Psychosocial experiences of parents of infants with hypoplastic left heart syndrome in the PICU

Exploration of trust between pediatric nurses and children with a medical diagnosis and their caregivers on inpatient care units: A scoping review

PROBLEM

Trust is central to the development of nurse-patient relationships. Pediatric nurses encounter difficulties developing trust with children and their caregivers. The purpose of this scoping review was to identify, examine, and summarize available evidence on the concept of trust among nurses and children/caregivers when admitted to hospital inpatient care units.

ELIGIBILITY CRITERIA

Using the Joanna Briggs Institute (JBI) methodology for conducing and reporting scoping reviews, CINAHL, MEDLINE, PsycINFO, Cochrane DSR, Cochrane Central, and JBI EBP were searched for qualitative, quantitative, mixed methods, and review studies with no time limits published in English. Included studies presented findings on the experiences of developing trust between pediatric nurses and children under 18 years of age and their caregivers within inpatient care units.

RESULTS

A total of 12,269 titles and abstracts were reviewed independently by two reviewers. 366 full-text articles were retrieved, a final of 81 studies were included in the review.

CONCLUSIONS

Trust was bi-directional between nurses and children/caregivers, developed over time during multiple interactions, and foundational to the development of relationships. Distinct facilitators and barriers to the development of trust between nurses and children/caregivers were identified. The development of trust was rewarding and enriching for both nurses and children/caregivers and was the fundamental to the provision of safe and high-quality nursing care.

IMPLICATIONS

Findings provide nurses with direction and strategies on how to develop and maintain trust with children/caregivers on inpatient care units. The development of training programs and interventions geared at equipping nurses with the skills to develop trust with children/caregivers is needed.

"We want to include him in that journey": A qualitative descriptive study of parental experiences and considerations for sibling inclusion in the paediatric ICU

OBJECTIVES

Siblings are an important yet often forgotten part of the paediatric intensive care unit (PICU) family experience. Commonly, siblings are supported through the experience by their parents; however, very little is known about parental experiences of providing this support. This study aims to explore parental experiences of supporting sibling inclusion in PICU.

RESEARCH METHODOLOGY/DESIGN

This study utilised a qualitative descriptive approach to conduct semi-structured interviews with 6 parents of 5 children with congenital heart disease who had spent time in PICU. Data were analysed using reflexive thematic analysis.

SETTING

Australian PICUs.

FINDINGS

Parental considerations and experiences for sibling inclusion were identified across three key phases: Pre-inclusion, The PICU visit, and Post-inclusion. Prior to including siblings in PICU, parents considered various ways of sharing information with siblings, and weighed up the risks and benefits of bringing siblings into PICU. Parents also recounted a number of challenges and facilitators to a positive sibling experience in PICU, including supportive staff and fun activities. Finally, parents, identified that siblings require ongoing support after their inclusion in PICU and made suggestions for ongoing availability of information and supportive resources.

CONCLUSIONS

This study has illuminated key parental experiences when supporting sibling inclusion in PICU before, during and after their visit. By understanding these parental experiences, PICU staff can work with and support parents where needed, helping to achieve a positive sibling inclusion experience.

IMPLICATIONS FOR CLINICAL PRACTICE

Parents need ongoing support to explain the PICU to siblings of critically ill children and may benefit from specific visual resources to aid communication. In addition, PICUs should aim to ensure the physical layout is supportive of sibling needs, with dedicated spaces for siblings to play and take time out during their experience.

EMpowerment of PArents in THe Intensive Care: A multicentre validation study in Japan

BACKGROUND

The importance of assessing family satisfaction in paediatric intensive care units (PICUs) is becoming increasingly recognised. The survey, EMpowerment of Parents in THe Intensive Care "EMPATHIC-30", was designed to assess family satisfaction and has been translated and implemented in several countries but not yet in Japan.

OBJECTIVES

The objective of this study was to translate, culturally adapt, and validate the EMPATHIC-30 questionnaire in Japanese and to identify potential factors for family-centred care satisfaction.

METHODS

We translated and adapted for patient-reported outcome measures via a 10-step process outlined by the Principles of Good Practice. Four paediatric PICUs in Japan participated in the validation study, and the parental enrolment criterion was a child with a PICU stay of >24 h. Reliability was measured by Cronbach's α, and congruent validity was tested with overall satisfaction-with-care scales by correlation analysis. Multivariate linear regression modelling was conducted to identify factors related to each domain of the Japanese EMPATHIC-30.

RESULTS

A total of 163 parents (mean age: 31.9 ± 5.4 years; 81% were mothers) participated. The five domains of the Japanese EMPATHIC-30 showed high reliability (α = 0.87 to 0.97) and congruent validity, demonstrating high correlations with overall satisfaction in nurses (r = 0.75) and doctors (r = 0.76). Multivariate modelling found that elective admission, mechanical ventilation, and parents who had experience of a family member in an adult intensive care unit had higher satisfaction scores in all five domains (p < 0.05). Moreover, Buddhists assigned higher satisfaction scores in the Care and Treatment domain (p = 0.03).

CONCLUSIONS

The Japanese EMPATHIC-30 questionnaire has demonstrated adequate reliability and validity measures. We also identified that elective admission, mechanical ventilation, and having previous adult intensive care unit experience of a family member were factors in assigning higher scores for all satisfaction domains. PICU clinicians need to be cognisant of ethical, cultural, and religious factors relating to the critically ill child and their family.

Experiences of parents of children with hypoplastic left heart syndrome during their treatment: a qualitative study

AIM

To investigate the opinion and personal experience of parents of children born with Hypoplastic Left Heart Syndrome and what advice they would give to other parents who have to decide between treatment options.

METHODS

We conducted a qualitative, descriptive and retrospective study by means of a survey directed to parents of children born with Hypoplastic Left Heart Syndrome in a tertiary hospital in Buenos Aires (Argentina). Their answers and data regarding medical procedures were analysed.

RESULTS

Parents of thirteen out of sixteen patients with Hypoplastic Left Heart Syndrome were surveyed. Norwood surgery had been performed in all the patients, many had received other procedures, and five had died. In relation to the decision-making process, sixty-one percent of parents would recommend other parents to remain at peace after having done everything possible and 54% would suggest to not feel guilt despite the final result. None of the parents would recommend rejecting surgical treatment and choosing comfort care.

CONCLUSION

The majority of parents of children with Hypoplastic Left Heart Syndrome would recommend continuing with the therapeutic effort in order to feel at peace and reduce feelings of guilt.

Prevalence and associated factors of post-traumatic stress disorder in parents whose infants have single ventricle heart disease

INTRODUCTION

Post-traumatic stress disorder occurs in parents of infants with CHD, contributing to psychological distress with detrimental effects on family functioning and well-being. We sought to determine the prevalence and factors associated with post-traumatic stress disorder symptoms in parents whose infants underwent staged palliation for single ventricle heart disease.

MATERIALS AND METHODS

A large longitudinal multi-centre cohort study evaluated 215 mothers and fathers for symptoms of post-traumatic stress disorder at three timepoints, including post-Norwood, post-Stage II, and a final study timepoint when the child reached approximately 16 months of age, using the self-report questionnaire Impact of Event Scale - Revised.

