ' s cond i t ion and their phys i c i an ' s recommendat ions wi thout the anxiety and gui l t expressed by other parents. G o u l d - M a r t i n and N g i n (1981) i n their study o f the med ica l pract ices o f Ch inese -Amer i cans found that immigran ts were usua l ly p rompt seek ing Wes te rn med i ca l care for cond i t ions requ i r ing surgery. A n d e r s o n & C h u n g (1982) f ound that i n Ch inese immigran t fami l ies the contentment and happiness o f an i l l c h i l d is o f p r imary concern . T h e f ind ings o f the current study revealed that parents were m u c h more ambiva lent about surgery that was o f a cosmet ic rather than a func t iona l nature. In these cases, the added responsib i l i t ies related to dec is ion m a k i n g were seen a lmost as a burden. Because o f the u n k n o w n outcome o f their c h i l d ' s surgery the parents felt less secure about their dec is ion to proceed w i th the surgery: M : It w i l l never affect her v i s i o n , her v i s i on was a lways f ine, but it was a cosmet ic type th ing. S o , to put her through a l l o f this, you k n o w , w e had to be sure that we wanted to, and the surgery i sn ' t a lways 100 percent. T h i s mother is recount ing how she struggled w i th a dec is ion that, i n her percept ion, had an uncer ta in long- te rm outcome and w o u l d result i n short term " t rauma" for her ch i l d . T h e not ion that parental act ion taken n o w w i l l be benef ic ia l for the c h i l d i n h is /her later years has been d iscussed by others as an example o f parents ' enact ing responsib i l i t ies to attain op t ima l phys ica l appearance or "no rma l i za t ion " fo r their 72 ch i ld ren (Anderson & C h u n g , 1982). T h e f o l l o w i n g quotat ion i l lustrates another mother ' s uncertainty about surgery that was p r imar i l y cosmet ic i n nature a long w i th her considerat ions for her daughter 's future phys i ca l appearance: M : W e thought about l eav ing it , but then w h e n she got o lder she might come to us and say " W e l l , w h y d idn ' t y o u get m y feet f i x e d when I was younger? " T h e parents w h o part ic ipated i n this study had not had prev ious exper ience w i th a c h i l d w h o had undergone day care surgery (see select ion cr i ter ia, Chapter 3, p. 35). A s a result , the study parents brought on l y l im i ted know ledge regard ing day care surgery w i t h them to the exper ience and were unsure o f what new needs and demands their young c h i l d might have. A l t h o u g h a l l parents were to ld i n advance by health profess ionals some o f what to expect f r o m the exper ience, they st i l l expressed fee l ing at least par t ia l ly unprepared for the it. F o u r o f the study parents art iculated that feel ings o f uncertainty lead to the ant ic ipat ion o f a very negat ive, unpleasant scenar io. F o r examp le , despite hav ing been g iven pre-operat ive in fo rmat ion , one mother stated that it " D o e s n ' t register.. .unti l you are actual ly there [ in the D a y Care Un i t ] , because y o u have set i n you r m i n d the w a y y o u th ink things are go ing to be. " She c lear ly ant ic ipated her exper ience to evo lve i n a certain way . Ano the r mother stated that despite be ing to ld what to expect, she was sure that " m y k i d ' s go ing to be di f ferent". B o t h these mothers went on to descr ibe h o w they ant ic ipated their exper ience to be " m u c h wo rse " than it actual ly was. F o u r other study parents revealed that they ant ic ipated changes in their ch i ld ren , but were unable to predict what these changes w o u l d be o r spec i f i ca l l y what the course o f their c h i l d ' s day care surgery might be l i ke . Fee l i ng unsure o f what to expect , or 73 ant ic ipat ing a negat ive exper ience, contr ibuted to the stress o f their exper ience and resul ted i n fee l ings o f fear, wor ry , and anxiety. O n e mother descr ibed it this w a y : M : I was af ra id for her [chi ld] . I th ink that 's it. I don ' t k n o w anybody w h o ' s ever had surgery, no one in our fami ly . . .no one c lose. N o one has ever been i n the hosp i ta l , even grandparents, y o u k n o w , no one has had anyth ing. S o , it was rea l ly scary. No te h o w this mother art iculates her lack o f p rev ious exper ience related to any type o f hosp i ta l iza t ion or surg ica l procedure as contr ibut ing to her appraisal o f her daughter 's day care surgery as threatening and resul ted i n feel ings o f anx iety and fear related to an u n k n o w n outcome. E v e n though parents have been to ld that speci f ic procedures are cons idered to be m i n o r f r o m the med ica l v iewpo in t , fears o f the u n k n o w n and/or p reconce ived not ions contr ibuted to their percept ions o f day care surgery as a "major " event. O n e mother expressed her fears this w a y : M : W e l l , I th ink, actual ly [pediatric surgeon] was ve ry good , I mean she kept emphas iz ing that it was m i n o r surgery and w o u l d on l y take about thirty minutes, and that he w o u l d rea l ly on ly have a l i t t le d iscomfor t i n h is o w n way . S o it was if, it was l o w - k e y you k n o w , no b i g deal here, but I th ink that we made it a b i g dea l , y o u k n o w , ourse lves, p robab ly just because, i t ' s p robab ly not k n o w i n g what to expect , so that a l l o f these things go through your m i n d : "Is this go ing to happen? Is this go ing to happen?" T h i s parent i s no t ing that "even a l i t t le d iscomfor t " i s a "b ig dea l " to the mother o f a y o u n g c h i l d as she feels responsib le to protect her c h i l d f r o m harm. T h i s mother is 74 a lso say ing that because o f her l ack o f exper ience, the uncertainty o f not k n o w i n g what to expect re lated to her son 's day care surgery contr ibuted to her interpretat ion o f the event as a " b i g d e a l " despite assurances that f r o m a med i ca l standpoint it was cons idered quite "m ino r " . H e r interpretation o f this event is c lear ly di f ferent f r o m that o f her phys i c ian . T h i s f i nd ing is consistent w i th the f ramework o f K l e i n m a n (1978) w h o states that l ay persons and health professionals have di f ferent explanatory mode ls for the same heal th care si tuat ion. T h i s f i nd ing has also been made by other nurs ing authors (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 i s same mother went on to emphas ize h o w a l ack o f in fo rmat ion about the impend ing procedure and her c h i l d ' s response to it a lso contr ibuted to her anxiety. T o her, in fo rmat ion is perce ived as a support fo r her ab i l i ty to cope. A l s o note that she is express ing that she felt that there was no opportuni ty to obtain the in fo rmat ion that w o u l d have decreased her anxiety related to the u p c o m i n g event. T h e larger issue related to the dec is ion to proceed w i th the surgery seemed to overshadow the in fo rmat ion this mother needed to cope w i th this exper ience in her everyday l i fe . She a lso po in ted out that her " l i tde quest ions" are a "bother" to the doctor i n her est imat ion: M : Y o u don ' t want to ask the doctor every l i t t le quest ion. P l u s there wasn ' t an opportuni ty to ask a l l those l i t t le quest ions, you k n o w , you were concerned w i th whether or not [chi ld] rea l ly needed the surgery and was it a good time to do it i n terms o f his age, or was it better to wai t unt i l later, and those k i n d o f sort o f more major quest ions than the l i t t le things. S o I th ink probab ly , it was probab ly just ignorance that made us sort o f bu i l d it up i n our m inds into this th ing that was go ing to be m u c h worse, no better than it was. 75 Ano the r mother descr ibed her need fo r in format ion i n the days pr io r to the day o f her c h i l d ' s day care surgery this w a y , "I had 50,000 quest ions [about the surgery] and nowhere to ask them" . In addi t ion to express ing her need for in fo rmat ion this mother a lso felt she d i d not have any resources to acquire the in fo rmat ion she wanted. She also went on to ment ion that she d i d not want to "bother the doctor" i n order to seek the answers to her quest ions. It is ev ident that parents i n this study had a prominent need fo r in format ion du r ing the pre-hospi ta l izat ion phases o f their exper ience. Ter ry (1987) conducted a study w i th 22 parents o f ch i ld ren aged three to 10 years hosp i ta l i zed for a per iod o f 14 to 30 days. Parents c lear ly ident i f ied that their most prominent need was fo r in fo rmat ion , par t icu lar ly in fo rmat ion about what was wrong w i th their c h i l d and what w o u l d happen to their ch i l d . Other authors have also documented that parents need in fo rmat ion i n order to cope ef fect ive ly w i t h their c h i l d ' s hosp i ta l iza t ion and d iscern their ro les as parents o f s i ck ch i ld ren (Fr ieberg, 1972; H a y e s & K n o x , 1984; H y m o v i c h , 1976; Smi the rman , 1979). T h e perce ived vu lnerab i l i ty o f the young c h i l d by the parents is apparent i n the b l ock quotat ion on page 74 as w e l l as i n the f o l l o w i n g account : M : I wasn ' t rea l ly a nervous wreck unt i l the week before and then I started to th ink about i t . . .you k n o w , just things l i ke , y o u k n o w , f irst c h i l d y o u had , and go ing in to an operat ion, even a l i t t le m i n o r operat ion, s t i l l i t ' s hard to take. It wasn ' t depress ing, it was just hard i n a w a y to take because he 's so young and he was by h imsel f . A g a i n , the mother quoted above is po in t ing out that her interpretat ion o f "m ino r " is m u c h di f ferent than health pro fess iona ls ' . She feels a strong respons ib i l i t y to protect 76 her c h i l d due to h is young age. H e r inab i l i ty to be phys i ca l l y present to protect h i m dur ing h is surgery is a source o f anxiety for her. Th i s quotat ion also i l lustrates the effect o f " tempora l i m m i n e n c e " (Lazarus & F o l k m a n , 1984), as the t ime for the event d raws c loser , the stress associated w i th it r ises. In separate studies, Sk ippe r (1966) and Sk ippe r , L e o n a r d , and R h y m e s (1968) each found approx imate ly 60 per cent o f parents o f hosp i ta l i zed ch i ld ren rated their fears as " intense" on the day before their c h i l d ' s surgery. In an attempt to cope to the best o f her know ledge w i th a n e w exper ience, one study mother actua l ly " imposed quarant ine" on hersel f and her c h i l d over a per iod o f several weeks p r io r to the surg ica l event. Th i s was her w a y o f m i n i m i z i n g her c h i l d ' s potent ia l r i sk o f acqu i r ing a c o l d or in fect ion pr io r to the scheduled date for the surgery, M : W e just thought maybe we shou ld keep h i m [chi ld] away f r o m other babies and , y o u k n o w , shopping ma l l s and stuff l i ke that, to sort o f try to keep h i m heal thy as poss ib le . T h i s se l f - imposed f o r m o f iso la t ion affected a l l members o f the fami l y . R : S o , fo r the last coup le o f weeks then, y o u haven ' t been go ing out as m u c h as usua l , y o u ' v e real ly been sort o f homebound . M : S o has m y husband to a certain extent. Because , you k n o w , we w o u l d do things on the weekend w i th h i m together and, you k n o w , when m y husband came home f r o m work and things l i ke that. S o , y o u k n o w , i t ' s had more o f an effect on me , but cer ta in ly on h i m as w e l l . Need less to say, the weeks p r io r to the ch i l d ' s surg ica l procedure were "out -of - the-ord inary" for this f am i l y . The i r lack o f know ledge and understanding o f 77 necessary and prac t ica l preparat ion for day care surgery l ed them to imp lement this f o r m o f se l f - imposed, temporary iso la t ion. Other parents a lso expressed that the weeks o f wa i t i ng p r io r to the actual surg ica l procedure contr ibuted to increased anxiety about their c h i l d ' s we l l -be ing . F o r examp le , one mother reca l led that " you w i s h the three weeks [preceding the day o f surgery] w o u l d be over " . Desp i te stating that she wasn ' t "scared i n any w a y " this mother d i d express that the wa i t i ng per iod was hard for her. D u r i n g the pre-hospi ta l izat ion phase o f the exper ience parents ant ic ipated some o f the concrete changes they were go ing to have to make i n their day to day l i ves i n order to cope w i th the needs o f the post-operat ive ch i l d . Parents commun ica ted that they ant ic ipated these changes to have a negat ive impact on their f a m i l y l i f e , and such ant ic ipat ion was a source o f anxiety for them. F o r example : M : F o r her, the fact that she enjoys hav ing baths and go ing in the water so m u c h and that she w o u l d n ' t be able to do this for , y o u k n o w , a coup le o f months and I don ' t k n o w , just the sheer nuisance w i th hav ing it a l l on top o f a l l the adjustments we were go ing to have to make and h o w she was go ing to react to that. T h i s mother was ant ic ipat ing h o w she w o u l d cope w i th the added parental respons ib i l i t ies related to post-operat ive care (cast care) w i th in the context o f her every day l i fe . She was ant ic ipat ing a negat ive post-hospi ta l izat ion exper ience. Ano the r mother s imp l y stated: "I thought, ahh , she 's [daughter] go ing to be imposs ib le " . In their efforts to enact new responsib i l i t ies as part o f their parental ro le , the study parents exper ienced ro le strain dur ing the pre-hospi ta l izat ion phase o f this exper ience. T h e added responsib i l i t ies o f prepar ing their c h i l d for the operat ive procedure were seen as a burden and i n con f l i c t w i th no rma l parent ing responsib i l i t ies. Parents w h o part ic ipated in this study saw it as their p r imary respons ib i l i t y to nurture their c h i l d , not carry out behaviors that i n their op in ions , contr ibuted to the c h i l d ' s d iscomfor t . T h e result o f ro le strain is often feel ings o f wor ry , anx ie ty , o r gui l t (Nye , 1976) as is i l lustrated i n the f o l l o w i n g : M : I guess I just wasn ' t l ook ing fo rward to hav ing , f i rst o f a l l , I thought he was go ing through this horr ib le exper ience and, y o u k n o w , the day o f the surgery, I d idn ' t rea l ly want to be part o f cont r ibut ing to any anxiety or anyth ing on his part ear l ier i n the day, I thought, g ive h i m to somebody else and let them have h i m for awh i le , u m m , so I don ' t have to l ook the b i g meany that's starving h i m and putt ing h i m through the b l ood test and a l l that. R : Y o u d idn ' t want to be associated w i th a l l that. M : N o . R : That puts a lot o f respons ib i l i ty on you as M o m . M : W e l l , that 's it. A n d I th ink y o u just want to get r i d o f it, and you just fee l , I th ink, y o u ' v e made a dec is ion for your c h i l d , that 's he ' s got to have surgery and that's enough to th ink about, y o u don ' t want a l l the other stuff as w e l l . T h i s mother is express ing that the added responsib i l i t ies related to prepar ing her c h i l d fo r surgery were anxiety p rovok i ng for h e r - s h e felt l i ke a "b ig meany" . She is a lso po in t i ng out that she anticipates the exper ience to be "hor r ib le" and she w i l l be unable to protect her young c h i l d f r o m harm. A th i rd emphasis is apparent i n her comment about the effect o f hav ing dec ided to proceed w i th the surgery. C lea r l y this mother 79 feels ambiva lent about the new responsib i l i t ies related to her c h i l d ' s day care surgery. W y c k o f f and E r i c k s o n (1987) studied the effects o f stress on 120 mothers o f ch i l d ren hosp i ta l i zed for an average o f n ine days . These authors ident i f ied that the c h i l d ' s age was a factor i n parents ' ab i l i ty to cope w i th the c h i l d ' s hospi ta l izat ion. "D i f fe rences in parental cop ing i n re lat ion to the c h i l d ' s age may be related to d i f ferences i n react ions to hosp i ta l iza t