Running head: STRESS DISTRESS OF PARENTS OF CHILDREN ADMITTED TO

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Stress distress of parents of children admitted to intensive care unit This paper will examine stress experienced by parents of children who are admitted to the pediatric intensive care unit (PICU). It will then identify the potential causes of stress in the PICU and nursing interventions that would reduce parental stress level in the PICU hence improving patient outcome as well as enabling parents to continue in their family roles to be effective and therapeutic to their children. Approximately 150,000 to 250,000 children are admitted to the PICU each year (Board & Ryan-Wagner, 2002). Admission to an intensive care unit usually comes with no warning, creating an uneasy situation for the families in which uncertainty, shock, helplessness, and confusion are some of the immediate responses (Lam & Beaulieu, 2004). Health care providers are often so focused on the patient who is severely ill or injured that the needs of the family are overlooked. Research has shown that having a child in the pediatric intensive care unit is a stressful experience for parents (Board, 1994; Board &Ryan-Wagner, 2002; Curley, 1988; Curley & Wallace, 1992; Miles et al., 1989). Miles, Carter, and colleagues studied 37 parents who recently had a child discharged from the PICU. Findings indicated that both mothers and fathers experience a high level of stress in PICU environment (Miles et al., 1984). Balluffi, Kassam-Adams, Kazak, Tucker, and Domingue studied the parents of 272 children admitted to the PICU and reported that 32% of the parents met symptom criteria for acute stress disorder (ASD) and 21% met symptom criteria for posttraumatic stress disorder (PTSD) when assessed two months after discharge (Balluffi et al., 2004). Researchers have found that parents experience a significant amount of anxiety, anger, and depression during their child’s stay in the PICU (Board & Ryan-Wagner, 2003). Board (2004) studied the experiences of fathers with critically ill children admitted to the PICU; headache, low energy level, unpleasant thoughts, easily annoyed, and worrying too much were specific stress symptoms reported by 93% of the fathers in the study. Similarly studies of mothers by Board & Ryan-Wenger (2003) and both parents by Balluffi et al. (2004) found that anxiety, anger, depression, confusion, feeling of low energy, unpleasant thoughts, crying easily, poor appetite, trouble falling asleep and worrying too much were common symptoms among parents with a child in the PICU. The symptoms experienced by these parents can have an affect on their behavior resulting in miscommunication between the parents and the health care providers. Parental anger and resultant aggressive behavior is not new to the PICU nurses. We often encounter frustrated, angry, scared, and worried parents in the intensive care unit who create an uneasy environment for health care providers especially nurses. Therefore, identifying the sources of stress of the parents with a child in the PICU is necessary and will provide valuable information that can be used to help the family in crisis and promote communication channels between parents and the health care providers. Researchers have identified alteration in parental role, child’s behavior and emotion, sight and sounds, procedures, staff communication, staff behavior, and child’s appearance as the sources of parental stress in the PICU (Board &Ryan-Wenger, 2002). “Sudden sounds of monitor alarm”, “sound of monitors and equipment”, and “seeing heart rate on the monitor” were reported as stressful by 100% of the parents whose children were in the PICU (Board & Ryan-Wenger, 2003). Furthermore, 97% of the parents reported “putting needles in my child for fluids, procedures, or tests”, “worry that my child might die”, “tubes in my child”, “injections/shots”, “not knowing how best to help my child”, and “too many people talking to us” as the sources of stress during their PICU experience (Board Ryan-Wenger, 2003 & 2002, Balluffi et al., 2004, Board, 2004). Health care providers can unwittingly contribute to creating a stressful environment for the parents. The health care team is often so centered in stabilizing the critically ill child that they forget about the needs and concerns of the parents. Mobilizing resources for the family in crisis and attending to the parents’ needs can reduce the amount of anxiety and uncertainty experienced by parents in the PICU (Lam & Beaulieu, 2004). Health care team, especially nurses must assess the parents carefully in order to identify their needs as well as their sources of stress. Nursing staff can approach the issue utilizing McCubbin and McCubbin’s Resiliency Model of Family Stress, Adjustment, and Adaptation (1993) to assess overall family function during stressful event such as PICU admission. The focus of the Resiliency Model is on understanding the family and capabilities which prevent the family from falling apart. Moreover, the Resiliency Model is a stress and coping framework based on a family systems approach which provides a theoretical basis for understanding a family's adjustment to demands placed upon the family (McCubbin et al., 1996).Exploring family’s perception of the stressful event and identifying stressors as well as stress symptoms of the parents will provide valuable information about family’s coping system. . In order to better understand the needs of the parents in such stressful environment as PICU let us look at the meaning of the word STRESS and the processes that follow a stressful event.
