1
MS student in pediatrics, School of Nursing & Midwifery, Shahid Beheshti University of Medical
Sciences, Tehran, Iran (Islamic Republic of)
2
PhD in nursing, instructor of pediatrics, School of Nursing & Midwifery, Shahid Beheshti
University of Medical Sciences, Tehran, Iran (Islamic Republic of)
3
Assistant professor in nursing, instructor of pediatrics, School of Nursing & Midwifery Shahid
Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
4
Assistant professor in biostatistics, School of Nursing & Midwifery, Shahid Beheshti University
of Medical Sciences, Tehran, Iran (Islamic Republic of)
Corresponding author details:
Fatemeh Feizi
MS student in pediatrics, School of Nursing & Midwifery
Shahid Beheshti University of Medical Sciences
Tehran,Iran (Islamic Republic of)
Copyright:
© 2020 Feizi F, et al. This
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under the terms of the Creative Commons
Attribution 4.0 international License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the
original author and source are credited.
Family-Centered Care; Anxiety; Mothers; Pediatric ICU
Hospitalization of children in pediatric ICUs is one of the most stressful experiences of
parents [1]. About %3 of children are hospitalized in healthcare centers at least once and
approximately 5% are admitted several times [2]. According to statistics reported by various
pediatric hospitals and institutes, about 150000-200000 children are annually hospitalized
in PICUs [3]. The prevalence of anxiety among the family members of PICU children has been
reported to be %35-73 in various studies [1]. The results of a study in Iran showed that %68
of family members of PICU patients sustained anxiety, %53.7 suffered from depression, and
46.7% sustained moderate to severe stress [4]. Parents play a significant role in promoting
their children’s state so that their behaviors and attitudes affect those of their children.
Parents with high levels of anxiety may lack the required ability to support their PICU
children [5]. Considering the unstable state of inpatients and the necessity of the use of
complex medical equipment by ICU nurses, they spend much of their time in giving care
to patients and monitoring them and thus overlook the patient’s family. Hence, parents are
reluctant or unable to express their needs leading to adverse effects on child care [6]. Nurses
have a unique opportunity for helping parents during this experience. Nurses’ support for
families is in line with family-centered care aiming at maintaining unity and empowering
family members to accept roles and familial support in stressful situations. PICU nurses
should not only give specialized care to each child, but also support their parents [7,8].
Implementation of family-centered care in ICUs converts patient care to family care since
family members, especially mothers, are natural supporters of children and thus fulfilling
their social, spiritual, and physical needs is seriously necessary [9]. Among the family
members, the mother plays a significant role in determining goals and care-treatment
planning due to her dominance over the child’s and family’s condition [10]. Unfortunately,
despite the many advantages of this approach, it has not practically received due attention. Lack of receiving sufficient amount of information promptly by the
patient’s family may cause insolvency with respect to the patient,
treatment and care, resulting in less control on the stressful situation
[11]. Mothers’ needs during child’s PICU hospitalization may be
classified into domains of physical care, support, confidence in
proper care of child, hope, proper responding to questions, useful and
prompt transfer of information, observation of their self-esteem and
respect by the treatment staff, contributing to child care planning,
and understanding mother’s condition. Lack of appropriate meeting
of mother’s needs and resolving of ambiguities may adversely affect
the outcomes of child care [12]. Despite the personnel’s awareness of
the importance of family-centered care, there is still some evidence of
problems among the personnel in planning care for families. Part of
this problem is due to lack of perception of family needs and another
part due to unawareness of components of family-centered care and
the method of its administration [13]. However, in Iran in spite of the
emphasis on implementing family-centered care in pediatric wards
of pediatric hospitals, little information is unfortunately available
on implementation of this care approach [14]. Given challenges like
“shortage of nursing personnel for PICU children, the great number of
PICU patients, the current financial problems, limited physical space
of the ward, lack of sufficient training, lack of cooperation among
nursing staff and parents, and ICU milieu with its limited supplies
and equipment”, the reduced quality of PICU care will be expected.
Considering that many children annually require PICU hospitalization
due to various medical reasons, this would lead to parents’ confusion
and anxiety, especially in mothers, so that the maternal role will
be reversed if the condition persists [15]. Given the importance of
family-centered care in managing PICU children and lack of sufficient
studies in Iran in this field, the present study aimed at determining
the effect of family-centered care on the rate of anxiety in mothers of
PICU children.