ion, dependent on the c h i l d ' s deve lopmenta l stage" ( W y c k o f f & E r i c k s o n , 1987, p. 5) . T h e c o m m o n pract ice o f w i thho ld ing f o o d and f lu ids f r o m the pre-operat ive c h i l d i n preparat ion for surgery was a s igni f icant factor cont r ibut ing to parental ro le strain. T h e p rov is ion o f f ood and f lu ids to young ch i ld ren is central to soc ia l norms fo r parental ro le behav ior (Hande l , 1970; F r i edman , 1986). Here the average age o f the ch i ld ren (23.8 months) whose parents part ic ipated in this study was a s igni f icant factor i n the parents ' fee l ings o f ro le strain. W i t h h o l d i n g f ood and f lu ids was par t icu lar ly d i f f i cu l t fo r the parents i n this study whose ch i ld ren were unable to comprehend w h y this preparat ion was necessary. F o r example : M : O f course y o u fee l gu i l ty 'cause, y o u k n o w , you fel t bad. ' C a u s e the c h i l d doesn ' t understand w h y you ' r e not g i v i ng h i m anyth ing to eat. Y o u k n o w , you can ' t te l l h i m unless o f course he ' s o l d enough to understand, but [chi ld] is not. S o , you k n o w , i t ' s rea l ly hard to say, " W e l l , you can ' t eat, i t ' s fo r your o w n good , y o u k n o w " . A n d he ' s too young to understand that and it bothered h i m , and it bothered me. Parenta l gui l t and anxiety is c lear ly evident i n the prev ious quotat ion. Parents commun ica ted to the researcher that wh i le car ry ing out the pre-operat ive day care surgery instruct ions, they felt they were l i tera l ly "s tarv ing" their ch i ld ren : 80 M : I d idn ' t want h i m to get upset, y o u k n o w . T h e hardest part was keep ing h i m happy, you k n o w , f r om that t ime [breakfast] on ' t i l w e left [for the hospi ta l ] . It was d i f f icu l t , y o u k n o w , 'cause he cou ldn ' t d r ink , he cou ldn ' t eat, he was l ook i ng a l l over h is p laypen , y o u k n o w , every th ing~I vacuumed every th ing so he cou ldn ' t f i nd a s ingle c rumb, and he was l ook i ng for c rumbs, i t was just terr ib le, y o u k n o w , poor ch i l d was starv ing and it was m y fault , I cou ldn ' t do anyth ing about it. A s is noted above, parents i n this study c o m p l i e d "to the letter" w i th the pre-operat ive instruct ions for restr ic t ion o f f o o d and f lu ids . T h i s mother 's fee l ings o f gui l t and helplessness regard ing not f u l f i l l i ng her usual nur tur ing ro le for her c h i l d are evident i n the above quote. A l t h o u g h parents expressed that they k n e w such procedures were in the best interest o f their c h i l d ' s we l l -be ing i n l ight o f the impend ing surgery, the f o l l o w i n g quotat ion i l lustrates h o w one mother d i d not fee l understood or supported, i n re lat ion to the d i f f i cu l ty that such a task posed to her: M : I f somebody had just recogn ized that I had a r ight to be upset about it, that to them it wasn ' t anyth ing maybe , but i t was to m e , i t rea l ly was , that m y l i t t le boy was go ing to have to do wi thout someth ing to dr ink, someth ing to eat, and was go ing to have that [surgery] done. A n d I was more upset w i th h o w I was go ing to cope w i th h i m not eat ing and d r i nk ing than anyth ing else. C o p i n g w i t h the w i thho ld ing o f f ood and f lu ids posed a major task fo r this mother and resul ted i n fee l ings o f anxiety. D u r i n g the pre-hospi ta l izat ion phase o f their exper ience parents rece ived both so l ic i ted and unso l i c i ted op in ions and adv ice about the p roposed surgery, a part icular phys ic ian /surgeon, and/or a part icular health care agency. S u c h op in ions often s ign i f icant ly in f luenced parents ' trust and conf idence i n the med ica l in format ion and recommendat ions they rece ived. A s migh t be expected, favourab le op in ions were perce ived as support ive and v i ce versa. Negat i ve op in ions often eroded the parents ' con f idence. F o r examp le : M : I ta lked to other peop le , m y m o m , [laughs] and she gave m e other ideas and , gee, she sa id there is some doctor f r o m Oregon. . .say ing that the scar t issue w i l l be left and i f it [the proposed surgery] doesn ' t wo rk , then the eye has to f ight against the scar t issue, and so o n , and so for th, and, you k n o w , that put negat ive thoughts i n m y m i n d and I th ink, gee, a m I do ing the r ight th ing, or whatever? M : I cons idered postpon ing it [the surgery] unt i l the F a l l , m y f r iends w o u l d say " O h , i t ' s so hot i n the summer and the casts are go ing to bother her" , and "she 's go ing to be i tchy, and whatnot." B o t h o f the above parental comments indicate that w h e n parents are m a k i n g dec is ions re lated to their c h i l d ' s day care surgery, comments f r o m fam i l y members and fr iends that are not i n agreement w i th their stance may be read i ly interpreted as sources o f doubt o r as non-suppor t ive. T h i s latter f i nd ing is congruent w i th that o f L y n a m (1987) i n an examina t ion o f the parent support network i n a pediatr ic onco logy sett ing. H e r observat ions were part o f a larger study on hospi ta l related stress ( K n o x & Hayes , 1983). A l t h o u g h she reported on parent support networks among parents o f ch i ld ren 82 hosp i ta l i zed w i th l o n g term condi t ions, she states that the data from this qual i tat ive study indicate that certain types o f parent re lat ionships "can contr ibute to the stresses associated w i t h the hospi ta l izat ion o f ch i l d ren " ( L y n a m , 1987, p. 7) . Parents a lso rece ived input f r o m fr iends and relat ives that had a very pos i t ive effect on their ant ic ipat ion o f the surg ica l event. F o r examp le : M : N o one was against i t [the surgery] o r anyth ing, i n fact, everyone that I ta lked to that had had it or whatever, o r I ment ioned it to, felt that it was the best. It k i n d o f helps to k n o w that other people fee l l i ke it is good , too, to have it [the surgery]. K n o w i n g that f r iends and f am i l y supported the parents ' dec i s ion to p roceed w i th the surgery was an important aspect o f the exper ience fo r most fami l i es i n this study. F o r examp le : R : S o y o u fel t a lo t better when— M : A f t e r I had fam i l y support, yes, after m y m o m agreed [with the dec is ion to proceed w i th the surgery]. T h e l i terature on soc ia l support agrees w i th this f i nd ing that f r iends and f am i l y can help i n areas that require agreement and pos i t ive affect (P i l i suk & F ro land , 1978). O n e f a m i l y w h o part ic ipated i n this study was a notable except ion to the re l iance on the support o f f a m i l y and f r iends, par t icu lar ly in the process o f dec is ion m a k i n g about the c h i l d ' s surgery. T h e Ch inese parents i n this study del iberately d i d not consul t or even i n f o r m their parents o r f am i l y members regard ing the dec is ion to proceed wi th the surgery because they felt that non-med ica l persons d i d not have suf f ic ient know ledge to of fer op in ions on the matter. These parents also ment ioned to the researcher that the c h i l d ' s paternal grandmother had not agreed w i th the need fo r surg ica l correct ion o f the c h i l d ' s cond i t ion . F : It doesn ' t matter i f you got b i g surgery or sma l l surgery. E v e n you ask anybody , your mother, your father, your f am i l y , they can ' t help you at a l l . T h e y don ' t k n o w anyth ing about that. Is on l y one th ing y o u can trust is doctor , nobody else. Y o u tel l them this and that, what can they do? [laughs] E v e n they say " y e s " , or they say " n o " , they may wrong . T h i s f i nd ing is inconsistent w i th the w o r k o f G o u l d - M a r t i n and N g i n (1981) w h o found that Ch inese- immig ran t fami l ies w i l l most l i ke l y turn to f am i l y members for sympathy or suggest ions i n matters o f phys i ca l i l lness. H o w e v e r , A n d e r s o n and C h u n g (1982) i n their study o f immigran t Ch inese fami l ies , f ound that i f parents d isagreed w i th the attitude o f their s igni f icant others i n re lat ion to their c h i l d ' s med i ca l cond i t ion and/or treatment, their response was to " l im i t their contact w i th these s igni f icant others" (p. 47) . In add i t ion to the Ch inese immigran t parents, four other study parents also expressed a h igh l eve l o f trust and fa i th i n their phys ic ians , a l though for these latter parents, cr i ter ia fo r j u d g i n g the phys ic ian/surgeon inc luded the w a y the he/she interacted w i th parent and ch i l d . M : Doc to r [pediatric surgeon] is the one w h o took care o f [chi ld ] . I had a lot o f fa i th i n h i m , he seemed to be a very good doctor. H e is a very n ice doctor , so I felt ve ry at ease w i th h i m . S o , i t ' s not l i ke when you meet a doctor and y o u got this strange fee l ing about h i m , you k n o w , I mean you ' re wonder ing , you k n o w , y o u just got strange fee l ings about cer ta in doctors, and he gave m e a comfor tab le fee l ing . 84 T h i s is an examp le o f commun ica t i on o f pos i t i ve affect as a component o f soc ia l support and p romot ing parental conf idence. Parents were sat isf ied i f the health profess ionals appeared to care about their c h i l d and themselves. Kups t , Dresser , S c h u l m a n , and P a u l (1976) noted i n their study on i m p r o v i n g phys ic ian-parent commun ica t i on that a fee l ing o f car ing f r o m health profess ionals helps enormous ly i n ma in ta in ing commun ica t i on . Severa l o f the phys ic ians/surgeons w h o were consul ted by the parents i n this study, were h igh l y recommended by fam i l y and f r iends: M : T h e fact m y g i r l f r iend [name], her l i t t le boy , [pediatric surgeon] took care o f h im. . .and [ female fr iend] was absolute ly p leased w i th h i m when I to ld her I was go ing to see h i m [pediatric surgeon]. She was just l i ke " O h , y o u ' r e go ing to be so happy w i th h i m " . T h i s mother fel t supported through her f r iend 's strong pos i t ive recommendat ion . T h i s is an another examp le o f the impor tance o f commun ica t i on o f pos i t ive affect as a component o f soc ia l support fo r the parents i n this study. In summary , parents w h o part ic ipated in this study appraised their c h i l d ' s day care surgery to be stressful fo r them dur ing the pre-hospi ta l izat ion phase o f their exper ience. T h e d imens ions o f their exper ience contr ibut ing to this appraisal i nc lud ing dec i s ion m a k i n g , lack o f in fo rmat ion , and added responsib i l i t ies , were reported i n this sect ion. T h e next sect ion presents the s tudy 's f ind ings related to the hospi ta l izat ion phase o f their exper ience. T h e Hosp i ta l i za t i on Phase T h e hosp i ta l iza t ion phase o f the exper ience refers to that per iod o f t ime that the parents and c h i l d were actual ly i n the hospi ta l sett ing. A s was p rev ious ly noted, the 85 average t ime spent by the fami l ies in this study i n the day care unit was three hours and 13 minutes. D u r i n g this acute phase o f the encounter w i th the health care system, their c h i l d ' s f i na l preparat ion fo r surgery was comple ted and parents re l inqu ished h i m or her to the care o f health care profess ionals i n order that the actual surg ica l procedure c o u l d be per formed. A l t h o u g h the span o f t ime dur ing this phase o f the exper ience was short, the parents ' fee l ings and emot ions dur ing this t ime were intense. T h e d imens ions o f this phase o f the exper ience that contr ibuted to the parents ' interpretat ion o f their exper iences as stressful were p r imar i l y re lated to event uncerta inty, o r not k n o w i n g what to expect due to their l ack o f p rev ious exper ience. R o l e strain was a dominant theme i n this phase par t icu lar ly when parents were phys i ca l l y separated f r o m their c h i l d dur ing the actual operat ion. W a i t i n g dur ing this pe r i od o f t ime was very d i f f i cu l t fo r parents. There were par t icu lar aspects o f the day care surgery environment—routines and commun ica t i on w i th health care professionals—that a lso contr ibuted to parents feel ings o f fear, wor ry , and anxiety . D u r i n g this phase o f the exper ience, parents re l ied o n c o p i n g mechan isms that func t ioned to cont ro l o r manage the stressful feel ings (Pear l in & Schoo le r , 1978). A s a l l parents were asked to have someone accompany them to the hosp i ta l , soc ia l support was a lso a factor i n parental cop ing dur ing this phase o f the exper ience. B y the time the parents i n this study ar r ived at the hosp i ta l , as p rev ious ly reported, they were already fee l ing anx ious and gu i l ty as a result o f their ant ic ipat ion o f a rather negat ive exper ience and their inab i l i t y to feed and comfor t their young ch i ld ren i n their usua l ways . Because o f the intensity o f their fee l ings at this t ime, delays in admiss ion procedures o r i n the scheduled t ime for surgery added to their interpretation o f the event as stressful. 86 A par t icu lar ly d i f f i cu l t t ime for parents dur ing the hospi ta l iza t ion phase o f the day care surgery exper ience was when they had to re l inqu ish the c h i l d to the operat ing r o o m staff i n order that the surgery c o u l d proceed. Three o f seven mothers reported b reak ing d o w n and c r y i ng at the po in t o f separat ion f r o m their c h i l d . Parents commun ica ted in i t ia l l y fee l ing re l ie f that the event was actua l ly p roceed ing , and anxiety because o f g i v i n g up cont ro l and their "protector" ro le . M : W e wa i ted i n the p lay area w i th [chi ld] w h i c h , I guess, w a s a l i t t le bit hard , that 's when I started to c ry , because, I guess, it [the surgery] was go ing ahead, and I was sort o f wor r ied . M : I was rea l ly ve ry good up unt i l when you saw m e [researcher met w i th parent] w h e n I started c ry ing . I he ld up r ight un t i l then, and then I thought, o h , it was just the release, y o u k n o w , because there she goes [to the operat ing room] . T h e amb iva lence associated w i th this point o f the exper ience is evident f r om the mothers quoted above. These mothers felt re l ie f and fear s imul taneous ly . C r y i n g was a w a y o f re leas ing their fee l ings o f fear is an obv ious ind icator o f the acute need for support at this t ime. F o r four o f the parents, soc ia l support was p rov ided to them by the person that had accompan ied them to the day care unit . A d d i t i o n a l factors that contr ibuted to parents ' anxiety, fear, and wor ry , were lack o f k n o w l e d g e and si tuat ional contro l as is ev idenced i n the f o l l o w i n g quotat ions: M : It was d i f f i cu l t because, again , I th ink the th ing is , y o u don ' t k n o w wha t ' s go ing on , and y o u don ' t have any cont ro l . N o t that y o u cou ld do anyth ing i f y o u were there [ in the operat ing room] anyway , but somehow, 87 y o u k n o w , y o u have this sense that even i f y o u cou ldn ' t do anyth ing, i f y o u were there, it w o u l d be more reassur ing, so I th ink i t ' s hard not k n o w i n g wha t ' s go ing on and hav ing a fee l ing that y o u don ' t have cont ro l ove r the situation and y o u aren' t there to assist i f someth ing goes w r o n g . I guess y o u just want to k n o w wha t ' s go ing o n , and y o u don ' t k n o w wha t ' s go ing o n , so it makes y o u wor ry more 'cause y o u don ' t k n o w wha t ' s go ing on . M : T h e cont ro l o f be ing there, and you are the one that's i n charge o f h i m , whereas w h e n he goes in to surgery and the doctor 's i n charge o f h i m , you have no say i n the matter or anyth ing, and y o u just have to sit there and wai t pat ient ly, and just wai t ' t i l he comes out. No te that these two mothers are say ing that dur ing the hospi ta l iza t ion phase o f the day care surgery exper ience, the usual