RESULTS

The prevalence of probable post-traumatic stress disorder post-Norwood surgery was 50% of mothers and 39% of fathers, decreasing to 27% of mothers and 24% of fathers by final follow-up. Intrusive symptoms such as flashbacks and nightmares and hyperarousal symptoms such as poor concentration, irritability, and sudden physical symptoms of racing heart and difficulty breathing were particularly elevated in parents. Higher levels of anxiety, reduced coping, and decreased satisfaction with parenting were significantly associated with symptoms of post-traumatic stress disorder in parents. Demographic and clinical variables such as parent education, pre-natal diagnosis, medical complications, and length of hospital stay(s) were not significantly associated with symptoms of post-traumatic stress disorder.

DISCUSSION

Parents whose infants underwent staged palliation for single ventricle heart disease often reported symptoms of post-traumatic stress disorder. Symptoms persisted over time and routine screening might help identify parents at-risk and prompt referral to appropriate supports.

Experiences and insights from partners of individuals with single-ventricle CHD: a pilot qualitative research study

INTRODUCTION

With advances in care, an increasing number of individuals with single-ventricle CHD are surviving into adulthood. Partners of individuals with chronic illness have unique experiences and challenges. The goal of this pilot qualitative research study was to explore the lived experiences of partners of individuals with single-ventricle CHD.

METHODS

Partners of patients ≥18 years with single-ventricle CHD were recruited and participated in Experience Group sessions and 1:1 interviews. Experience Group sessions are lightly moderated groups that bring together individuals with similar circumstances to discuss their lived experiences, centreing them as the experts. Formal inductive qualitative coding was performed to identify salient themes.

RESULTS

Six partners of patients participated. Of these, four were males and four were married; all were partners of someone of the opposite sex. Themes identified included uncertainty about their partners' future health and mortality, becoming a lay CHD specialist, balancing multiple roles, and providing positivity and optimism. Over time, they took on a role as advocates for their partners and as repositories of medical history to help navigate the health system. Despite the uncertainties, participants described championing positivity and optimism for the future.

CONCLUSIONS

In this first-of-its-kind pilot study, partners of individuals with single-ventricle CHD expressed unique challenges and experiences in their lives. There is a tacit need to design strategies to help partners cope with those challenges. Further larger-scale research is required to better understand the experiences of this unique population.

Examining the Real-Life Journey of Individuals and Families Affected by Single-Ventricle Congenital Heart Disease

Background The lifetime journey of patients with single-ventricle congenital heart disease is characterized by long-term challenges that are incompletely understood and still unfolding. Health care redesign requires a thorough understanding of this journey to create and implement solutions that improve outcomes. This study maps the lifetime journey of individuals with single-ventricle congenital heart disease and their families, identifies the most meaningful outcomes to them, and defines significant challenges in the journey. Methods and Results This qualitative research study involved experience group sessions and 1:1 interviews of patients, parents, siblings, partners, and stakeholders. Journey maps were created. The most meaningful outcomes to patients and parents and significant gaps in care were identified across the life journey. A total of 142 participants from 79 families and 28 stakeholders were included. Lifelong and life-stage specific journey maps were created. The most meaningful outcomes to patients and parents were identified and categorized using a "capability (doing the things in life you want to), comfort (experience of physical/emotional pain/distress), and calm (experiencing health care with the least impact on daily life)" framework. Gaps in care were identified and classified into areas of ineffective communication, lack of seamless transitions, lack of comprehensive support, structural deficiencies, and insufficient education. Conclusions There are significant gaps in care during the lifelong journey of individuals with single-ventricle congenital heart disease and their families. A thorough understanding of this journey is a critical first step in developing initiatives to redesign care around their needs and priorities. This approach can be used for people with other forms of congenital heart disease and other chronic conditions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04613934.

Early growth trajectory is associated with psychological stress in parents of infants with congenital heart disease, but moderated by quality of partner relationship

PURPOSE

To explore the relationships between growth trajectory, parenting stress and parent post-traumatic stress (PTS), in infants with congenital heart disease, and the moderating role of parents' dyadic adjustment on those associations.

DESIGN AND METHODS

A secondary analysis of data from the REACH Telehalth home monitoring multi-site randomized clinical trial. Parents completed the Parenting Stress Index (PSI), Post-traumatic diagnostic scale, and the Dyadic Adjustment Scale. Multivariate logistic regression models were used to examine the associations of interest.

RESULTS

During 4-month follow-up after hospital discharge, parents of infants with 'Never recovered' and 'Partially recovered' growth trajectories had 2-5 times higher odds of experiencing higher stress on the Parent Domain (OR = 4.8, CI = 1.3-18.0; OR = 2.5, CI = 1.0-5.9, respectively) than those with stably grown infants. Parents of "Never recovered" infants had 4 times higher odds of PTS symptoms (OR = 3.9; CI = 1.6-9.9). Parental dyadic adjustment moderated the relationships. Parents of 'Partially recovered' infants and having low dyadic adjustment had 3-5 times higher odds of high stress on all PSI domains, while parents with high dyadic adjustment did not have increased stress due to poor infant growth. Parents of "Never recovered" infants had four times higher odds of PTS symptom, even with high dyadic adjustment.

CONCLUSIONS

Infant growth trajectory over the first four months is associated with parenting stress and PTS. Quality of partner relationship moderates some of these associations.

PRACTICE IMPLICATIONS

Infant growth should serve as a screening aid for identifying parents at psychological risk. Interventions targeting the quality of partner relationship may support parental coping and mitigate stress.

CLINICAL TRIAL REGISTRATION

NCT01941667.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Parental perceptions and experiences of an oral health care promotion intervention for children with congenital heart defects

Purpose

Congenital heart disease (CHD) is one of the most common congenital anomalies in children. Children with major CHD are at risk for developing endocarditis. Acute endocarditis may be life threatening and lead to heart failure. The purpose of this study was to explore parental perceptions and experiences of an early oral health promotion intervention (OHPI) targeting children with major CHD at risk for developing endocarditis later in life, and use this information to examine intervention feasibility.

Methods

Nine parents (three fathers and six mothers) participating in a one and a half year OHPI were purposefully selected for qualitative evaluation of intervention feasibility using semi-structured interviews. The interviews were analysed with an inductive content analysis method.

Results

The analysis resulted in four main categories and 14 subcategories that describe parental perceptions and experiences of the OHPI. The four main categories were timing of first intervention contact, effortlessness of intervention process, individuality of support, and relevancy of support.

Conclusion

Parents of children with CHD perceived the OHPI as important and feasible to be implemented in daily life in children with systemic diseases overall. Further studies on timing of first contact and use of additional Web-based support are needed.

Effectiveness-implementation hybrid-2 randomised trial of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children (DAISY): pilot study protocol

INTRODUCTION

In Australia, while paediatric intensive care unit (PICU) mortality has dropped to 2.2%, one in three survivors experience long-term neurodevelopmental impairment, limiting their life-course opportunities. Unlike other high-risk paediatric populations, standardised routine neurodevelopmental follow-up of PICU survivors is rare, and there is limited knowledge regarding the best methods. The present study intends to pilot a combined multidisciplinary, online screening platform and general practitioner (GP) shared care neurodevelopmental follow-up model to determine feasibility of a larger, future study. We will also assess the difference between neurodevelopmental vulnerability and parental stress in two intervention groups and the impact of child, parent, sociodemographic and illness/treatment risk factors on child and parent outcomes.

