Family structures

In addition to discussing their own experiences and perceptions as relatives, patients and professional nurses, participants also acknowledged their parental role and discussed their thoughts in relation to their own children.

Differing perspectives were discussed in relation to parental decisions about visiting and that individual families will have their own opinions:

If you're leaving it up to the parents to make the decision if they think their child should come in everyone’s going to have a different way because how I bring my child up might be different to how you would bring your child up (P-AN06 - FG1 A Lines 177-179).

There was an awareness of the different reactions of children to events depending upon their ages, although these related to personal experiences rather than knowledge gained through education:

When I had my daughter she was in special care. My son was two. He thought all babies were born into incubators. He had no idea that that was not normal because he had no idea what normal was. So I don't think that young children have got a problem (P-AN24 - FG1B Lines 140-143).

163 Empathy: Participants not only discussed differing viewpoints but also displayed a range of empathetic responses towards parents admitted to hospital relating to the different challenges encountered in different age groups. Teenagers were considered to be the most challenging group:

It's difficult for parents of children, well teenagers particularly. Bad enough bringing a teenager up when you're well and outside in your own home let alone trying to do it from a hospital bed. (P-AN24 - FG1B Lines 204-206)

Empathy was also shown towards the feelings of the parents, especially from those who were parents themselves. A number of the adult nurse participants worked in clinical specialities with large numbers of young patients and there was an emphasis on the parental positon if an admission was required:

You know for any parent … it's the most important thing in your life. And at that point when you're ill it's probably even more so because that's your first thought is oh ‘God, what am I going to do with the kids? What are the kids going to think about this?' (P-AN24 - FG1B Lines 453-456).

Proximity: During the discussions about personal experiences the subtheme of ‘proximity’ emerged. This related to consideration of family dynamics and individuals patients situations. In the quote below the participant highlighted that some patients with small children may not have other family members close by who could help with babysitting:

164 No extended family, no Grandparents on hers or her husband’s side well that means then that her husband wouldn’t have been able to have visited because he would have had nobody to look after the siblings and so she’s then not got any support in hospital from the relatives point of view (P-AN08 - FG1A Lines 233-237).

This case highlighted that although a well parent could take care of the children at home, the lack of any close family or significant others who could provide childcare could result in a patient having no visitors. Increased mobility in recent years has resulted in families with both regular contact through technology, and families with no contact (Chambers, Allan, Phillipson and Ray, 2009). Therefore, even those with regular family contact using technology, may not have the proximity to provide child care support during a hospital admission.

Other participants discussed differing family structures which may impact the family dynamics and affect children support for visiting the hospital. In additional to those who lived a distance from their intended family, patients who were single parents stood out as an area of specific concern. Participants had described situations where children of single parents had been left at the hospital with the patient (reasons for exclusion theme); raising the issue of child abandonment as a reason to restrict child visitation.

This concern reoccurred throughout the PAR cycle and despite information and reassurance from the child health team participants, it was still highlighted as a concern during the evaluating action phase.

165 Single parents: Linked to the changing structures of families, such as single parents, were the changing roles within families. The adult nurse participants raised the perception that there were increased numbers of grandparents caring for their grandchildren during the day and this was associated with an increasing closeness and dependence upon them:

The other thing as well is there's quite often in erm single-parent families where the parents have split up, if the children are, say, with the mother then she will quite often be supported by her parents so the child will be quite close to the grandparents in that case. Because I know quite a few of my daughter's friends who've been in that situation where her granddad runs her everywhere you know. So he's like a surrogate father, if you like. (P-AN24 - FG1B Lines 181-186).

Grandparents as surrogates: Research has demonstrated that there are many different types of grand-parenting styles, with some highly active in the lives of their grandchildren whilst others have only intermittent contact (Chambers, Allan, Phillipson and Ray, 2009). Those with very active involvement may increase the exposure that adult nurses have with children in the future. It had been noted by adult nurse participants that patients attending some outpatient clinics often did so with their grandchildren even when accessing treatment:

And grannies bring them as well, don't they? Quite a lot of kids are looked after by granny in the school holidays and quite often granny will be the one that's having the treatment (P-AN24 - FG1B Lines 88-90).