sense o f cont ro l they have w h i c h enables them at a l l t imes to care for and protect their c h i l d was gone when they were phys i ca l l y separated f r o m their ch i l d . " B e i n g there" somehow meant be ing able to f u l f i l l a ro le to protect their c h i l d . N o t hav ing cont ro l over their young c h i l d resul ted i n intense feel ings o f ro le st ra in, gui l t and anxiety. C l a r k e (1984) states that "perce ived lack o f cont ro l where c o p i n g is important leads to negat ive emot ion and this is associated w i th loss o f se l f -es teem" (p. 8). W i thou t except ion , a l l o f the parents i n this study expressed fears and concerns about a l l o w i n g their c h i l d to undergo a general anesthetic. Parenta l consent fo r what they perce ived to be a large r isk fo r their c h i l d resul ted i n feel ings o f con f l i c t and anxiety . M : I was concerned because he had the c o l d , but even i f he hadn ' t had the c o l d I w o u l d have been concerned. Y o u k n o w , each i nd i v idua l reacts d i f ferent ly and h e ' d never had one [operation] before, and I was , quite f rank ly , m y b i g concern was that someth ing was go ing to happen w i th the anesthetic and he was go ing to d ie , bra in damage o r someth ing as a result. I mean , that was m y b i g concern , it rea l ly was . S o I was quite petr i f ied o f that, and I mean , I k n e w that it doesn ' t happen very often but it was st i l l i n the back o f m y m i n d . M : Tha t ' s m a i n l y every parent 's concern is the anesthetic, y o u k n o w . W o n d e r h o w i t ' s go ing to, y o u k n o w , affect. Because y o u have heard a lot o f gruesome stories about anesthetic so, y o u k n o w , I 'm not rea l ly too happy about it. No te h o w these two mothers are forthr ight about the intensi ty o f their fears regard ing an anesthetic for their ch i l d . Parents spec i f ied that the sources o f the "gruesome stor ies" they had heard were p r imar i l y newspaper and te lev is ion reports about mor ta l i ty and morb id i t y associated w i th general anesthetics. O n e mother c i ted "news reports i n the back o f m y m i n d " as the source o f her fears. T h e pe r iod o f wa i t i ng wh i l e the c h i l d ' s surgery was actual ly tak ing p lace cont r ibuted to fee l ings o f anxiety and wor ry . M : W e l l , you see, i t ' s rea l ly hard to exp la in ; i t ' s just that y o u go through dif ferent emot ions. Its l i ke you ' re wonder ing i f you ' r e go ing to make it, i f he ' s go ing to sleep through the who le , y o u k n o w . I mean , i f he ' s go ing to w a k e up i n the m idd le o f it or [pause], i t ' s s i l l y th ings, but you 89 d o go through it, y o u k n o w . Y o u do th ink about it and i f he ' s ever go ing to w a k e up f r o m i t . . . .You ' re si t t ing there because y o u got a l l that t ime to k i l l and, what else w o u l d happen when y o u have noth ing else to amuse yourse l f w i th? Y o u k n o w , you r m i n d starts p l a y i n g games on y o u , you can rea l ly get upset. In add i t ion to express ing h o w d i f f icu l t the wa i t i ng per iod is wh i l e the ch i l d is i n the operat ing r o o m , this mother is express ing her con fus ion and fears re lated to her ch i l d ' s anesthetic. Ano the r parent stated that the wa i t i ng was d i f f i cu l t because she was very aware that "someth ing freak can happen [whi le c h i l d is i n the operat ing room] " . O n e o f the cop ing strategies parents used dur ing the wa i t i ng pe r iod for their c h i l d to return to the day care unit f r o m the recovery r o o m was that o f " soc ia l c o m p a r i s o n " (Pear l in & Schoo le r , 1978). Th i s strategy invo lves the compar i son o f one ' s mis for tune w i t h the mis for tune o f others and is perce ived by some as a f o r m o f support. F o r examp le , M : I was watch ing this lady in front o f m e [in the wa i t i ng area]. H e r l i t t le boy was i n fo r an ear operat ion or something.. .apparent ly her son ' s operat ion took an hou r . . .You k n o w , for what [chi ld] was hav ing [surgical procedure] , it d idn ' t seem as terr ible as what her l i t t le boy was go ing through. B y compa r i ng her p l igh t to that o f other parents i n the wa i t i ng area this mother is say ing that her si tuat ion d idn ' t seem as bad as that o f other parents. Th rough use o f the technique o f " soc ia l compar i son " this mother is ind ica t ing that she felt reassured. Parents i n this study had c lear ideas about how their ch i ld ren were go ing to appear and h o w they w o u l d behave in the immedia te post-operat ive per iod . F o r 90 examp le , M : I thought, general anesthesia and everyth ing, go home r ight after a coup le hours, I was a bit concerned, but not w h e n I saw h i m . W h e n he came out and every th ing, there was actual ly no p rob lem. I was very happy w h e n they to ld m e I cou ld take h i m home. T h i s mother is express ing h o w she had not rea l ly be l ieved that her son w o u l d be w e l l enough to go home w i th in a f ew hours o f h is surgery. W h a t changed her op in ion was her son ' s actual phys i ca l appearance when he returned f r o m the recovery r o o m w h i c h , she 's i m p l y i n g , was more pos i t ive than she had thought it w o u l d be. Other parents a lso expressed that they d i d not expect the c h i l d to do w e l l i n the post-operat ive per iod . Parents ' negat ive expectat ions were based on their appraisal o f their son o r daughter 's day care surgery as an event that m a y i n v o l v e ha rm to their ch i l d . F o r examp le , one parent descr ibed it this w a y , "She l o o k e d a lot better when she came out [of the recovery room] than I thought she was go ing to be" . A number o f parents echoed the feel ings o f one mother w h o sa id , "I guess I expected h i m to be ve ry groggy, you k n o w , very s leepy f r o m the anesthetic. A c t u a l l y , he wasn ' t that s leepy. " These parents ' exper ience i n the immedia te post-operat ive per iod was more pos i t i ve than they had expected. The i r intense feel ings o f fear and wor ry were replaced w i th ones o f rel ief . Parents reported that the moment o f reuni t ing w i th their c h i l d after returning f r o m the recovery area was a very spec ia l one: "It was a very spec ia l moment just to see h i m . I guess, you k n o w , just go and run up to h i m and g ive h i m a b ig h u g " . P h y s i c a l contact w i th their c h i l d was very important fo r the parents to k n o w that their c h i l d was alr ight and also to renew their parental ro le o f p rov id i ng comfor t and care. 91 A s one mother stated: " T h e minute I got h i m [chi ld] i n m y arms, I k n e w he wasn ' t [s ick ] " . Ano the r mother commented on her frustrat ion o f not be ing able to phys i ca l l y " reuni te" w i t h her c h i l d because she was left a lone immed ia te ly after her c h i l d returned to the day care unit and she d i d not k n o w h o w to put s iderai ls d o w n on the hospi ta l c r ib therefore was unable to phys i ca l l y comfor t her ch i l d . She exp la ined : M : W h e r e they [nurses] d isappeared to a l l o f a sudden I don ' t k n o w . I f they w o u l d have stayed w i th me just fo r a second unt i l I c o u l d f i nd out what I c o u l d do. Y o u k n o w , it was k i n d o f a matter of , " Y o u r daughter 's back " [ f rom P A R ] , and I went i n there [to the cub ic le ] , and they were gone. T h i s mother went on to emphas ize the impor tance o f phys i ca l contact for her i n those f i rst f e w minutes after the c h i l d returns from the recovery r o o m . She is a lso commen t i ng on h o w her reuni t ing w i th her c h i l d might have been better handled by nurs ing staff. Three other study parents commented that they d i d not ant icipate their c h i l d ' s a r r i va l back i n the day care unit at the t ime that it occur red and this contr ibuted to their fee l ings o f stress related to this phase o f their exper ience. A l t h o u g h the parents had been i n fo rmed o f an approximate t ime for their c h i l d ' s return to the day care unit , parents reca l led fee l ing surpr ised upon the c h i l d ' s actual return and somewhat unprepared for the w a y their c h i l d ' s return was handled. O n e mother descr ibed her c h i l d ' s return this w a y : M : A l l o f a sudden, y o u k n o w , we heard the doors open and then this lady, w h o we d idn ' t k n o w , came out and sa id , " W h o does this one be long to?" A n d , uhh , so that was it and we said " W e l l , he ' s ours" and she handed 92 h i m over to us and that was it...I d idn ' t th ink the who le recovery th ing was hand led very w e l l fo r us. Just, y o u k n o w , we were very happy and reassured just to have h i m back w i th us. T h i s mother 's comments ref lect a lack o f know ledge regard ing both w h e n and h o w her c h i l d w o u l d be returned to her. A l t h o u g h she is express ing re l ie f at hav ing her c h i l d back w i t h her, she w o u l d l i ke to have k n o w n in advance when her c h i l d was returning f r o m the post-anesthetic recovery r o o m and perhaps have a more personal and empathic approach used i n reun i t ing her w i th her post-operat ive ch i l d . Ano the r mother descr ibed a m u c h more pos i t ive scenar io related to the wa i t ing per iod pr io r to her son ' s return f r o m the post-anesthetic recovery r o o m . In the f o l l o w i n g quotat ion she is emphas iz ing h o w important in fo rmat ion and a car ing attitude he lped a l lay her anxiety dur ing the d i f f i cu l t wa i t i ng per iod . M : I was so concerned about, was he i n Recove ry o r whatever? A n d I never even had to ask them. T h i s nurse came up to me and sa id , "I just thought I 'd let you know* I phoned Recove ry and your son is do ing just f i ne " . Y o u k n o w , I d idn ' t have to ask, l i ke she d i d it. T h e nurses ant ic ipat ion o f this mother 's needs had an obv ious pos i t ive effect on this parent. T h e hosp i ta l iza t ion phase o f the exper ience was d i f f i cu l t fo r parents because they exper ienced the fears and anxiet ies associated w i th ro le strain wh i l e wa i t i ng for their c h i l d to return f r o m the operat ing room. A l l parents, as requested by the day care unit staff, had another person w i t h them at the hospi ta l . M o s t re l ied heav i l y on the other person fo r support dur ing this t ime. One mother sa id this regard ing her husband 's presence w i t h her that day : 93 M : I mean , he took the day off, you k n o w , f r o m w o r k to come and spend, y o u k n o w , to go to the hospi ta l w i th me , so that was very spec ia l . I f it wasn ' t fo r h i m , I don ' t th ink I c o u l d rea l ly have gone through it as w e l l as I d i d . T h i s mother is referr ing to the component o f soc ia l support others refer to as integrat ion ( D i m o n d & Jones, 1983). She feels supported just k n o w i n g that her husband was there to help her i n t ime o f her need. A number o f parents adopted a pos i t ive attitude and used pos i t i ve "se l f - ta lk" to support themselves dur ing this t ime. F o r example : M : [It was me] te l l ing myse l f not to wor ry about it, y o u know. . . .No t to wor ry because [chi ld ] 's i n good hands...the doctor 's f ine , the baby ' s go ing to be f ine, i t ' s not a major operat ion. Pear l i n and Schoo le r (1978) descr ibe this cop ing strategy o f "se lect ive i gno r ing " as one that is attained by seek ing some pos i t i ve attribute w i th in a stressful s i tuat ion. Three mothers stated that they found nurses to be support ive dur ing their wa i t ing pe r i od after the c h i l d had gone to the operat ing r o o m . O n e mother i n par t icu lar remembered it this w a y : M : I remember when I was rea l ly upset, when he [chi ld] went in to the th ing [the operat ing room] . A n d then I came back and sat d o w n , and this nurse came over , and knee l ing d o w n , l i ke ta lk ing to m e on eye l e v e l , and just, y o u k n o w , ta lk ing to me about it. I don ' t remember what she sa id even, just ta lk ing to me , I remember that 'cause that got m e under cont ro l . A n d , I guess, it was that I felt that they c a r e d - t h e y cared about [chi ld] , they d idn ' t k n o w him.. .and they cared about me. I guess that is what it rea l ly came out as, and it was important. T h e fee l ing that the descr ibed nurse cared about them was an important cr i ter ion o f support dur ing a d i f f i cu l t t ime. F o r these study parents, trust and fa i th i n health profess ionals was extended to a be l ie f that they w o u l d a lways act w i th the c h i l d ' s best interest i n m i n d . F o r example , parents commun ica ted that they were conf ident that health profess ionals w o u l d ensure that they rece ived the appropriate in format ion about car ing for the pre- and post-operat ive c h i l d . M : I mean , i f i t was someth ing that is rea l ly sort o f a p ress ing quest ion, you k n o w , I don ' t th ink I w o u l d hesitate to ask it. Bu t , w h e n they ' re sort o f l i t t le th ings, that y o u th ink " O h m y goodness, w e l l , that 's p robab ly a d u m b th ing to ask because i f it was an important th ing, they w o u l d have ment ioned it," o r someth ing l i ke that. Y o u tend not to ask those things. T h i s mother is under the assumpt ion that the health care pro fess iona l k n o w s and understands what in fo rmat ion is important to her i n order for her to manage her c h i l d ' s care w i t h i n the context o f her everyday l i fe . S u c h a f i nd ing corresponds to the research done by R o b i n s o n and Thorne (1984) w h o ident i f ied one phase i n the deve lopment o f re lat ionships between consumers and health care workers as "na ive trust", where fami l i es "wai t pass ive ly fo r the pro fess iona l health care prov iders to fu l f i l their respons ib i l i t ies" (p. 599). One parent w h o part ic ipated in the current study descr ibed her feel ings this way : " Y o u tend to put a lot o f trust i n people i n the hospi ta l I th ink. A n d you k n o w , you f igure, w e l l , this is the w a y i t ' s done. " Interact ions w i t h health care profess ionals were not a lways perce ived to be he lp fu l o r support ive. In several instances, inconsistent in format ion about what parents 95 shou ld expect i n terms o f contact w i th the c h i l d ' s surgeon contr ibuted to increased anxiety and wor ry . T h e major i ty o f study parents were anx ious ly "wa i t ing to get the news, to hear that yes , he ' s [chi ld] out o f there [O.R. ] and yes , he ' s O . K . " . O n e mother descr ibed her exper ience this w a y : M : W e l l , i t ' s p robab ly just s i l l y th ings, but the nurse sa id the doctor was go ing to come r ight out after the cast. H e d idn ' t , either he d idn ' t or we m issed h i m , went d o w n to have lunch o r someth ing. S o w e thought he was st i l l i n there do ing cast and a l l , and a l l o f a sudden [chi ld] appeared and she was f in ished [soft laugh] . S o , I, you k n o w , I back i n m y m i n d I k n e w there was probab ly noth ing w r o n g , but y o u k n o w these l i t t le doubts y o u have. T h i s mother is say ing that when the surgeon d i d not come out to talk to her as she had been led to expect , it in t roduced a strong fee l ing o f doubt that someth ing had gone w r o n g w i t h her daughter 's procedure. T h i s contr ibuted to her fears and anxiety about her c h i l d ' s we l l - be ing . Ano the r parent descr ibed it this w a y : M : I understood that he [pediatric surgeon] w o u l d c o m e out once he f in ished [the surgery] , he w o u l d talk to me about it. A n d then I thought " W h a t ' s go ing o n ? " y o u k n o w , " W h y isn ' t he c o m i n g ? " R : Y e a h , and then y o u start to wor ry . M : Y o u start to wor ry , yeah. B u t I thought, i f there was someth ing terr ibly w r o n g h e ' d c o m e out and tel l me , y o u k n o w , if, if, they w o u l d just tel l m e that i f I lost h i m [chi ld] . R : S o y o u sort o f had that i n the back o f your m ind . 