METHODS AND ANALYSIS

Single-centre randomised effectiveness-implementation (hybrid-2 design) pilot trial for parents of children aged ≥2 months and <4 years discharged from PICU after critical illness or injury. One intervention group will receive 6 months of collaborative shared care follow-up with GPs (supported by online outcome monitoring), and the other will be offered self-directed screening and education about post-intensive care syndrome and child development. Participants will be followed up at 1, 3 and 6 months post-PICU discharge. The primary outcome is feasibility. Secondary outcomes include neurodevelopmental vulnerability and parental stress. An implementation evaluation will analyse barriers to and facilitators of the intervention.

ETHICS AND DISSEMINATION

The study is expected to lead to a full trial, which will provide much-needed guidance about the clinical effectiveness and implementation of follow-up models of care for children after critical illness or injury. The Children's Health Queensland Human Research Ethics Committee approved this study. Dissemination of the outcomes of the study is expected via publication in a peer-reviewed journal, presentation at relevant conferences, and via social media, podcast presentations and open-access medical education resources.

REGISTRATION DETAILS

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Pilot testing of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children' (the DAISY Pilot Study).

TRIAL REGISTRATION NUMBER

ACTRN12621000799853.

Rates of depression, anxiety, and stress in parents of children with congenital heart disease using the Depression Anxiety Stress Scale

Context and Background

The Cardiac Neurodevelopmental Outcome Collaborative has recommended using the Depression Anxiety Stress Scale (DASS) to evaluate for depression, anxiety, and stress in parents of children with congenital heart disease (CHD). There has not been a longitudinal study investigating its utility in these parents.

Aims

The aim of this study was to determine the trend of depression, anxiety, and stress in parents of patients with CHD.

Methods

Our center uses this self-reported survey at every visit between 6 and 36 months of age. This was a single-centered, retrospective study from January 1, 2018, to June 1, 2020.

Statistical Analysis

Cox regression analysis was conducted using a composite end point of having an abnormal score in any of the three domains.

Results

Two hundred and seventy-three mothers and 139 fathers were included in the study. For mothers, scores in each domain were elevated at 12 and 24 months. For fathers, scores in each domain were elevated at 6 months, followed by a decrease before peaking again, with depression increasing at 36 months and anxiety and stress increasing at 30 months. Increased length of stay for the index surgery was associated with an abnormal score for mothers (B = 0.02, P < 0.01) and fathers (B = 0.01, P = 0.04). Being in a relationship with the father (B = -0.8, P < 0.01) was associated with freedom of an abnormal score for mothers.

Conclusions

Scores concerning for depression, anxiety, and stress peak at different points for parents. Length of stay for the index surgery and being in a relationship are important factors in the mental health of parents.

Acute Stress in Parents of Patients Admitted to the Pediatric Intensive Care Unit: A Two-Center Cross-Sectional Observational Study

OBJECTIVE

To examine medical and psychosocial risk factors associated with the development of acute stress in parents of patients unexpectedly admitted to the PICU.

DESIGN

Cross-sectional observational study.

SETTING

Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICU.

PATIENTS

Parents of patients unexpectedly admitted to the PICU.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

265 parents of 188 children were enrolled of whom 49 parents (18%) met ASD qualification and 108 (41%) parents developed ASD symptoms as determined by the ASDS-5 scale. Risk factors making parents likely to meet ASD qualification include parents from area served by Penn State (p < 0.001), prior psychiatric illness (p < 0.01), and female gender (p < 0.05), while graduating college was protective (p < 0.05). In the multivariate analysis, parents from area served by Penn State (OR 3.00 (1.49-6.05) p < 0.01) and parents with prior psychiatric illness (OR 2.16 (1.03-4.52) p < 0.05) were associated with ASD qualification. Parents who graduated college or had prior medical problems were not significant.Risk factors making parents more likely to develop ASD symptoms (significant symptoms that do not meet ASD qualification) include patients with higher PRISM-III scores (p < 0.01), patients receiving cardiovascular support (p < 0.05), parents with a history of prior physical/sexual abuse (p < 0.01), parental involvement in the past with a major disaster/accident (p < 0.01), a family member admitted to an ICU in the past (p < 0.05) and preexisting parental psychiatric/medical disorders (p < 0.001). In a multivariate analysis, prior parental psychiatric disorder (OR 4.11 (1.80-6.42) p < 0.001), history of parental abuse (OR 3.11 (1.14-5.08) p < 0.05), and parental prior medical problem (OR 2.03 (1.01-3.05) p < 0.05) were associated with the development of ASD symptoms. However, PRISM-III score and prior involvement in major disaster were not significant.

CONCLUSIONS

A combination of psychosocial parental risk factors and patient factors were associated with acute stress in parents. Further studies evaluating targeted hospital interventions towards parents most at-risk are needed.

Parents’ Challenges beyond the Pediatric Intensive Care Unit: Fraying at the Seams while Balancing between Two Worlds, Home and Hospital

Background: The dominant tradition in studying parents’ responses to their child’s hospitalization in the pediatric intensive care unit (PICU) is to focus on their immediate environment and their children’s well-being. This view of the parents’ experiences fails to describe the broader set of concurrent challenges beyond the PICU that parents carry with them into the PICU. Objectives: This study describes (a) parents’ reactions to juggling their two worlds, home and hospital, when their child is hospitalized in the PICU, and (b) the impact of this juggling on their lives. Methods: Fifteen parents whose child was admitted into a PICU at a tertiary medical center for children in the Pacific Northwest participated in semi-structured interviews. Data analysis and interpretation were guided by grounded theory. Results: The theory grounded in the data and integrated with the core category was Fraying at the Seams while Balancing between Two Worlds, Home and Hospital. Analyses revealed two categories: Bringing My Life to a Halt and Throwing Our Whole Life Off. Conclusion: Even though parents were physically and emotionally present with their child in the PICU, they felt frayed as they concurrently struggled with their physical distance from other children at home. This strain of living in two worlds caused feelings of inadequacy to fulfill their parental role.

Family Outcomes After the Pediatric Intensive Care Unit: A Scoping Review

BACKGROUND

Intensivists are increasingly attuned to the postdischarge outcomes experienced by families because patient recovery and family outcomes are interdependent after childhood critical illness. In this scoping review of international contemporary literature, we describe the evidence of family effects and functioning postpediatric intensive care unit (PICU) as well as outcome measures used to identify strengths and weaknesses in the literature.

METHODS

We reviewed all articles published between 1970 and 2017 in PubMed, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), or the Cochrane Controlled Trials Registry. Our search used a combination of terms for the concept of "critical care/illness" combined with additional terms for the prespecified domains of social, cognitive, emotional, physical, health-related quality of life (HRQL), and family functioning.

