Communication with parents of hospitalized children Mgr. Jana Majerová Seminární práce 2022 INTRODUCTION With my impending birth and two children at home, it was clear to me that I would choose a topic for my ethics essay that would deal with children. I was deciding between Ethical aspects of surrogacy and Communication with parents of hospitalized children, and chose the latter. In this work, I mainly deal with communication with parents and whether parents of hospitalized children are allowed to stay with their children, I made this decision after a wave of surprise went through the public again that in the Czech Republic it is not usual for parentsto be hospitalized together with their children. More surprisingly, with their breastfed children. Given that I am focusing on the environment in the Czech Republic, I have chosen from studies that were written in the country. As a nurse and a mother, I try to look at the situation from both sides, however, I feel that the perspective of a mother is a bit more dominant at the moment. As far as theoretical sources are concerned, I mainly use the book Ethics in nursing practice by Heřmanová J., where the author writes about anchoring of children's rights, the Charter of rights of hospitalized children, and the children’s right to have contact with their parents. The Charter represents the legislative framework that is followed when a child is hospitalized. I believe that it is important to talk about this topic, even though in many hospitals it has already been common practice for children to stay with their parents. Yet, such practice is not common everywhere. It is vital to take this approach as a standard and take it into account when planning new hospital departments, reconstructing the existing ones, training healthcare workers, and creating healthcare procedures. 1 ETHICAL ASPECTS OF CHILDREN‘S TREATMENT Childhood and adolescence is a period from birth to 18 years of age. For an individual, this means physical growth, mental development, and a period of learning and playing. This period is also accompanied by a number of acute and chronic diseases. Vulnerability of children lies in their immature organism and low physical, cognitive and social abilites which would protect them from harmful behavior of some adults. Ethical problems, which can accompany this period, mainly include protection of rights of hospitalized children, information provision, and decision-making in some medical procedures (especially for adolescents). Communication of medical personnel with parents or children‘s guardians is also problematic. (Heřmanová, J., 2012) It is vital to remember the above specification of children's age. After all, children are not small adults, and they need to be approached with their specific needs in mind. 1.1 The rights of children In this part, I touch upon the legislative framework that deals with children's rights. The Convention on the Rights of the Child was signed by the UN General Assembly in November 1989, and the Czech Republic has been bound by this convention since 1 January 1993. The Convention is a part of the Czech legislation and is enshrined in the collection of laws as Act No. 104 /1991 Coll. It applies to every human being under the age of 18. Article 3 states that primary consideration shall be given to the best interests of children in any action concerning children, and Article 6 states that every child has an inherent right to life. Article 24 states that children have right to the highest attainable level of health and to the use of rehabilitation and treatment facilities. This work places great emphasis on educating parents and children in the area of hygiene, healthy nutrition, and preventing accidents. Children’s nurses and midwives should also participate in this activity, in addition to pediatricians, as one of their priority tasks is health support. (Heřmanová, J., 2012) 1.2 Rights of child patients The Charter of Rights of Hospitalized Children has been approved by the Central Ethics Commission of the Ministry of Health of the Czech Republic in 1993. The Charter aims to provide children with medical and nursing care in an environment that meets their specific psychosocial needs. If the child's state of health allows, outpatient and home treatment should be preferred. 1.2.1 Charter of Rights of the Hospitalized Child 1. Children shall only be admitted to hospital if the care they require cannot be equally well provided in home care or outpatient care 2. Children in hospitals have the right to keep close contact with their parents and siblings. Where possible, parents should be helped and encouraged to stay with their children in hospitals. To be able to participate in the care of their children, parents should be fully informed and encouraged to actively participate in daily running of hospital wards. 3. Children and/or their parents also have the right to information appropriate to their age and understanding. They should also have the opportunity to openly discuss their needs with staff. 4. Children and/or their parents shall have the right to participate in all decisions regarding health care provided to their children, and to do so in an informed manner. Every child shall be protected from all interventions that are not necessary for their treatment and from unnecessary actions to alleviate their physical and/or emotional distress. 5. Children shall be treated with tact and understanding, and their privacy must be respected at all times. 6. Children shall be cared for by trained staff who are fully aware of physical and emotional needs of children of every age group. 7. Children should be able to wear their own clothes and have their belongings with them in hospital. 8. Children shall be looked after together with other children of the same age group. 9. Children shall be in an environment that is designed and equipped to meet their developmental needs and that complies with safety regulations and childcare policies. 10. Children shall have full access to playing, resting, and education, adapted to their age and state of health. (Heřmanová, J., 2012) I believe it would be appropriate for parents to familiarize themselves with the Charter of Rights of Hospitalized Children upon entering a hopsital ward. In practice, however, I have only seen the Charter in frames on walls of hospital corridors. 