96 M : W e l l , i f i t takes longer... than y o u expect , I th ink every no rma l mother does that, pray for noth ing [to happen]. A n d it can happen, you k n o w , it can happen i f the anesthesia o r someth ing goes w rong . A n d somet imes I th ink there is noth ing people can do. These parents ' are descr ib ing their acute sense o f t ime wh i l e they are separated f r om their c h i l d as w e l l as a their sense o f helplessness. T h e y are express ing that d iscrepancies i n what they have been led to expect i n terms o f commun ica t i on w i th their phys ic ians is par t icu lar ly stressful i f not f o l l o w e d through. O n e mother stated, "I th ink i t ' s rea l l y n ice i f he [surgeon] makes sure he sees the parents r ight afterwards [after the surgery is per formed] . " Other authors (Hayes & K n o x , 1984; Te r r y , 1987) have documented that parents want in format ion d i rect ly f r o m their phys ic ians w h o they see as p r imary sources o f in format ion regard ing their c h i l d ' s d iagnos is , treatment reg ime, and expected outcome. In summary , there were several d imens ions o f this phase o f the exper ience that contr ibuted to the parents ' interpretation o f their exper ience as stressful . These were related to event uncertainty and re l inqu ish ing the respons ib i l i ty for cont ro l and protect ion o f their c h i l d to health profess ionals resul t ing i n ro le strain and anxiety. Parents descr ibed par t icu lar aspects o f the day care surgery env i ronment—wai t ing, fears o f a general anesthetic, reun i t ing w i th the post-operat ive c h i l d , and commun ica t i on w i th health care professionals—that contr ibuted to their fee l ings o f fear, wor ry , and anxiety. D u r i n g this phase o f the exper ience parents re l ied on cop ing mechan isms that funct ion to cont ro l o r manage the stressful feel ings (Pear l in & Schoo le r , 1978). A s a l l parents brought someone w i th them to the hospi ta l , soc ia l support was one such factor i n parental c o p i n g dur ing this phase o f the exper ience. 97 T h e next sect ion presents the f ind ings related to the post -hospi ta l izat ion phase o f the day care surgery exper ience for parents. T h e Pos t -Hosp i ta l i za t ion Phase T h e post -hospi ta l izat ion phase began w h e n the c h i l d and parent(s) were d ischarged f r o m hosp i ta l and cont inued unt i l the c h i l d had recovered phys i ca l l y and emot iona l l y f r o m the surgery and a l l f am i l y members had returned to their regular patterns and act iv i t ies o f da i l y l i v i n g . A l t h o u g h the parents ' i nd i v i dua l exper iences dictated the rate at w h i c h they m o v e d through the phases o f their exper iences, f i ve fami l i es i n this study c lear ly ident i f ied when the recovery phase o f their exper ience had ended, usua l ly w i t h in a week to 10 days o f the actual surg ica l procedure. D u e to uncertainty about the ef fect iveness o f the surg ica l procedure, one parent w h e n in te rv iewed for the second t ime, was st i l l unable to art iculate w h e n she felt this phase o f her exper ience w o u l d actual ly end. L i k e the pre-hospi ta l izat ion and hospi ta l izat ion phases o f the parents ' exper ience, the post -hospi ta l izat ion phase was a lso stressful for parents. Parents reported fee l ing wor r ied and anx ious dur ing this t ime. D imens ions o f the post -hospi ta l izat ion per iod that contr ibuted to parents ' interpretations o f the events as stressful i nc luded new respons ib i l i t ies for the care and superv is ion o f the post-operat ive c h i l d , changes in the c h i l d ' s behav ior and patterns o f act iv i ty , and changes i n f am i l y act iv i t ies and rout ines. A l ack o f in fo rmat ion regard ing these d imens ions o f the post -hospi ta l izat ion phase o f the exper ience was ident i f ied by the parents as cont r ibut ing to the stressful nature o f this phase o f the exper ience. Parents imp lemented several c o p i n g strategies and u t i l i zed soc ia l support to manage this phase o f their exper ience. 98 Desp i te hav i ng rece ived in fo rmat ion and instruct ions f r o m day care unit staff, the f o l l o w i n g quotat ion reveals one mother 's concerns regard ing her new responsib i l i t ies i n the post -hospi ta l izat ion phase. She descr ibes a l ack o f in format ion regard ing her "m ino r " concerns once she has returned home and her need for support at this t ime. M : M a y b e what happens is , you k n o w , right after the surgery you have certa in ma in concerns l i ke , w e l l , is [chi ld] back to no rma l , you k n o w ? Is he recovered f r o m the anesthetic? W h i c h was one o f the major things. S o that a l l o f those other things y o u forget about them for awhi le . A n d then i t ' s not unt i l you get home, and those ma jo r concerns have k i n d o f sett led d o w n , but then the m i n o r concerns become more obv ious , or you start to wor ry . T h i s mother indicates that at home the parents ' percept ion and appraisal o f their s i tuat ion changes. T h e major issues become less o f a source o f stress, but these are rep laced w i t h immedia te issues related to car ing for a post-operat ive c h i l d at home. K u p s t , Dresser , S c h u l m a n , and P a u l (1976) in their study on i m p r o v i n g parent-phys ic ian commun ica t i on , f o u n d that parents tend to focus their attention on areas where they, as parents, are d i rect ly responsib le such as instruct ions about med ica t ions and phys i ca l act iv i t ies. These authors also noted that parents often th ink o f quest ions for health care pract i t ioners after they leave the hospi ta l . T h i s was a lso the case fo r parents w h o par t ic ipated i n this study. In their attempts to fu l f i l parental responsib i l i t ies for the care, protect ion, and nurturance o f their post-operat ive c h i l d , parents imp lemented a pattern o f "protect ive behav io rs " par t icu lar ly i n the f irst 24 to 48 hours after returning home. T h e imp lementa t ion o f protect ive behaviors o n the part o f the parents served to c o m p l y w i th 99 parental ro le expectat ions and decrease ro le strain. Parents reported that the f irst o r second night at home was of ten the most d i f f i cu l t for the c h i l d and the parent: M : T h e f i rst n ight, yeah , he was fussy about that. ' C o u r s e I was fussy too. I was a lways m a k i n g sure every th ing was f ine , y o u k n o w . M : Na tu ra l l y as a mother you get up a coup le o f t imes to check , "Is he a l r igh t?" No te h o w these mothers cope w i t h the new responsib i l i t ies o f their parent ing ro le by increas ing the f requency o f their phys ica l checks on the post-operat ive ch i l d . A l l study parents acknowledged some degree o f "over-protect iveness" dur ing the in i t ia l post-operat ive per iod . C a r l s o n , S imacek , H e n r y , and M a r t i n s o n (1985) i n their descr ip t ion o f a home care p rog ram for termina l ly i l l ch i ld ren state that home care o f an i l l c h i l d is stressful and "potent ia l sources o f stress inc lude uncertainty about what to expect and about h o w to care for the c h i l d and the assumpt ion o f f u l l respons ib i l i ty fo r the c h i l d ' s comfor t " (Car l son et a l . , 1983, p. 115). Parents w h o par t ic ipated i n the current study a lso expressed uncertainty about car ing for their c h i l d dur ing the post-operat ive day care surgery per iod . In assuming the responsib i l i ty fo r the care o f their ch i l d dur ing this phase o f their exper ience, most parents carr ied out post-operat ive instruct ions "to the letter". F o r examp le , M : I w o u l d n ' t let h i m [four year old] w a l k anywhere yesterday [day o f surgery] wi thout ho ld ing m y hand because he [doctor] to ld me he [chi ld] c o u l d get d i z z y and fa l l , and I d idn ' t want to take a chance. 100 M : A l l he [chi ld] d i d was c ry for someth ing to eat and someth ing to dr ink a l l the w a y home [ f rom the hospital]. . . they [day care staff] to ld m e not to feed h i m fo r four hours y o u see. S o I d idn ' t . I gave i n 15 minutes before the four hours and let h i m have a coup le o f crackers. These mothers are descr ib ing how v ig i lan t they were i n their approach to imp lement ing post-operat ive instruct ions for their c h i l d ' s care. T h i s mother a lso indicates her l im i ted know ledge and exper ience w i th post-operat ive care w h i c h does not a l l ow her to interpret the post-operat ive instruct ions w i th any degree o f f l ex ib i l i t y . Parents reported that i n the week f o l l o w i n g the day care surgery they not iced behav ior changes i n their post-operat ive ch i ld ren . These behav ior changes often in f luenced usual patterns o f act iv i ty and as a result , contr ibuted to the stresses o f this phase o f the exper ience. F o r example : M : S h e ' s rea l ly good around home, but when we ' r e out some p lace shopping o r someth ing , she w o n ' t wa lk . She wants m e to carry her...she just seems rea l ly unsure o f herself. M : H e hangs on more to me , you k n o w . H e c r ied so hard when I left, and even on M o n d a y and Tuesday he wou ldn ' t let go o f me , and c r ied and c r ied . B e h a v i o r changes i n v o l v i n g fear o f separat ion f r o m mother requi red extra t ime, energy, and p lann ing o n the part o f mothers dur ing the f irst week at home. Other parents descr ibed increased aggressiveness and i r r i tabi l i ty that was not character ist ic o f their c h i l d . F o r examp le : M : H e ' d try to get away w i th more things. 101 M : H e was just miserab le to get a long wi th. . .you k n o w what he acted l i ke? L i k e he was over- t i red. B u t he had had enough sleep. Parents were of ten p u z z l e d by the changes, " H e was just terr ible.. .and I don ' t k n o w w h y ! " Parents coped w i th their ch i l d ren 's behav ior changes by increas ing parental attention, permiss iveness, d i sc ip l i ne , and/or af fect ion. These f ind ings that indicate a change i n the ch i l d ren ' s behav ior f o l l o w i n g day care surgery are consistent w i th the f ind ings o f other authors w h o stated that behav ior changes such as increased separat ion anxiety , increased sleep anxiety , and increased aggress ion f o l l o w i n g surgery and a general anesthetic are c o m m o n ( B r o w n , 1979; Hanna l l ah & Rosa les , 1983; S i p o w i c z & V e r n o n , 1965; V e r n o n et a l . , 1966). O n e o f the most prominent d imens ions o f the post -hospi ta l izat ion per iod , ident i f ied by a l l the study parents as cont r ibut ing to their interpretations o f this phase as stressful , were changes in f am i l y rout ines and act iv i t ies. These changes affected a l l f a m i l y members not just the post-operat ive ch i l d . The changes were dictated by the c h i l d ' s treatment, the c h i l d ' s react ion to treatment, and/or by the parents ' attempts to manage the exper ience w i th in the context o f their everyday l i ves . M o s t o f the changes were concrete i n nature and related to the post-operat ive c h i l d ' s act iv i t ies such as bath ing and s leeping. F a m i l y members were affected by changes i n the f requency and nature o f f a m i l y out ings and act iv i t ies. Parenta l management o f changes i n f am i l y act iv i t ies and rout ines often l ed to creat ive and f lex ib le cop ing strategies on their part w h i c h served to a l l ow them to fu l f i l their responsib i l i t ies and m i n i m i z e ro le strain. Ba th i ng the post-operat ive c h i l d was a major change c o m m o n to a l l fami l ies i n the study. T h e regular bath time rout ine for a lmost a l l the ch i ld ren was changed to 102 sponge bath ing at least fo r the f irst few post-operat ive days. T h i s was a s igni f icant change i n an act iv i ty that was cons idered to be a "spec ia l t ime" for these ch i ld ren . M : H e just loves his bath, you know. . .and he ' s not a l l owed to. A n d he doesn ' t understand that now. N o t yet, I don ' t think...he c l i m b e d i n the bathtub a l l day [post-operat ively] , i n and out, no water i n there. T h i s mother is descr ib ing h o w the age o f her c h i l d makes it d i f f i cu l t to exp la in the change related to bath ing rout ine, and h o w this in f luenced her c h i l d ' s behavior . She is a lso express ing her frustrat ion w i th this change in rout ine. One parent c lear ly acknowledged the inconven ience o f the change i n the ch i l d ' s bath ing rout ine: M : I 've a lways k i n d o f en joyed bathing l i t t le k i ds i n the tub. S o , y o u k n o w , fo r m e it was k i n d o f the inconven ience o f hav ing to start sponge bath ing over again . S o m e o f the bath ing changes were for obv ious reasons such as casts o r bandages. Other parents based their rat ionale on their interpretat ion o f the c h i l d ' s cond i t i on , and the r isks they perce ived to be associated w i th tub bath ing. F o r example : M : I d i dn ' t g ive h i m a bath for a f ew days because I was wor r ied about water gett ing i n h is eye and gett ing in fected and stuff. I just gave h i m one o f those sponge baths 'cause he tends to splash a lot. In order to decrease the stresses associated w i th this s ign i f icant change in rout ine , alternate fo rms o f act iv i ty were imp lemented i n many fami l ies to take the p lace o f bath t ime. T h e f o l l o w i n g quotat ions i l lustrate the impact o f this change in f am i l y rout ine as w e l l as the invo lvement o f both parents i n imp lement ing alternative act ivi t ies. 103 M : W e ' v e dec ided that we ' r e go ing to have some sort o f entertainment after d inner [laugh] to take the p lace o f bath t ime because that 's the t ime she rea l ly enjoys. S o , we ' r e p lann ing o n tak ing lots o f l o n g wa l ks outs ide to try to occupy the evenings a l i t t le bit d i f ferent ly than we have been. M : W h e n he cou ldn ' t have his bath for a week, boy , we went through times where , y o u k n o w , l i ke it was after d inner for instance, he a lways has his bath, and m y husband w o u l d go have his shower, and [chi ld] w o u l d hear the water and go try runn ing after it, and go into the bathroom and have his bath. R : N o t be ing able to have the bath t ime was rea l ly qui te a change in his rout ine. W h a t k inds o f things d i d y o u do to make that t ime easier? M : I rea l ly don ' t k n o w . W e p layed a lot w i th h i m , and let h i m run around more than w e usua l ly do , kept h i m occup ied , and I gave h i m sponge baths, but he hated sponge baths. B u t somet imes he d idn ' t m i n d it, there was water, so I let h i m p lay w i th the d ish . It went a l l ove r the f loor , but at least he was happy, you k n o w . These parents are say ing that they had to make modi f i ca t ions to their rout ines in order to please their c h i l d and meet deve lopmenta l needs. T h e increase i n parental permiss iveness ev ident i n the above quotat ion was exempla ry o f attempts to m i n i m i z e parental ro le strain. That is , wh i l e restr ict ing some act iv i t ies, parents took advantage o f any other ava i lab le opportuni t ies to keep their ch i ld ren happy and content. T h e ch i l d ren ' s s leeping and napp ing rout ines were a lso changed. These changes af fected the parents ' ab i l i ty to p lan and imp lement their o w n day- to-day act iv i t ies. 104 M : Tuesday [the s ixth post-operat ive day] was the f irst day he settled d o w n fo r both naps. R : S o that w o u l d rea l ly change your act iv i ty i n the day. M : U h huh , fo r a more exhaust ing day [ laughs]. Bu t , yeah , it d i d make it harder to get th ings done and everyth ing. A n d y o u can ' t predict when he ' s go ing to go to s leep, or i f he ' s go ing to go to s leep, 'cause usual ly I can count on an hour i n the morn ing and an hour i n the afternoon type th ing, and usua l ly around the same t ime. A s this mother