Developmental Tasks of the Infant

Erikson identified eight crises that must be resolved at major stages of human development.²⁷ He theorized that the developing infant, child, or young adult leaves each crisis with both positive and negative aspects. The developmental crisis of infancy is to acquire a sense of basic trust while overcoming a sense of mistrust. To acquire a sense of trust, the infant must develop a sense of physical safety and confidence that physical needs will be met. The quality of the parent-infant interaction and the parents’ ability to interpret the infant’s cues are important to the development of trust. When an infant is frustrated repeatedly in attempts to make needs known and have them met, distrust and pessimism can develop. Once a sense of trust is achieved, unfamiliar or unknown situations can be tolerated with minimal fear.

Both Erikson²⁷ and Freud³¹ have identified infancy as the oral phase of development. Sucking is of primary importance to the infant, because it is the infant’s major source of gratification and tension release.

When an infant is hospitalized in a critical care unit, the potential for frustration is high. Illness disrupts many of the infant’s physiologic processes and normal routines and rhythms, such as eating, sleeping, and exercise. The infant is in an unfamiliar environment, with care provided by strangers who are not as sensitive as the parents were to the infant’s cues. The presence of an endotracheal tube or restraints can prevent the infant from sucking, eliminating a major source of gratification and comfort.

The infant’s affective experience is determined largely by the emotional reactions of significant caregivers. This social referencing can be seen, for example, in a situation in which an infant looks to the mother after a surprise event to determine by her reaction whether to laugh or cry. This example further indicates the important role that parents play in their infant’s life.⁴² Because the parents typically know the infant very well, they can to teach the nurse about the infant’s unique cues, needs, and responses; their presence during the infant’s hospitalization is essential to help meet the baby’s needs.

Although infants are unable to express their feelings and needs with language, they can indicate their need for more attention or stimulation in other ways.^76,93,99 Perhaps more important, they communicate when they are becoming overstimulated and need rest. It is crucial that nurses constantly assess the infant’s tolerance during planning and provision of nursing care. In older children, it may be useful to group procedures and then to allow longer periods of uninterrupted rest, but this approach may not be optimal for infants. Too much stimulation at one time can diminish the infant’s coping resources, resulting in adverse physiologic reactions such as vomiting, respiratory distress, apnea, or bradycardia. Gaze aversion is a behavioral cue of fatigue or overstimulation that nurses and parents sometimes miss.

Because the nurse was not sensitive to early indications that Jamie was becoming overstimulated and could not tolerate eye contact at that point in time, the stimulation continued and led to a more extreme response.

States of Consciousness in the Infant

The infant’s state of consciousness exerts a powerful influence on the infant’s response at any given time. Two sleep states (deep and light) and four awake states have been identified in full-term infants (drowsy, quiet alert, active alert, and crying).^10,14,89

During deep sleep the infant is motionless except for occasional startles or twitches. There are no eye or facial movements except for occasional sucking movements at regular intervals. The infant’s threshold to stimuli is high; only intense and disturbing stimuli will arouse infants in this state. Although it is possible to arouse the infant with gentle shaking or stimulation, usually the infant will return to sleep. Generally, the nurse will be frustrated in attempts to feed an infant in this state or to arouse the infant to an alert state. It is more effective to wait until the baby cycles to a more responsive state. It is important for the nurse to be aware that this deep sleep state exists normally. Although inability to arouse an infant can result from neurologic abnormalities, it requires strong stimuli to arouse infants from this normal deep sleep state.

Light sleep accounts for the highest proportion of an infant’s sleep. During this state, the infant may demonstrate some body movement, rapid eye movements (fluttering of eyes beneath closed eyelids), and irregular breathing. Infants are more responsive to stimuli and more easily aroused during this period.

During the drowsy state, the infant has a variable activity level, irregular breathing, and delayed response to sensory stimuli. The infant’s eyes appear heavy-lidded and have a dull, glazed appearance. Infants in this state can often be aroused to the more interactive quiet alert state by providing visual or auditory or oral stimulation. Such intervention can be helpful in facilitating parent-infant interaction in the critical care unit.

It is during the quiet-alert state that the infant can be the most interactive and provide the most positive feedback to parents or other caretakers. Infants in this state have wide, bright eyes, regular breathing, and minimal body activity. They are interested in their environment and focus attention on their caretakers, moving objects, or other stimuli. It can be gratifying and comforting for parents to be able to smile at and talk to the baby in this state.

Infants in a critical care unit may spend a large portion of their awake time in an active-alert state. This state is characterized by significant body activity with periods of fussiness. Breathing is irregular. The infant’s eyes are open but are not as bright as in the quiet alert state, and there is frequent facial movement. The infant can become sensitive to and upset by disturbing stimuli such as hunger, background noise in the critical care unit, and excessive handling. As the infant becomes more active and upset, intervention is often necessary to bring the infant to a lower (i.e., quiet-alert) state and avoid escalation to a crying state. Many critical care units have attempted to reduce excessive background noise and other auditory and visual stimulation.

Crying is one of the infant’s major methods of communication.¹⁰ Crying is associated with increased body activity, grimaces, wide-open or tightly closed eyes, and irregular breathing. Although the infant’s color can change to bright red, very sick patients or those with cyanotic heart disease may demonstrate peripheral or more generalized cyanosis. Infants may be able to bring themselves to a quieter state by instituting self-consoling behaviors such as sucking on their fingers, fist, or endotracheal tube or by paying attention to voices or faces nearby. However, ill infants often need consolation from their caregivers and are often unable to provide self-consoling maneuvers, or such maneuvers may be ineffective. The nurse should attempt soothing maneuvers such as changing the infant’s diaper, feeding the infant, moving close to the infant, making eye contact, or talking to the infant in a calm, soft voice. The infant may also be comforted if held closely, swaddled, or rocked with a pacifier. Infants frequently are highly upset when uncovered or wrapped loosely, but become calm and drowsy when they are swaddled. A combination of verbal and tactile stimuli, such as patting, stroking, holding, or rocking is generally more effective in alleviating distress in hospitalized infants than verbal stimuli alone. Rocking seems to bring comfort and build trust and may relax the parent or nurse as well as the patient.

Touch is extremely important to infants, who need to be caressed, stroked, cuddled, held, hugged, and loved to feel secure and develop normally, and detrimental long-term effects from lack of tactile stimulation during infancy have been documented.^92,99 Therapeutic touch is a potentially useful therapeutic modality to relax the patient and enhance recovery.^43,46 However, premature and severely stressed infants can exhibit negative responses to excessive handling and stimulation.⁹⁹ The nurse must identify a therapeutic balance between too much and too little handling for each infant and modify the nursing approach based on the infant’s cues (e.g., gaze aversion, respiratory effort).

Cognitive Development in the Infant

Cognitive or intellectual development in normal children has been observed and described in detail by the Swiss psychologist Jean Piaget, who identified five major phases in a child’s development of logical thought.^69,71,72 The nurse is more likely to communicate effectively with children by understanding these phases and the basis of the child’s perceptions, fears, and misunderstandings.

Piaget named the period of infancy and early toddlerhood, from birth to approximately 2 years, the sensorimotor phase. There are six stages in this phase of intellectual development. From birth to 1 month, the infant generally uses reflexes such as sucking, grasping, and crying. The infant is completely self-centered and cannot differentiate self from others. Infants in this stage show little or no tolerance for frustration or delayed gratification.

In the second stage, approximately 1 to 4 months, the use of reflexes is gradually replaced by voluntary activity. Infants begin to recognize familiar faces and objects such as a bottle, and they show awareness of strange surroundings. They begin to differentiate themselves from others and discover parts of their own bodies. Young infants delight in playing with their fingers, hands, and feet. These infants seem to believe that an object or person exists only while within their sight. If an object falls to the floor or is hidden, the infant immediately loses interest and will not search for it. If a person leaves the room or moves out of sight, the infant acts as if that person no longer exists. Infants in this stage show no anxiety around strangers and may become bored when left alone for more than a few minutes.

In sensorimotor stage three, approximately 4 to 8 months, causality, time, deliberate intention, and appreciation of separateness from the environment are beginning to develop. During this stage the infant begins to develop the concept of object permanence—that is, objects and people still exist even when they cannot be seen. The infant will search for partially hidden objects and will look for objects that have disappeared from view, realizing that parents are present even when they are not in sight. Once the infant develops object permanence, attachment to parents or primary caretakers is obvious and strong. The baby demonstrates stranger anxiety and will likely protest when the parents depart. In this stage, infants begin to be able to postpone gratification and await anticipated routines with eager expectation. The baby develops an association between objects and events. For example, an infant may cry in response to nursing interventions related to insertion of an intravenous catheter, but may not yet be able to take constructive action, such as withdrawal, to try to prevent the painful event.

During the fourth sensorimotor stage, approximately 9 to 12 months, the infant’s concept of object permanence develops further. The baby learns that hidden objects still exist, and that he or she can take action, such as retrieving an object from under a blanket, to make the object reappear. This is the beginning of intellectual reasoning. The infant begins to understand the meaning of some words and simple commands and begins to associate gestures with events. For example, waving means someone is leaving. The presence of the infant’s mother is extremely important to the infant’s sense of security, and the threat of her departure is met with protest. The infant is developing a sense of independence in feeding and locomotion and begins to venture away from the mother for short periods to explore the surroundings. The infant now responds when addressed by name and inhibits behavior when told “no.” By the end of this stage, the infant is jabbering expressively, verbalizing words that refer to the parents, and saying a few other simple words.

During this period the infant may adopt a favorite blanket, pillow, or stuffed animal as a transitional object¹⁰¹ that provides comfort and a sense of security during the parents’ absence. Absence of the transitional object, particularly during times of stress, will increase the infant’s anxiety. Thumb sucking, genital play, and transitional objects are all potential mechanisms of self-consolation when parents are absent. The last two stages in the sensorimotor phase are discussed in the section, Emotional and Psychosocial Development of Toddlers, in The Critically Ill Toddler part of this chapter, below.

The Infant in the Critical Care Environment

Young infants admitted to a critical care unit may be most affected by the strange environment and disruption of normal routines. The infant’s usual sleep-wake cycles are interrupted by procedures, lights, alarms, or other noxious stimuli. Providers often attempt to arouse the infant regardless of the infant’s sleep state. Ironically, the critical care unit may also produce sensory deprivation with a lack of meaningful stimulation. Some characteristics of a stress-enhancing intensive-care environment—one that adds to the demands placed on the ill infant or child—and those of a more growth-enhancing unit are shown in Box 2-1.

The nurse must maintain a soothing and reassuring environment. Providers should attempt to interrupt constant, rhythmic sounds (e.g., the whooshing of a ventilator or beeping of a cardiac monitor) by introducing more meaningful, varying sounds such as talking, humming, or singing to the infant or by playing soft, soothing music. Providers should be aware that noises such as loud laughing or talking at the nurses’ desk, loud music, music with a rapid beat or uninterrupted music can be highly disturbing. Infants and children who receive pharmacologic paralytic agents are hypersensitive to bright lights, loud music, and voices. Because they are not able to move, they may become extremely anxious.