RESULTS

We identified 71 articles reporting on the postPICU experience of more than 2400 parents and 3600 families of PICU survivors in 8 countries. These articles used 101 different metrics to assess the various aspects of family outcomes; 34 articles also included open-ended interviews. Overall, most families experienced significant disruption in at least five out of six of our family outcomes subdomains, with themes of decline in mental health, physical health, family cohesion, and family finances identified. Almost all articles represented relatively small, single-center, or disease-specific observational studies. There was a disproportionate representation of families of higher socioeconomic status (SES) and Caucasian race, and there was much more data about mothers compared to fathers. There was also very limited information regarding outcomes for siblings and extended family members after a child's PICU stay.

CONCLUSIONS

Significant opportunities remain for research exploring family functioning after PICU discharge. We recommend that future work include more diverse populations with respect to the critically ill child as well as family characteristics, include more intervention studies, and enrich existing knowledge about outcomes for siblings and extended family.

Psychological Outcomes in Fathers of Critically Ill Children in the Pediatric Intensive Care Unit: A Systematic Review

Systematically review evidence of psychological distress in fathers of children admitted to the pediatric intensive care unit (PICU). Two reviewers independently reviewed 24 published articles that studied fathers during and closely following a PICU admission. Results are presented for psychological outcomes of stress, PTSD, anxiety and depression, family functioning, and other forms of distress. Potential moderators of distress are also presented. Although methodological variance and inconsistent findings make it difficult to draw definitive conclusions, mothers and fathers appear to experience similar levels of distress and psychiatric symptoms during and after a PICU admission. Fathers' distress may be characterized by feelings of helplessness and often manifests after discharge, later than for mothers. More research is needed to understand gender differences in the expression of parental distress during and after a PICU admission as this will serve to inform interventions designed to improve family functioning.

Parental experiences of their infant's hospital admission undergoing cardiac surgery: A systematic review

AIM

To explore parents' experiences of parenting a child hospitalised with congenital heart disease (CHD) and undergoing surgery.

METHODS

Five electronic databases were systematically searched for articles describing the experiences of parents with a child with a CHD. A thematic analysis approach was used to identify the most common themes.

RESULTS

A total of 188 articles were identified. Eight studies were included in the review. Four themes emerged, including balancing the parental role, experiencing anticipatory grief, decreasing parental stress using coping strategies and professional support.

CONCLUSION

Having a child with CHD undergoing heart surgery is a stressful experience due to, among other things, the different situation-related parenting role during the hospital stay and feelings of anticipatory grief. Healthcare professionals in the PICU have an essential role in supporting parents and understanding the needs that are crucial for the parents in order to provide better support and reduce stress and anxiety. More qualitative research regarding the pathway from the prenatal diagnosis through the early childhood period is warranted.

Integrated Behavioral Health in Pediatric Subspecialty Clinics

Millions of children and adolescents are living with a chronic condition. It is common for mental and behavioral health challenges to arise during their courses of illness. With the complexity of care needed, pediatric subspecialty providers have recognized the need to integrate behavioral health interventions into practice. Continued research in this area has allowed for focused behavioral interventions, particularly in diabetes and asthma. Adult congenital heart programs have adapted a similar model of care and have shown promising success in promotion of health. More established programs have been in existence for childhood cancer and cystic fibrosis.

Defining a new normal: A qualitative exploration of the parent experience during the single ventricle congenital heart disease interstage period

AIM

To explore parents' experience of transition in the period between the palliative cardiac surgeries (i.e., the interstage period) of an infant with single ventricle congenital heart disease.

DESIGN

We conducted an exploratory naturalistic inquiry using a qualitative descriptive approach.

METHODS

A purposive sample of 11 parents of children with single ventricle disease was selected among families that participated in an interstage-period parental home monitoring program during the past 2 years. Interviews and field observations were conducted September-October 2019, and data were analyzed for themes. Analysis of data was inductive, although study questions and the interpretation of results were informed by Meleis' transition theory.

RESULTS

Parents described the experience of transition in interstage as a striving for normality, a theme that was clustered in subthemes of home, self, and infant.

CONCLUSION

Parents' experiences of striving for normality indicated a need for more targeted efforts to address parents' psychosocial needs during the highly stressful interstage transition.

IMPACT

This research underscored the complexity of parents' psychosocial support needs on returning home after their child's first palliative surgery. The findings also suggest need for examination of the transition following the second palliative heart surgery, when the home monitoring program is withdrawn. Understanding parent needs will help guide healthcare teams in developing ways to support parents as they adjust to home, self, and child.

Skin-to-Skin Care is Associated with Reduced Stress, Anxiety, and Salivary Cortisol and Improved Attachment for Mothers of Infants With Critical Congenital Heart Disease

OBJECTIVE

To estimate the effect of skin-to-skin care (SSC) on biobehavioral measures of stress (anxiety and salivary cortisol) and attachment (attachment scores and salivary oxytocin) of mothers before and after their infants' neonatal cardiac surgery.

DESIGN

A prospective interventional, baseline response-paired pilot study.

SETTING

Cardiac center of a large, metropolitan, freestanding children's hospital.

PARTICIPANTS

Thirty women whose infants were hospitalized for neonatal cardiac surgery.

METHODS

Participants acted as their own controls before, during, and after SSC at two time points: once before and once after surgery. We measured the stress response of mothers, as indicated by self-reported scores of anxiety and maternal salivary cortisol, and maternal-infant attachment, as indicated by self-reported scores and maternal salivary oxytocin.

RESULTS

Significant reductions in self-reported scores of anxiety and salivary cortisol were found as a result of SSC at each time point, as well as increased self-reported attachment. No significant differences were found in oxytocin.

CONCLUSION

Our findings provide initial evidence of the benefits of SSC as a nurse-led intervention to support maternal attachment and reduce physiologic and psychological stress responses in mothers of infants with critical congenital heart disease before and after neonatal cardiac surgery.

Caregiver experiences of paediatric inpatient cardiac services: A qualitative systematic review

BACKGROUND

Advances in paediatric care have contributed to an increasing survival of children with complex heart disease. Yet, life-saving management demands prolonged inpatient admissions, which contribute to emotional and psychological distress for parents and other caregivers in a role of main custody.

AIM

The purpose of this study was to identify, appraise and synthesise qualitative studies exploring caregivers' experiences of paediatric inpatient cardiac services, generating an understanding of their needs in hospital and informing priorities for change in healthcare delivery.

METHODS

Searches were conducted in Medline, Allied and Complimentary Medicine Database, Cumulative Index of Nursing and Allied Health Literature, EMCARE, Scopus, PsychINFO, Proquest, OpenGrey and ETHOs from 2008-2019, reflecting recent advances in cardiac healthcare. Articles were selected using predetermined eligibility criteria dictating qualitative inquiry into caregiver perspectives whilst their child received hospital-based interventions for heart disease. All eligible studies underwent quality appraisal. Framework synthesis was used to analyse and summarise findings.

RESULTS

Twenty-seven studies involving 689 caregivers from 11 countries were included. Three overarching themes were identified: 'emotional capacity to care', 'practicalities of caring', and 'the bigger picture of caring'.

CONCLUSIONS

Through analysis and summary of qualitative primary research, this review captures the emotional challenges that caregivers face and practicalities of undertaking a caregiver role, whilst looking after their child with heart disease in hospital. The results widen the context of the caregiver role, encompassing the whole family unit beyond the hospital environment. This review exposes the impact of these challenges on caregiver competence, wellbeing and attachment to their unwell child, informing priorities for development of family-centred paediatric inpatient cardiac services.