The study population in this descriptive study included all
mothers of PICU children hospitalized in Mofid Subspecialty Pediatric
Hospital in Tehran, capital of Iran, that entered the study on the basis
of inclusion criteria, i.e., mothers of PICU children aged 1-6 years,
the ability to communicate, familiarity with Persian language, being
literate, lack of history of child’s hospitalization in PICU, and children
cared for by family members other than mother. Besides, mothers
with a history of anxiety and depression disorders, or affliction
with physical impairments, death or transfer of the child to another
ward before completion of the study, and lack of cooperation of the
study samples in the course of the study, or lack of completion of
the questionnaires formed the exclusion criteria. The samples were
selected with convenient sampling method. In so doing, the research
goals and procedures were explained to each sample that qualified for
inclusion and informed written consent was obtained. To carry out
the study, a two-part questionnaire was used. The first part included
demographic information and the second part was Spielberger’s
Anxiety Checklist (1996). Galvan, et al [16]. investigated the
psychometric features of Spilburger’s Anxiety Checklist and reported
an acceptable reliability coefficient (Cronbach’s α=0.83). The study
by Khanipoor, et al. in Iran explored the validity and reliability
coefficients of this cheklist and confirmed them (Cronbach’s α=0.76)
[10]. Besides, the stuides by Rabiee et al. [17] and Rouhi, et al. [18]
reported the test-retest reliability coefficient of this checklist as 0.89
and 0.90, respectively. Having obtained the required permissions
from hospital authorities, the researcher attended the research
setting in person and explained the research goals and procedures.
To collect data, mothers of PICU children that qualified for
participation were selected with convenient sampling and entered
the study after signing informed written consent. Family-centered
care was implemented for the participating mothers on the basis of a
protocol developed on the basis of library research, consultation, and
the present scientific sources. Before the onset of intervention (24
h after child admission in PICU), mothers’ level of anxiety was first
measured with Spilburger’s Anxiety Checklist. Then, a 30-45-min training session was held to implement the protocol that included:
making good rapport with the mother, familiarity with the ward
and the existing supplies and equipment, creation of preparedness,
justification of the contribution program and its implementation
course, paying attention to child’s and mother’s needs, the required
awareness on child’s disease, hospitalization care and post-discharge
care related to pediatric nutrition, changing clothes and nappies,
measuring axillary temperature, controlling uptake and removal,
pediatric cleansing, changing sheets, arranging child environment,
and administration of oral drugs. To compare changes in the levels
of mothers’ anxiety after intervention (discharge time), Spielberger’s
Anxiety Checklist was again completed by mothers. The data gleaned
in two stages were coded (before and after intervention) and
imported to SPSS20 for analysis using descriptive and inferential
statistics.
In this study, 40 mothers of PICU children hospitalized in Mofid
Subspecialty Pediatric Hospital, Tehran, were studied. The results
indicated that the mean (Mean ± SD) age of children under study was
2.92 ± 1.57 years and that of mothers was 31.20 ± 2.83 years. Of 40
children under study, most (n=24, 60%) were male. Also, 31 (77.5%)
were the first child of the family and the only offspring. Besides, 31
mothers of children (77.5%) were housekeepers, 27 (67.5%) held a
high school diploma, and 30 children (75%) resided in civil regions
(Table 1). The results of paired t-test (Table 2) demonstrated that the
mean score of mothers’ overt anxiety on children’s PICU admission
was 74.27 ± 2.29 and the mean score of covert anxiety was 65.90 ± 2.53. Moreover, the mean score of mothers’ overt anxiety on
children’s PICU discharge was 26.27 ± 3.59 and the mean score of
covert anxiety was 27.50 ± 3.23 showing a significant reduction in
the mean score of mothers’ anxiety (P<0.05). The results given in
Table 3 show those 29 mothers (72.5%) had severe levels of overt
anxiety whereas 28 mothers (70%) manifested severe levels of
covert anxiety. Investigation of mothers’ anxiety level on children’s
PICU discharge (after intervention) revealed that 35 (87.5%) had
mild levels of covert anxiety whereas 36 (90%) had mild levels of
overt anxiety. Fisher’s exact test suggested no significant correlation
between “mothers’ and children’s age and children’s gender, number
of offspring’s and the order of their birth, mothers’ literacy level,
occupation, children’s place of residence” and “mothers’ overt and
covert anxiety levels” (P>0.05).