The often stark, sterile environment of the critical care unit can be made more comforting by the use of natural lighting, colorful walls and curtains, and bright mobiles. Pictures, blankets, or toys from home can help make the environment more attractive. The infant’s parents can personalize the environment by mounting pictures of themselves or other family members on the crib in the infant’s line of sight to give the infant something to look at.

From approximately 6 months of age through the preschool period, separation anxiety is the infant’s major source of fear. Separation from parents is extremely stressful.^12,87 Because separation is so traumatic, it is helpful for a parent to stay with the hospitalized infant as much as possible. Most hospitals have facilities for parents to stay with young children. If it is not possible for a parent to remain with the child throughout the hospitalization, it is beneficial to maintain flexible visiting opportunities at all hours for parents.

Robertson⁷⁷ has identified three distinct phases in the crisis of separation: protest, despair, and denial. Although shorter length of stay and more liberal visiting hours have reduced the separation of children from parents during hospitalization, some aspects of this crisis of separation may still be observed. During the protest phase the child cries loudly and screams for the parents while visually searching for them. The infant will tightly cling to the parent if the parent shows signs of leaving. Attention from others is rejected and may even intensify the protest of a child who is experiencing stranger anxiety. The child may seem inconsolable, sometimes quieting only when exhausted. This anxiety, which can last from hours to days depending on the child’s energy and degree of illness, adds to the child’s stress in the critical care unit. It can be frustrating to care for the infant who is protesting, but the nursing staff should still attempt to provide comfort, with consoling gestures, conversation, and objects (such as a pacifier or transitional object). If the nurse takes the time to interact with the infant while the parent is present, that nurse may seem safe to the infant, and the infant may be more receptive to that nurse’s interactions. It can also be helpful to attempt to distract the infant with a colorful toy or musical mobile.

The second phase of the separation crisis is the phase of despair. In this phase the child continues the mourning process, but becomes more passive and withdrawn. The child seems disinterested in play, food, or the environment and looks lonely, apathetic, or even depressed. Some of the child’s activities during this phase may be thumb sucking, head banging, rocking, sitting quietly and sadly, or clutching objects. The child continues to watch for the parents’ return. When they do come, the child may ignore them or act angry, but will usually cling ferociously to them if they show signs of leaving again.

The last phase of the separation crisis is denial, or detachment. The child seems to have adjusted at last, appearing friendly and interested in the environment and other people. More receptive to strangers, the child accepts caretaking from many people. This phase may be interpreted by inexperienced staff as a positive sign that the child is adjusting and is no longer anxious. This behavior may not be a sign of contentment, however, but of resignation. The child detaches from the parent to escape the pain of separation and denies longing for the parent’s presence.⁷⁷ The child may react with indifference when the parent returns or may seem to prefer the nurse or another staff member.

If the parents do not understand the basis of the child’s distress, they can become extremely upset. They may restrict their time with the child in an attempt to minimize the child’s distress; however, this will only reinforce the child’s fears. It is important for the nurse to explain the child’s behavior to the parents and encourage them to spend as much time as they can with their child. The nurse should assure the parents that they are helping their child to cope effectively with the frightening environment in the critical care unit. By minimizing the parents’ distress, the nurse will be helping to maintain the child’s best support system.

Preparation of the Infant for Procedures and Surgery

Older infants react intensely to potentially painful situations (Box 2-2). They are uncooperative and may refuse to lie still, attempting to push the threatening person away or to escape. Distraction is not as effective as it is with younger infants. The best technique to decrease fear and resistance is to familiarize the older infant with some of the equipment beforehand (e.g., let the older infant play with a stethoscope), to perform the procedure as quickly as possible, and to maintain parent-child contact. Advance warning of a painful procedure is essential. Painful procedures should never be initiated while the child is asleep, unless the child is anesthetized.

The Infant and Play

Play is critical for development, providing an important opportunity for infants to learn about themselves and the world.⁴⁷ Six features differentiate play from other behaviors⁵³:

Three types of infant play have been described. The earliest type of play, appearing at a young age, is social-affective play. The infant interacts with people, imitating adult actions, such as coughing or sticking out his tongue. The second type is sense-pleasure play, during which the infant derives pleasure from objects in the environment such as lights and colors, tastes and odors, textures and consistencies. Body motion—such as rocking, swinging, or bouncing— and pleasant sounds also provide pleasurable experiences. Sensorimotor activity is the third category of infant play. Infants initially play with body parts, bringing hands and feet into their mouths; oral testing is an important means of exploration. Motor activity is highly enjoyable for infants, and they take great pleasure in kicking their feet and waving their arms. Between 7 and 10 months of age, infants are able to enjoy throwing things out of the crib onto the floor. This game seems to be an endless source of fun. At approximately 9 months old, infants show a newly developed sense of object permanence. Games such as peek-a-boo and toys that go away and come back, such as a jack-in-the-box, provide enjoyable ways for the infant to work through fears associated with separation anxiety.⁵³

Infants can become highly frustrated if their feet and arms are restrained, particularly if they are accustomed to being active. Restraints should be used in the critical care unit only when medically necessary. When restraints are necessary for safety, they should still allow the infant as much movement as possible.

Pediatric critical care nurses should be creative when facilitating the play of these very ill patients. Toys that are appropriate for the baby’s age should be available, and the nurse should encourage the parents to bring toys from home. The older infant may benefit from observing as the nurse plays with puppets or dolls or punches a balloon. This form of passive play can provide the infant with a pleasant distraction from discomfort and fear.

The Infant and Death

The infant’s reactions to fatal illness and dying will be based on the degree of discomfort involved and on the parents’ reactions. Emotional expression in an infant is at a primitive level that is directly linked to impulse and sensation.⁴⁴

Emotional empathy exists between parents and children; this enables special communication that makes the feelings of each transparent to the other. Parents serve as the frame of reference for the child, and parental attitudes and feelings are clearly transmitted, even when the child does not fully understand the words being used. If the parents are helped to cope with their anxiety, they will be more calm and supportive and can decrease the infant’s anxiety. Because separation from parents is the most stressful event that can happen, even highly anxious parents should not be kept away from their child; instead they should be supported to promote effective coping.

Emotional and Psychosocial Development of Toddlers

The major developmental task for toddlers is beginning the development of autonomy and self-control,²⁷ so toddlers typically become more independent as the months pass. They can be a bountiful source of enjoyment and satisfaction as they take delight in exploring and discovering new things. They are often liberal with expressions of affection such as engaging smiles, hugs, and kisses. However, the reputation of this period as the “terrible twos” is well deserved, and caregivers must have a great deal of patience and understanding.

This is the “no” stage, and toddlers often adamantly state this newly learned word even when the toddler may want to say “yes”—a concept not learned until later. Parents and caregivers see resistive behavior as the toddler struggles to assert independence and gain control of the environment. Frequent temper tantrums can result from the toddler’s low frustration tolerance and need to test the limits of acceptable behavior. Dawdling behavior is common, particularly at mealtimes.

The toddler is extremely attached to and dependent on the parents. Parents represent safety and security. The toddler is typically more aware of separation from the mother and seeks more attention and greater closeness to her. The child forms relationships with the parents, rather than simply requiring their presence. Although a toddler can tolerate some physical distance from a parent and ventures away to explore and play, the toddler needs to find the parent or call to the parent at short intervals. Separation from the parents for prolonged or unexpected periods is difficult, especially when other stresses are present. Older toddlers are more able to accept symbols, such as a parent’s keys, as an indication that the parent will return. The toddler also may be more able to accept care and consolation from another caregiver if given an opportunity to become familiar with that caregiver over a period of time, particularly if the toddler sees that the caregiver has the parents’ approval.

Freud refers to the toddler years as the anal stage, because elimination and retention are important skills developed during this period.³¹ Toilet training begins during these years. Because bowel and bladder control are newly acquired skills, they may be lost when the toddler is stressed. Toddlers who have been toilet trained find it distressing to be placed in diapers. They also may find it confusing and anxiety-provoking to be told that it is acceptable to wet in their diaper or go to the bathroom in their bed after being told the opposite so frequently during toilet training. Toddlers require sensitivity and reassurance from parents and staff to help them feel less anxious. If possible, the child should be allowed to use a bedside potty chair.

Cognitive Development of the Toddler

The toddler makes massive strides in intellectual development, beginning to think and reason, although in a way that is different from adult cognition. During Piaget’s fifth sensorimotor stage of intellectual development, from approximately 13 to 18 months, the toddler further differentiates the self from other objects and will search for an object where it was last seen.⁶⁹ Early traces of memory also begin to develop during this period.

The child in this stage is beginning to be aware of causal relationships and can understand that flipping one switch will cause a machine to make noise, and flipping another switch may turn on a light. However, the child is not able to transfer that knowledge to new situations; for example, may not be aware that turning a switch of another machine may cause it to make noise. The toddler must continuously examine the same object every time it appears in a new place or under changed conditions. For this reason the toddler is likely to want to examine each stethoscope brought to the bedside by a different person.

During the final stage of the sensorimotor period, from approximately 19 to 24 months, egocentric and magical thinking begin. Toddlers view themselves as the center of the universe and can appreciate no point of view but their own. As toddlers become aware of their thoughts, they believe that others must also be aware of them and that events happen because of their activity, thoughts, and wishes. For example, they may think that their parents went away or hospitalization occurred because they misbehaved.

The toddler is extremely ritualistic and takes comfort from consistency of environment and daily activities. The global organization of thought that is characteristic of this period causes the child to recognize experiences or events as parts of a whole. As a result, if even small changes in the environment or schedule are made, the child may require time for readjustment.

The toddler is beginning to develop a sense of time and understands some temporal terms and relationships, such as “in a minute” or “after lunch,” although specific time intervals, such as “3   hours” are meaningless. The toddler’s attention span, which is limited, is characterized by a sense of immediacy and concern for the present. Language abilities increase and the toddler can understand simple directions or requests.

From approximately 2 to 4 years of age, children demonstrate the preoperational or preconceptual phase of cognitive development. Vocabulary and language development markedly increase during this period. Magical thinking and egocentricity are still prevalent during this phase, giving the child feelings of omnipotence and supreme authority. This ideation also causes the child to feel guilty, assuming that bad thoughts are responsible for events. The child’s inability to reason the cause and effect of illness or injuries makes these events especially stressful.

The toddler will begin to demonstrate animism, a process in which lifelike qualities are attributed to inanimate objects. For example, the child may blame a glass of milk for falling or believe that an x-ray machine or elevator is a monster.

Toddlers do not use deductive reasoning (from the general to the particular) or inductive reasoning (from the particular to the general); instead they reason transductively (from the particular to the particular). Children frequently will believe that there is a causal relationship between any two events that occur at the same time or are contiguous to each other in time and space. For example, the color of a balloon can explain why it is floating, or the need for sleep makes it dark outside.

