University of Huddersfield
Tokenism or true partnership:
to what extent is parental
involvement in the child’s
acute pain care facilitated by
nurses within a culture of
family centred care in general
children’s wards?
Jackie Vasey
Historical perspective- the early years
• Dr George Armstrong 1717-1789- instigated ambulatory
care, and believed in families caring for their children at
home. He stated that to separate a child from their families
would “break their hearts immediately”. (Miles, 1986 p 83)
• But that is exactly what happened when children’s
hospitals/wards began to open, with very limited or no
parental visiting. In 1951, 150 hospitals completely banned
visiting for parents (Robertson, 1989)
• Nurse felt that parental presence was detrimental to the
child settling in and a hindrance to the nurse! (Glasper and
Richardson, 2006: Jolley, 2008)
Who would dare to argue with this matron?
Historical perspective- late 1900’s
• Bowlby and Ainsworth (Betherton,
1992)
• Robertson- stages of separation anxiety
(Robertson, 1970)
• Platt Report (Committee of the Central
Health Services Council, 1959)
• NAWCH/ASC (ASC, 2002)
Stages of separation anxiety during maternal
deprivation
• Protest
• Despair
• Denial/ detachment
(Robertson, 1970)
The 2 year old who went to hospital
Parental involvement in this eraparents were still trying to get
through the door!
Historical perspective- late 1900’s
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Concept of family centred care emerged from the 1950’s following the work of Bowlby
and Robertson (Bowlby, 1953: Robertson, 1989: Smith et al, 2002)
The Platt report resulted in slow adoption of open visiting (Committee of the Central
Health Services Council, 1959)
Other reports followed- Court report (Department of Health and Social Security, 1976),
Welfare of children and young people in hospital (DH, 1991), Audit Commission
Report (1993), The Patient’s Charter (DH, 1996)
Some reluctance by nurses who felt parental presence was not a positive move.
Questions were raised about this “cherished policy of involvement”. FCC has been
argued to be ill-defined (Franck & Callery, 2004).
Darbyshire identified inconsistencies in how the meaning of family involvement is
interpreted, resulting in parental involvement occurring more at the level of
professional ideology that in everyday practice (Darbyshire, 1994)
Callery described it as “ad hoc and unpredictable” and highlighted the financial,
social and personal costs to parents (Callery, 1997)
Shields et al (2008) argues that it’s effectiveness has not been measured.
Started to let mums in
And dads too!
Even both parents at the same time!
Family centred care continuum
“Family centred care is an approach to the planning, delivery and evaluation of healthcare that
is governed by mutually beneficial partnerships between healthcare providers, patients and
families” (Shields et al 2006, p. 1318)
No
Involvement
Involvement
Participation Partnership
Parent-led
Nurse-led
Nurse-led
Nurse-led
Parent-led
Equal status
Smith et al (2002)
Current perspectives regarding pain care-
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Abundance of literature regarding children’s pain management emerged in the 1990’s
(Helgadottir, 2000; Cunliffe & Roberts, 2004; Gold et al, 2006 Johnstone et al, 2007;
Reaney, 2007)
However, few studies explicitly explored parental involvement and the most recent
appears to be in 2002. (Woodgate & Kristjanson, 1996: Simons et al, 2001: Simons &
Roberson, 2002)
RCN/RCPCH developed guidelines that advocate the involvement of parents (Royal
College of Paediatrics and Child Health, 2004: Royal College of Nursing, 2009)
NSF’s standards 4.28-4.33- whilst this document sets standards in response to the
Kennedy report and attributes the lack of partnership with parents as a contributory
factor in the events at Bristol- it does not specifically include parental involvement in
a child’s pain care in the pain management section (DH, 2003).
However, the parent version states “you should be able to discuss with the staff what
more they could do to help with your child if he or she is in pain” (DH, 2003 p 15).
Also, whilst the Care Quality Commission looked at how the standards had been met
in relation to aspects of pain management it did not specifically audit parental
involvement- perhaps this reflects the relative importance placed on this
Clayton (2000) states that the culture in child nursing, is one where nurses would not
contemplate using an approach to care that did not involve families.
How may parents be involved in pain care?
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Provide a pain history
Assist with the assessment of the child’s pain
Assist in the selection of the most appropriate pain control methods
Administer pharmacological and non- pharmacological pain relief
Alert the nurse to any adverse effects of the treatment
Evaluate it’s effectiveness
Continue pain care at home
Positive and less positive aspects of FCC for the
parents/child
Positive aspects of FCC for the
parents/child
Less positive aspects of FCC for
the parents/child
Child has security of a consistent and stable parent
present who assists with their needs- as normal
(Hutchfield, 1999).