166 Family dynamics: The different family structures and situations discussed

resulted in the introduction of family dynamics and family systems by the child health team. Illness within the family can have a profound effect and each family will react differently depending upon its structure, reactions to stress and levels of resilience (Price, Price and McKenry, 2010). The participants from the child health team shared their admission process and the importance attributed to the initial holistic assessment of the child and the family:

What I’d say straight away is on the admission process we get the family dynamics straightaway (P-CN23 - FG1A Line 48).

A detailed history about a patient’s family is not a feature of the admission assessment in adult clinical areas. However, the clinical experiences discussed by the adult nurse participants contained the issues relating to family dynamics, family structures, and responses to stress. In the cases where children had been left with single parents, knowledge of the family structures and support mechanisms may have prevented the crises that occurred due to family stress responses and a lack of childcare.

Some adult nurse participants initially considered that decisions relating to children visiting clinical areas should be made by the parents and so nurses would not need to provide any support to those children. However, as the focus groups progressed they began to question whether the parent’s ability to make decisions and provide support to their children could be affected by the family illness:

You'd hope the parent or the guardian would do it but you don't know whether the parent or guardian's in the right frame of mind at the time. (P-AN29 - FG2A Lines 425-427).

167 There was a link with role conflict and role duality. There was also the acknowledgement that even as a registered nurse, there may be times when you need support with your children. One participant related this back to a situation where it was noted that even as a nurse her confidence was affected (Winch, 2001), as she was unsure of how to provide support in her role as a parent to her own children:

I think there are situations where you need support with children. I'm a nurse and I certainly didn't know how to deal with my little ones going through - I took the older one but there are times when you think, 'I wish somebody was here to give me a bit of advice on this. Am I doing the right thing? (P-AN55 - FG4 Lines 103 – 106).

Parental capability: The stress related to parental capability in the acute clinical situation was illustrated by one participant who shared feelings associated with having one very ill child:

But me as a mother, my worst worry was, 'How do I support one child when I've lost another?' (P-CN23 - FG4 Line 72-73).

Although related to a young child who was ill, there are situations within adult clinical nursing where this could also be an issue. A number of the adult clinical specialities have young patients aged from eighteen years, particularly respiratory, oncology, ICU and the emergency department. Any of these patients may have younger siblings and so this parental situation is relevant in both paediatric and adult clinical areas.

168

“Illness typically occurs within the context of family systems, where family members are seen as mutually influential” (Yorgason, 2010, p.97), and as such hospital admissions and bereavement affect the whole family including the children. When discussing parental capability one participant shared that she had stopped her own children from going to her mother’s funeral as it would be too upsetting for them, a reason often given for also restricting hospital visiting (Clarke, 2000; Goodall, 1980;

Morgan, 2012). On reflection, she attributed to this decision to her own inability to cope and distress (Winch, 2001) at the time. During this discussion, a link to the potential long term effects on children of excluding them from hospital visits and death rituals was evident when another participant shared the long lasting impact that exclusion following bereavement in childhood had had for them:

I was 13 and they didn't let me see my Nan at the chapel of rest and I hate my parents for that still to this day. Isn't it weird? (P-CN23 - FG4 Lines 81 – 82).

It is well recognised that children have differing needs depending upon their development stage and individual personalities. Some may want factual information, some emotional support and others the opportunity to participate (Winch, 2001).

Research has found that children need information during family illness in order to feel safe and secure (Davey, Tubbs, Kissil and Niño, 2011; Maynard, Patterson, McDonald and Stevens, 2013). They will also need information and support in order to be facilitated to make informed choices. Distress can be caused if a child is forced to visit a patient in hospital (Knutsson and Bergbom, 2007b), in the same way that distress was caused to the participant by their wishes being discounted.

To summarise, the theme ‘family structure’ consisted of five subthemes;

proximity, single parents, grandparents as surrogates, family dynamics and parental

169 capability. The changing nature of family structures was recognised and the challenges that this presented during family illness was discussed. Empathy was shown for those parents and guardians who may require hospital admission or who may need to support a hospitalised parent without a social network to support them.

Throughout discussions related to this theme, the issue of parental responsibility and capability evolved. Initially, many adult nurse participants felt that as the parents were responsible for the children, there was no requirement for nurses to be involved with supporting them. There was however, an evolving awareness that some parents and guardians may not feel confident in their decision making about the children and so may require support from the nurses.