The Toddler in the Critical Care Environment

Toddlers can become terrified in a critical care unit. They are in a new place where they see, hear, smell, and feel frightening things. There are many strangers around who sometimes do scary and painful things, and the toddler is unable to freely move about. Gone is the security of familiar surroundings and routines. The toddler may be separated from parents, and may be uncomfortable or in pain. As a result of egocentric thinking, toddlers may think their bad behavior caused their illness or hospitalization. Because most of the direct contacts in the PCCU are intrusive instead of comforting, interactions with staff can create fear.

Parental presence and support are more crucial than ever to the toddler during this period. When a parent is not present, a toddler may believe that punishment through abandonment is occurring. The toddler is terrified of complete desertion, and fears that the parent is angry; therefore, cries of “I want my mommy; I be good!” may be heard. The toddler can exhibit the same three stages of protest, despair, and denial that the infant does, but is able to be more verbal and assertive in protest.⁷⁷ Toddlers may call for their parents and may verbally reject consolation and care from others. Physical aggression, hostility, fighting, kicking, hitting, pinching, and biting may be displayed during this period. If nurses are not familiar with a child’s particular rituals for comfort, provision of different comfort measures can add to the child’s confusion and distress.

The best way to minimize the toddler’s anxiety is to minimize separation from the parents. During the toddler years, perhaps more than any other, every effort should be made to arrange for one parent or another familiar adult to stay with the child as much as possible. It is important for the nurse to convey to the parents that they are welcome in the unit to provide necessary support for their child. The PCCU is no place for restrictive visiting hours that might benefit the staff but add to the anxiety of the child or parents.

Rooming-in or frequent regular visiting by the parent decreases the possibility that the child will enter the despair phase of separation crisis. Children who progress to the despair state may become listless, anorexic, uncommunicative, and withdrawn. Regression to an earlier stage of development usually is demonstrated as loss of sphincter control, reduced verbal communication, or passivity. When the parent returns, the toddler often cries or expresses anger, distrust, or rejection. If the parent attempts to depart again, however, the child may cling tightly, crying and begging the parent to remain. If toddlers progress to denial, they can appear to be more accepting and interactive, but might actually be more disturbed.

It is helpful when a small number of nurses consistently care for the hospitalized toddler, to minimize the variety of schedules and personalities to which the child must adapt. In addition, the child who has the opportunity to build trust in a few nurses may be able to take comfort from them when a parent is not present.

Physical restraint or restriction, altered routines and rituals, and enforced dependency represent a loss of bodily control to the toddler who is striving for more autonomy. This loss can make the toddler frightened and resistant. By allowing toddlers as much movement and independence as possible, the nurse can increase their cooperation and decrease their fears and frustrations. The toddler often can be allowed to sit upright or remain on a parent’s lap during frightening procedures. Less physical restraint may be required if the child is given the opportunity to handle the equipment being used. For example, toddlers often enjoy listening to their chest (or to that of a toy or another person) with the stethoscope. When physical restraint is necessary, lost activity should be replaced with another form of activity whenever possible.

Loss of familiar rituals and routines decreases the toddler’s the sense of control, predictability, and security.

If the toddler’s mother or nurse can continue some home routines in the hospital, it will help the toddler’s sense of familiarity and security. Routines and rituals that are most important to the toddler must be recorded as part of the child’s history and incorporated into the plan of care, when possible.

All children need limits to feel secure and may be more frightened without them. This is particularly true of toddlers who have not yet mastered a great deal of control over their own impulses. They need to feel that there is someone close who will protect them from injuring themselves, others, or their environment. Setting limits can help children channel strong feelings into safe, socially acceptable, pleasurable activities. To prevent children from hurting themselves, others, or property, they should be restrained temporarily or removed from the situation with an explanation of why they cannot continue the behavior. Adults should acknowledge the child’s feelings and then direct the youngster into acceptable behavior for dealing with these strong emotions.

The immature thought processes of toddlers can contribute to their anxiety. Egocentricity, magical thinking, transductive logic, and animism can magnify fears of known events and make unknown or unfamiliar situations terrifying. Sinister characteristics may be attributed to machines and hospital personnel. Toddlers, thinking that their misbehavior caused their illness, might not understand their parents’ inability or unwillingness to rescue them. Toddlers need frequent reassurance that they are not bad, are not being punished, are loved, will get better (if true), and will be able to walk and talk and go home again. The toddler might not understand the concept of returning home, but will be comforted by gentle reassurance.

Preparation of the Toddler for Procedures and Surgery

Any real or perceived painful experience will be met with extreme emotional distress and physical resistance. Because toddlers have a poorly defined concept of body integrity, any intrusive procedures—even painless ones such as measuring body temperature or examining of the ears—can provoke an intense reaction. Toddlers can understand only very simple explanations. Prolonged or detailed explanations or explanations given too far in advance may create more anxiety (see Box 2-2, earlier in chapter). When it is necessary to perform painful procedures, lengthy discussions or provisions of choices are best avoided. It is best to provide a brief explanation, assure the child that you will be there, perform the procedure as quickly as possible, and then comfort the child. Offer choices when you are able to do so.

The Toddler and Play

Most of the toddler’s time is normally spent in some type of play activity. Play is a major component in learning about the world, communicating feelings, overcoming boredom, developing motor skills and independence, and working through anxieties.²³ The toddler’s need for play continues during periods of illness. Through play the toddler can find a constructive, acceptable outlet for fears, frustrations, anxieties, and anger. Familiar toys can be comforting and provide a sense of security. Play can serve as a diversion from pain and fear and can become a replacement for mobility. It also can provide some feeling of autonomy and independence by providing control over something.¹¹

Play might have to be passive when the child is critically ill; creativity is needed to find activities that are meaningful and provide positive sensory stimulation. Bright, colorful mobiles, posters, stuffed animals, and toys can provide visual stimulation. Musical mobiles, CDs, talking story books, radios, tape recordings made by the child’s parents or other family members, and visits from the music therapist can help substitute pleasant and meaningful sounds for hospital noises. Favorite television shows or movies can help bring a sense of familiarity into the critical care unit. A book of fabrics and other materials with various textures can be stimulating for the child. Any of these activities will be especially comforting when initiated by the child’s parents.

When the toddler is recovering, more active play can be introduced. Hammering or pounding boards, punching balloons, water play, and active toys such as a “busy box” are all meaningful outlets for toddlers who are immobilized or confined to bed rest. Peek-a-boo is still enjoyed at this age and reinforces the toddler’s learning that things and people go away but come back. The child may also enjoy “talking” puppets or dolls or listening to tapes of books read by parents or siblings.

The Toddler and Death

The toddler’s egocentrism, lack of a concept of infinite time, and inability to distinguish between fact and fantasy prevent comprehension of the absence of life and the permanence of death. The toddler is developing cognitive concepts of consistency and permanence, and presence and absence, and does so through games such as hide and seek and peek-a-boo. Although toddlers can repeat what sounds like a definition of death, such as “people who die go to heaven,” they are unable to comprehend what this means. Death may mean separation from the love objects and people the toddler needs and depends on.⁹ The most frightening aspects of hospitalization for the toddler usually include pain, anxiety, and separation from parents, but they do not include anxiety about death. Rather than fear of death, the dying toddler will respond to comforting support offered by the parents and will also respond with fear or sadness to the anxiety, sadness, depression, or anger expressed by parents.

Emotional and Psychosocial Development of the Preschooler

The preschooler, at 3 to 5 years old, has come a long way in the development of motor, verbal, and social skills. This is a time of enthusiastic and energetic learning and exploration. The chief developmental task of the preschooler is creating a sense of initiative.²⁷ Tolerance of frustration is still limited, but is better developed. Guilt feelings result when the child is not able to live up to the child’s own or other’s expectations of appropriate behavior. The preschooler’s conscience is fairly primitive, is likely to be overzealous and uncompromising, and can be unnecessarily cruel.^27,30 Thoughts about “being bad” or wishing for “bad things” to happen to other people can also lead to feelings of guilt and anxiety. Painful treatments, isolation, separation from parents, loss of autonomy, and immobilization are likely to be interpreted as deserved punishments for real or imagined wrongdoing.

During the preschool years, the child begins the process of sex-role identification. Freud has termed this period the phallic stage.³¹ Initially, in the oedipal phase, the child is drawn to the parent of the opposite sex. Late in the preschool period, the child begins to strongly identify with and seeks to imitate the parent of the same sex. It is during this time that children discover that boys and men have penises and girls and women do not. For some children, seeing another child naked in the critical care unit (however briefly) may be the child’s first experience with this discovery. During this period, boys have a fear of castration as punishment for real or imagined misdeeds. Urinary catheterization or other procedures near the genital area may cause a great deal of anxiety, provoking frantic resistance. It is important to provide careful explanation of exactly what will and will not happen during such procedures in order to decrease the child’s fear and increase cooperation. In addition, protecting modesty by keeping the genital area covered and asking permission to look, listen, and touch conveys respect for the child.⁷³

The development of the superego or conscience is also a major task for the preschooler. The child begins to learn right from wrong and good from bad. Although preschoolers cannot comprehend all of the reasons why something is acceptable or not acceptable, they learn appropriate behavior through reward and punishment and from examples set by parents or other adults. Preschoolers are more aware of danger and will usually obey simple limits or rules that have been explained to them.

The preschooler is generally able to tolerate brief separations from the parents if given explanations of where the parents will be and when they will return. The preschooler is also less frightened and more trusting of strangers and thus is often able to relate well to unfamiliar people. Serious illness is likely to cause regression in the preschooler, however, and the need for parents may once again become very strong. The preschooler can manifest some or all of the stages of separation anxiety experienced by the infant and toddler, but the older child’s protest behaviors are usually more passive and subtle than those of the infant or toddler. The preschool child may ask parents repeatedly when they will return, cry for them, refuse to eat, demonstrate sleeplessness, throw things, break toys, or refuse to cooperate in activities or care. The critical care staff must be alert to these signs and reassure the child regarding the parents’ return, providing other comforts and interventions as necessary.

Cognitive Development of the Preschooler

The preschooler continues in the preoperational phase of intellectual development until approximately 4 years old. An egocentric view of the world continues, and magical thinking remains. As the imagination develops, the preschooler has a difficult time differentiating reality from fantasy, thus increasing the potential for misunderstanding. Transductive reasoning remains.

The preschooler’s magical, egocentric, and transductive thinking, combined with a developing conscience, strengthens the child’s view that illness and hospitalization are punishments for misbehavior. This view presents a special problem if the child received an injury while engaged in a forbidden activity, such as playing with matches or crossing the street alone. If the child was injured with others, particularly family members, the patient may feel inordinate guilt and anxiety regarding the event. This is particularly true if the child had preinjury fantasies or wished for injury to or death of parents or siblings. The child might be terrified when it appears that such fantasies have come true. If these fears are extreme, the child could require psychiatric evaluation and counseling.