expressed, changes i n f am i l y act iv i t ies and rout ines as a result o f the c h i l d ' s day care surgery were , at times, "exhaust ing" . S u c h changes demanded more energy and f lex ib i l i t y on the part o f the parents and are exempla ry o f the stresses parents fel t dur ing this phase o f their exper ience. Ano the r examp le o f change i n f am i l y rout ines was a decrease in the f requency o f act iv i t ies outs ide the home such as shopp ing and v is i t ing . T h i s cur ta i lment o f outs ide act iv i t ies occur red dur ing both the pre- and post -hospi ta l izat ion phases o f the exper ience and lasted f r o m a few days up to several weeks . F o r example : M : W e sort o f stayed in on the weekend , a l though I went out, I left h i m [chi ld] w i th m y m o m , and I went out and tr ied to do some shopping. D i d n ' t get m u c h done but, other than that I d idn ' t take h i m out in to any o f the stores o r anyth ing 'cause I was st i l l sort o f wo r r i ed about h i m . S o , by M o n d a y both o f us were back to no rma l . T h i s quotat ion i l lustrates the car ry -over o f wor ry and anxiety to the post -hospi ta l izat ion phase. Parenta l adjustments i n usual rout ines, such as not tak ing the c h i l d shopp ing , ref lects the respons ib i l i ty theme for do ing what was interpreted to be i n the best interest 105 o f the c h i l d . M : I t 's k i n d o f cur ta i led our act iv i t ies a l i t t le bit...I don ' t take her shopping as m u c h . I don ' t th ink w e ' v e been out as m u c h , I don ' t k n o w what the reason is . E v e n though the mother quoted above was unable to art iculate her rat ionale for adjust ing f a m i l y act iv i t ies, she nonetheless changed her da i l y rout ine, s im i la r to other parents i n the study w h o ident i f ied that such behavior was "better" fo r the post-operat ive ch i l d . Parents ident i f ied that s ib l ings o f the c h i l d w h o underwent the surg ica l procedure were also affected by the changes i n f am i l y act iv i t ies and rout ines. F o r example , the change in bath ing rout ine fo r the post-operat ive c h i l d a lso affected the bath ing rout ine fo r s ib l ings : M : W e don ' t bath [sibl ing] i n the even ing any more w h e n [child] is around. W e wai t ' t i l she [chi ld] goes to bed and then bath [s ib l ing] . I guess i t ' s pretty m u c h the same except that we have to have act iv i t ies to f i l l that spot. No te h o w the change i n rout ine for the post-operat ive c h i l d af fected the rout ines o f the s ib l ing . S u c h changes requi red more creat iv i ty on the part o f the parents to come up w i t h "ac t iv i t ies" to f i l l the t ime usual ly used by bath ing. S o m e act iv i ty changes were spec i f i ca l l y related to seasonal opportuni t ies. F o r examp le , i n four fami l i es , summer act iv i t ies were cur ta i led fo r a l l the ch i ld ren , not just the post-operat ive ch i l d . M : I was go ing to put them [ch i ld & s ib l ing] both i n s w i m m i n g lessons, but n o w , I guess I w o n ' t put either one o f them i n s w i m m i n g lessons. 106 T h i s mother is c i t ing another examp le o f changes i n rout ine and act iv i t ies requi red by the post-operat ive c h i l d that a lso s ign i f icant ly af fected the act iv i t ies o f the s ib l ing . Th i s dec i s ion was made by the mother because she felt it w o u l d be "too ha rd " on the post-operat ive c h i l d i f her s ib l i ng was i n s w i m m i n g lessons and she was not. Other changes descr ibed by parents that occur red w i th in the f a m i l y uni t dur ing the post -hospi ta l izat ion phase inc luded protect ive behav ior patterns on the part o f o lder s ib l ings. M : I th ink he ' s [sibl ing] been a l i t t le more, u m m , concerned about her than he usua l ly i s , i n a w a y , not quite as qu i ck to push her over , w h i c h is n ice . M : I guess he [sibl ing] just accepted it but, u m m , actual ly he seems quite protect ive o f her r ight now . H e k n o w s there is someth ing w r o n g w i th her, so he ' s been pretty good about it. B u t I th ink it w i l l bother h i m eventual ly , because she 's go ing to take more t ime. In add i t ion to commen t i ng on the s ib l i ng ' s protect ive behaviors , this latter parent is also express ing concern that the extra t ime requi red to care for the post-operat ive c h i l d m igh t be perce ived by the s ib l i ng in a negat ive fash ion. T h e theme o f soc ia l support was prominent dur ing the post-hospi ta l izat ion phase o f the exper ience. Parents perce ived their p r imary sources o f support to be fam i l y members and f r iends. A g a i n , k n o w i n g that there were others w h o cared about the parents ' s i tuat ion and exper ience and hav ing someone ava i lab le to l is ten were important components o f support. F o r example : 107 It sounds l i ke y o u ' v e had a lot o f f am i l y support and input f r o m your f r iends. O h yeah, a lo t o f support f r o m m y fam i l y . E s p e c i a l l y m y f am i l y and [husband] 's f am i l y , y o u k n o w , both our fami l ies . W e ' v e had a lot o f support, and f r iends, a lot o f f r iends, too. A l w a y s te l l ing m e not to wor ry about it, and every th ing l i ke that. A n d i f I need help just g ive them a ca l l . Y o u k n o w , things l i ke that. I t 's n ice to k n o w that everyone cares. Y o u understand fam i l y a lways cares but f r iends, y o u k n o w , i t ' s n ice to k n o w that y o u have f r iends that care. M : O h yeah, it [ fr iends ca l l ing] g ives you this great fee l ing , somebody else is concerned and cares about y o u , that 's the r ight w o r d , cares about you . A s is consistent w i th the l i terature (Hel ler , 1979), helpers were rated h igh l y when they engaged i n act iv i t ies i n v o l v i n g af fect ive support (eg. comfor t ing) . R : W h o was there, w h o d i d y o u re ly on to help y o u w o r k through those feel ings when you were so upset on F r i d a y [due to unsuccessfu l surg ica l procedure]? M : O h , just f r iends, because m y husband had other things on his m i n d , too...he was upset...so I cou ldn ' t rea l ly talk to him....I to ld the g i r ls at w o r k and then I felt better. T h i s mother , l i ke others i n the study, sought support f r o m f r iends and col leagues as opposed to her husband. l i n g e r and P o w e l l (1980) i n their descr ipt ions o f the ro le o f soc ia l networks i n support ing fami l ies under stress, stated that support m a y be situation spec i f i c that i s , "co-workers may support each other exc lus i ve l y at w o r k " (p. 570) . R : M : 108 T h i s was the case for the mother quoted above. A s was p rev ious ly stated, f i ve fami l ies i n this study c lear ly ident i f ied when the post -hospi ta l izat ion o r recovery phase o f their exper ience had ended. These parents expressed sat isfact ion w i th their exper ience and v i e w e d it as " f a i t - accomp l i " w i th in approx imate ly ten days o f the surgery. Parents of ten descr ibed a sense o f re l ie f f r o m the stressful fee l ings o f wor ry and anxiety when their exper ience had ended. M : O h yeah, it is a n ice fee l ing , I 'm g lad i t ' s over w i t h , done w i th , f in ished, no th ing to wor ry about again. M : [ I 'm g lad i t 's] rea l ly beh ind m e [the surgery exper ience] . I th ink on F r i d a y [fourth post-operat ive day ] , y o u k n o w , he was runn ing around and screaming, and c l i m b i n g l i ke noth ing else happened. I thought, " W e l l , i t rea l ly doesn ' t hurt h i m or h e ' d be c ry ing more , or do ing someth ing e lse." S o I thought, "Tha t ' s i t - i t ' s gone." In addi t ion to express ing her feel ings o f re l ie f , this mother is say ing that it was her c h i l d ' s response to the surgery that a l l owed her to conc lude that the exper ience for her was "ove r " . Other parents a lso commented o n the post-operat ive c h i l d ' s l eve l o f act iv i ty as an ind icator that the exper ience was over. Other parents w h o part ic ipated i n the study were not as def in i te i n conc lud ing that their exper ience was "over " . F o r two study parents, the changed phys i ca l appearance o f their c h i l d i n the post-hospi ta l izat ion pe r iod contr ibuted to the stressful nature o f their exper ience and led to cont inued feel ings o f anx iety and wor ry regarding poss ib le fa i lure o f the ant ic ipated outcome for the surgery. F o r examp le : 109 M : T h e n I saw her this morn ing and her eye was a l l red . A n d then I again had m y doubts, gee, a m I do ing the r ight th ing? It just l o o k e d aw fu l . F o r this mother , the phys i ca l appearance o f her daughter was a factor determin ing her sat is fact ion w i t h the exper ience and the t im ing o f her sense o f comp le t ion . Three parents i n the study v i e w e d the surgeon's op in ion about the c h i l d ' s post-operat ive progress as a key point i n be ing able to fee l sat isf ied w i th their exper ience and be ing able to conc lude that this f i na l phase was over . D u r i n g the wa i t i ng per iod pr io r to obta in ing the surgeon's op in ion , parental fee l ings o f anxiety, fear, and wor ry that had typ i f ied the pre-operat ive phase cont inued to be present. R : W o u l d y o u say at this point that things are back to norma l? M : Y e a h , I guess so, yeah. R : Y o u sound a l i t t le hesitant. M : W e l l , I guess the on ly th ing is I th ink i n m y o w n m i n d , things w i l l rea l ly be back to norma l when he goes back to another v is i t to the eye doctor and she says every th ing is O . K . T h e n I guess I ' l l fee l that things are back to no rma l when I have some reassurance that, y o u k n o w , the operat ion has rea l ly done the tr ick. R : S o that w i l l a l lay some o f the things y o u are st i l l wor r ied about i n the back o f your m i n d there. S o , y o u are st i l l wonder ing , has this who le thing...? M : W e l l , i t ' s just that, yeah. It 's very , ve ry encourag ing for me that he 's w a l k i n g that, you k n o w , the other m o m s said how straight h is head l ooked . Bu t , I s t i l l , you k n o w , I guess I just want to hear it f r om a doctor , "It 's great, it rea l ly w o r k e d . " S o , fo r me , no , th ings w o n ' t be 110 back to no rma l comple te ly ' t i l I see her [pediatric surgeon]. T h i s mother is emphas iz ing the impor tance o f the ro le o f the phys i c ian in p rov id i ng her w i t h in fo rmat ion and reassurance regard ing the results o f her c h i l d ' s surgery. F o r her, it was not unt i l she rece ived such in format ion and reassurance that her feel ings o f anx iety and wor ry were re l ieved and she was able to conc lude that this f i na l phase o f her exper ience was "over " . A l t h o u g h the post -hospi ta l izat ion phase o f the parents ' exper ience was typ i f ied by changes in behav ior patterns and fam i l y rout ines as w e l l as feel ings o f wo r ry and anxiety , parents d i d report that, i n general , this phase o f the exper ience was more pos i t i ve than they had ant ic ipated. In fact, the major i ty o f the parents were pleasant ly surpr ised by their c h i l d ' s react ion to the surg ica l event. F o r example : M : I rea l ly expected more c r y i ng and I was go ing to carry h i m around a l l day , and he w o u l d n ' t want to w a l k , y o u k n o w . A n d hav ing p rob lems l i ke that, but he surpr ised me [ laughs]. I t 's a good fee l ing , y o u k n o w . M : I w o u l d n ' t have ant ic ipated that she w o u l d do that w e l l . I mean , people to ld me she w o u l d , but I cou ldn ' t quite p icture it. M : B u t afterwards, he [chi ld] was fine. It wasn ' t near ly as bad as I thought it was go ing to be. It is ev ident f r o m the above quotat ions that parents had imag ined expectat ions regarding their c h i l d ' s behav iora l react ions to this event. T h e parents ' l ack o f p rev ious exper ience contr ibuted to their ant ic ipat ion o f a more negat ive post-operat ive course. O n e mother stated, "It [day care surgery] wou ldn ' t bother me as m u c h the second I l l t ime...I w o u l d understand it more , y o u k n o w . " T h i s sect ion has d iscussed the parents ' exper iences dur ing the post -hospi ta l izat ion phase o f their c h i l d ' s day care surgery. D imens ions o f this phase that contr ibuted to parents ' interpretat ion o f the event as stressful i nc luded new responsib i l i t ies for the care and superv is ion o f the post-operat ive ch i l d , changes i n the c h i l d ' s behav ior and patterns o f act iv i ty , and changes i n f am i l y act iv i t ies and rout ines. A lack o f in fo rmat ion regard ing these d imens ions o f the post -hospi ta l izat ion phase o f the exper ience was also ident i f ied by the parents as contr ibut ing to the stressful nature o f this phase o f the exper ience. A l t h o u g h parents had ant ic ipated a rather negat ive post-operat ive course, i n genera l , they were p leased w i th their c h i l d ' s response to the surg ica l procedure. Parents imp lemented several cop ing strategies to manage this phase o f their exper ience. S u m m a r y T h i s chapter has presented the theory generated i n answer to the research quest ion: what is the parents ' exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery? The accounts presented i n this chapter represent a synthesis o f this s tudy 's data in to a descr ip t ion that prov ides a basis for understanding h o w part ic ipant parents interpreted and assigned mean ing to the day care surgery exper ience and coped w i th it in their everyday l i ves . A s can be seen f r o m the presentat ion o f the parents ' accounts, the exper ience of hav ing a toddler o r preschooler at home f o l l o w i n g day care surgery was on ly one aspect o f the parents ' m u c h broader exper ience o f hav ing their son or daughter undergo a day care surg ica l procedure. T h e t ime span o f this broader exper ience extended far beyond the f e w short hours the parents actual ly spent i n the day care unit. T h e major f ind ings o f this study revealed that the n ine part ic ipant parents interpreted their 112 exper ience as a stressful one and that they and their fami l ies were s ign i f icant ly affected by their c h i l d ' s day care surgery. T h e chapter began w i th an in t roduct ion to the s tudy 's analyt ic f ramework . Nex t , the concepts and themes w h i c h fo rmed the theory deve loped f r o m the parents ' accounts were presented and d iscussed in re lat ion to theory ex is t ing i n the l i terature. There was a deta i led descr ip t ion o f the part ic ipant fami l ies and f ina l l y a presentat ion o f the parents ' accounts o f their exper iences accord ing to the structure o f the analyt ic f ramework . T h e fou r major themes w h i c h character ized the parents ' exper iences, and fo rmed the structure o f the s tudy 's analyt ic f ramework , represented d imens ions that either contr ibuted to the nature o f the stressful exper ience o r enhanced parents ' ab i l i ty to manage the stresses. T h e themes were: parental respons ib i l i t y , ro le strain, cop ing , and soc ia l support. Re la ted l i terature was used throughout the chapter to d iscuss the spec i f ic f ind ings o f this study and of fer ev idence to ei ther support or contrast them. T h e theory generated f r om the parents ' accounts is based on the f i nd ing that parents that it is stressful fo r them to have a c h i l d undergo day care surgery—more stressful than health profess ionals may perce ive or understand. O n e mother, w h o was e m p l o y e d as a technic ian in an acute care hosp i ta l , compared her perspect ive as both a parent and a health care profess ional wh i l e undergo ing the exper ience o f her c h i l d ' s day care surgery. T h i s par t icu lar mother stated that as a health care pro fess iona l she knew " i t ' s so rout ine.. . i t 's noth ing, i t ' s no b i g d e a l " , and yet when her o w n daughter had to undergo a surg ica l procedure, she descr ibed hersel f as just another "upset parent". Th i s mother 's personal exper ience h igh l ights the stressful nature o f this exper ience as w e l l as the d iscrepancies between the explanatory mode ls he ld by parents and health 113 profess ionals for the same health care si tuat ion. Such di f ferences of ten result i n misunderstandings and dissat is fact ion w i th care ( K l e i n m a n et a l . , 1978). Three-quarters o f the parents w h o part ic ipated i n this study descr ibed, i n retrospect, that the overa l l pediatr ic day care surgery exper ience was m u c h more pos i t i ve than they had thought it w o u l d be. A s one parent stated, "I guess overa l l the who le th ing was not as bad as I had ant ic ipated" i n essence h igh l igh t ing that the ant ic ipat ion o f it was worse than the actual event itself. Chapter 5 offers further d iscuss ion o f the s tudy 's f ind ings , summar izes the study, d raws conc lus ions , and ident i f ies nurs ing imp l i ca t ions for pract ice, educat ion, and research. 