This chapter considers issues surrounding the emotional well-being of the sick child, and the psychological preparation of children for hospitalisation. Saile et al (1988 p 109) define psychological preparation as:

The latter half of the 20th century, and indeed the first few years of the 21st, saw growing recognition within paediatric nursing of the potentially harmful effects that may result from children’s hospitalisation. A range of initiatives have been implemented to minimise such harmful effects, including parental participation in care, play specialists, shorter inpatient stays, preadmission preparation programmes and the development of more ‘child friendly’ hospital environments. It is therefore important that the child health practitioner has a sound understanding of these issues, and of the historical background to these initiatives.

The original founders of the UK children’s hospitals, which were built during the reign of Queen Victoria, were primarily motivated by the alleviation of the physical elements of illness during childhood. Children’s nurses of the past might not always have embraced the concept of family-centred care in the same way as contemporary nurses; this was perhaps a reflection of the poor understanding of the psychological aspects of health and illness prevalent at that time. Despite this, the maxim of the first of these Victorian edifices, the Hospital for Sick Children in London, is ‘the child first and always’ (Glasper & Charles-Edwards 2002). Indeed, during the 18th century, Dr George Armstrong is credited as being highly influential in delaying the opening of tertiary inpatient facilities for children in London, suggesting that children and their parents should not be separated as doing so would break the child’s heart (Miles 1986). He believed that parents would not be able to look after their children in hospital because of economic pressures (Glasper & Lowson 1998). However, in reality the appalling sanitary conditions, the overcrowding and the general poverty prevalent at that time ensured that the little care available in the home was also often of a poor quality (Kosky & Lunnon 1991).

It should be remembered that the early children’s hospitals were built in the pre-Nightingale era and before the professionalisation of nursing. The Nightingale tradition subtly changed the dynamics of the children’s hospitals, and military principles developed by Nightingale in the Crimea began to be applied. The move away from essentially lay care and the development of professional paediatric nursing had some disadvantages, namely the gradual exclusion of parents from the direct participation in care. So although there is evidence from historical drawings of the first ward at Great Ormond Street that parents were able to be with their children in hospital and participate in their care, the military changes eventually resulted in the establishment of strict visiting hours, with parents prohibited from visiting at a time convenient to them. Some hospitals allowed parents to visit only once a week or less often.

Bed rest for children until the advent of antibiotics was long and continuous and the screams and incessant crying bouts that accompanied each weekly visit convinced the nursing staff that parents were generally a hindrance rather than a help. Eventually, parents were perceived to be such an infection risk that some hospitals abandoned visiting altogether. Relatives were therefore often excluded because they were likely harbingers of disease and, perhaps more importantly, potential disturbers of the smoothness of long-established ward routines. The visiting times in many children’s hospitals were severely restricted. In the Southampton Children’s Hospital, for example, at least up until the outbreak of the First World War, visiting was allowed from 2 to 4 p.m. daily, except Sundays. As the century progressed, it became confined to 1 hour on Wednesday and Sunday afternoons, and then in 1947 was banned completely. Visiting was recommenced in 1950 on a limited basis and parents had to wear face masks. Indeed, looking at the UK as a whole, of the 1300 hospitals in Britain in 1951 that admitted children, only 300 allowed daily visiting (usually limited to 30 minutes) and 150 prohibited visiting altogether (Robertson 1989). The white-coated doctors and the starchly uniformed nurses who were so confident about the rightness of traditional practice often intimidated parents and were inaccessible for discussion. There was little in the curricula of either profession on the emotional aspects of childhood and it was not until after the Second World War that the real detrimental effects of early hospital admission became widely recognised.

There were, however, some enlightened paediatricians who had begun to make observations on the detrimental effects on personality development of institutional care. Sir James Spence, Professor of Child Health at the University of Newcastle’s Royal Victoria Hospital, began to allow mothers to stay in hospital with infants and young children, although he did not extend this service to older children (RCPCH 2000).

The recognition that psychological trauma might be perpetrated on children during their hospital stay came about slowly, and in the UK owes much to the work of John Bowlby and James Robertson. Their work was instrumental in providing the precursors necessary for the creation of a much more family-focused approach to the care of hospitalised children.