Greater parental understanding of and participation
in decisions regarding their child’s care (MacKean et al,
2005)
More control over what happens to their child
(Clayton, 2000)
Mutual respect between nurses/parents (Hutchfield,
1999: Smith & Coleman, 2010).
More prepared to care for the child at home on
discharge (Smith &Coleman, 2010)
Minimises effects of hospitalisation (Hutchfield, 1999).
Gate control theory- parental presence reduces
anxiety for the child (Twycross et al, 1998)
Parents may pick up on their child’s pain behavioural
cues, as they know them best (Simons et al, 2001:
Gimbler-Berglund et al, 2008)
Child more likely to tell parent if they have pain
(Simons et al, 2001)
Parents are a true advocate for the child (MacKean et
al, 2005)
Empowerment may increase parent confidence in
themselves as care-givers (MacKean et al, 2005)
 Increasing anxiety and stress for parents (Shields et
al, 2008).
Captive mothers (Meadow, 1969)
Parent trap- parents prisoners by expectation
(Darbyshire, 1994)
Nurses are in control of their involvement (Callery &
Smith, 1991: Clayton, 2000)
Parents have to learn in minutes/hours what nurses
take years to learn (Valentine, 1998)
Information overload or lack of information for
parents (Hutchfield, 1999: Shields et al, 2008)
Parents may find it a financial, social and/or
emotional burden (Callery, 1997)
Is fully informed, fully burdened? (Callery, 1997)
Parents may have conflicting demands- for example
work/siblings/marriages (Callery, 1997: Clayton, 2000))
If parents indicate they want to be involved- they may
feel it becomes an expectation. Feel unable to take a
break (Smith et al, 2002).
Nurses hold power and select which roles to involve
parents in (Nethercott, 1993)
Guilt- bad parents if they are not involved (Nethercott,
1993)
Parenting in public- Human Rights Act (DH, 1998)
“ the right to respect for private family life”.
Older children/young people may not want their
parents to be involved (Franck & Callery, 2004)
Captive mother caught in the parent trap?
Positive and less positive aspects of FCC
for the nurse
Positive aspects for the nurse
Less positive aspects for the
nurse
Can work with parents to minimise the negative
effects of hospitalisation (DH, 2003)
 Increased job satisfaction (Smith et al, 2002)
Encourages communication with families (MacKean,
2005)
Children’s nurses taught FCC and pain care from preregistration- so not unexpected (Nethercott, 1993:
Twycross, 2000).
Lack of clarity about the concept and implementation
of FCC (Callery, 1997: MacKean, 2005)
Blanket approach- assuming parents are willing to be
involved (Callery, 1997: Shield et al, 2006).
Perceived increase in workload- teaching parents
nursing skills (Simons et al, 2001)
Shorter hospital stays result in limited time to assess
desired parental level of involvement (Darbyshire, 1994:
Corlett & Twycross, 2006)
May feel threatened by expert parents (Simons &
Roberson, 2002)
Nurses may feel they have “failed” if parents are
unable/unwilling to be involved (Smith et al, 2002)
Lack of knowledge and skills regarding pain
management may make nurses feel vulnerable/less
likely to involve parents (Manworran, 2007, Zisk et al,
2007)
Lack of understanding of FCC between nurses and
other nurses and other professionals (Clayton, 2000)
Concerns about accountability if tasks are delegated
to parents (Smith & Coleman, 2010)
Nurses may feel de-skilled. Anecdotally our students
report that “they can’t get near children” to develop
their skills when parents present
Requires the nurse to be able to judge when to
initiate parent involvement (Lee, 1999: Lee, 2004: Smith
et al, 2002)
Safeguarding parents
“Nurses must be trained in how to share care
with a resident mother and how to use her as
an efficient and willing source of labour”
(Meadow, 1969, p 366)
These are the questions I hope to answer.
• Are parents involved in their child’s
acute pain care?
• If so, to what extent is parental
involvement implemented
effectively?
• What influences involvement?
• Should they be involved?
• If so, how can this be better
facilitated?
So how do I intend going about it?
• Approach- Ethnography
• Method- Non-participant observation with
potential follow up semi-structured
interviews with nurses, parents and
children
• Data analysis- possibly content analysis
References
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ASC (2002) Online. Available at: http://www.action forsickchildren.org/about_history.html.
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