Parental Experiences Caring for Their Hospitalized Medically Fragile Infants: A Description of Grief, Stress, and Coping

BACKGROUND

Advances in care have increased survival and improved outcomes of infants with complex and chronic diseases. These medically fragile infants require long-term hospitalization and depend on technology for survival. Parents of these infants experience stress and difficulties adapting to their parental role.

PURPOSE

To present an account of parental experiences as they provided care for their hospitalized medically fragile infant.

METHODS

This study was part of a larger constructivist grounded theory study to provide a holistic understanding of the processes of care for medically fragile infants. For this sub-study, 21 parents of hospitalized medically fragile infants were recruited from a pediatric hospital in Western Canada. Parents participated in face-to-face, semi-structured interviews, which were transcribed and analyzed using initial and focused coding.

RESULTS

Parents of hospitalized medically fragile infants grieved the loss of parenting a healthy infant, and they experienced multiple stressors. Parents utilized various coping strategies to manage their grief and stressors. Some parents were unable to cope, which exacted a heavy toll on their physical and mental health. Parents recommended psychological support, access to physical activity, primary nursing, and health system navigators.

CONCLUSIONS

Parental recommendations can inform the design of interventions for parents of hospitalized medically fragile infants.

The impact of prenatal counselling on mothers of surviving children with hypoplastic left heart syndrome: A qualitative interview study

Objective

To explore the role of antenatal counselling in how parents make treatment decisions following an antenatal diagnosis of Hypoplastic Left Heart Syndrome (HLHS).

Background

Antenatal counselling is a critical part of patient management following a diagnosis of fetal congenital heart disease; however, there is a very limited evidence base examining how parents actually experience antenatal counselling and make decisions in this context.

Methods

Semi‐structured interviews were conducted with women who had received an antenatal diagnosis of HLHS. Interviews were digitally recorded, anonymised and transcribed verbatim. A thematic content analysis was performed using a constant comparative approach.

Results

Eight mothers of surviving children with HLHS were interviewed. Eight key themes emerged including new perspectives on how women receive antenatal counselling and how it affects their decision making. Three themes in particular are new to the literature: (a) Mothers of children with HLHS reported feelings of intense guilt that arose in the antenatal period around potentially causing the condition in their child. (b) For this group of women, recollections of perceived pessimism during antenatal counselling had a lasting impact. (c) Despite support from partners or extended family, women nevertheless experienced a strong sense that antenatal decision making was largely a ‘maternal’ responsibility.

Conclusions

When recounting their experiences of antenatal counselling, mothers of surviving children with HLHS offer new perspectives that can guide fetal cardiologists in how best to support their individual patients. Further research is needed to comprehensively understand the experience of prospective parents counselled for severe forms of fetal congenital heart disease.

Health Care Professionals' Experiences of Providing Care to Hospitalized Medically Fragile Infants and Their Parents

PURPOSE

To understand contemporary experiences of pediatric health care professionals' (HCPs) caring for hospitalized Medically Fragile Infants (MFI) and their parents.

DESIGN AND METHODS

Convenience sampling was adopted to recruit 26 HCPs who provided care to MFI and their parents on inpatient units at a large tertiary pediatric hospital in Western Canada. Participants participated in either a focus group or individual face-to-face interview. Themes and concepts emerged during open and focused coding.

FINDINGS

HCPs encountered barriers to establishing relationships with parents, including: (a) intricate nature of MFI, (b) lack of social supports, (c) inconsistency, (d) moral distress, (e) burnout, and (f) struggle to gain control. HCPs utilized strategies to establish relationships with parents, including: (a) normalizing and building parental confidence, (b) tailoring care and being flexible, (c) providing parent care, and (d) optimizing communication.

CONCLUSION

HCPs aimed to establish relationships built on trust with parents of MFI to empower and enable parents to care for their infants. The relationship was the vehicle to enhance the care provided and well-being of MFI. HCPs encountered barriers to establishing trusting relationships and utilized strategies to establish such relationships.

PRACTICE IMPLICATIONS

It is valuable to understand the importance that the parent-HCPs relationship plays in the care provided to hospitalized MFI and how lack thereof can lead to moral distress and burnout among HCPs. Increasing HCPs' awareness of barriers and strategies to the establishment of a trusting relationship with parents could help improve the collaborative relationship between parents and HCPs.

A scoping review of parental experiences caring for their hospitalised medically fragile infants

AIM

To synthesise and summarise evidence from published research articles regarding parental experiences caring for their hospitalised medically fragile infant.

METHODS

We searched four electronic databases in April 2018 using three main concepts individually and in combination: infant, medically fragile, parents. We examined articles about experiences of parents caring for the medically fragile infant in a hospital setting. We conducted thematic analysis on the 34 included articles.

RESULTS

Parents experienced high rates of depressive symptoms, depression, stress, anxiety, distress and post traumatic stress. Parent-infant interactions were disrupted. Parents experienced loss and worry in response to the diagnosis of their infant, which altered or delayed parental role attainment. Supports and coping were key for parents to manage their stress.

CONCLUSION

Parents of medically fragile infants experience multiple stressors, elevated levels of mental health difficulties, trouble attaining their parental role and often struggle to cope. Development of interventional research is needed to test targeted strategies aimed at reducing parental stress and mental health difficulties. Interventions should include: screening for parental mental health, psychological support, healthcare professional education, strategies to enhance parent-infant interactions and improved relationship competencies among healthcare professionals.

Mental health care for parents of babies with congenital heart disease during intensive care unit admission: Systematic review and statement of best practice

INTRODUCTION

Congenital heart disease (CHD) is one of the most common causes of infant admission to pediatric intensive care and is associated with profound psychological stress for mothers, fathers and their infants. Intensive care unit admission represents an opportunity to offer evidence-based strategies to prevent or minimize severe psychological distress and promote secure bonding and attachment, alongside high-quality infant medical care.

OBJECTIVES

We aimed to identify, synthesize and critically appraise published evidence on the efficacy and cost-effectiveness of mental health interventions delivered in neonatal, pediatric or cardiac intensive care units for parents of infants with CHD. A secondary goal was to develop recommendations for advancing health policy, practice and research in the field.

METHODS

In accordance with a prospectively registered protocol (CRD42019114507), six electronic databases were systematically searched for studies reporting results of a controlled trial of a mental health intervention for parents of infants aged 0-12 months with a congenital anomaly requiring intensive care unit admission. To maximize generalizability of results, trials involving infants with any type of structural congenital anomaly requiring surgery were included. Outcomes included intervention type, process, efficacy, and cost-effectiveness.

RESULTS

Across all forms of congenital anomaly, only five trials met inclusion criteria (four in CHD, one in gastrointestinal malformation). All interventions engaged parents face-to-face, but each had a distinct therapeutic approach (parent-infant interaction and bonding, early pediatric palliative care, psycho-education, parenting skills training, and family-centered nursing). Four of the five trials demonstrated efficacy in reducing maternal anxiety, although the quality of evidence was low. Positive results were also found for maternal coping, mother-infant attachment, parenting confidence and satisfaction with clinical care, as well as infant mental (but not psychomotor) development at 6 months. Mixed results were found for maternal depression and infant feeding. No evidence of efficacy was found for improving parent, infant or family quality of life, physical health or length of infant hospital stay, and there were no data on cost-effectiveness.