Global organization of thought still ties the early preschooler to rigid routines. The familiar patterns of the rituals of daily activities provide the child with a sense of security. Preschoolers want to know both the cause and the purpose of everything; to them, nothing happens by chance. Questions such as, “Why am I here?” and “Why are you doing that?” or “Why is she crying?” may be incessant. Because preschoolers believe there must be a reason for everything that happens, they are troubled by the purposes of or explanations for many events. They are beginning to generalize in thinking. For example, after being stuck with a needle by a person in a white coat, the child might believe that everyone in a white coat is going to stick him with a needle. Although the preschool child can perceive an event correctly, the interpretation of the event might be inaccurate.

During ages 4 to 6 years, the child is in the stage of intellectual development called the intuitive phase. Why questions persist. The child has a larger vocabulary, but tends to define objects in terms of their functions, such as “a bed is to sleep in.” When the preschooler asks “why?” simple answers beginning with to and followed by the function may be best understood. The child’s attention span and concept of time are increasing. Toward the end of this period the preschooler’s rigidity and ritualism begin to decrease, allowing more flexibility and fewer negative reactions to changes in environment and routines.

The Preschooler in the Critical Care Environment

In this disturbing scenario, none of the staff members showed empathy for Timmy or tried to decrease his anxiety before deciding to administer neuromuscular blockers—a solution that makes care easier for the staff but terrifying to the child. Use of neuromuscular blockers without adequate sedation and analgesia and communication is inappropriate and intensifies fear. It is sometimes too easy for busy professionals to forget that the struggling patient in the bed in front of them is a frightened child.

For the preschooler who has difficulty separating fantasy from reality, the critical care unit can provide plenty of material for an active imagination. The environment and personnel in the critical care unit can appear threatening or hostile to a child who is already frightened, in pain, and sleep deprived. The preschooler believes in supernatural beings such as ghosts, monsters, and cartoon characters and may develop an explanation for a strange sight or noise involving one of these fantasies. Fears can be reinforced by the alarms and other frightening noises, smells, behaviors, bright or flashing lights, or overheard snatches of conversation.

The preschooler also has fears of the unknown, the dark, and being left alone. The nurse can eliminate some of the child’s fears by reminding the child that a light will be on and a nurse will always be nearby. Creativity and understanding are necessary on the part of staff and parents if the preschooler is to feel safe and secure in the critical care unit.

Because preschoolers have primitive ideas about their bodies,³⁴ major fears of bodily injury and mutilation can cause many misconceptions and a great deal of anxiety about hospitalization. Any intrusive procedure, whether painful or not, is highly threatening to the preschool child. The child not only fears the pain of an injection, but also may worry that the puncture site will not close and that all the body “insides” will leak out. Bandages are sources of comfort, because many preschoolers feel that they will “hold everything in.” The nurse should anticipate the child’s concern if dressings or stitches are removed, especially in the child who believes that a large dressing or many stitches are holding a large part of him together. Assuring the child that the dressing will be replaced or showing the child that the skin has healed may decrease fear and resistance. Bandaging and unbandaging a doll or stuffed animal may help the child work through such fears.

It is highly stressful for critically ill preschoolers to lose control of their bodies or emotions. Although the critically ill child cannot be offered control for most aspects of care, realistic choices should be offered whenever possible to provide the child with a sense of some control.

Because the preschooler has a great need for movement and large muscle exercise, immobility at this age presents a special problem. The preschooler can use various coping strategies to deal with the stress of critical illness. Regression is most common because young children usually abandon their most recently acquired skills first. The reappearance of self-comforting behaviors such as thumb sucking, a loss of previously acquired body control, or increased need for physical comfort may be upsetting to the child’s family. Parents will require reassurance that such behavior is the child’s temporary way of coping with a stressful situation and that the child will regain lost skills after recovery. It is important to accept the regressive behavior and support the child rather than pressing the child to “act his age” or admonishing the child for behavior such as thumb sucking.

Preschool children can display additional coping strategies, including projection (attributing their own feelings, wishes, or behavior to other people or objects), repression, denial, withdrawal, aggression, fantasy, and motor activity. Children also may identify with the aggressor during play and assume the role of the nurse or physician or other perceived aggressor. In this way they attempt to reduce fear and anxiety by assuming some of the characteristics of these all-powerful adults to vicariously feel more control over their situation.

Preparation of the Preschooler for Procedures and Surgery

Explanations in advance are vital to decrease the preschooler’s anxiety about a procedure and to increase the child’s cooperation (see Box 2-2, earlier in chapter). When explaining surgical procedures to preschoolers, it may be best to tell them that something will be “fixed” rather than “removed” or “taken out,” because the threat of losing a part of the body might be frightening. If anesthesia is described as “being put to sleep,” it might invoke images of the way the neighborhood dog died. To decrease the child’s fear, it is important to assure the child that he or she will wake up after the procedure.

Honesty is needed when explaining procedures to children. It is unfair to tell the child that a painful treatment will not hurt, because this approach deprives the child of an opportunity to prepare in advance. It is better to avoid use of analogies when describing the sensations the child will experience during a procedure, such as “this will feel like a bee sting,” because the analogy may mean something different to the child. Instead, the nurse can tell the child something like “now this is going to hurt, but we’re going to do this very fast, start counting with me, 1—2—3… almost done… 4—5—6… OK, done! It’s all done.” Honesty about the pain of the procedure strengthens the effectiveness of the nurse’s reassurance that the procedure is over. Dishonest explanations, changes in plans, unfulfilled promises, and deviations from the procedure as explained also can threaten the child’s trust in the staff. When changes are unavoidable, they must be acknowledged and explained to the child. Explanations also should emphasize that staff members care about the child and that the purpose of the procedure is not to punish the child but to help the child get well.

After the procedure has occurred, assess the child’s perception of what happened, explain any misconceptions, and give the child an opportunity to work through feelings about what occurred.⁸ Children who are admitted to the unit on an emergency basis also can benefit from such retrospective review.

The Preschooler and Play

During therapeutic play, stressful situations, fears, and disturbing facts of life can be dramatized repeatedly until the experience is assimilated and the fear or strong feeling is mastered. This type of play is a way for children to communicate what they cannot yet verbally express, and it is an acceptable outlet for negative feelings. Play also serves an important normalizing function; regardless of what is happening in terms of the illness or injury and treatments, the child is still able to play and to have fun. The preschool child may assume the roles of others and involve other people, often adults, assigning roles.

The preschooler’s play reflects more fine motor coordination and verbalization, and a longer attention span than a toddler’s play. The preschooler has a need for large muscle movement during play. Therapeutic play periods are an important part of any stable critically ill child’s plan of care. Some guidelines for helping critically ill children play are listed in Table 2-1.

Table 2-1 Guidelines for Helping the Critically Ill Child Play

Adapted from Petrillo M, Sanger S: Emotional care of hospitalized children: an environmental approach, ed 2, Philadelphia, 1980, JB Lippincott.

The nurse can serve an important role in creating an environment that makes play possible. Several factors influence the child’s ability to play: the availability of physical space, permission from adults, safety during play, and the child’s condition and physical limitations.²³ Children can learn about their environment through hands-on experiences and imaginative play that help them describe and integrate new sights, sounds, and experiences.

The Preschooler and Death

For many years, incorrect assumptions were used to justify failure to discuss death with children. One such assumption was that children could not comprehend death and if they did, it would be harmful to discuss it with them. However, young children are aware of death, and their understanding of death follows a developmental progression based on their cognitive development.⁴⁵

The preschooler is aware that death exists, but views death as an altered form of life⁹ and as a temporary, reversible condition. Magical thinking and egocentrism dominate preschool children’s views of death and lead preschoolers to believe that their naughtiness, anger, or bad thoughts are responsible for what is happening to them.⁷⁰ Preschoolers have difficulty understanding causality (i.e., the intent or reasons behind events) and tend to attribute magical or supernatural causes to what they see and cannot understand. For example, preschoolers may believe that people die because they misbehaved.

It is important to recognize that it is not bad—or good—that a preschooler thinks of death in these ways; it simply is fact. Interventions delivered at an inappropriate developmental level, such as attempting to teach the preschooler about the permanence of death, will be ineffective and may provoke anxiety. Caregivers instead must use reassurance and explanations to clarify frightening misconceptions. Children need a great deal of reassurance that they are not being punished and that they are not responsible for their illness or condition.

Much of a preschool child’s experience with death consists of the sight of dead birds, dogs, cats, or other animals that are often mutilated in death. In addition, the child has fears regarding bodily injury during this period. As a result, the preschooler may view death as mutilation or prolonged torture.²⁵ Pain, restraints, and intrusive procedures that the critically ill child experiences can lend credence to these fantasies. It is important to explore the child’s view of death, to dispel misconceptions, and to decrease the patient’s anxiety. Simple reassurances are often not helpful. It is often difficult or even impossible for an adult to think at a preoperational level and thus anticipate and fully understand the child’s misconceptions without first exploring the child’s beliefs.

The child’s view of death is also affected by past experiences, such as the death of a family member. The child may identify with the illness or death of characters portrayed on television programs or the evening news and may come to view death as being killed or murdered. The family and child’s cultural and religious beliefs also will play important roles in how the young child thinks about death and must be taken into account when planning explanations and interventions. Such beliefs might be shared by the family only after the nurse has demonstrated support and compassion.

Preschool children think of death more often than most adults are aware. Death should be discussed with the preschooler in a simple, honest way, with consideration given to the child’s cognitive development and previous experiences. Children often understand how things are said better than what is said; therefore, the mood and amount of anxiety conveyed may be more important than the actual words used. When children ask whether they are going to die, it is important to discover what the term die means to the child and the child’s perception of her prognosis. The nurse might ask, “What do you think?” or “What do you think is going to happen?” Lengthy explanations are rarely necessary or helpful at this age. If the child asks a direct question, a direct response is appropriate, such as reassurance and description of the care and support that will be provided.

Emotional and Psychosocial Development of the School-Aged Child

During the school-age period of 6 to 12 years old, the child develops a sense of industry.²⁷ This is the age of accomplishment, increasing competence, and mastery of new skills. The child takes pride in the ability to assume new responsibilities, set goals, and complete tasks; with increasing independence comes increasing self-esteem. If the child experiences repeated failure or frustration in attempts at achievement during this period, a sense of inadequacy or inferiority may develop instead.

As peer relationships and peer-group approval become important, the child becomes less dependent on the family. In the course of the school year, the child often becomes a member of a clique, club, or gang and frequently has a best friend. Most peer-group interactions take place with members of the same sex, and the opposite sex may be viewed with distaste. This attitude often begins to change as the child enters preadolescence at approximately 11 to 13 years of age.