Stress theory Hans Selye, known as “the father of stress”, defines stress as “the rate of tear and wear in the body” (Selye, 1976, p. 1). He further explains stress as a “nonspecific response of the body to any demand” (Selye, 1976). According to Selye, stress can be experienced in any event: a normal life, in an extremely pleasurable time, and during crisis; “the same stress which makes one person sick can be an invigorating experience for another” (Selye, 1976, p. 1). Hans Selye was born in Vienna in 1907. He entered medical school as early as age nineteen and continued his education in Prague, Paris, and Rome universities. He graduated from German University of Prague at age 22 and three years later at age 25 he obtained his Ph. D. degree and moved to Johns Hopkins University to begin his research in biochemistry. Selye held a position as Associate Professor of Histology (the microscopic, scientific study of organic tissue) at Montreal’s McGill University and he was the first director of the Institute of Experimental Medicine and Surgery at University of Montreal. It was as early as the second year of medical school that Selye began developing the concept of stress and its influence on human body. During his first lecture on internal medicine while reviewing cases of patients at early stages of various infectious diseases Selye noticed that “so few signs and symptoms were actually characteristic of any one disease; most of the disturbances such as ill feeling, joint pain, upset stomach, loss of appetite, and weight loss were apparently common to many or even perhaps to all, diseases” (Selye, 1976, p. 17). At this time Selye proposed his “general syndrome of sickness,” a state of sickness that is superimposed upon all individual diseases (p. 18). Selye’s curiosity led him to approach his physiology professor asking for some lab space so he could analyze the “general syndrome of sickness” however, he was merely ridiculed for he was a novice and had no precise plan to guide his work. About ten years later, Selye’s experiments on rats led to the birth of “general adaptation syndrome” (G.A.S.) also known as the stress syndrome (Selye, 1976, p. 38). In his research on rats, Selye found that injection of sex hormone in rats produced a characteristic triad: adrenal enlargement, thymicolymphatic involution, and gastrointestinal ulcers. Searching for a new hormone as a cause to all these changes, Selye realized that all toxic substances such as extracts of kidney, spleen, and other organs produced the same characteristic triad. Subsequently, these three changes were identified as the omnipresent signs of damage to the body when under attack which became the basis for the development of the stress concept (Selye, 1976). Selye (1976) explained that body goes through three stages of coping in response to a noxious agent or stress: 1. Alarm reaction 2. Adaptation or Resistance 3. Exhaustion According to Selye, alarm reaction is body’s initial response that is the triad mentioned previously. Selye adds, “No organism can be maintained continuously in a state of alarm. If the agent is so damaging the continued exposure becomes incompatible with life, the animal dies during the alarm reaction within the first hours or days” (Selye, 1976, p. 5).If the body survives the alarm reaction the second stage of G.A.S., resistance will pursue. During this stage body builds resistance to the stressors and manifests characteristics quite different from the first stage. However, resistance or adaptation can be lost with continued exposure to the stressor resulting in exhaustion due to “wear and tear” (Selye, 1976). Selye, an endocrinologist and a physician, continued his research in the field of stress and later explained the biological mechanism of stress response as the hypothalamus-pituitary-adrenal system (Selye, 1976). Upon the activation of the hypothalamus-pituitary-adrenal system in response to stress, the hypothalamus signals the pituitary to produce adrenocoritcotropic hormone (ACTH) which stimulates the adrenal cortex to produce glucocorticoids such as cortisol or corticosterone (Selye, 1976). As a result inflammation is reduced; immune cells are suppressed by glucocorticoids; and blood volume and pressure increase. However, if