Research Strategy

During the protocol phase, inclusion criteria were defined according to the Scoping PCC methodology - Population: Child/ Youth (0-18 years old) and family; Concept: Interventions promoting adaptation and Context: Hospitalization. The choice of these criteria aims to standardize research and provide a clear view on the inclusion or non-inclusion of individual sources.

The search was carried out at an early stage through searching grey literature (evidence not published in commercial publications), Google Scholar, and the EBSCO research databases, in order to have an overview of the knowledge produced on the subject, and to understand the index terms used to describe the subject under study, which helped to outline the research. According to JBI ¹⁵, on research strategy, it is recommended to search a minimum of three large databases of bibliographical citations. Accordingly, a search was carried out in the following electronic databases PUBMED, MEDLINE and CINAHL on 21 January 2020, using the descriptors DeCS - Adaptation, Psychological; child, Hospitalized; Pediatric Nursing, and MeSH Adaptation, Psychological; child, Hospitalized; Nursing and using the Boolean operator AND.

It was established that qualitative and quantitative studies and systematic literature reviews would be included. Date of publication was also used as a selection criterion, having included articles found dated between 2012 and 2019. This timeline is considered to have the most recent scientific evidence, and, furthermore, is a way to limit publications for content analysis. In addition, only full text publications were included. It was also considered as languages of inclusion the articles found in Portuguese and English. Subsequently, an analysis of the articles resulting from this research was carried out, using the words present in the titles, as well as the key words associated with them, the abstracts and finally their full reading, in order to find the target articles of this Scoping Review.

Data Extraction

After the research, all articles obtained were identified and all those that were duplicated were removed. Titles and summaries were analysed against the inclusion criteria. Full text studies that did not meet the inclusion criteria were excluded. The data from the included articles were extracted using a mapping tool aligned with the objective and the research question ¹⁵ (Appendix I). The results are presented in a PRISMA Flow Diagram ¹⁶ (Appendix II). A table of excluded articles is also presented in the Appendix (Appendix III).

Child's adaptation to hospitalization

When confronted with the hospital environment, as well as having to deal with the illness, the child is separated from the family environment, friends, school and personal objects. This environment requires the child to interact with unknown people such as nurses and doctors, to undergo interventions that can be painful or uncomfortable, and to experience noise and changes in daily routines. These can contribute to the child perceiving hospitalization as a traumatic or stressful experience ¹⁸.

When it comes the family perceptions of the difficulties felt by their children during the adaptation to hospitalization, it should first be noted that the hospital setting changes their ability to adapt and increases their vulnerability ¹⁸. In this setting, the child recognises the presence of the family as protection, becoming their point of reference, affection and source of security. Hospitalization can cause a number of different behaviours from an emotional point of view, and children may experience mood changes. The most common way a child manifests discomfort, fear and pain is through crying. They may also feel agitated, nervous and may find it difficult to sleep. Another common reaction, noticed by families, is quietness, the child may become less talkative and, apparently, unreactive. This research highlights the need to humanize the hospital environment in pediatric settings, involving the family into care. How a child copes with hospitalization and illness depends on their adaptation process? Nursing care is essential for the child to be able to process feelings through emotional support, information supply, recreational activities and active listening. Supporting the caregiver is crucial to enable them to care for themselves and their child, interacting positively and building relationships that are beneficial to everyone ¹⁹.

Specific articles related to the adaptation of children living with a chronic disease were analysed. In a study on the hospitalization of adolescents, its impact on their daily lives was reported. These point to dietary restrictions as a major interference with routine due to new dietary recommendations, which is one of the most difficult parts of the treatment. When adolescents consider the new situation as a problem to be solved and an opportunity to learn, they become less vulnerable. Therefore, it is essencial that children/young people know their diagnosis and participate in the treatment in order to better deal with the disease ²⁰.

Adaptation of parents with hospitalized children

Hospitalization is also a stressful time for the family, and nursing care should be planned around the needs of children and their families in order to minimize its negative effects¹⁸. The child's caregivers should be active care partners, since, they provide important information that supports care and should be valued by the nurses due to the potential to transform and enrich it. During their care, nurses should provide information, clarification and guidance on the child's health conditions so that the parents know what to expect and what is expected of them ¹⁸.