114 C H A P T E R 5 Summary, Conclusions, and Implications for Nursing T h i s chapter begins w i th a summary o f the study w h i c h answered the research quest ion: what is the parents ' exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery? F o l l o w i n g this, the conc lus ions , imp l i ca t ions , and recommendat ions fo r nurs ing pract ice, educat ion, and research are presented. A l t h o u g h the core f ind ings o f this study are r i c h i n both the general and spec i f i c imp l i ca t ions and di rect ions they of fer for nurs ing pract ice, on l y the major conc lus ions and imp l i ca t ions for nurs ing are br ie f ly summar i zed i n this chapter. Summary o f the Study T h i s study has p rov ided an answer to the quest ion: W h a t is the parents ' exper ience o f hav ing a toddler or preschooler at home f o l l o w i n g day care surgery? U s i n g a phenomeno log i ca l method, the study exp lo red in-depth the parents ' b road perspect ive and personal interpretations o f their c h i l d ' s f irst time day care surgery exper ience w i th in the context o f everyday f am i l y l i fe . A l t h o u g h there is m u c h documentat ion that pediatr ic day care surgery offers both psycho -soc ia l benefi ts fo r the f am i l y unit as w e l l as f inanc ia l sav ings for the Canad ian Hea l th Care Sys tem ( A t w e l l et a l . , 1973; C l o u d et a l . , 1972; Johnson, 1983; L a w r i e , 1964; Shah , 1980) there is a lack o f emp i r i ca l know ledge addressing this top ic f r o m the parents ' perspect ive. Because parents are the p r imary caretakers fo r pre- and post-treatment ch i ld ren , i t was argued by the researcher that it was mutua l l y benef ic ia l to t ru ly understand the parents ' percept ions and personal 115 interpretat ions o f the day care surgery exper ience w i th in the context o f their every day l i ves . Parents o f toddlers and preschoolers were selected for this study because it is k n o w n that parents are anx ious and concerned about their ch i l d ren 's i l lnesses and hospi ta l izat ions, and also because ch i ld ren i n these age groups are par t icu lar ly vu lnerab le to the real and imag ined threats o f hospi ta l izat ion and surgery. T h e number o f ch i ld ren and fami l ies rece iv ing treatment i n med i ca l and surg ica l D a y Care Un i t s is g row ing steadi ly every year (Shah, 1980; B r i t i sh C o l u m b i a ' s C h i l d r e n s ' Hosp i t a l , 1987). Nurses w o r k i n g i n both hospi ta l and commun i t y settings have opportuni t ies to in f luence the exper iences o f parents whose young ch i ld ren undergo day care surgery, both before and after the event. T h e conceptua l f ramework for the study was based upon the w o r k o f K l e i n m a n and h is co l legues (1978). K l e i n m a n ' s m o d e l adheres to two fundamenta l not ions: the f i rst i s a d is t inct ion between the concepts o f "d isease" , " i l l ness " and "s i ckness " , and the second is a conceptua l izat ion o f a health care system w i t h three di f ferent but interact ing soc ia l "arenas": popular , p ro fess iona l , and fo lk . These three arenas serve to soc ia l l y leg i t im ize s ickness and health care for the ind iv idua ls they represent. W i t h i n the context o f this f ramework , diseases are treated and i l lnesses are exper ienced. S ickness is def ined as a comp lex human phenomenon encompass ing both disease and i l lness. Ind iv iduals represented by each o f the three soc ia l arenas use dif ferent explanatory mode ls to exp la in and def ine par t icu lar s ickness episodes. K l e i n m a n (1978) directs health care professionals to e l ic i t the c l ien ts ' exp lanatory mode ls i n order to enhance health p ro fess iona ls ' understanding o f i l lness as a persona l , soc ia l , and cul tura l exper ience and, i n do ing so, faci l i tate the 116 p rov i s i on o f nurs ing care that is mutua l ly sat is fy ing. T h e parents, represented by the "popu la r " arena o f K l e i n m a n ' s Hea l th Care Sys tem, have explanatory mode ls for the post day care surgery exper ience that have been shaped b y their know ledge , be l ie fs , va lues , cul ture, and past exper iences. T h e parents ' explanatory mode ls can on l y be fu l l y understood by e l i c i t ing their percept ions and explanat ions about their exper ience. T h e invest igator selected the phenomeno log ica l method o f qual i tat ive research to gu ide the invest igat ion because it emphasizes l i fe i n the everyday w o r l d as it is understood and interpreted by one l i v i n g through the si tuat ion ( G i o r g i , 1975a). Phenomeno logy a l l ows the real i ty o f the par t ic ipant 's exper ience to be fu l l y expressed and, through a process o f exhaust ive descr ip t ion, the researcher can deve lop an understanding o f the phenomenon under study (Ray , 1985; L y n c h - S a u e r , 1985). U s i n g this method, the author was able to learn h o w the parents interpreted and gave mean ing to their exper ience o f hav ing their young c h i l d undergo a surg ica l day care surgery procedure. In order to substantiate the need for research on the spec i f i c top ic o f parents ' exper ience w i t h their young ch i ld rens ' day care surgery, and to establ ish a background o f in format ion about what was general ly k n o w n about fami l ies w i th ch i ld ren w h o undergo hospi ta l izat ion for a short- term i l lness , a body o f related l i terature was rev iewed . T h e pauc i ty o f l i terature about parents ' exper ience w i th pediat r ic day care surgery lead to a rev iew o f several subject areas exp lo r i ng i n general the impact o f pediatr ic hospi ta l izat ion and surgery on ch i ld ren and their parents. 117 T h e l i terature rev iew documented that: parental ro les and responsib i l i t ies change w h e n a c h i l d becomes i l l o r requires hospi ta l iza t ion even on a short term bas is ; maternal anx iety affects the c h i l d ' s l eve l o f anx iety du r ing hospi ta l izat ion; and the short term hospi ta l izat ion o f toddlers and preschoolers results i n post -hospi ta l izat ion behav ior changes. It was apparent that the current pub l i shed l i terature d i d not p rov ide an in-depth understanding o f the parents ' o w n exper ience i n the post -hospi ta l izat ion per iod f o l l o w i n g their c h i l d ' s day care surgery. T h e data were co l lec ted by means o f 16 in-depth in terv iews w i th n ine parents o f post-operat ive toddlers and preschoolers w h o underwent a var ie ty o f pediat r ic day care surgery procedures. T h e in terv iews were audiotaped and then t ranscr ibed verba t im. E igh t f i rst in terv iews and eight second in terv iews were c o n -ducted. T h e in terv iews were semi-structured and an in terv iew gu ide (Append i x F , p. 149) was used dur ing the f irst in terv iews to help e l ic i t the parents ' descr ipt ions o f their exper ience. T h e content o f the second in terv iews was d rawn f r o m analys is o f the mater ia l d iscussed dur ing the f irst in terv iews and f r o m in terv iews w i th other parents. D u r i n g each o f the in terv iews, the researcher exp lo red and c la r i f ied the mean ing the parents ass igned to their c h i l d ' s day care surgery exper ience. T h e process o f ana lyz ing data began w i th the onset o f data co l lec t ion and cont inued concurrent ly throughout this phase o f the research process. F o l l o w i n g comp le t i on o f a l l o f the in terv iews, data analys is cont inued unt i l the parents ' accounts were synthesized into a descr ipt ive f ramework o f their exper ience w i th a toddler or p reschoo le r ' s day care surgery. In the presentat ion o f the parents ' accounts, ve rba t im quotat ions f r o m parent in terv iews were used extens ive ly for i l lust rat ive purposes. 118 T h e s tudy 's analyt ic f ramework represented the researcher 's conceptua l izat ion and interpretat ion o f the s imi lar i t ies and shared aspects o f the parent 's accounts o f their exper iences as revealed by in-depth analys is . T h e s tudy 's analyt ic f ramework was based on a core concept o f stress and was organ ized accord ing to a ch rono log i ca l structure cons is t ing o f three dist inct phases descr ibed b y the parents. These three ch rono log i ca l phases were named the pre-hospi ta l izat ion or preparatory phase, the hospi ta l iza t ion or operat ive phase, and the post -hospi ta l izat ion or readjustment phase. The major themes ident i f ied i n data analys is represented d imens ions o f the parents ' exper iences that contr ibuted to their interpretat ion o f the event as stressful . A d d i t i o n a l themes f r om the parents ' accounts a lso revea led aspects o f their exper ience that enhanced or inh ib i ted their ab i l i ty to manage w i th in the context o f their everyday l ives . T h e concepts and themes w h i c h fo rmed this s tudy 's analyt ic f r amework were presented and d iscussed in Chapter 4 i n re lat ion to ex is t ing theory i n the l i terature. A c c o r d i n g to the study part ic ipants, this "f i rst t ime" exper ience was perce ived as a stressful event i n their everyday l ives . Desp i te hav ing rece ived assurances f r o m health care profess ionals that pediatr ic day care surgery was not on l y safe, but a lso cons idered m ino r and rout ine, the parents i n this study were unable to v i e w it as such for their ch i l d . T h e events, occurrences, and dec is ions inherent i n the exper ience in tens i f ied parental fee l ings o f respons ib i l i ty fo r their c h i l d ' s present and future we l l - be ing . Throughout the course o f the exper ience, new responsib i l i t ies such as mon i to r ing the c h i l d ' s post-operat ive course and assessing the need fo r ana lges ia , were added to the usual tasks o f parent ing a toddler o r preschooler . T h e add i t ion o f new responsib i l i t ies resul ted in the parents ' repor t ing feel ings o f ro le 119 strain at par t icu lar points o f the exper ience, such as w h e n they were requi red to w i t hho ld f ood and f lu ids f r o m the pre-operat ive ch i l d . A s parents coped w i th the exper ience o f their c h i l d ' s day care surgery, they made concrete changes to their establ ished patterns and act iv i t ies o f da i l y l i v i n g . F o r examp le , i n a l l o f the part ic ipant fami l i es the operat ive c h i l d ' s bath ing rout ine was changed f r o m a tub bath to a sponge bath for at least several days post-operat ively. Throughout the three phases o f their exper ience, the parents ' thoughts, fee l ings, behav iors , and react ions changed and var ied i n intensi ty and parents expressed fee l ings o f fear, wor ry , and anxiety. Parents used a var ie ty o f c o p i n g strategies, i n c l ud ing soc ia l support, i n order to manage the stresses o f their exper ience. Ret rospect ive ly , the major i ty o f the study parents ref lected on their exper ience w i t h their young c h i l d ' s day care surgery as be ing more pos i t ive than they had ant ic ipated. F o r d iscuss ion purposes, the f ind ings o f this study were compared w i th the f ind ings o f numerous other studies. A l t h o u g h there have not been any other studies exp lo r i ng this exper ience f r o m the parents ' perspect ive, the l i terature rev iewed does of fer support fo r this wr i te r ' s f ind ings and v i ce versa. Conc lus ions T h e ma jo r conc lus ions d rawn f r o m the f ind ings o f this study are: 1. Parents o f toddlers and preschoolers v i e w the day care surgery exper ience as one w h i c h occurs over a span o f t ime m u c h greater than the few hours actual ly spent i n the hospi ta l sett ing. 2. Parents interpret and assign mean ing to their exper ience on l y w i th in the context o f a l l three phases (pre-hospi ta l izat ion, hospi ta l izat ion, and post-120 hospi ta l izat ion) o f their exper ience. 3. Parents o f toddlers and preschoolers interpret this f irst time exper ience as stressful and ident i fy par t icu lar d imens ions o f the exper ience that contr ibute to their interpretat ions. 4 . Parents o f toddlers and preschoolers v i e w this exper ience w i th in the broad context o f everyday f am i l y l i f e and descr ibe s igni f icant changes that take p lace i n f am i l y l i fe as a result o f the event. 5. There are spec i f ic appl icat ions o f the theory generated f r o m these parents ' accounts w h i c h c o u l d be app l ied to improve the qua l i ty o f nurs ing care to pediatr ic day care surgery fami l ies . A select ion o f these f o l l ow : Impl icat ions for N u r s i n g Prac t ice A l t h o u g h the f ind ings and conc lus ions o f this study suggest imp l i ca t ions for nurses i n v o l v e d i n the assessment, p lann ing , implementa t ion , and evaluat ion o f nurs ing care for parents whose young ch i ld ren undergo day care surgery, it i s " important to po in t out that the appl icat ion o f research to pract ice is t yp ica l l y not a st ra ight forward p rocess" ( K n a f l , C a v a l l a r i , & D i x o n , 1988, p. 297) . T h e nurses w h o p rov ide care fo r pediatr ic day care surgery fami l ies may be 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 Care U n i t s , commun i t y health care agencies, or doc tors ' o f f i ces , and m a y c o m e into contact w i th parents at di f ferent phases o f this exper ience. T h e conc lus ions d rawn f r o m this study ref lect the f i nd ing that parents have their o w n un ique explanat ions o f their i l lness exper ience w h i c h are constructed f r o m the personal meanings o f the exper ience he ld w i th in the i nd i v i dua l s ' personal , soc ia l , and cu l tu ra l contexts. T h i s is consistent w i th 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 profess ionals h o l d explanatory mode ls that d i f fer f r o m those he ld b y ind iv idua ls in the popu lar culture system or, s imp ly put, these parents ' v i e w s o f the day care surgery exper ience d i f fer f r o m those he ld by health profess ionals . D isc repanc ies between the explanatory mode ls u t i l i zed by parents and health profess ionals often result i n misunderstandings and dissat is fact ion w i th care. It is therefore i m p l i e d that i n order to p rov ide care that is mutua l l y sat is fy ing and support ive to parents dur ing the f irst t ime exper ience o f their toddler or p reschoo le rs ' day care surgery, nurses must e l ic i t parents ' perspect ives and acknow ledge the parents ' interpretat ion o f the event. A s a result o f exp lora t ion o f the parents ' explanatory mode ls for their day care surgery exper ience, the f ind ings o f this study have emphas ized the impor tance o f ant ic ipat ing parental needs, concerns , and responses in order to prov ide empathic parent care and m i n i m i z e the stresses parents associate w i t h this exper ience. In add i t ion to exp lo r ing the parents ' explanatory mode ls , nurses also need to examine their o w n explanatory mode ls , va lues, and attitudes about parents ' exper ience o f their c h i l d ' s day care surgery. B y do ing