1.3 The right to contact parents With a few exceptions, before 1989 in the Czech Republic it was uncommon for parents to stay with their children during hospitalization. Visiting hours were only twice week for two hours, as with adults, and health professionals did not always support parental or family visits for child patients. The argument for this was that the presence of parents caused the children to be upset after they left, and also that children who did not have their parents with them were negatively affected. These children then showed signs of hospitalism and, if the separation from their parents was longer, also signs of mistrust and alienation. (Heřmanová, J., 2012) Although I was hospitalized as a child only after 1989, it was very similar to what Heřmanová describes above. There was not even room for me in the children's ward, so I was in the ENT ward 3 times with other adult women. As a child, I assumed that my parents had forgotten about me for which I was very sorry and I cried. Nowadays, the fact that parents should be allowed to be hospitalized together with their children is taken for granted. This would also be desirable for older children as well. If the hospital ward does not allow for a 24-hour stay, parents should have the opportunity to be in the room with their children for as long as possible during the day. This should also be possible in intensive care units and resuscitation departments. Even in these wards, being at the children‘s bedside and being able to participate in their care is very important, especially from the point of view of managing the challenging situation. This can be beneficial to both the parents and children, even if they are in a coma. (Heřmanová, J., 2012) Nowadays, it is common practice that hospitalization is automatically offered to parents of children as we can find in the works of Hanzalova (2014) and Janásová (2011) who investigated offering of this option in hospitals. It is evident that parents themselves often had to ask for or even force the stay, especially with pre-school children, In my opinion, this is not something that should be happening. I still remember a case from May of this year, when a hospital called the Police on a mother because she did not want to leave her child who was about to undergo surgery. The mother wanted to stay with her child until the anesthesia had been administered. The hospital did not want to allow this and argued with the legislative framework, internal regulations, and disruption of the provision of health services. The situation escalated to the point where the mother was recording everything and the Police were called. (Martinek, 2022) At the moment, I feel more for the mother who had to leave her child alone and was cornered by medical staff. Because, as I often know from practice, everything is about people and where there is a will there is a way. After all, there are in fact hospital facilities where parents can be with their children until anesthesia is administered, which prevents from jeopardizing the running of operating theaters and maintaining sterile conditions. Only one thing is needed; to create a procedure and properly train all participants, especially for planned medical interventions. I consider the stay of parents with their children during hospitalization very beneficial. It makes the work of medical staff easier, although I understand that it may not be pleasant for the staff when someone is constantly observing them. Healthcare workers do not always consider parents' stay beneficial and see it as more work. I believe that it is vital to get used to this and take it as common practice. The already mentioned proper education of parents by medical staff is also a pre-requisite. Hanzalová’s work also supports this, mentioning opinions of parents who themselves see the benefit of their presence and approach the situation this way. 1.4 Relationship of medical Staff, children, and parents Children's nurses are in frequent contact with parents of hospitalized children, often looking for a balance between friendly and impersonal approach. A balanced relationship should be professional and should instill confidence in parents but also respect the work of nurses and the entire medical teams. Nurses should see the parents as their partners in the care of children, encouraging, educating, and listening to their concerns. However, nurses must know that the goal and purpose of their relationship with parents is the care of children. (Heřmanová, J., 2012) Sundal (2020) mentions two characteristics of an ideal cooperation between parents and health professionals: flexibility and sharing responsibility and tasks in the care of children. There are, of course, different areas of responsibility of medical staff and parents, and different purposes of nursing care. I agree that, if possible, parents should be primarily responsible for maintaining home care, and medical staff for treatment-oriented care, in accordance with the severity of children’s conditions. I agree with conclusions of Beránková (2011), who states that mutual trust between a family, a nurse and, a child, is a basic prerequisite for their relationship. A difficult life situation they experienced, such as hospitalization of a child, can be different for each individual and a family, depending on their psychological, social, financial, and spiritual state before the hospitalization. Fear for a child is a family‘s natural reaction, and the need for information is therefore self-evident. Communication and education are two areas that need to be worked on the most, so that results are as satisfactory as possible for all parties. The fact that there is room for improvement for all parties is also reflected in the Diploma thesis of Faiereis. Nurses themselves do see the need to inform mothers of children, however, for some reason, this does not happen. There is also a difference in when information is provided by parents and staff. It would be appropriate to ensure that parents clearly understood the information they received, I realize this information will need to be provided to parents repeatedly, as what is a routine for medical staff can be