Table 1: Frequency distribution of demographics of mothers and
PICU children
Table 2: Comparison of changes in mean scores of mother’s overt
and covert anxiety on PICU admission with their mean scores on
PICU discharge
Table 3: Frequency distribution of mother’s overt and covert anxiety on PICU admission with their frequency distribution on PICU discharge
The present study investigated the level of anxiety in 40 mothers
of PICU children before and after implementation of family-centered
care. The findings showed that most mothers experienced severe
anxiety at the time of admission of their children in PICU. The changes
in mothers’ anxiety level before and after intervention demonstrated
that the training and implementation of family-centered care reduced
their anxiety level significantly on children’s discharge from PICU.
In other words, mothers’ contribution to their children’s daily care
program diminished their anxiety level significantly. The results of
the study by Shooshi et al. [19] showed that the mean score of anxiety
in family members was 4.24 ± 2.07 on discharge from hospital and
10.73 ± 3.6 during hospitalization [19]. This is consistent with our
findings. Additionally, the findings of the study by Martin, et al. [21]
on the effect of family-centered care on the incidence of anxiety in
patients suggested that the mean score of anxiety was 8.63 ± 4.85
on PICU admission and 6.89 ± 5.32 on discharge from hospital [20].
Moreover, Sarin, et al. [21]. investigated qualitatively the experiences
of mothers of PICU children and found that all mothers experienced
a lower level of anxiety after family-centered care intervention [21].
The findings of the last two studies are consistent with our findings.
On the other hand, the results of the study by Sadeghi et al. [22]
indicated a significant decrease in the mean score of anxiety in family after training in family-centered care (before intervention=21.6 ± 8.4;
after intervention=12.6 ± 8.4) [22]. Furthermore, Balbino et al. [23]
showed that the mean score of anxiety in parents was decreased from
4.2 to 3.8 on discharge from PICU [23]. Riley et al. [24] also showed a
significant decrease in their anxiety after intervention and discharge
from ICU. The results of the systematic review by Shields et al. [25]
demonstrated a significant decrease in parents’ anxiety level after
family-centered care intervention compared to PICU hospitalization.
The findings of all of the studies above were consistent with our
results indicating the positive effect of contribution of family
members and family-centered care on diminishing anxiety among
mothers. Given that specific situations like the status of ICU patients,
especially decision-making about the course of patient treatment and
care, may upset the patient mentally driving family members towards
experiencing greater anxiety, contribution of family members to the
course of care in ICUs seems mandatory. It was also observed that
high level of anxiety among members of the family of ICU patients
are manifested as changes in sleep patterns, nutritional diet, thought
process, rate of energy and familial roles or their responsibility. Due
to the effective role of this contributory high quality care-giving, a
feeling of usefulness was induced in mothers that attenuated their
anxiety level. Thus, family members not only visit the patient in a
controlled mode, but also contribute to patient’s care-giving program.
The results of most studies on anxiety in parents and patient’s family
indicate that most causes of anxiety and stress in the family of ICU
patients are attributed to lack of accessibility of information on
patient prognosis and treatment and also lack of familiarity with ICU
environment and its complex equipment. Increased ICU stay exposes
families to these challenges to a greater degree. Therefore, patient’s
family members may be aided by increasing their performance
and ability in giving care to the patient to prevent their mental and
psychological problems. It should be mentioned that no results were
found to contradict our findings. This suggests the importance of
the family-centered approach as one of care-giving methods that
shows the basic and vital role of the family in decision-makings for
patient care and contributing to ICU interventions. Finally, it should
be emphasized that ICU nurses can apply this approach to patient’s
family and increase coping in the patient and the family through
cooperation of family members.
Training individuals in family-centered care is effective in
decreasing level of anxiety in mothers of PICU children. Hence, given
the key role of nurses in education and provision of family-centered
care-giving, an attempt must be made to highlight this educational
approach in improving quality care and encouraging parents and
family members to contribute to the process and take giant strands
in decreasing anxiety in parents and families.
Since this study was conducted in just one subspecialty pediatric
hospital, the results could not be safely generalized to new contexts or
populations thereby jeopardizing the external validity of the findings.
This paper is distilled from an MSc thesis in NICU nursing with
code of research: IR.SBMU.PHARMACY.REC.1398.141. The study
proposal was approved by Committee of Ethics in Human Research
at School of Nursing and Midwifery, Shahid Beheshti University of
Medical Sciences. The researchers extend their special thanks to all
authorities in Mofid Subspecialty Pediatric Hospital and university
authorities who supported them financially and spiritually.
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