this, nurses w i l l ensure that they do not assume to k n o w what parents need and understand about the exper ience. Nurses w i l l beg in to establ ish the "g round o f c o m m o n unders tanding" ( K l e i n m a n et a l . , 1978) between themselves and the patient that is essential i n order to negotiate a mutua l l y acceptable p lan o f care. If a pediatr ic heal th care agency adheres to a ph i l osophy o f f a m i l y centered patient care, the need for mutua l understanding between parents and members o f the health care team is further emphas ized . A s K n a f l , C a v a l l a r i , and D i x o n (1988) observed, 122 T o be f a m i l y centered imp l ies that consistent, systemat ic efforts are made to understand one another 's v iewpo in ts and that open negot iat ion between f a m i l y members and nurses is encouraged and va lued . F a m i l y centered nurs ing care requires that nurses and fam i l y members w o r k together as equals i n de f in ing and manag ing the pediatr ic hospi ta l izat ion exper ience (p. 300-301) . T h e conc lus ions d rawn f r o m the f ind ings o f this study revea l that pediatr ic day care surgery is v i e w e d by parents as a threatening, stressful exper ience occu r r i ng ove r a span o f t ime beg inn ing w i th the rea l izat ion o f a p rob lem, and extending to when the parent(s) decides the exper ience is over . T h e parental exper ience is m u c h longer than the few hours actual ly spent i n the hospi ta l sett ing and is v i e w e d i n the broad context o f every day l i fe as an important f a m i l y event. T h e imp l i ca t ions for nurses are two fo ld . F i rs t , nurses must examine their current pract ices and address the f i nd ing that parental needs for nurs ing care extend beyond the parents ' stay i n the pediatr ic M e d i c a l / S u r g i c a l D a y C a r e Un i t . S e c o n d , nurses must consistent ly app ly the four steps o f the nurs ing process at each o f the three tempora l phases o f the parents ' exper ience. In re la t ion to app l ica t ion o f the nurs ing process, the need for ongo ing assessment is imperat ive i n order to ascertain the d imens ions o f the parents ' exper iences that contr ibute to feel ings o f stress. P lann ing and nurs ing intervent ion w i l l va ry accord ing to the i nd i v idua l needs o f the c l ient and the phase o f their exper ience. In general , nurs ing intervent ions w i l l be di rected towards enhanc ing parents ' c o p i n g strategies to manage stress. Eva lua t i on , the essent ial fourth step o f the nurs ing process, w i l l ensure that nurs ing goals for parent care cont inue to be 123 met o n an ongo ing basis. E x a m p l e s o f spec i f i c imp l ica t ions for nurs ing pract ice w i l l be presented here accord ing to the f ramework o f the three ch rono log ica l phases: pre-hosp i ta l iza t ion, hosp i ta l iza t ion, and post-hospi ta l izat ion. It i s expected that these examples m a y assist nurses w o r k i n g i n var ious settings to ident i fy c o m m o n concerns w h i c h shou ld be ant ic ipated by health profess ionals w h e n p lann ing care for the parents o f toddlers and preschoo ler w h o undergo a day care surgery procedure. T h e pre-hospi ta l izat ion o r preparatory phase o f the parents ' exper ience began w i t h the parents ' rea l iza t ion that someth ing was " w r o n g " w i t h their c h i l d and ended w i t h the c h i l d ' s admiss ion to hospi ta l to undergo correct ive surgery. D u r i n g this phase parents read ied themselves and their fami l ies emot iona l l y and phys i ca l l y fo r the day care surgery event. D u r i n g the pre-hospi ta l izat ion phase o f the exper ience the nurse must assess the parents ' interpretat ion, understanding, and expectat ions o f the event. In par t icu lar , gaps and misinterpretat ions o f in fo rmat ion , as w e l l as potent ia l sources o f stress, shou ld be ident i f ied. T h e parents ' usual methods o f cop ing w i th stressful si tuat ions and sources o f soc ia l support, shou ld also be assessed i n order that these m a y be strengthened and enhanced as needed. A n examp le o f a spec i f ic imp l i ca t ion for nurs ing pract ice dur ing this phase is the p rov i s i on o f ant ic ipatory gu idance regard ing the poss ib le factors cont r ibut ing to the stresses o f this exper ience. T h i s nurs ing intervent ion m a y inc lude parental gu idance re lated to: dec i s ion -mak ing regard ing the actual surg ica l procedure; inc reas ing anxiety and uncertainty as the event approaches; and/or parental fee l ings o f gu i l t and wor ry due to added responsib i l i t ies (part icular ly w i thho ld ing food and 124 f lu ids) . A t the present t ime, i n the agency where the study was conduc ted (Br i t i sh C o l u m b i a ' s C h i l d r e n s ' Hosp i ta l ) , the opportuni t ies to assess parents dur ing the pre-hosp i ta l iza t ion phase o f their exper ience are l im i ted . W h e n the surgery is actual ly booked by the phys i c ian , the parents m a y o r may not be seen by a nurse, however , they do rece ive a detai led in format ion pamphlet "Get t ing R e a d y fo r D a y C a r e " (Br i t i sh C o l u m b i a ' s C h i l d r e n s ' Hosp i ta l ) . In addi t ion to p rov id i ng important and essent ia l in fo rmat ion , the pamphlet addresses concerns related to the c h i l d ' s react ion to the surgery. A l t h o u g h an excel lent source o f in fo rmat ion for parents, the pamphle t does not address parental fears related to the ant ic ipat ion o f day care surgery event o r the resul t ing impact o f the event on fam i l y l i fe . A pamphle t cannot be cons idered a substitute for systematic nurs ing assessment and in tervent ion, and in fo rmat ion of fered to parents shou ld , whenever poss ib le , ref lect an i nd i v i dua l assessment. In add i t ion to the pamphlet , there is a preparatory v ideotape ava i lab le fo r v i e w i n g by parents and ch i ld ren p r io r to the c h i l d ' s day care surgery. There is also an exper ienced day care nurse ava i lab le fo r one hour per week to address parental concerns regard ing preparat ion o f the ch i l d . T h e ava i lab i l i ty o f both o f these resources is a pos i t i ve factor i n the preparat ion o f fami l ies fo r day care surgery. T h e "Ge t t i ng Ready for D a y C a r e " pamphlet c lear ly states that parents may c a l l the D a y Care U n i t i f they have any quest ions or concerns about their c h i l d ' s i m p e n d i n g surgery. It is important to note, however , that based on the f ind ings o f this study and 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 & Thorne , 1984), f i rst t ime parents assume that health professionals tel l them every th ing they need to 125 k n o w and are often very reluctant and af ra id to make requests fo r further in fo rmat ion . Parents i n the current study stated that they thought their quest ions are " d u m b " , that they should already k n o w the answers, or their concerns were too ins ign i f i can t to "bother" a health profess ional w i th . Hea l th profess ionals w h o are not aware that parents h o l d this perspect ive may inadvertent ly re inforce to parents that they th ink parental concerns are ins ign i f icant . A t B r i t i s h C o l u m b i a ' s Ch i l d rens ' Hosp i t a l , one or two days pr io r to the actual day care surgery a preadmiss ion nurse f r o m the D a y Care U n i t phones the parent to obta in some basic demograph ic in fo rmat ion about the c h i l d , "answer any quest ions and r e m i n d parents o f fast ing inst ruct ions" (Br i t i sh 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, p.3). Unfor tunate ly , between the time that the c h i l d ' s surgery is booked and pr io r to the nurse 's telephone c a l l , there is a s igni f icant gap i n contact w i t h the day care surgery fami l ies . C o m m u n i t y health nurses or nurses emp loyed in doc to r ' s o f f ices m a y come into contact w i th these fami l ies dur ing the pre-hospi ta l iza t ion phase o f their exper ience and may have an opportuni ty to assess their percept ions o f the event, o f fer reassurance regard ing the va l id i t y o f their concerns, and answer quest ions. T h e p readmiss ion nurse 's telephone ca l l to the parent one or two days pr io r to the c h i l d ' s surgery is t ime ly because it is k n o w n that the parents ' anxiety about their c h i l d ' s day care surgery increases as the event approaches. I f t ime permi ts , this te lephone c a l l i s an excel lent opportuni ty to d iscuss parental anxiet ies and address parental concerns i n an empath ic manner. Parenta l wor r ies and fears at this po in t are rea l . I f parents are to ld that they have "noth ing to wo r r y about" , it on l y serves to re in force the di f ferences between the parent 's perspect ive o f the event and 126 that o f the health pro fess iona l ( K n o x & H a y e s , 1983). T h e hosp i ta l iza t ion or operat ive phase occur red dur ing the three to s ix hours that the parent(s) and c h i l d were actual ly i n the hospi ta l sett ing. T h i s is a h igh ly emot iona l , intense phase o f the exper ience as the f i na l preparat ions fo r surgery are made and the parent(s) re l inqu ish their ch i l d to the care o f health care professionals i n order that the surgery can be per fo rmed. T h e f ind ings o f this study revea l that parents ar r ived at the D a y Care U n i t fee l ing anx ious as a result o f be ing unable to comfor t their ch i ld ren i n usual ways and fee l ing uncertain about the impend ing event and its outcome. Re l i nqu i sh i ng the c h i l d , wa i t i ng for the c h i l d ' s return, and then reuni t ing w i th h im/her were a l l stressful points o f this phase o f the exper ience fo r parents. A t these points , nurses have an important ro le to p lay i n demonstrat ing sensi t iv i ty to the parents ' needs by p rov id ing relevant in fo rmat ion , reassurance, and support. F o r examp le , when parents felt prepared fo r their c h i l d ' s return to the D a y Care U n i t f r o m the Recove ry R o o m , it had a very pos i t i ve effect on the parent and h is /her fee l ings about their day care surgery exper ience. A par t icu lar ly stressful time for parents was dur ing the wa i t i ng per iod fo r them i n the D a y Care U n i t after their c h i l d had left fo r the operat ing r o o m . Parents expressed acute fears related to their ch i ld ren 's morb id i t y and morta l i ty espec ia l ly related to the r isks inherent i n rece iv ing a general anesthetic. Appropr ia te nurs ing intervent ions at this t ime shou ld inc lude not on l y reassurance but an empathet ic acknowledgement o f the intensi ty o f parental fears. N u r s i n g intervent ions to enhance parental cop ing strategies at this t ime w o u l d a lso be appropriate. T h e fact that a l l parents are asked to have another adult accompany them to the D a y Care U n i t i s important i n the p rov i s ion o f soc ia l support at this t ime. 127 W h i l e i n the D a y C a r e U n i t , most parents rema in focused o n the c h i l d ' s immed ia te pre- and post-operat ive needs. It is often not un t i l they return home that the more m i n o r issues af fect ing their day to day l i ves become apparent. D u r i n g the hosp i ta l iza t ion phase, nurses need to of fer ant ic ipatory gu idance that is relevant to parents ' needs and perspect ives i n order to a id i n their t ransi t ion to the post -hosp i ta l iza t ion phase o f their exper ience. Post -operat ive instruct ion pamphlets and ve rba l post-operat ive teaching help to br idge the gap between hospi ta l and home. Pamph le ts , howeve r he lp fu l , are by nature fo rced to be somewhat general therefore cannot address the concerns o f a l l parents and shou ld not be cons idered a substitute for i nd i v i dua l i zed nurs ing intervent ions. D u r i n g the hospi ta l izat ion phase o f the exper ience parents m a y fa i l to "take i n " a l l o f the in fo rmat ion that has been of fered to them. The i r l ack o f p rev ious exper ience and their fa i th i n their care prov iders , often prevents them f r o m ask ing pert inent quest ions. T h i s h ighl ights the need for nurses to p rov ide appropriate and relevant ant ic ipatory guidance, rather than wa i t fo r these parents to ask quest ions. T h e post -hospi ta l izat ion o r re-adjustment phase began upon hospi ta l d ischarge and cont inued unt i l the c h i l d had recovered phys i ca l l y and emot iona l l y from the surgery and a l l f a m i l y members had returned to acceptable patterns o f da i l y l i v i ng . T h e telephone c a l l that parents rece ive from a nurse in the D a y Care 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 ' Hosp i ta l ) on the c h i l d ' s f i rst post-operat ive day is a ve ry t ime ly opportuni ty to address some o f the parental concerns that m a y have ar isen s ince the ar r iva l home. Spec i f i c nurs ing imp l ica t ions for this phase o f the parents ' exper ience relate to enhanc ing creat iv i ty and f l ex ib i l i t y i n parental cop ing 128 abi l i t ies. P r o v i d i n g in format ion and support w i l l assist parents w i th the concrete changes they face i n their da i l y rout ines and act iv i t ies. In add i t ion , this f o l l ow-up telephone ca l l is an excel lent opportuni ty to begin the eva luat ion phase o f the nurs ing process. A " f l ow- th rough" nurs ing care p l a n , w h i c h c o u l d be in i t ia ted by the preadmiss ion day care nurse, added to by the nurses car ing for the f a m i l y dur ing the hospi ta l izat ion phase, and comp le ted by the day care nurse m a k i n g the fo l l ow-up telephone ca l l , w o u l d faci l i tate app l ica t ion o f the nurs ing process and ensure cont inui ty o f nurs ing care for these fami l ies . P r o v i s i o n shou ld be made for further f o l l ow-up o f fami l ies i f needed. Refer ra ls to commun i t y heal th and home care nurses to p rov ide f o l l ow -up home v is i ts may be appropriate i n some situat ions. T h e f ind ings o f this study not on l y revea l imp l i ca t ions for nurs ing pract ice but a lso show that parents are resourcefu l in the management o f their c h i l d ' s care du r ing the day care surgery exper ience. In general , parents ref lect that this f i rst t ime exper ience was more pos i t ive than they had ant ic ipated. Nurses have a s igni f icant ro le to p lay in the care o f fami l ies w i th young ch i ld ren w h o undergo day care surgery. A s was stated by K n a f l , C a v a l l a r i , & D i x o n (1988), the "uniqueness o f the pediatr ic nurse 's w o r k rests i n the fact that she pract ices her nurs ing sk i l l s on ch i ld ren and must take the parents in to account as she p rov ides care" (p.272). In the f o l l o w i n g sect ion, imp l i ca t ions fo r nurs ing educat ion w i l l be d iscussed. Impl icat ions for N u r s i n g Educa t i on T h e f ind ings and conc lus ions f r om this study point to several imp l i ca t ions for nurs ing educat ion. F i rs t , i f nurses are to p rov ide respons ib le , support ive, and 129 ef fect ive health care, they must deve lop the commun ica t i on sk i l l s needed to exp lore c l ien ts ' explanatory mode ls for their i l lness exper iences. Inserv ice educat ional opportuni t ies w i th in agencies, cont inu ing nurs ing educat ion courses, and opportuni t ies i n f o rma l nurs ing educat ion programs shou ld be made ava i lab le to support the deve lopment o f such sk i l l s . A s nurses and nurs ing students learn to enl ist c l ien ts ' explanatory mode ls , they must also care fu l l y examine their o w n assumpt ions, va lues , and be l ie fs , and learn to incorporate this understanding and awareness in to c l i n i ca l pract ice (Anderson , 1987). A s the f ind ings o f this study ind icate, an understanding o f the parents ' exper ience f r o m the parents ' po int o f v i e w w o u l d enable nurses to incorporate this know ledge into a mutua l l y sat is fy ing p lan o f care. Ano the r imp l i ca t ion f r o m this study relates to the care o f the c l ient outside the acute care sett ing. N u r