cortisol levels stay increased for too long, negative affects such as muscle breakdown, a decreased inflammatory response, and suppression of the immune system will occur (Selye, 1976). Selye continued his laboratory and clinical study of somatic diseases regarding stress. “I have tried to arrive at a code of ethics based on the scientifically verifiable laws that govern the body’s reactions in maintaining homeostasis and living in satisfying equilibrium with its surroundings” (Selye, 1976, p.32). Selye attempted to show how personal reactions can be adjusted to make one enjoy the eustress of fultillment without suffering the distress generated by frustrating friction and purposeless aggressive bahavior against our surroundings (Selye, 1976). Furthermore, Selye argues that life is largely a process of adaptation to the circumstances in which we exist. “The secret of health and happiness lies in successful adjustment to the ever changing conditions on this globe and the penalties for failure in this great process of adaptation are disease and unhappiness" (Selye, 1976, p. xv). “Our failure to adjust ourselves correctly to life situations is at the very root of the disease-producing conflicts” (Selye, 1976, p. 406). Selye (1976) states that psychoanalysis cures because it helps individuals to adapt to changes happening in their lives. Most of Selye’s work on the strssor effect of anxiety, anticipation, fear, and arousal made it clear that anxeity does cause distress and interferes with performance in various areas (Selye, 1976). “The sorrow of the parents whose children suffered from serious disease led to an increase in adrenal cortical activity which depended largely upon the individual’s coping behavior” (p. 200). Further studies suggested that the same visual stimulus would produce various amount of stress depending upon the nature of the cognitive appraisal the person makes regarding its significance for him (Selye, 1976). For example, same anxiety-producing film was shown with three different sound tracks, one of which was designed to increase its stressor effect by emphasizing threatening aspects while the other two were based upon the theory of ego defense, encouraging defensive and cognitive interpretation. The results showed that the defensive sound tracks produced the least amount of stress (Selye, 1976). According to Selye (1976), stressors such as failure of group mission or objectives, unrelaistic goals, difficult tasks, sudden emergencies, deprivation of physical, social, emotional, and cognitive needs, discomfort from cold, heat, fatigue, and lack of sleep result in stress sypmtoms such as panic, apathy, loss of will-to-live, exhaustion, and collapse. Selye dedicated his life to research on general adaptation syndrome and wrote about 32 books and more than 1,500 articles on stress including The Stress of Life (1956) and Stress without Distress (1974). He held earned doctorates in medicine, philosophy and science, as well as 19 honorary degrees from universities around the world. Selye was a recepient of numerous honorary citizenships and medals, including the Starr Medal (the highest distinction of the Canadian Medical Association). Selye’s contributions to science opened new avenues in understanding and treating stress through out the world. Hans Selye known as the father of stress died at age 82 in Montreal. Nursing diagnosis Parental anxiety is the most prominent nursing diagnosis related to a child’s illness and PICU admission. Parental anxiety is evidenced by irritability, crying, angry outbursts, losing control, and restlessness (Board & Ryan-Wegner, 2002, Board, 2004, Balluffi et al., 2004). Moreover, altered parental role and altered parental coping mechanism are two other nursing diagnoses identified in relation to the child’s PICU admission. Furthermore, knowledge deficit related to child’s medical condition as well as the PICU setting is a relevant nursing diagnosis that if not addressed can lead to stress. Health care providers must initiate a thorough assessment of the patients and their family in a timely manner in order to formulate the proper nursing plan in which nursing interventions would focus on identified needs of the intended learner, in this case the parents.