Politicians of all political parties have described the health services for children as a potent investment in the country’s future. Ambulatory care, of which daycare is a central component, provides the minimum of disruption to the family unit, as a result of shorter hospital stays, and is a potentially powerful weapon in the prevention of psychological trauma caused by an inpatient admission. Many hospitals now have purpose-built day units for children. Such units cater for children undergoing minor surgery, medical therapy, investigative procedures or observation (Ireland & Rushforth 1998). Day units function in a variety of ways; some keep patients for a full day before discharge and others only half a day. For day units to run optimally, a paediatric community nursing service is vital to provide an essential link between hospital and home (Atwell & Gow 1985). Without the provision of such services, the management of children undergoing daycare is fraught with difficulties.

Smith (1986) believes that emotional factors might be an even greater source of concern than the child’s physical condition during a hospital admission. Although improvements have occurred since the publication of the Platt report, it is important not to be complacent. The many practical tasks and physical needs required by the child and family can, due to time constraints, all too easily dominate the day. It can therefore be easy to lose sight of the child’s psychological needs. In a seminal quote, Jolly (1976 p 1532) recorded the words of a 6-year-old child:

Fear of the unknown, fear of physical harm and pain, loss of control and identity, uncertainty about what is expected of them and separation from security and family routine are identified by Visintainer & Wolfer (1975) as five key potential threats to a child on admission to hospital. Anecdotal evidence suggests that, 30 years later, these fears are no less real. Anxiety may be displayed in some by, for example, regressive behaviour, tearful/fearful mood, sleep disturbance or changes to eating pattern. Everyone, to a greater or lesser degree, will have concerns, questions and apprehensions when they are admitted to hospital; a child is no exception. In addition to this, the way in which children interact with the world and attempt to understand and interpret what they see and hear is influenced enormously by their age and stage of development (Piaget & Inhelder 1969 and see Chapter 11).

In contrast to the well-established practice within paediatric nursing of measuring pain, it is interesting to note, as highlighted by James’ comments, how rarely nurses explicitly seek to ‘measure’ children’s emotional states. A notable exception is seen in the work of Ellerton & Merriman (1994), who used an ‘anxiety faces scale’, similar to the well-established ‘faces’ pain tools, to measure children’s emotional anxiety. However, both scales are vulnerable with regard to their accuracy and it is – arguably – important to consider more objective means of measuring anxiety as well.

The link between physiological change and a person’s psychological status has been recognised and researched (Hyland & Donaldson 1989). One such early study detected changes in urinary excretion in connection with anxiety responses (Wilson 1981). Additionally, seminal work by Brain & Maclay (1968) showed a higher incidence of complications, such as infection and haemorrhage, in a control group whose mothers were not resident during a child’s stay compared with an experimental group whose parents were present. These studies support the fact that disease and illness are not purely a biological phenomenon. However, contemporary research tends to measure anxiety more by behavioural change and attitudinal scales; unfortunately there is a paucity of recent work exploring the physiological manifestations of anxiety.

On the premise that emotional needs might be as great, if not greater, than a child’s physical needs during a hospital admission, a number of different strategies have been developed to help children and their families cope with hospital admission.

Family preparation for day and inpatient surgery is thought to be important in reducing the psychological effects of hospitalisation. Modern child healthcare services require integration between hospital and community. The service should provide for the child as a whole and should meet the social, emotional, spiritual needs of children and their families as well as their physical needs. The growth of paediatric preadmission programmes throughout the UK represents one facet only of this integrated service. Since the publication of the Platt report, paediatric nurses have developed a reputation for endeavouring to improve the care of their patients and families. Attempting to protect children from the stresses of hospital admission may be partially facilitated through the provision of preadmission programmes. Although the evidence base for the efficacy of these programmes has yet to be firmly established, the Commission for Health Audit and Inspection (CHAI, formerly CHI) has developed an audit tool for NHS Trusts to use to measure compliance to the standards of hospital services developed under the auspices of the National Service Framework for Children. One of the paediatric benchmarks that CHAI will audit is related to preparation, and preadmission clubs are specifically cited as examples of best practice.