a completely new situation for parents. Moreover, situations where children are sick can be tense and emotionally demanding. It is, therefore, necessary to ensure that parents have understood the information given to them, and that medical staff have feedback on whether the delivery of information was effective. Unfortunately, this does not happen very often, as Vystrčilová (2017) states in her work. Some information may, therefore, need to be repeated to parents. Parents could receive brochures during the first briefing by healthcare workers. What would also need to be thought trhough would be the way information is conveyed, for example in an environment that is suitable for children, being mindful of noise, ensuring intimacy, considering verbal and non-verbal elements of communication, introducing oneself, etc. It would be a good idea to consider publishing a brochure where the most important information and illustrations would be available at all times. Information provided to parents would then be unified. Similarly, a professional relationship is also required for children who are ill. A good knowledge of nursing in pediatrics and children‘s psychomotor development is, therefore, vital. Children react differently to hospitalization, depending on their health status, age and previous experience. It is important for parents to consider all these factors, as children might not neccessarily accept the smiles of staff or the effort to make physical contact. It is, therefore, important not to take children‘s reactions personally and not to avoid negative children. Sometimes, there are also situations when nureses are confronted with children’s inappropriate behavior, which can disrupt the running of the ward, the children‘s treatment, and the rights of other children to a safe and peaceful environment. This inapproprietness might just be the way of children trying to cope with a difficult situation, and therefore it woud be advisable to involve psychologists, play therapists, or other specialists (Heřmanová, J., 2012). In my opinion, the presence of a parent, especially for children under 6 years of age, is always necessary. A parent represents a familiar face and security to a child. I, therefore, believe that, according to the above, parents‘ presence helps mitigate negative reactions of children during daily care. I also believe that although children may seem more tearful during medical treatment in the presence of parents, this is because they allow themselves to experience unpleasant emotions right away and are, effectively, better able to cope with hospitalization. Although according to the work of Hanzalova (2014), medical staff believe that presence of parents is rather a burden, thanks to sufficient education they can be made aware that it is actually more beneficial for children to have parents with them during the medical treatment. Sundal (2020) also came to this conclusion in her work, and states thet presence of parents and their active approach during medical treatment are necessary for children to feel safe. What enabled parents to be actively involved was their appropriate education as well as thier attachment to children. Therefore, having children’s interest as a goal proved to be the best thing for children. There is, however another point of view, and that is when medical personnel observes inappropriate behaviour of parents which could be labeled as psychological or physical abuse. In such cases, the duty of the staff is to bring this to the attention of their superiors. The parents' behavior could also result from poor handling of the challenging situation, which children’s illnesses represent, but it might also be a long-term issue when punishment or humiliation of children is common in families. (Heřmanová, J., 2012) In conclusion, I realize that the circumstances and work environment may not always be on the side of parents being able to be comfortably hospitalized with their children and to communicate well with medical staff. My point of view is that the benefit of children should always be a priority. I often wonder if us, health professionals/adults, have forgotten what it is like to be small and scared when making decisions about restricing the presence of parents. Just the fact that children have to be in an unknown environment and undergo procedures that are not exactly pleasant for them should be enough to allow the presence of parents who symbolize safety and security. LIST OF BIBLIOGRAPHY BERÁNKOVÁ, Ž. Etické problémy při hospitalizaci dítěte. Ošetřovatelství a porodní asistence: recenzovaný vědecký časopis. 2011, roč. 2, č. 3, s.272-280. ISSN 1804-2740. FAIEREISLOVÁ, M. Hospitalizace rodičů spolu s nemocným dítětem z pohledu zdravotní sestry. Praha, 2009, Diplomová práce. Univerzita Karlova v Praze, Fakulta humanitních studií, Katedra řízení a supervize v sociálních a zdravotnických organizacích. Vedoucí diplomové práce Prof. PhDr. RNDr. Helena Haškovcová CSc. HANZALOVÁ, J. Spolupráce s rodiči hospitalizovaných dětí. Praha, 2014. Bakalářská práce. Univerzita Karlova v Praze, 2. Lékařská fakulta. Ústav ošetřovatelství, Vedoucí bakalářské práce PhDr. Tomová Šárka HEŘMANOVÁ, J. Etika v ošetřovatelské praxi. Praha: Grada, 2012. Sestra (Grada). ISBN 978-80-247-3469-9. JANÁSOVÁ, A. Přínos rodičů a rodinných příslušníků pro dítě hospitalizované na infekční klinice. Brno, 2011, Bakalářská práce. Masarykova univerzita, Lékařská fakulty, Katedra ošetřovatelství. Vedoucí bakalářské práce Mgr. Marta Šenkyříková MARTINEK, J. Chtěla být se synem, než usne. Nemocnice zavolala policii. In: Novinky. [online] 6. 5. 2022 [cit. 2022-10-28]. Dostupné z: https://www.novinky.cz/clanek/domacichtela-byt-se-synem-nez-usne-nemocnice-zavolala-policii-4039606 SUNDAL, Hildegunn a Solfrid VATNE. Parents’ and nurses’ ideal collaboration in treatment-centered and home-like care of hospitalized preschool children – a qualitative study. BMC Nursing [online]. 2020, 19(1) [cit. 2022-10-28]. ISSN 1472-6955. Dostupné z: doi:10.1186/s12912-020-00445-7 VYSTRČILOVÁ, D. Komunikace a informovanost rodičů dětí přijímaných na dětské oddělení a JIP. Brno, 2017. Diplomová práce. Masarykova univerzita, Lékařská fakulta. Katedra ošetřovatelství. Vedoucí diplomové práce doc. PhDr. Miroslava Kyasová, Ph.D.