Rejection by a peer group can be devastating to the child during this stage of development. Chronic illness, injury, or conditions causing visible disability can set the child apart as different from peers and can make the child the object of ridicule. Separation from the peer group is often a significant and challenging consequence of illness and hospitalization during school years. Visits, letters, telephone calls, or e-mail messages from peers that help the child to maintain contact will help the child to cope. Because school is a significant part of the child’s life, the parents might encourage the child’s teacher and classmates to send cards and letters to the hospital. Occasionally, children are able to read or complete some uncomplicated schoolwork while in the critical care unit. Some children will be comforted by the fact that they can still do their homework, whereas others might prefer the freedom from schoolwork to reduce pressures during hospitalization.

The school-aged child is also an integral part of a family. Because separation from siblings can be particularly difficult at this time, every attempt should be made to continue contact with the child’s siblings through visits, phone calls, emails, or exchange of photographs. School-aged children are able to tolerate separation from their parents and usually do not react to such separations with the intensity of the younger child. Older school-aged children might even enjoy periods away from their parents. During periods of critical illness and hospitalization, however, the child’s need for parental support and involvement may be increased.

The school-age period marks the beginning of a major change in the parent-child relationship. Children begin to realize that the parent is not the omnipotent, omniscient being consistent with their images from early childhood. They discover that the parent is sometimes wrong and will not always be able to protect them from injury or pain. As a result, they can begin to question their parents’ judgment. Relationships with other authority figures during this period influence future parent-child relationships.

The child is trying to find a balance between increased need for independence and control and continued desire for parental support and guidance. This conflict will intensify as the child approaches adolescence. For these reasons, it is important to ask for the child’s opinion and understand the child’s viewpoint, especially when caring for children with chronic or terminal illnesses.⁸⁰

Parents might have difficulty relinquishing some of their control of the child during this period. They need to be patient and sensitive to support the child appropriately during illness and hospitalization, yet avoid forcing the child into a dependent role. The parents’ response may be complicated if the child alternates unpredictably between dependent and independent behavior. The parents may require assistance in understanding their child’s behavior in order to decrease potential feelings of hurt, anger, or frustration. Older, school-aged children often will criticize the parents in an attempt to declare independence.

Cognitive Development in the School-Aged Child

At approximately 7 years of age, the child enters the period of concrete operations, marking the beginning of logical thought.⁶⁹ Although still functioning very much in the present, the child is able to use deductive reasoning and to see the relationship of parts to the whole. As a result, the child becomes more flexible and may no longer require absolute consistency in daily routine. However, the school-age period still involves magical rituals that help children cope with stressful situations and give them security. Rituals such as “crossing fingers and toes” and incantations such as “step on a crack and break your mother’s back” help school-aged children feel some sense of control over the world and their situations.

The child’s concepts of time, space, and causality are more sophisticated and realistic during these years. True cooperation becomes possible because children are now able to differentiate their viewpoint from those of peers and authority figures and are able to value and respect viewpoints and opinions of others. As they learn to tell time, read, write, and do arithmetic, a new world is opened. They are able to understand events happening in the past, present, and future and are receptive to the acquisition of knowledge and learning new things.

The child’s moral judgment becomes more developed during this period. Preschool and early school-aged children follow rules because they believe rules are unalterable and imposed from above. They learn to judge the rightness or wrongness of an act by its consequences, rewards, or punishment rather than by its motives. Although young school-aged children know the rules and what they may or may not do, they do not understand the reasons behind them. They see behavior as either totally right or totally wrong and think that everyone else believes the same. Children of 6 or 7 years of age can interpret accidents and illness as punishment.

Older school-aged children no longer view rules as rigid and unchangeable, but recognize that rules are established and maintained through social agreement. They also realize that rules may be flexible and based on circumstances. They no longer judge an act solely on its consequences, but on the motivation and intentions behind the act and the context in which it appears. Although older school-aged children can view rule violation in relation to the total situation and the perceived morality of the rule itself, it is not until adolescence or later that they will be able to view morality on an abstract basis, using reasoning and principled thinking.

The school-age period has been described by Freud as the period of latency.³¹ During this period, there is less concern over physical issues. The child who is hospitalized for a serious illness or injury, however, finds attention centered on the body and its functions. School-aged children generally take an active interest in their condition, but may be self-conscious when the attention of the healthcare team is focused on their bodies.

The School-Aged Child in the Critical Care Environment

School-aged children are keenly aware of the critical care environment and sensitive to noise, activities, behaviors of staff, and sleep deprivation. They are susceptible to fear, confusion, anger, and disorientation. Fears during the school-age period are more realistic, although elements of magic and fantasy can still contribute to anxiety. Because school-aged children are struggling to become independent, loss of control is a major concern. The critical care unit is an unfamiliar place, and the child is subjected to many procedures and examinations by many unfamiliar people. Physical examinations in open areas without privacy can lead to feelings of resentment and anxiety, because the child has acquired feelings of modesty and shame concerning nakedness.⁷³ The hospitalized child is forced to depend on strangers for assistance with basic personal needs such as taking a bath, voiding, and having a bowel movement. It is important to respect the child’s privacy and modesty and to give the child choices in scheduling care activities if possible.

Fears regarding possible mutilation and bodily injury or harm are prevalent during this period. School-aged children are typically concerned about the benefits, hazards, and techniques of procedures such as anesthesia and surgery. They may fear that the physician will start the operation before they are asleep or that they will awaken during the surgery. In addition, they usually fear the helplessness of anesthetized sleep, afraid that they may not wake up again and that they may die.⁶⁴ Older school-aged children are usually concerned about the consequences of the procedure or operation, including the postoperative appearance of the wound.

If the child is unable to communicate verbally, the child needs an alternative means of conveying requests, questions and feelings. For younger (prereading) children, pictures such as faces with different expressions (such as happy, sad, and crying) or common conversational objects can be used. For older children, a variety of electronic devices (particularly hand-held computers or telephones with text messaging) can be helpful.

Tools, such as the Children’s Critical Illness Impact Scale, a self-report measure, can be useful in measuring psychological outcomes for 6 to 12 year olds after hospitalization in a PCCU.⁷⁵ Domains such as worries, fears, friends and family, sense of self, and behaviors were analyzed in initial studies of this scale.

Preparation of the School-Aged Child for Procedures and Surgery

To help school-age children cope and cooperate during procedures and to comply with the prescribed treatment regimen (see Box 2-2 in preceding pages), nurses should provide advance preparation for each procedure plus explanations during the procedure. Such explanations increase the chances that the child will gain confidence from the procedure rather than be overwhelmed by it.

At this age, the child’s ideas about illness and body function are often nonexistent, vague, or false. The nurse cannot assume that the child actually understands the location or function of organs and body parts. Older school-aged children and adolescents will often nod and appear to understand explanations or words when in reality they have either no idea or a distorted idea of body functions and may not understand the explanations given. Note that explanations provided to the child by the parents may be inaccurate. Children are often reluctant to ask questions or admit that they do not know something they believe they are expected to know. To verify the child’s comprehension, the nurse should ask the child to explain his or her illness or to draw a picture of his or her body and note any illness, injury, or problem present.

Children may be able to repeat information about their condition after listening attentively to all that is said around them; however, their interpretations of what they overhear may not always be accurate. Children are quick to pick up contradictions and often will request factual information. Cognitive mastery provides a way to maintain a sense of control over what is happening to them. With their newly acquired ability for logical thought and deductive reasoning, they are better able to understand the relationships between their illness or injury and its symptoms, and the need for and effects of treatments. The school-aged child also is more aware of the prognosis of illness, indispensability of certain body parts, potential hazards of treatments, life-long consequences of permanent injury, and the meaning of death.

A doll or human figure outlines can be used to discuss the functions of the body and explain procedures and operations. Some older children object to handling a doll, even if it is described as a teaching doll or dummy, and in those cases, body outlines can be used. School-age children enjoy learning scientific terminology and manipulating equipment that will be used in their treatment. Various coping techniques such as relaxation, imagery, deep breathing, and self-comforting talk have been found to be helpful for some children.^17,66

The school-aged child might not always wish the parents to be present during procedures, and healthcare providers should respect the child’s preference for parental support or privacy. If their presence is not desired by the child, the parents might require help to understand this assertion of their child’s growing independence. The child’s preference and needs may change, however, and will have to be ascertained on an ongoing basis.

The school-aged child may fear disgracing himself or disappointing parents or other significant adults by losing control. School-aged children, especially boys, are often given the message that they are expected to be brave and not cry. It is important to realize that school-aged children frequently exhibit the greatest amount of bravado when they are feeling the most helpless and most in need of support and reassurance. Parents and staff members should let the child know that it is all right to be frightened, angry, or upset and that crying can help decrease some anxiety.⁷³

Parents sometimes need help understanding that crying and protest behavior are healthy and often helpful outlets for the child facing extremely stressful situations. Parents might need reassurance that such outlets do not indicate weakness or failure on the part of the child or parents.

The School-Aged Child and Play

Unstructured play gives the child an opportunity to gain diverse skills and a greater sense of competence. It also enhances the child’s feelings of control and predictability.¹¹ When a school-aged child begins to recover from a critical illness, boredom can result. Play can serve as a means of entertainment and distraction, as a temporary escape from stress, and as a vehicle for resolving emotions. School-aged children have a longer attention span and increased cognitive abilities. They particularly enjoy playing with hospital equipment, and their own accurate use of this equipment reflects their keen observations of protocol, procedure, and technique. Role reversal with members of the healthcare team provides the child with the opportunity to exert some control and can give the team members valuable insight into the child’s interpretations of and feelings about his illness and care. School-aged children also enjoy books, storytelling, and word games, and they may enjoy reading about their disease or procedure. It is often difficult to arrange peer interaction in a critical care unit, but it might be possible for a visiting sibling or young friend to play with the patient. Competitive games are particularly enjoyable during the school-age years and it is important to the child that rules, often made up by the child, be obeyed. School-aged children also enjoy ordering and collecting things. Older school-aged children begin to engage in daydreaming.

The School-Aged Child and Death

Early school-aged children often have a real understanding of the seriousness of their illness, although their understanding of death is still influenced by their cognitive development. The child relies less on magical explanations to explain happenings and is less egocentric. However, during these years death is often personified as a ghost, skeleton, boogeyman, or the devil, and the child may believe that death will come to take him away from his parents and friends. Nightmares and fear of the dark are common, and it is helpful for the nurse to leave a dim light on at night. If the child is convinced that there will be nurses nearby throughout the night to provide protection, the child often will be able to relax and fall asleep more confidently. The finality of death is not appreciated in young school-aged children. At approximately age 7, however, children are beginning to suspect that they themselves will die one day.

After the ages of 8 or 9 years, children begin to develop a more permanent view of death because they have a more complete concept of time. Children realize that their parents are not omnipotent, that they are powerless to avert death, and that ultimately everyone will die. Children at this age often use symbolic methods such as drawings or stories to express needs and fears. In the next few years, the child’s concept of death is elaborated by cultural and religious experiences. The adult concept of death as final, irreversible, and inevitable is reached during the late school-age years.