CONCLUSIONS

Stronger evidence for the efficacy of mental health interventions to buffer the effects of intensive care unit admission for parents of infants with CHD is urgently needed. Robust, high-quality trials are lacking, despite the established need and demand, and health policies prioritizing parent mental health care in the context of early childhood adversity are needed.

Posttraumatic stress and health-related quality of life in parents of children with cardiac rhythm devices

PURPOSE

Studies have shown a high prevalence of post-traumatic stress disorders (PTSD) among parents of children with life-threatening diseases. However, it is yet unknown whether parents of children with cardiac rhythm device develop posttraumatic stress symptoms or even PTSD.

METHODS

This cross-sectional investigation is part of a comprehensive single-center study of long-term medical and psychosocial outcomes in pediatric patients with pacemaker (PM) and implantable cardioverter defibrillator (ICD). 69 patients (78%) were included in the study, with the participation of 69 mothers and 57 fathers. Parents completed the Posttraumatic Diagnostic Scale and Medical Outcomes Study Short Form-36 item questionnaire. Child's medical data was collected retrospectively from patients' hospital records.

RESULTS

At assessment, the patients (39% females) were on average 11.2 years old. The predominant device type was PM in 56 cases (81%). The mean time since device implantation was 6.3 years (SD = 4.3). Full heart-disease related PTSD was diagnosed in one mother and no father, while partial heart-disease-related PTSD was diagnosed in 3 mothers (4%) and 2 fathers (4%). Parental HRQoL-especially regarding the mental health dimension-was affected in both parents. In both parents, total PTSD symptom severity scores were a significant predictor for mental health summary scores after controlling for child age at implantation, presence of other non-cardiac disease in the child, parental age, and presence of own chronic disease.

CONCLUSIONS

Special attention should be given to parental PTSD symptoms in the clinical follow-up of PM and ICD patients as some parents might probably benefit from psychological support.

From crisis to self-confidence and adaptation; Experiences of being a parent of a child with VACTERL association - A complex congenital malformation

Aim

Knowledge is scarce regarding mothers’ and fathers’ experiences of being a parent of a child with VACTERL association—a complex malformation. The aim of the study was to describe experiences of being a parent of a child with VACTERL association.

Method

Semi-structured interviews were performed with ten mothers and nine fathers face-to-face or by telephone and analyzed by using Qualitative content analysis.

Results

The parents described crisis reactions at the discovery of malformations in their child. Involvement in care was reported from the initial hospital admission until actively taking responsibility for treatments at home. Eventually the health condition became an integrated part of everyday life. The parents expressed the importance of meeting other families with a child with VACTERL. Descriptions were given of more or less professionalism with perceived discrepancies of knowledge and experience between the healthcare professionals in the tertiary hospital and those in the local hospital. Difficulties in receiving medical support during the initial period at home were described. Furthermore, emotional support and practical arrangements regarding parental accommodation and transportation varied.

Conclusion

Being a parent of a child with VACTERL association involves crisis, mixed emotional reactions and shared responsibility for the child´s treatment and care with the professional care providers. Psychological processing, good medical care and support from experts, and peer support from other parents is essential in the parents’ struggle to reach self-confidence and adaptation. A care plan with individualized tailored care for each child including a training and support plan for the parents is warranted. To reduce the described discrepancies in knowledge and experience between the local and tertiary hospital, video sessions with the parents and responsible professionals at the local and tertiary hospital could be an appropriate mode of transferring information at discharge and follow up of the child.

Parent perceptions of the impact of the Paediatric Intensive Care environment on delivery of family-centred care

OBJECTIVES

To examine parent perception of how the physical and cultural environment of the paediatric intensive care unit impacted the implementation of family-centred care as outlined by the Institute for Patient and Family Centered Care.

RESEARCH DESIGN

A qualitative descriptive design utilizing secondary analysis from a longitudinal study. Sixty-one interviews with three mothers and three fathers (31 interviews with mothers, 30 interviews with fathers) of infants with complex congenital heart defects treated in a paediatric intensive care unit were subjected to secondary analysis via content analysis. The previously completed individual interviews with parents took place at least monthly ranging from soon after birth of their infant to one year of age or infant death, whichever occurred first.

FINDINGS

The family-centred care core concepts of information sharing, participation, respect and dignity were present in parent interviews. Parents indicated that the physical and cultural environment of the pediatric intensive care unit impacted their perceptions of how each of the core concepts was implemented by clinicians. The unit environment both positively and negatively impacted how parents experienced their infant's hospitalisation.

CONCLUSION

In the paediatric intensive care unit, family centred care operationalised as policy differed from actual parent experiences. The impact of the physical and cultural environment should be considered in the delivery of critical care, as the environment was shown to impact implementation of each of the core concepts.

Grief and coping of parents whose child has a constant life-threatening disability, hypoplastic left heart syndrome with reference to the Dual-Process Model

This paper reports on a study that examined the grief and coping of 29 parents whose child has hypoplastic left heart syndrome using the Dual Process Model. The study employed a secondary thematic analysis of interviews at key times of treatment and recovery for the child. After the diagnosis, parents experienced intense loss (LO), but focused upon restoration-orientated tasks (RO) to support their child. Over time, most parents employed a healthy oscillation between LO coping and RO coping, with waves of grief and with some grieving suppressed. There are some specific grief and coping and gender patterns employed by parents.

Family-Centered Care From the Perspective of Parents of Children Cared for in a Pediatric Intensive Care Unit: An Integrative Review

PROBLEM

The Institute for Patient- and Family-Centered Care's (IPFCC) definition of family-centered care (FCC) includes the following four core concepts: respect and dignity, information sharing, participation, and collaboration. To date, research has focused on the provider experience of FCC in the PICU; little is known about how parents of children hospitalized in the pediatric intensive care unit (PICU) experience FCC.

ELIGIBILITY CRITERIA

Articles were included if they were published between 2006 and 2016, included qualitative, quantitative, or mixed methods results, related to care received in a PICU, and included results that were from a parent perspective.

SAMPLE

49 articles from 44 studies were included in this review; 32 used qualitative/mixed methods and 17 used quantitative designs.

RESULTS

The concepts of respect and dignity, information sharing, and participation were well represented in the literature, as parents reported having both met and unmet needs in relation to FCC. While not explicitly defined in the IPFCC core concepts, parents frequently reported on the environment of care and its impact on their FCC experience.

CONCLUSIONS

As evidenced by this synthesis, parents of critically ill children report both positive and negative FCC experiences relating to the core concepts outlined by the IPFCC.

IMPLICATIONS

There is a need for better understanding of how parents perceive their involvement in the care of their critically ill child, additionally; the IPFCC core concepts should be refined to explicitly include the importance of the environment of care.

Parenting a child at home with hypoplastic left heart syndrome: experiences of commitment, of stress, and of love

OBJECTIVE

To evaluate the experiences of parenting a child with hypoplastic left heart syndrome after the child has been discharged home from hospital.