s i n g cur r i cu la , w i th their prominent acute care f o c i , often fa i l to emphas ize the care o f the c l ient outside the hospi ta l env i ronment . C l i en t preparat ion for hospi ta l izat ion and p lann ing fo r d ischarge are often not emphas ized i n nurs ing course content. A s the f ind ings o f this study ind icate, the hospi ta l izat ion phase o f the parents ' exper iences was on l y one aspect o f the total i l lness exper ience. It i t therefore i m p l i e d that nurs ing educat ion emphas iz ing the needs o f the c l ients i n the pre- and post- hospi ta l izat ion phases o f their i l lness m a y better prepare nurses w h o pract ice outs ide the hospi ta l setting to p rov ide qual i ty care to par t icu lar c l ient groups. It m a y a lso sensi t ize the nurses w h o wo rk i n acute care settings to the needs o f their c l ients before and after hospi ta l izat ion. A th i rd imp l i ca t i on for nurs ing educat ion is related to f a m i l y centered nurs ing care i n a pediatr ic sett ing. A s is w e l l documented by other authors ( H y m o v i c h , 1976 & 1981; L i t m a n , 1974), a c h i l d ' s i l lness invo lves and affects a l l members o f the f am i l y , espec ia l ly parents and s ib l ings. A s nurs ing mode ls often focus care on the c l ient as an i nd i v idua l , nurs ing educators must cont inue to emphas ize the need for f am i l y centered care. F a m i l y centered care in the acute care sett ing has often been equated w i th certa in po l i c i es such as open v i s i t i ng hours and increased parental par t ic ipat ion i n care. In the app l ica t ion o f research f ind ings to pract ice and educat ion nurses must be aware that " too of ten programs o f fami ly -centered care ref lect what profess ionals th ink fami l ies shou ld want as opposed to what fami l ies actual ly may want" ( K n a f l , C a v a l l a r i , & D i x o n , 1988, p. 299) . It is therefore essential that parents ' perspect ive o f their health care encounters be inc luded i n nurs ing cur r icu la . In the f o l l o w i n g sect ion, imp l i ca t ions fo r nurs ing research w i l l be d iscussed. Impl ica t ions for N u r s i n g Research D u r i n g the process o f the current study, the researcher became aware o f imp l i ca t ions fo r further research i n the area o f parent care and pediatr ic day care surgery. F i rs t , a l though the current study exp lo red the parents ' f i rst time exper ience w i t h young ch i ld ren undergo ing a day care surg ica l procedure, a large propor t ion o f day care procedures per fo rmed are second or subsequent procedures. W i t h a h igh percentage o f fami l ies exper ienc ing repeat procedures on their ch i ld ren , it w o u l d be va luab le for nurses to learn h o w the parents ' perspect ive o f the exper ience changes w i th subsequent hospi ta l admiss ions. T h e results o f such a study w o u l d of fer nurses guidel ines as to how they c o u l d best assess, p lan , imp lement , and evaluate care fo r parents returning to the D a y Care U n i t fo r repeat admiss ions . 131 T h e current study examined the exper iences o f parents o f toddlers and preschoolers on ly . A va luab le addi t ion to current know ledge w o u l d result from an examina t ion o f the perspect ives o f parents o f younger or o lder ch i ld ren w h o undergo day care surgery. In addi t ion, a study incorporat ing the perspect ives o f a greater number o f fathers as w e l l as s ib l ings w o u l d add a f a m i l y perspect ive to this impor tant exper ience. A further imp l i ca t ion fo r nurs ing research w o u l d be to use a re l iab le and v a l i d measurement too l to measure the leve ls o f stress parents fee l at var ious points o f their exper ience. T h e f ind ings o f such a study w o u l d document i n a quant i f ied manner the need for intervent ion at par t icular points o f the parents ' exper ience. A l og i ca l f o l l ow-up to the current study w o u l d be a c o m b i n e d qual i tat ive and quant i tat ive research project des igned to evaluate and compare the effect o f nurs ing intervent ions on the exper iences o f two groups o f parents undergo ing their son or daughter 's day care surgery for the f irst t ime. T h e exper imenta l group o f parents w o u l d rece ive nurs ing intervent ion d i rected at reduc ing the stresses inherent i n this exper ience. T h e cont ro l group w o u l d be we l l -matched subjects w h o w o u l d rece ive on l y standard nurs ing care. T h e intent o f such a study w o u l d be to support or reject the va lue o f spec i f ic nurs ing intervent ions in i m p r o v i n g the qual i ty o f care of fered to these fami l ies . It is ev ident f r o m the suggest ions presented here that parent care i n pediatr ic day care surgery requires cont inued invest igat ion. T h e need for further research in this important area is emphas ized by R o b i n s o n (1972) w h o observed that " m u c h is k n o w n and wr i t ten about c h i l d patients, their behaviour , their needs and their treatment, ve ry l i t t le is k n o w n systemat ica l ly about the attitudes and behav iour 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. 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M . (1986). Quant i tat ive and qual i tat ive research: Issues in sampl ing . In P . L . C h i n n (Ed. ) , N u r s i n g research methodo logy: Issues and implementat ion (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). The surgery o f in fancy . B r i t i sh M e d i c a l Journa l . 2 , 753-754 . N y e , F.I. (1976). R o l e structure and analys is o f the f am i l y ( V o l . 24) . 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 phenomeno log ica l approach in nurs ing research. N u r s i n g  Research . 3 1 , 178-181. O m e r y , A . (1983). Phenomeno logy : A M e t h o d for N u r s i n g Research . A d v a n c e s in  N u r s i n g Sc ience . 5(2), 49 -63 . Othersen, B . H . , & C la twor thy , H . W . (1968). Outpat ient hern iorrhaphy fo r infants. A m e r i c a n Journa l o f the D iseases o f C h i l d r e n . 116. 78 -80 . Pea r l i n , L . I., & Schoo le r , C . (1978). T h e structure o f cop ing . Journa l o f Hea l th and  S o c i a l Behav io r . 19(3), 2 -21 . P i l i s u k , M . & F ro land , C . (1978). K i n s h i p , soc ia l networks, soc ia l support and heal th. S o c i a l Sc ience and M e d i c i n e . 12, 273-280. P r u g h , 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 emot iona l react ions o f ch i ld ren and fami l ies to hosp i ta l iza t ion and i l lness. A m e r i c a n Journa l o f Or thopsych ia t ry . 32 , 70-106. R a y , M . A . (1985). A ph i l osoph ica l method to study nurs ing phenomena. In M . M . Le i n i nge r (Ed. ) , Qual i ta t ive research methods i n nurs ing (pp. 81-91) . O r l ando , F L : G r u n e & Stratton. Redpa th , C . C , & Rogers , C . S . (1984). Hea l thy young ch i l d ren ' s concepts o f hospi ta ls , med i ca l personnel , operat ions, and i l lness. Journa l o f Pediat r ic  P s y c h o l o g y . 9(1), 29 -39 . R i s t , R . C . (1979). O n the means o f k n o w i n g qual i tat ive research i n educat ion. N e w Y o r k Un ive rs i t y Educa t ion Quar ter ly . Summer . 17-21. Rober ts , S . (1988). S o c i a l support and help seek ing: R e v i e w o f the l i terature. A d v a n c e s i n N u r s i n g Sc ience . 10. 1-11. Rober t son , J . (1970). Y o u n g ch i ld ren in hospi ta l . L o n d o n : Tav is tock . R o b i n s o n , C . (1983). T h e exper ience o f hospi ta l izat ion fo r parents o f a ch ron ica l l y  i l l c h i l d : A n interpret ive study. U n p u b l i s h e d master 's thesis, Un i ve rs i t y o f B r i t i sh C o l u m b i a , V a n c o u v e r , B . C . R o b i n s o n , D . (1972). I l lness behav iour and ch i ld ren 's hosp i ta l iza t ion: A schema o f parents ' attitudes towards authori ty. S o c i a l Sc ience and M e d i c i n e . 8, 447-468 . R o b i n s o n , C , & Thorne , S . (1984). Strengthening f a m i l y " inter ference". Journa l o f  A d v a n c e d N u r s i n g . 9, 597-602 . S a n d e l o w s k i , M . (1986). T h e p rob lem o f rigor i n qual i tat ive research. A d v a n c e s in  N u r s i n g Sc ience . 8(3), 27-37 . 140 Schowa l te r , J . E . (1977). " W e w o n ' t leave y o u " (Letter to the editor). Pediat r ics . 60 , 651-52 . S h a h , C . P . (1980). Day -ca re surgery i n Canada : E v o l u t i o n , p o l i c y , and exper ience o f p rov inces . Canad ian Anesthet ists Soc ie ty Journa l . 27 , 399-405 . S h a h , C . P. , Papageorg is , D . , R o b i n s o n , G . C , K i n n i s , C , & Israels, S . (1969). A study o f the need for alternative types o f health care for ch i ld ren i n hosp i ta l : Parenta l attitudes toward day care. Pedia t r ics . 44 , 338-347 . S h a h , C . P . , R o b i n s o n , G . C , K i n n i s , C , & Davenpor t , H . T . (1972). D a y care surgery for ch i ld ren : A cont ro l led study o f med i ca l compl i ca t ions and parental attitudes. M e d i c a l Ca re . 10, 437-449 . S i p o w i c z , R. , & V e r n o n , D . T . (1965). Psycho log i ca l responses o f ch i ld ren to hosp i ta l iza t ion: A compar i son o f hosp i ta l i zed and non-hosp i ta l i zed twins. A m e r i c a n Journa l o f the Diseases o f C h i l d r e n . 109. 228 -231 . Sk ippe r , J . K . (1966). M o t h e r ' s distress over their ch i l d ren ' s hosp i ta l iza t ion fo r tons i l lec tomy. Journa l o f Ma r r i age and the F a m i l y , 28 . 145-151. Sk ippe r , J . , L e o n a r d , R . & R h y m e s , J . (1968). C h i l d hosp i ta l iza t ion and soc ia l in teract ion: A n exper imenta l study o f mothers ' fee l ings and stress adaptat ion. M e d i c a l Ca re . 6, 496-506 . Smi the rman , C . (1979). Parents o f hosp i ta l i zed ch i ld ren have needs, too. A m e r i c a n  Journa l o f N u r s i n g . 7 9 , 1423-1424. Sussman , M . B . (1965). Re la t ionsh ips o f adult ch i ld ren w i th their parents i n the U n i t e d States. In Shanas & Stre ib (Eds. ) , S o c i a l structure and the f am i l y :  Genera t iona l re lat ions (pp. 91-93) . N e w Jersey: P ren t i ce -Ha l l . Te r ry , D . G . (1987). T h e needs o f parents o f hosp i ta l i zed ch i ld ren . C h i l d r e n ' s Hea l th  C a r e . 1 6 , 18-20. Tho rne , S. (1983). T h e f a m i l y cancer exper ience: A qual i tat ive study o f fami l ies i n  w h i c h an adult member is l i v i n g w i t h cancer. U n p u b l i s h e d master 's thesis, Un ive rs i t y o f B r i t i sh C o l u m b i a , Vancouve r , B . C . U n g e r , D . G . , & P o w e l l , D . R . (1980). Suppor t ing fami l ies under stress: T h e ro le o f soc ia l networks. F a m i l y Re la t ions . 29 . 566-574. U y e r , G . (1986). E f fec t o f nurs ing approach i n understanding o f phys i c i ans ' d i rec t ions, by the mothers o f s ick ch i ld ren in an out-patient c l i n i c . Internat ional Journa l o f N u r s i n g Studies. 2 3 , 79 -85 . V a r d a r o , J . A . (1978). P readmiss ion anxiety and mother -ch i ld re lat ionships. Journa l  o f the Assoc i a t i on for the Care o f Ch i l d ren In Hosp i ta ls . 7(2) , 8-15. 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  psycho log i ca l responses o f ch i ld ren to hospi ta l izat ion and i l lness. Sp r ing f i e ld , I L : 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). Changes i n ch i l d ren ' s behav ior after hospi ta l izat ion. A m e r i c a n Journa l o f the Diseases 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). N u r s i n g care o f infants and ch i ld ren (3rd ed.). St . L o u i s : M o s b y . W i l k e n s o n , A . (1978). Behav io ra l disturbances f o l l o w i n g short- term hospi ta l izat ion. Issues in Comprehens ive Pediat r ic N u r s i n g . 3(1), 11-18. W o l f e r , J . A . , & V is in ta iner , M . A . (1975). Pediat r ic surg ica l pat ients ' and parents ' stress responses and adjustment. N u r s i n g Research . 24 , 244-55 . 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 on mothers o f ser ious ly i l l , hosp i ta l i zed ch i ld ren . C h i l d r e n ' s Hea l th Ca re . 16(1) , 4 -12 . 142 A P P E N D I C E S 146 A P P E N D I X D Participant Information Letter Dear Parent : M y name is P a m e l a Ot terman and I am a student i n the Mas te r o f Sc ience i n N u r s i n g P r o g r a m at the Un ive rs i t y o f B r i t i sh C o l u m b i a . I a m also a pediatr ic nurse. I a m conduct ing a study to learn more about what parents exper ience when their young c h i l d has been hosp i ta l i zed for day care surgery. There is very l i t t le in fo rmat ion avai lab le about what parents think about this exper ience and how they manage at home w i th a c h i l d w h o has just had an operat ion. T h i s letter is to inqui re i f y o u are interested i n par t ic ipat ing i n m y study. S h o u l d y o u agree to part ic ipate, I w i l l talk w i t h y o u two or three t imes i n you r o w n home after y o u return f r o m hospi ta l w i th your ch i l d . T h e f irst in terv iew w i l l be the f irst o r second day after y o u return home, and the second in terv iew w i l l be one to two weeks after you r ch i l d ' s operat ion. A th i rd in terv iew may be arranged i f necessary. E a c h meet ing w i l l be approx imate ly one hour l o n g and w i l l be arranged at a t ime most convenient fo r you and you r f am i l y . W i t h your permiss ion , the in terv iews w i l l be tape recorded, t ranscr ibed (typed), and ana lyzed after our v is i ts . D u r i n g the in terv iews, I a m interested i n learn ing about your react ions to the day care surgery exper ience and h o w it affected y o u and the other members o f your f am i l y . A l l o f the in fo rmat ion that y o u share w i th me w i l l be kept str ict ly conf ident ia l and your ident i ty w i l l never be revealed i n any w a y whatsoever. T h e tape record ings are so that I do not have to take wr i t ten notes wh i l e we talk. T h e y are for m y personal use and w i l l on ly be shared w i th two o f m y advisors w h o are a lso exper ienced pediatr ic nurses. I w i l l assume a l l respons ib i l i ty for the tape record ings and w i l l persona l ly destroy then when I have comple ted the project and any related pub l ica t ions ( in general , this takes about three to f i ve years). I be l ieve that i f pediatr ic nurses learn more about the exper iences o f parents related to their c h i l d ' s day care surgery, we cou ld use the know ledge to better prepare parents for cop ing w i th a s im i la r exper ience. Other parents w h o have had an opportuni ty to talk w i th a nurse after their ch i l d ' s hospi ta l izat ion have ind icated that they en joyed and benef i ted f r o m the in terv iews. Y o u are under no ob l iga t ion to part ic ipate i n this study. I f you should dec ide to part ic ipate, y o u have the r ight to change your m i n d and wi thdraw at any t ime. Y o u also have the r ight to refuse to answer any quest ions that I may ask o r comment on any topic dur ing the course o f an in terv iew. I f you should decide not to part ic ipate, you r refusal w i l l not i n any w a y affect your c h i l d ' s scheduled surgery o r any subsequent nurs ing o r med i ca l care. W i t h you r pe rmiss ion , I w i l l ca l l you at home tomorrow to find out your 149 A P P E N D I X F I n i t i a l I n t e r v i e w G u i d e 1. W o u l d you descr ibe you son/daughter 's cond i t ion for me please? 2. H o w w o u l d y o u descr ibe your c h i l d ' s react ion the his/her day care surgery? 3. H o w have the day to day act iv i t ies o f you r househo ld changed, i f at a l l? 4. C o u l d y o u descr ibe some o f your impress ions on the f irst n ight at home after the surgery? 5. W h a t has it been l i ke for you l ook i ng after (ch i ld 's name) since you ar r ived home f r o m hospi ta l? Is this what you expected? 6. C a n y o u th ink o f a reason w h y the exper ience o f your c h i l d ' s day care surgery has affected y o u the w a y it has? 7. W h a t / w h o m has been most he lp fu l to y o u dur ing this t ime? W h a t w o u l d have been more he lp fu l? 

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