Terminally ill school-aged children are often aware of their fatal prognosis without being told, because they understand nonverbal cues and often overhear more than staff and parents realize. Although attempts to shield the child from knowing a fatal prognosis may be made with good intention, such an approach is rarely beneficial for the child. Open communication allows the child an opportunity to discuss fears and apprehensions and minimizes risks of incomplete information or erroneous assumptions. The child then can be helped to work through fears, find more effective coping strategies, and ultimately accept the inevitable.

Deaths of other patients in the critical care unit may be a source of stress for the child. Older children may identify with the deceased child, particularly if their diagnoses are similar. Children need honest explanations if they ask what happened to the other child, because nervous or evasive answers will only heighten anxiety. If accurate, children should be reassured that the deceased child did not have the same medical problems. Staff members should answer the child’s questions as simply and honestly as possible. If staff members or parents feel uncomfortable answering the child’s questions, an advanced practice nurse, palliative care specialist, social worker, chaplain, or physician with particular skill in discussing death with children should be asked to help the child work through some of the anxiety. Parents often feel frustrated and helpless when faced with the child’s questions about death and may need assistance in addressing their own needs.

Emotional and Psychosocial Development of the Adolescent

The major sources of anxiety during adolescence include separation from parents, adaptation to a rapidly changing body, the development of a sexual identity, and acquisition of a sense of identity and autonomous function.²⁷ The behavior of adolescents is frequently inconsistent and unpredictable, and it is often as bewildering to the adolescent as it is to others. Behaviors such as mood swings, depression, periodic regression, and mild antisocial behavior that are normal during adolescence would likely be viewed with more concern if exhibited by children of other ages.

Adolescence can be divided into three stages—early, middle, and late adolescence—although the boundaries of these stages are imprecise. Early adolescence extends from approximately 12 to 15 years in girls and approximately 13 to 16 years in boys. During this period, body image issues are of primary concern. Younger teenagers are extremely preoccupied with body changes and sensations. Because they are aware of every possible individual flaw or imperfection, they worry that others are also aware. The peer group grows in importance and becomes the standard against which adolescents measure acceptability. The most intense relationships outside the home are with best friends of the same sex. Separation from parents normally increases and the teenager spends more time away from home, but is still willing to adhere to parental wishes, communicate with parents, and be accountable to them. The parent-child relationship still remains relatively intact. Young adolescents who become ill are primarily concerned with how the illness or injury will affect appearance, function, mobility, and peer relationships.

Mid-adolescence is often the most difficult and trying time. Conflicts over issues of autonomy, accountability, and self-determination can create tension between teenagers and parents. Teenagers often reject and rebel against parental support and control while continuing to depend on the parents. Mid-adolescents are still highly egocentric, narcissistic, and preoccupied with appearance, attraction to the opposite sex, and ability to meet gender role expectations. Peer reactions and relationships determine the teenager’s body image and behavior and become the venue for experimentation with new roles and behaviors. Because illness or injury results in forced dependency and perceived loss of control, hospitalization is highly stressful for a mid-adolescent. Hospitalized mid-adolescents will be extremely anxious about changes in physical appearance that could make them different from or unacceptable to their peer group.

The late adolescent, aged approximately 17 to 22 years, is normally fairly secure in self-esteem, inner controls, independence, and relationships. Late adolescents function at a highly independent level; they listen to parental advice but then make their own decisions. During this period the primary concern is role definition in terms of education, career, marriage, or lifestyle. Serious illness or injury during this period is most threatening in its potential for affecting the realization of career and lifestyle goals or forcing changes in vocational plans.

Cognitive Development in the Adolescent

During adolescence, Piaget’s fourth and last stage of cognitive development is attained—formal operations.⁶⁹ Most adolescents develop the ability to think abstractly and are able to project to the future and see the potential, long-term consequences of actions and illnesses. Although they are able to understand others’ opinions, feelings, and points of view, adolescents are still fairly self-absorbed. The adolescent discovers the ability to interpret observations, understand broad concepts, and develop new insights and opinions. Increased cognitive abilities allow adolescents to have a greater understanding of their condition, treatment, and prognosis. It is appropriate and important to include teenagers in the planning of and decisions about medical therapy.

The adolescent perception of illness and its significance can be distorted. Illness or injury is often viewed in terms of how it will alter appearance or level of activity. An adolescent may react more negatively to an insignificant but visible or restrictive illness or injury than to an invisible but potentially life-threatening one.

Magical thinking still exists to some degree during the adolescent years. Teenagers often believe that they are to blame for an illness or injury and sometimes believe that they are being punished for rebellion against parents, forbidden fantasies, or for sexual activities. As a result, they also may be dealing with feelings of guilt and shame while coping with the physical aspects of their illness. Adolescents may, in fact, be responsible for injuries they receive, because they often take enormous risks and engage in dangerous behaviors to convince themselves and others of their bravery and invincibility. When such behavior results in serious injury to the adolescent or to others, the resulting guilt, grief, and mourning may cause depression or other serious reactions.

The Adolescent in the Critical Care Environment

When first admitted to a critical care unit after a serious injury or sudden illness, the adolescent may be in a state of emotional and physical shock and concerned about bodily functions and pain. Occasionally the teenager feels protected in the critical care unit and has little or no anxiety about being there. However, as this initial shock phase subsides, the critical illness may become terrifying or humiliating. The major threats to seriously ill adolescents are loss of control and of identity, altered body image, and separation from peer group.

Illness and hospitalization constitute a major situational crisis for the adolescent. Helplessness is much more threatening to adolescents than to younger children, although adolescents have more sophisticated coping mechanisms. They are extremely concerned that others will discover their inadequacy, dependency, and confusion; therefore, they hide it from everyone, including themselves. Because they have heightened body awareness and developing sexuality, privacy is of paramount importance to teenagers. Every attempt should be made to keep the adolescent covered, particularly over the genital areas (and, in females, over the breasts), during examinations and treatments. If the critical care unit does not contain private rooms, many adolescents will prefer to keep the curtains drawn around the bed to maintain privacy. It is embarrassing and traumatic for adolescents to lie exposed while several members of the healthcare team examine and discuss them. Lack of respect for and inattention to these needs can cause the adolescent even greater stress than experienced from physical pain.

Although separation from parents may be welcomed and appreciated during this time, separation from peer group support can be extremely disturbing. Healthcare providers should facilitate peer group contact as much as possible. However, while some adolescents benefit greatly from peer visits, others may not wish to be seen by friends if they believe they look disfigured or will be seen as being different. Such determinations need to be made individually.

Although the adolescent often uses denial to cope with stress, regression also may be used. The adolescent can become demanding of staff and parents and may be afraid to be alone. Such regression enables adolescents to return to the more dependent state of early childhood, allowing them to set aside the burden of dealing with tasks they are physically and emotionally unable to handle.

The teenager may also use other coping strategies, such as varying degrees of withdrawal. In addition, intellectualization may be useful to adolescents who wish to deal with the objective facts about their condition rather than the emotional aspects. High scholastic achievers in particular may use this strategy, requesting information and reading material to supplement their knowledge. Intellectualization can be a helpful coping strategy unless the information provided is distorted by the adolescent’s fears and fantasies. The staff should support the patient’s attempts at cognitive mastery, while frequently verifying the accuracy of perceptions. Other coping strategies include reaction formation, projection, and displacement of hospitalization-related anxiety into complaints concerning less significant aspects of care. Some adolescent behaviors that are distressing to staff members include manipulation, verbal abuse, physical attacks, sexual suggestiveness, and refusal to cooperate with the plan of care. Staff members should establish consistent limits, particularly for physical attacks and sexual suggestions.

Preparation of the Adolescent for Procedures and Surgery

Adolescents do not wish to be passive recipients of healthcare, but rather, active participants in planning and implementing their care. Preparation for procedures reduces fear of the unknown and helps the teenager maintain some feelings of control (see Box 2-2, earlier in chapter).

Adolescents react not only to what they are told but also to the manner in which the information is given. They are often reluctant to admit that they do not understand explanations, and their fears may be manifested as overconfidence, conceit, or pretentiousness. Many adolescents have little understanding of the structure and workings of the body. Therefore, the nurse must carefully and tactfully evaluate the adolescent’s knowledge and individualize each teaching program.

Minor injuries and illnesses are often magnified and can affect a teenager’s body image; consequently, a critical illness can be terrifying. Adolescents need assistance and reassurance in trying to gain a more realistic view of their illness. Because they are facing many unique problems during hospitalization, they need help identifying their strengths and effective coping mechanisms. Four types of stressful situations have been identified by adolescents hospitalized for minor surgical procedures⁹⁴:

Pain was reported as the most frequently anticipated and distressing aspect of hospitalization. Therefore, it is important to teach coping strategies before performing painful procedures and to later review the adolescent’s perceptions of and responses to the procedure. Provide analgesics when necessary and assess and document their effectiveness.

The Adolescent and Play

Although the idea of play may seem more appropriately applied to the care of younger children, adolescents also need the opportunity for a temporary escape, an outlet for strong feelings, and meaningful stimulation that will decrease the possibility of sensory deprivation or overload. Familiar activities, such as television or video games, personal music selections, e-mail, text messaging, and other peer communications may be appropriate and meaningful activities for a critically ill adolescent. As the adolescent recovers, reading, schoolwork, and other activities can be helpful diversions. Music therapists are often helpful in engaging adolescents in familiar activities. Some adolescents may use journaling as a way of venting thoughts and feelings in a private way. Others can benefit from the opportunity to share thoughts and feelings with an adult they trust and admire, with other adolescents, or through blogs. Daydreaming is a useful occupation for adolescents. It helps them decrease feelings of loneliness, master fears, safely establish a new identity, solve current problems, test themselves imaginatively in situations they have never experienced, and focus on the future.

The Adolescent and Death

Although adolescents have the intellectual capacity to understand death on the adult level, they usually do not view death in the same way as adults do. They can understand cognitively that death is permanent and that it will happen to everyone one day. However, they do not accept death as a believed reality, but may fantasize that death can be defied.⁹ Adolescents may be unable to totally accept the finality of death, because they believe they are invincible. This belief can lead to self-destructive or daring behavior, resulting in injury, drug use and abuse, and suicide. Because remnants of magical thinking persist, the adolescent may view fatal illness as punishment; this can create guilt and remorse. Reassurance and open discussions of feelings, concerns, and fears are important.

Adolescents have a great deal of difficulty coping with the idea of their death. At a time when they are striving to establish their own identity and make plans for their future, it is extremely difficult to face the fact they have no future. Such a realization of death before fulfillment adds further turmoil to the challenges of adolescence.