DESIGN

A study of the parents' experiences using face-to-face interviews and psychometric measures with parents whose child had survived stage surgery.

SETTING

Parents were interviewed within the home environment or within the hospital if that was their choice.

SUBJECTS

A total of 29 parents (16 mothers and 13 fathers) of surviving children. Intervention A semi-structured face-to-face interview plus psychometric tests (parent demographics, Maslach Burnout Inventory, Impact on Family Scale, and the Psychological Check List - Civilian). Measurements and main results The parents' experience in supporting a child with hypoplastic left heart syndrome is one of stress, of commitment, and of love. Although parents experienced joy in their child, they were also subjected to anxiety with four parents test positive to post-traumatic stress disorder and hypervigilance while monitoring their child's condition. Parents lived with many difficulties, and demands.

Parent Participation in Pediatric Intensive Care Unit Rounds via Telemedicine: Feasibility and Impact

OBJECTIVES

To evaluate feasibility and impact of telemedicine for remote parent participation in pediatric intensive care unit (PICU) rounds when parents are unable to be present at their child's bedside.

STUDY DESIGN

Parents of patients admitted to a 14-bed PICU were approached, and those unable to attend rounds were eligible subjects. Nurse and physician caregivers were also surveyed. Parents received an iPad (Apple Inc, Cupertino, California) with an application enabling audio-video connectivity with the care team. At a predetermined time for bedside rounds with the PICU team, parents entered a virtual meeting room to participate. Following each telemedicine encounter, participants (parent, physician, nurse) completed a brief survey rating satisfaction (0?=?not satisfied, 10?=?completely satisfied) and disruption (0?=?no disruption at all, 10?=?very disruptive).

RESULTS

A total of 153 surveys were completed following 51 telemedicine encounters involving 13 patients. Parents of enrolled patients cited work demands (62%), care for other dependents (46%), and transportation difficulties (31%) as reasons for study participation. The median levels of satisfaction and disruption were 10 (range 5-10) and 0 (range 0-5), respectively. All parents reported that telemedicine encounters had a positive effect on their level of reassurance regarding their child's care and improved communication with the care team.

CONCLUSIONS

This proof-of-concept study indicates that remote parent participation in PICU rounds is feasible, enhances parent-provider communication, and offers parents reassurance. Providers reported a high level of satisfaction with minimal disruption. Technological advancements to streamline teleconferencing workflow are needed to ensure program sustainability.

Risk factors for the development of post-traumatic stress disorder and coping strategies in mothers and fathers following infant hospitalisation in the neonatal intensive care unit

AIMS AND OBJECTIVES

The aim of this study was to identify the potential risk factors for the development of post-traumatic stress disorder in mothers and fathers following infant hospitalisation in the neonatal intensive care unit.

BACKGROUND

The development of neonatal intensive care units has increased the survival rate of infants. However, one of the major parental problems is post-traumatic stress disorder.

DESIGN

An observational study covered 125 parents (72 mothers and 53 fathers) of infants aged 3-12 months who were hospitalised in the neonatal intensive care unit during the neonatal period.

SETTING

Third-referral neonatal intensive care unit. Several standardised and self-reported research tools were used to estimate the level of post-traumatic stress symptoms (Impact Event Scale-Revised), perceived stress (Perceived Stress Scale) and coping strategies (COPE Inventory). The respondents also completed a Parent and Infant Characteristic Questionnaire.

RESULTS

The mothers and fathers did not differ in their parental and infant characteristics. Post-traumatic stress disorder was present in 60% of the mothers and 47% of the fathers. Compared to the fathers, the mothers felt greater stress (p = .020) and presented a higher severity of post-traumatic stress disorder (p < .001). Previous miscarriages (p = .023) and the presence of chronic diseases (p = .032) were risk factors for post-traumatic stress disorder in the mothers. In the fathers, an Apgar test at 1 min after birth (p = .030) and a partner's post-traumatic stress disorder (p = .038) were related to post-traumatic stress disorder. The mothers compared to the fathers were more likely to use strategies such as: positive reinterpretation and growth, focusing on and venting of emotions, instrumental social support, religious coping and acceptance. In the fathers, the predictors included an Apgar score at 1 min after birth, a lack of congenital anomalies in the child and mental disengagement.

CONCLUSION

Risk factors for post-traumatic stress disorder, as well as coping strategies, differ in women compare to men.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of risk factors for post-traumatic stress disorder, specific to men and women, may help identify the parents in whom probability of the occurrence of this disorder is increased.

The Impact of Ethnic and Cultural Differences on Parental Satisfaction in the PICU

OBJECTIVES

This study examined satisfaction of parents whose children were admitted to the PICU to identify priority areas for improvement. We hypothesized that differences exist in satisfaction of parents of different ethnicities.

DESIGN

Prospective observational study.

SETTING

PICU in a tertiary care pediatric hospital.

PATIENTS

All English-literate parents whose child was admitted to our PICU between February 2014 and February 2015 were eligible after informed consent was obtained. Parents included in this study in previous admission(s) were excluded.

INTERVENTION

Nil.

MEASUREMENTS AND MAIN RESULTS

We adapted Empowerment of Parent in the Intensive Care Questionnaire, a validated questionnaire survey specific for measuring parental satisfaction in PICUs. This adapted survey consisted of 31 questions (based on a scale of 1-6) examining five domains as follows: information giving, care and cure, parental participation, organization, and professional attitude. Reliability of Empowerment of Parent in the Intensive Care Questionnaire in our population was analyzed using Cronbach's alpha. We used ordinal logistic regression, controlling for socioeconomic status and educational level, to examine differences in parental perceptions of various ethnicities. We obtained a total of 206 responses (36.5%) from 543 admissions. There were 116 (56%) emergency and 90 (44%) elective admissions. The proportion of respondents were Chinese (126 [61%]), Malay (32 [16%]), Indian (23 [11%]), and "Others" (25 [12%]). Cronbach's alpha for domains of information giving (α = 0.80), care and cure (α = 0.93), parental participation (α = 0.84), organization (α = 0.79), and professional attitude (α = 0.88) were good. In all five domains, our median PICU scores were 6 (interquartile range, 5-6). Compared to other ethnic groups, Malay parents did perceive that domains of "care and cure," "parental participation," and "professional attitude" were less satisfactory.

CONCLUSIONS

Significant differences were found in satisfaction ratings between parents of different ethnicities. Further studies are needed to explore and determine reasons for these differences.

Analysis of the psychosocial impact of caretaking on the parents of an infant with severe congenital heart defect

This case report considers the psychosocial burden of caring for an infant with a severe congenital heart defect (CHD) on parents. Improved prenatal diagnostics and postnatal surgical intervention have created a new and increasing demographic of children and adults with CHDs that require lifelong medical care. For this reason, primary caregivers spend excessive amounts of time in hospitals and medical facilities, and must regularly decipher vast amounts of unfamiliar medical terminology and concepts with varying levels of assistance from medical personnel. This often leads to marked psychological morbidities in parental caregivers, such as stress, anxiety and depression. The financial cost of caring for infants with CHD, including loss of employment opportunities, is another important factor that impacts the quality of life of caregivers. Frequent and extended travel to seek specialised medical care, often at distant medical centres, represents an additional burden.

Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review

Background

Parents of children with critical congenital heart defects (PCCHDs) may be at high risk for mental health morbidity; however, the literature is not well characterized. Given that compromised parental mental health can lead to long‐term cognitive, health‐related, and behavioral problems in children, a systematic review of this literature could provide informed recommendations for continued research and enhance the care of families of children living with critical congenital heart defects.

Methods and Results

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines that resulted in 30 studies on the mental health of PCCHDs. The literature revealed that PCCHDs are at an elevated risk for psychological problems, particularly in the immediate weeks and months following cardiac surgery. Up to 30% of PCCHDs have symptoms consistent with a diagnosis of posttraumatic stress disorder, with over 80% presenting with clinically significant symptoms of trauma; 25% to 50% of PCCHDs reported clinically elevated symptoms of depression and/or anxiety, and 30% to 80% reported experiencing severe psychological distress. There was high variability in measurements used to assess study outcomes, methodological quality, and sociocultural composition of the parents included in the studies.

Conclusions

There is an urgent need for additional research on the severity, course, persistence, and moderators of these mental health problems over time, and for the development and testing of screening approaches and interventions that can be feasibly delivered in the context of ongoing pediatric cardiac care.

Mental Health Problems in Parents of Children with Congenital Heart Disease

This review will provide a concise description of mental health problems in parents of children with a (non-syndromic) congenital heart disease (CHD) during different stressful periods. Predictors of these problems and also implications for clinical practice will be mentioned. Having a child with CHD can be very stressful for parents, who have to face overwhelming emotions and also extra physical, financial, and other practical challenges. Parental distress has been reported in 30-80% of parents and appears not to be related to severity of CHD. Parental mental health, parenting, the parent-child relationship, and parental quality of life can all be affected. Parents, and especially mothers, are at risk of psychological distress, anxiety, depression, somatization, hopelessness, and posttraumatic stress symptoms, which in turn may influence mother's responsiveness. In the long term, the majority of parents adapt successfully to living with a child with CHD, but approximately 40% report a need for psychosocial care. These families may be helped by early psychosocial interventions to alleviate stress and reduce children's emotional and behavioral problems. A holistic approach to early psychosocial interventions should aim at improving coping and enhance parenting. During routine medical checkups, medical professionals should ask about parental stress, family functioning, and psychosocial functioning of the child and, when needed, adequate psychosocial care should be provided.

Caregiver anxiety due to interstage feeding concerns

INTRODUCTION

Improved weight gain during the interstage (IS) period has been shown to improve overall outcomes in patients with single ventricle physiology (SVP). This emphasis on nutrition may have untoward effects, such as increasing anxiety/stress levels in caregivers, who are already known to be at risk for increased anxiety/stress levels. The goal of this study was to evaluate anxiety/stress levels of caregivers as it pertains to feeding during the IS period and to determine if certain characteristics were associated with higher anxiety/stress scores.

METHODS

Caregivers of children with SVP who completed the IS period, defined as the time between the first and second cardiac surgeries, were recruited. Baseline demographics were obtained. Anxiety/stress levels were measured via eight questions using a 0- to 10-point scale. Correlations were performed between demographic variables and anxiety/stress level scores.

RESULTS

Fifty-six surveys were completed (39 males, 27 females) on 43 children. Fourteen children required tube feeds during the IS period. There were significant correlations between anxiety/stress scores and caregiver's gender, caregiver's age, caregiver's level of education, percent of time a caregiver spent feeding the child, if caregivers were taking medications for anxiety, and if the child was seen in the emergency room during the IS period. There were no correlation of anxiety/stress scores with caregiver's race, child's underlying cardiac diagnosis, age of child, route of feeding during the IS period, birth order of the child or number of children in the family, relationship status, or distance from the hospital.

CONCLUSION

In general, caregivers of children with SVP experience anxiety/stress during the IS period specifically due to feeding concerns. Certain intrinsic and extrinsic characteristics were associated with higher anxiety/stress levels. Future studies are needed to determine how to minimize anxiety/stress levels during this stressful time period.

Mortality-related resource utilization in the inpatient care of hypoplastic left heart syndrome

BACKGROUND

Quantifying resource utilization in the inpatient care of congenital heart diease is clinically relevant. Our purpose is to measure the investment of inpatient care resources to achieve survival in hypoplastic left heart syndrome (HLHS), and to determine how much of that investment occurs in hospitalizations that have a fatal outcome, the mortality-related resource utilization fraction (MRRUF).

METHODS

A collaborative administrative database, the Pediatric Health Information System (PHIS) containing data for 43 children's hospitals, was queried by primary diagnosis for HLHS admissions of patients ≤21 years old during 2004-2013. Institution, patient age, inpatient deaths, billed charges (BC) and length of stay (LOS) were recorded.

RESULTS

In all, 11,122 HLHS admissions were identified which account for total LOS of 277,027 inpatient-days and $3,928,794,660 in BC. There were 1145 inpatient deaths (10.3%). LOS was greater among inpatient deaths than among patients discharged alive (median 17 vs. 12, p < 0.0001). BC were greater among inpatient deaths than among patients discharged alive (median 4.09 × 10(5) vs. 1.63 × 10(5), p < 0.0001). 16% of all LOS and 21% of all BC were accrued by patients who did not survive their hospitalization. These proportions showed no significant change year-by-year. The highest volume institutions had lower mortality rates, but there was no relation between institutional volume and the MRRUF.

CONCLUSIONS

These data should alert providers and consumers that current practices often result in major resource expenditure for inpatient care of HLHS that does not result in survival to hospital dismissal. They highlight the need for data-driven critical review of standard practices to identify patterns of care associated with success, and to modify approaches objectively.

Psychosocial responses of parents to their infant's diagnosis of hypoplastic left heart syndrome

OBJECTIVE

To evaluate the psychosocial status of mothers and fathers in response to their infant's diagnosis of hypoplastic left heart syndrome.

DESIGN

A study on interviews with parents whose children had survived staged surgery.

SETTING

Tertiary hospital paediatric ICU.

SUBJECTS

A total of 29 parents (16 mothers and 13 fathers) of surviving children.

INTERVENTION

A semi-structured face-to-face interview was conducted to explore experiences of parents in response to their infant's diagnosis, their interaction with the doctor delivering the diagnosis, their deliberation about staged surgery, and their reasons for this choice.

MEASUREMENT AND MAIN RESULTS

All parents were devastated about their infant's diagnosis, and most (83%) of them said that the time of the diagnosis and the aftermath was the worst time of their lives. Parents reported helpful and unhelpful communication at this time. Although all parents in this study chose surgery for their infant, when faced with the choice, 17 of them made an immediate decision "to protect their infant's life", 8 were initially unsure when their infant was diagnosed in utero, and 4 were unsure when the infant was diagnosed after birth. Parents also experienced loss and other stressors.

CONCLUSIONS

All parents of the infants diagnosed with hypoplastic left heart syndrome experienced intense loss and stressors. Physicians need to be sensitive to the needs and thinking of the parents when discussing treatment options before surgery. The nature of the relationship with the doctor at this time can support parents or be a further source of stress.