Nursing intervention Developing a therapeutic relationship with the parents of a critically ill child in the PICU is one of the most important steps in providing quality nursing care. Parents who are annoyed, irritable, and frustrated can pose a great challenge to the nursing staff. Directing all nursing actions toward meeting patients and their families needs psychosocially as well as physically can help reduce the tension experienced by the parents and promote communication between parents and the health care providers. Therapeutic communication is the key to meeting the psychosocial needs of the parents in any settings especially in the PICU where environmental stimuli are overwhelming and stressful. In respect to environmental stimuli, nurses can orient parents to the equipments, machines, and monitors and provide a general explanation of their use and what alarms signify. Furthermore, nurses can set proper alarm limits to control unnecessary alarm sounds. Controlling the noise level in the ICU can help reduce the effect of environmental sources of stress for the parents of critically sick patients (Board & Ryan-Wenger, 2003). Establishing a trusting relationship with the parents will create an environment in which feelings and needs of the parents can be explored. Nurses should actively listen to the parents and acknowledge their feelings of anger, helplessness, fear, and frustration because the acknowledgement is an expression of empathy and creates an opening for further exploration. In addition, parents should be allowed to stay with their child and be involved in their child’s care as much as possible. Parents who stay at the bedside of their children wish to be involved in their care and report significantly less feelings of loss of control over their child (Dudley & Carr, 2004). Allowing parents to participate in their child’s care and perform tasks as simple as handing the nurse a wash cloth or wiping child’s mouth may ease their coping with issues related to protection, uncertainty, and control. Limiting the number of people in and out of the patient’s room is necessary as PICU parents perceived it as a source of stress (Board & Ryan-Wenger, 2003). Nursing staff should be the gatekeeper and prevent unnecessary contacts between different types of hospital staff and the parents. Effective communication among team members and frequent parent updates by the team leader such as the attending physician can reduce the amount of anxiety and stress family experience in the PICU. Performing invasive procedures such as line placement, intubation, shots, and injections were also identified as the source of stress for parents in the PICU. Nursing intervention include educating the parents on the necessity of the procedure, allowing parents to remain with their child during the procedure, and preparing the child appropriately for the procedure. However, nurses need to assess the parents knowledge base in regard to their child’s status and the procedure as well as any misconception they may have prior to teaching. Moreover, nurses as the patient advocate must assure that the issue of pain is taken care of prior to performing any procedures. Additionally, nurses need to explore psychosocial support system available to the parents to help them get through this difficult time. Other family members, religious groups, and friends often provide a strong support system for the families in crises. Furthermore, as the care facilitators, nurses should inform the parents of the services available to them through the hospital and mobilize the appropriate services.

In conclusion, nursing intervention should be gauged in such manner that all aspects of the family as a whole unit are addressed during the child’s hospitalization.
Primary prevention Orientation to the intensive care unit prior to the admission can be helpful in reducing parental anxiety related to the PICU. Allowing patients and their families to walk through the intensive care unit and explaining the equipment, monitors and alarms to them would lessen the anxiety related to the ICU environment. However, most PICU admissions are unexpected and come with no warning leaving parents in total shock. Nursing staff can orient the parents to the intensive care unit as soon as possible after arrival to the PICU. Educating parents may be a challenge at this time due to high levels of anxiety related to their child’s sickness which can affect their attention span. However, nurses need to assess the situation tactfully and approach the family at the right time. Allowing the parents to arrive and remain with the child in the PICU has been reported to promote parental coping mechanism and family adaptation (Dudley & Carr, 2004). Nursing staff need to be more aware of their behavior and interaction upon admitting the child and reassure the parents that the PICU staff is their child’s advocate and will provide the best possible care. Providing written material such as parents welcome letter, pain pamphlet, and other educational resources may help reduce parental anxiety upon admission to the PICU.
Conclusion
Parents of the critically ill children who are admitted to the pediatric intensive care unit experience a high level of stress and anxiety. Identifying stressors and stress symptoms related to ICU setting can help health care providers implement nursing intervention that would preserve parental role and promote communication between health care providers and the family. Moreover, Caring for critically ill children and their parents requires a delicate nursing care that would enable parents to continue in their family roles to be effective and therapeutic to their children. Providing a family-centered care to a critically ill child in the PICU may contribute to a better hospital experience for both staff and families.

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