Adolescents need to be highly involved in decisions about their care and treatment, even if it requires preparation for their own death. The critical care nurse must be alert to nonverbal cues and unasked questions when caring for critically ill adolescents, particularly if the patient is unable to speak as the result of intubation or other interventions. These patients may need to write, draw, or use electronic communication devices to express feelings and questions. Some adolescents might request that treatment be discontinued and that they be allowed to die. Each situation must be handled individually. Adolescents can have the cognitive understanding of death without the emotional maturity that is necessary to make final decisions regarding withholding or withdrawing medical care. They may be highly aware, however, that prolongation of life will increase suffering. Certainly, all adolescents who are conscious and able should be involved in decisions about treatment.

Parenting Children of Different Ages in the PCCU

Some of the concerns and reactions of parents of critically ill children will vary depending on the child’s age. Parents of the critically ill neonate have awaited the arrival of their child with such high hopes that feelings of inadequacy, failure, and guilt can accompany the parents’ discovery that they have failed to keep their child healthy. They may need assistance in developing their parenting roles and in recognizing their importance to their child’s care. Parents should be encouraged to participate in their infant’s care as much as possible. Activities in which the family can participate, such as stroking, holding, calming, singing, diapering, and feeding, are all important aspects of care. In one study, maternal optimism was found to be reflected in the use of active, cognitive coping strategies during the infant’s stay in the critical care unit.⁵¹ Staff members can intervene with patients who are not as optimistic by encouraging active involvement in care.

Parents of toddlers need to be encouraged to continue their central role in their child’s life. Their presence is extremely important, because it can help alleviate much of the child’s distress. If the toddler has been hospitalized following injury or ingestion, parents may have to cope with guilt. Parents sometimes blame one another for an unintentional injury and require support and assistance in resolving anger. They often will benefit from performing purposeful activities that will help the child. Parents of toddlers are also valuable interpreters of the child’s beginning verbal and nonverbal communication, routines, and rituals. Parents should be asked to make a list of the child’s likes and dislikes, favorite toys and games, nicknames, special words for body parts and functions, and routines at home. This helps the parents to be involved in and contribute to their child’s care and provides important information for individualizing care.

During the preschool period, attitudes about discipline and beginning sexual curiosity can influence parental concerns. The parents also may be anxious about their child’s regression during hospitalization. In general, parents of preschool children are helpful in explaining procedures and treatments in language the child can understand, and parental participation in comforting and caretaking activities remains important to the child.

During the school-age period, the parent-child relationship changes as the child develops independence and relationships outside the home. Parents may feel guilt for allowing independent activity that led to an injury. The child’s regression may be difficult for the parents to accept, particularly for fathers who want sons to be brave. Parents may need assistance in interpreting their child’s demanding or rejecting behavior. Family members can dispel some of the child’s loneliness and boredom by engaging in activities within the limits placed by the illness or injury. Parents can help the patient keep abreast of news from home, school, and friends during this period and can assist in providing comfort and explanations for the child. However, older school-aged children may prefer that care be performed by the nurse.

Adolescence is often a trying time for the parent-child relationship. Any disagreements or arguments that preceded the adolescent’s hospitalization may cause the parents guilt and remorse when the adolescent becomes critically ill. If the adolescent was injured in an accident, the parents may feel guilty or frustrated because they could not prevent the injury. The adolescent often demonstrates both dependent and independent behavior, which can be confusing to parents. Parents often do not expect regression from their teenagers and need to be prepared for this behavior and reassured that it is normal and temporary. Parents should be encouraged to include the adolescent in decisions about care. Visits from other family members and friends should be encouraged so that the adolescents will maintain contact with their peer groups.

Parental Stressors

The admission of a child to a critical care unit meets the criteria for a “traumatic stressor,” an event that reflects “actual or threatened death or serious injury or a threat to the physical integrity of self or others.”⁶ When the diagnosis, injury or treatment will result in body disfigurement or when the hospitalization is unplanned, dramatic, or far from home, it is even more stressful.^1,65 The effects are more significant for a family without previous exposure to critical illness or medical settings.

The child’s critical illness or injury can produce monumental stressors, particularly if sudden or unexpected. The hospital environment may provide other sources of stress, such as lack of privacy in the waiting room, unfamiliar people who might be crying or talking loudly, an unfamiliar location, and disrupted sleeping and eating patterns.

Sources of stress from outside the hospital, such as financial, social, or personal costs, can add to the parents’ burden.^1,32 Parents may be worried about the care or problems of other children at home or the cost of lodging, transportation, babysitters, food, hospitalization, and time lost from work. They may incur personal losses, such as loss of autonomy and privacy.³² Other family members may be ill or injured at the same time as the child. If the child is hospitalized at a great distance from family and friends, the parents will be forced to stay in a strange city, away from support systems. At such times, relatively small associated stresses, such as trying to find a parking place, can become intolerable.⁴⁹ Family problems that existed before the hospitalization are often exacerbated during this time, particularly if one member is believed to be responsible for the child’s illness or injury.

Of all the stressors the parents face, the critical care unit itself may be the most significant. If the child requires critical care, most people assume that this means that the child is seriously ill or even close to death. However, most nonmedical family members cannot imagine how complex or busy the unit is. Simply entering a critical care unit can be overwhelming for lay people who may already have emotional overload; the unit then adds sensory stimuli from alarms or other noises, unfamiliar sights, and unpleasant smells. Parents often are shocked at the first sight of their child in the critical care unit. Characteristics of the critical care experience that were reported to be important to parents included privacy, proximity to their child, adequate space, reduced sensory stimuli, cleanliness, and safety.⁵⁶ When the child dies in the critical care unit, positive connections and memories can be a source of comfort to bereaved parents, whereas negative memories contribute to the devastation felt by the parents.⁵⁵

Responses to Stress

It may be therapeutic to help parents acknowledge that their child’s critical care hospitalization is a traumatic stressor.⁶⁵ Families who are not in denial are better able to engage themselves and their child in active problem solving and mobilize supportive resources.⁶⁵ When events are too overwhelming to process immediately, the mind may alternate between denial and awareness until the information can be processed in sufficiently small segments to manage.⁶⁵ Staff members can help by listening to the parents’ feelings and communicating acceptance that the parents’ feelings are both understandable and manageable.⁶⁵

People under stress are often unable to function at normal levels. Sedgwick⁸³ identified seven responses to stress that are important to understand when working with families of critically ill children. Behavior that would otherwise be inappropriate can reflect a normal response to stress.

Under stress, it is only possible to absorb a small amount of threatening information at any one time. When explaining treatments and equipment, the nurse should give brief explanations about their typical use for particular types of patients and problems. Family members sometimes act surprised when hearing information that was previously provided, denying that the doctor and nurses informed them. Before reacting to the parents’ denials, it is important to realize that even if family members were told the information, they were likely unable to assimilate it.

A parent may unconsciously cause or aggravate nursing staff discord by comparing information or nursing care provided by different nurses. If inconsistencies in the quality of care are present, these should be investigated and corrected. However, nurses should avoid discussion or criticism of minor variations in staff members’ personalities or styles with parents.

To facilitate effective communication of medical information, familiar staff members should establish frequent and consistent methods of communication with the family. In some units, parents participate during medical rounds. An observation of parental presence on rounds found that it did not interfere with education and communication, parents were satisfied with participation, medical staff found it beneficial, and privacy was not a concern despite implementation in an open unit.⁶⁸

Although guidelines for obtaining informed consent are clear legally, the degree of involvement of parents in medical decision making varies with the decision, location, and parental abilities.⁶⁵ Parents are more likely to support interventions if they have been involved in the discussions and decision-making and in the formulation of the plan of care.³⁶ In a study comparing parents of children in PCCUs in different countries, the authors noted that in some cases, the quality of communication was more important than whether ultimate decisional authority rested with the parents, and that some degree of medical paternalism was unavoidable, regardless of existing legal or ethical norms.¹⁹

Communication concerning serious events or decisions should be held in a location where parents can listen and ask questions without disruptions. They need a quiet, private space to hear upsetting news and time to assimilate information before they are required to respond or make decisions. In a study of physician communication with parents of critically ill children, the most significant issue identified by parents was the physician’s availability to meet their need for information.⁵⁵ Parents noted that it was important to receive honest information presented in a straightforward manner in understandable language at a comprehensible pace. Nurses can facilitate conferences between physicians and parents and ensure that the parents understand the information provided.

Anyone who is overwhelmed by a stressful life event may enter a crisis state, characterized by an inability to cope with actual or perceived problems.^18,29 A crisis for one person will not necessarily be a crisis for another or, for that matter, may not be a crisis for the same person at another time. Difficulty arises when previously used strategies are not sufficient to solve the current challenge. Aguilera² identified balancing factors that modulate vulnerability to crisis: a realistic perception of the events, adequate coping strategies, and adequate situational support and support systems.

To help support family members during the crisis, it is important to determine the member’s perception of the stressful event. Family members must have a realistic perception of the situation in order to manage it. Problem solving will probably not be successful until the real issue is identified, so nurses should correct any important misconceptions as tactfully as possible.

Coping describes ongoing efforts to manage a problem or situation. Coping strategies are behaviors that an individual typically demonstrates when stressed. They are highly individual, may be subconscious, and are subject to change depending on the context and demands of the situation. It is important to remember that the behavior you are viewing indicates the individual’s strategy for coping with that specific situation at that specific moment. Coping strategies can include behavior that is inappropriate under normal circumstances but appropriate during periods of stress. Although nurses tend to see positive behaviors and affect as coping,²⁶ more negative responses, such as a toddler crying in protest when his mother leaves the room, can also be adaptive coping responses. In fact, in resilient children (i.e., children who have come through stressful experiences with a healthy adaptation), the actual coping behavior is not the most important factor in determining long-term outcome.⁷⁸ Longitudinal studies of children who have experienced stressful situations have identified three major processes or factors that led to more positive outcomes³³:

Parents may demonstrate various stages in coping with their child’s admission to a critical care unit, particularly if the admission is unexpected. These stages are similar to the stages of the grieving process. Initially, most parents experience a period of shock, disbelief, and denial. These reactions are characterized by comments such as “This can’t be happening to us” or “It’s not that serious, she’ll be OK.” This initial stage may be brief for some families, but can last longer if the child remains unstable. Denial is often necessary for the parents to be able to function. While unrealistic expectations should not be supported, the staff should not remove all hope. Parents often understand the seriousness of the situation, but may not initially be able to admit it to themselves or others. As this stage progresses, the parents may feel helpless and guilty as they blame themselves or each other for the child’s illness or injury.

Anger is another frequent reaction. Although parents may be angry at the child for injuring himself or at God for allowing this to happen, these are not acceptable targets for some parents. Other family members may not be safe targets for anger if the parent feels a need for support from them. Parents can turn against each other, particularly if they had previous disagreements or if they differ in coping styles or priorities. Although some parents are afraid to criticize staff members for fear of reprisals against the child, anger may also be displaced onto the staff, resulting in complaints about the child’s care. Parents may need help in recognizing the source of their anger and finding constructive outlets for strong feelings. Some parents feel anger that has no simple target, so it results in negative behaviors such as angry outbursts, blaming, and desire for revenge.⁶⁵

Depression is common and can indicate that the parent is attempting to handle the strong feelings the situation has triggered. A supportive listener is usually helpful to the parent during this stage. Eventually, the parents may reach a stage of resolution and acceptance in which they are able to make plans and decisions and can discuss the child’s condition realistically.

Rarely do both parents react in the same way at the same time during a child’s critical care; differing reactions can add to their stress. Staff members can help by including the parents in decision-making, engaging them in the care of their child, and referring them to appropriate resources to enable them to work together to support their child. Parents may not be able to return their lives and their child’s life to the way it was before, but may find some benefit in the adaptation that the crisis required.⁶⁵ For example, they may find comfort and strength from having revised priorities. “Parents who are helped to survive and thrive have much to teach us if we are open to listening.”⁶⁵

The presence of adequate situational supports is important. A person experiencing a crisis is more dependent than usual. It is important that the nurse obtain information about the family structure and relationships, religious affiliations and beliefs, and other possible support systems. If family members are too stressed to support the patient or one another, the assistance of the healthcare team and outside resources (e.g., social services, chaplain, community support) will be vital to the family’s constructive resolution of the crisis.

Strategies to Support Families

Siblings

A child’s illness or injury can have a profound effect on other siblings in the family. When a critical illness or injury strikes one child and requires that parents spend a large amount of time at the hospital, the other healthy children in the family often feel excluded or forgotten. Young siblings may fear that their behavior or wishes caused the ill child to get sick. Their response to stress can manifest in different ways, such as negative behavior, mood changes, eating or sleeping disturbances, and loss of interest in favorite activities. School performance, peer relationships, and behavior at school or home can be affected. Alternatively, siblings may concentrate on academic pursuits as a way of escaping stresses at home or as a way of demonstrating competence in an effort to win attention from parents or combat feelings of hopelessness. The sibling’s peer relationships can be affected if the sibling must frequently be absent from school, spends time with family members instead of friends or becomes irritable and preoccupied. Siblings can develop somatic complaints as a way of seeking parental attention or as a way of identifying with the ill sibling.

Attempts to shelter siblings from unpleasant information will likely increase—rather than decrease—the siblings’ fears and fantasies. They know something is wrong with their brother or sister but, without explanations from trusted adults, they have only their own imaginations. Often the situation imagined by the sibling is much more distressing than a visit to the PCCU would be. Such visits should occur, however, only after an assessment of the sibling and the family coping styles and relationships, and only after the sibling has been prepared for the sights and sounds in the unit. After the visit, a debriefing session with the sibling is important to allow the nurse and the parents to assess the sibling’s reaction, answer questions, and clarify misconceptions.⁸⁶

Often the parents are extremely concerned about the effect of one child’s critical illness on their other children, but are not sure what to do or say to support the children at home. Nurses should help parents identify ways to reduce sibling anxiety. Parents may also need encouragement to remain at home for several hours per day to spend time with other family members or to split responsibilities between the hospitalized child and siblings, especially during lengthy hospitalizations. If the hospitalized child is unstable, close family members, such as grandparents, can bring siblings to the hospital to visit parents and the child. Child life therapists can help both siblings and parents.

Interpersonal Relationships

Interpersonal conflict has been identified as one of the greatest sources of stress for critical care nurses, and it can affect patient outcomes.^52,81,82,91 The most frequently cited and intense stressors are nurse-physician conflicts. Nurse-management and nurse-nurse conflicts are additional identified stressors. If the team is not cohesive and supportive, it is likely that the helplessness felt around traumatic events in the unit or inability to cure the patient will erupt into inappropriate staff behavior. Another type of interpersonal conflict, nurse-family conflict, has been addressed above.

Systems Issues

The current shortage of qualified nurses means that many critical care units remain understaffed. The critical care nurse must bear the increased work load, double shifts, and the stress of working with reassigned staff and registry/traveler nurses who may not be familiar with all the skills and activities required in critical care. Staffing shortages may necessitate frequent schedule changes and postponement of vacations; these factors further increase stress.

Even moderate nursing turnover demands ongoing orientation, which is challenging for the experienced staff, who may already be overburdened. An organized preceptor orientation program helps ensure that preceptors for new staff are enthusiastic, educated, and committed to the process. Many departments have also found that pairing new staff with mentors after the orientation process helps to continue the supportive environment for newer staff.

If well-developed continuing education programs in the critical care unit are not available, nurses may feel insecure about their own knowledge and dissatisfied with the lack of opportunity. Creative ongoing educational programs include many resources, such as advanced practice nurses, physicians, educators, administrators, and staff nurses. Involved physicians have the opportunity to explain their philosophy and preferences for patient care and better appreciate the nurses’ knowledge of and interest in specific patient care problems. The participating nurses can raise questions or suggest alternative care techniques in an environment conducive to an exchange of ideas. When patient census is low, the staff nurse may be relieved of patient care responsibilities to research a clinical problem and deliver a brief summary of the findings to other staff. This allows each staff member to develop specific areas of expertise and helps staff nurses to gain respect for and respect from colleagues.

From a human factors engineering standpoint, the PCCU is a demanding environment, making staff susceptible to physical and workload stresses in addition to the emotional stressors. Evidence indicates that the combination of fatigue, workload, and the sensory-overloaded environment can be a factor in less than optimal staff performance, potentially contributing to errors.⁶² Equipment malfunctions, cramped facilities, a noisy environment, and lack of supplies can add to stressful working conditions and compassion fatigue (for system factors contributing to caregiver burnout and compassion fatigue, see Burnout and Compassion Fatigue Among Caregivers and Evolve Table 24-4 in the Chapter 24 Supplement on the Evolve Website).

Patient Care Issues

If the patient’s clinical course is unpredictable, disturbing, or out of control, or the nurse feels helpless, vulnerable, exhausted, closely bonded to the child, or identifies similar characteristics in the patient and his or her own child, then PCCU nurses may experience primary or secondary traumatization.⁶⁵ Primary traumatization occurs when the medical event itself is highly traumatic for the staff member. Secondary traumatization can occur in the caregiver who empathizes closely with the pain of the child and family and allows the intense feelings to accumulate, often resulting in burnout.⁶⁵

The pediatric critical care nurse is faced with many challenges and stressful situations with which he or she must cope. Caring for any unresponsive child for several days can lead to feelings of vulnerability, exhaustion, frustration, sorrow, and anxiety. Caring for neurologically impaired children can raise questions about the quality of patient life that is being salvaged. Pediatric nurses described caring for a child in a persistent vegetative state as emotionally stressful and ethically challenging.⁶¹ The decision to withdraw life support, regardless of the circumstances, is always difficult for the healthcare team.

Nurses may feel frustrated and powerless when their views are not considered or they may feel a share in the heavy responsibility if they participate in the decision. Enormous amounts of emotional energy are required to support family members through this experience. It can also be particularly stressful to care for children who have been abused or are victims of violent crimes, because the nurse may have strong feelings of revulsion or anger. Staff members must try to avoid the temptation to assign guilt, take sides, and express anger they feel toward abusive parents.

The pediatric critical care nurse has frequent encounters with death. These nurses not only have to deal with their feelings about the child’s death, but may receive the brunt of parental anger and anxiety. Each patient requires an investment of time, energy, and technical skills. The nurse often becomes attached to and involved with patients, and this emotional bond makes it difficult for the nurse when the child dies, although it is this same emotional bond that allows the nurse to provide compassionate support to the family. It is also important that the nurse be able to maintain a therapeutic relationship with the family. If the nurse becomes overly involved, she or he will be unable to effectively support the family. Benner and Wrubel⁷ note that the remedy for over-involvement is not avoiding involvement, but identifying the right level and kind of involvement.

Trusted colleagues, managers, and other social support can assist traumatized staff by acting as an outlet for emotions. Staff members also need to develop a lifestyle outside of work that involves personal life-affirming activities and nurturing relationships.⁶⁵ Unit leaders and managers should assess staff members’ responses to dramatic events and look for chronic “numbing,” which occurs when staff members exhibit decreased emotion or growing irritability.⁶⁵ Some longtime PCCU nurses grow weary of the pain of too many suffering or dying children, too many traumatized families, and too much of everything. These nurses need a break.

Strategies for Coping

Supportive relationships with colleagues are by far the most significant factors in reducing stress in the critical care unit. When nurses have close, positive relationships in a unit, that unit usually has high morale. Shared intense, emotional, and stressful experiences can foster camaraderie, closeness, and an understanding for the feelings of other members of the healthcare team. If a co-worker is extremely frustrated, it might be necessary to relieve that nurse from patient care responsibilities for a short period.

Emotional empathy and reassurance from those with whom one works closely is highly meaningful. Sometimes people need to hear that someone realizes how they feel and recognizes the intensity of their efforts. Physical contact is important, too. Supportive physical contact, such as hugs, can be beneficial in the professional setting. Praise from co-workers can also be especially satisfying. It is important to take a moment to tell a co-worker when he or she does something especially well.

After the death of a child, the child’s nurse will need time to grieve and regroup and will typically not be ready to received another assignment the moment the grieving family leaves the critical care unit. It is important to allow for such time, even when the patient census is high and another child is waiting in the emergency department for a critical care bed. If the nurse has empathized with the family’s sorrow, it will be difficult to abandon or suppress those feelings and immediately form a new relationship with another child and family. Nurses need to be sensitive to the feelings and needs of those with whom they work and be sure that they are giving their colleagues time, understanding, and support.

Coping strategies such as the use of laughter, bravado, detachment, and other self-protecting maneuvers have been recognized as being temporarily helpful for the intense feelings of pain and threat that critical care staff members experience.⁷ Although acknowledgment of feelings and colleague support are the most beneficial long-term coping strategies,⁷ the use of humor can sometimes provide short-term relief and a feeling that the situation is not too overwhelming. Tears of laughter are much less threatening than tears of grief and frustration. Because staff members’ use of humor can be perceived by families as insensitive, its use is best reserved for locations where family members are not present.

Group meetings or debriefings can provide a constructive outlet for feelings and can be a means of sharing and discovering mutual concerns. A staff psychologist or employee assistance personnel can be invited to coordinate the meetings. After dramatic or distressing events, critical incident stress debriefing has been shown to be helpful.²⁹ Such meetings can foster open communication and can be used for problem solving and conflict resolution or can even facilitate the use of humor in an appropriate setting.

The use of regular physical activity and relaxation techniques can reduce stress on a long-term basis. Each nurse should recognize when his or her own breathing is rapid and shallow and should learn to concentrate on slow diaphragmatic breathing. Doing so will help to decrease the level of physiologic arousal and lead to a decrease of anxiety and restlessness. In addition, staff members should have a location where they can find a few moments of quiet and peace to relax and defuse. It is important that the nurse has a balance between work life and personal life. See the Chapter 24 Supplement on the Evolve Website, for more information about Burnout and Compassion Fatigue Among Caregivers.