In a context of intensive care, a child's hospitalization has a great impact on the family given that at that moment, when faced with the seriousness of the child's situation, all dreams and life projects turn into fear ²¹. In this instance, the relationship between family members tends to change. In most cases, family members become closer to support those most in need of support, even though they may be physically distant. By strengthening these bonds, family members develop a behaviour based on their adaptation process, defined by internal and external actions and reactions in order to strengthen their support system. The support system is based on RAM's Interdependence Adaptive Mode. This interdependence is clear among family members who experience a process of hospitalization, being revealed through the emotional, spiritual and even financial support provided ²¹.

In this sense, Foster et al.²²⁾ reflects on the experiences and needs of parents of seriously injured children. These authors identify three main themes: 1) dealing with childhood injury, 2) accepting the complexity of the injury and 3) finding ways to deal with family needs. Regarding the first topic, parents showcase a number of reactions including shock (with references to feelings of sadness, fear and grief, and, on others cases, to keep emotions under control by recognizing that they would probably feel those emotions later).; a focus on managing their child's treatment (most parents consider their responsibility to understand the type of treatment their child receives and to ask staff questions about their progress) and a struggle to balance hospital and home environments (there is always tension between caring for the hospitalized child versus meeting the demands of life and family outside the hospital). The authors report that parents come to progressively accept the injury during hospitalization by understanding the impact of the disease and how it will affect both the child and the family. Finally, a number of personal and external factors influence how parents seek support and accept help. Some parents may find difficult to accept support for their emotional needs, focusing exclusively on their child's needs. Others accept emotional support from health professionals, family and friends in the form of visits, phone calls, or through social networks, while others receive practical support from neighbours and friends ²². Therefore, it is essential that the emotional needs of parents are recognized and addressed during the hospitalization of children, since the suppression of emotions can damage mental health and increase stress symptoms. The authors emphasize the need to address and demystify the feeling of guilt felt by the parents ²².

Similarly, Hagstrom ²³⁾ emphasizes seven sources of stress for parents: separation, uncertainty, illness and suffering of the child, emotional stress, physical stress, financial stress and work stress, and previous experiences. Separation is mentioned as the primary source of stress for the families of inpatient children, with references to feelings of division between being at home or in the hospital and the alteration of parental roles (tasks and responsibilities). Parents also refer to their children's own illness and suffering as a source of stress. Uncertainty is referred to in different ways, from not knowing whether the child will be well, to how they will be after the discharge and what the future consequences of the disease may be. The sensation of a roller coaster is also frequently mentioned, alternating between periods of discouragement and excitement. These parents mention as stress relieving factors the welcoming environment (single room, family space in the child's room, place for siblings to be present for periods of time during hospitalization), preparation and explanation on the health status and the performed procedures, inclusion in the care plan, explaining how to interpret alarms and warning signs. Therefore, during nursing care is relevant to consider the potential sources of stress, planning the most opportune moments for parents' absence and providing when possible sibling visits. It is also important to support the psychological state of the family, often evaluating their feelings, taking into account their unstable condition during the hospital stay ²³.

To summarise, based on the articles analszed, a schematic representation of the process of adaptation of the child and family to hospitalization is presented (Figure 1).

Figure 1.  Adaptation Process of the Child and Family to Hospitalization 

Interventions to promote adaptation to hospitalization aimed at children

Nursing interventions that promote children's adaptation to hospitalization focus on strengthening coping mechanisms and increasing their sense of security. With this in mind, the interventions referred to in the analysed articles were grouped accordingly: (1) communication strategies; (2) playful activities/playing and relaxation; (3) promotion of hope, and (4) coping strategies ¹³.

To summarise, nurses should use effective non-pharmacological strategies to help children deal with fear through techniques such as relaxation and guided imagination; listening to music; activities with video games; watching television; activities with toys; and the use of comfort massages ²⁵.

Interventions to promote adaptation to hospitalization directed at the family

Regarding nursing interventions to support the adaptation of the parents of hospitalized children, it is essential that the nurse acts to support the development of a support system, since this can help to minimize the negative effects of the hospitalization process. The family feels supported not only by their own family, friends, health professionals, and their spirituality, but also by the families of other hospitalized children. Families share the same space, the experiences and feelings related to the health-disease process of their children, and support each other so that they can recover together. Building the support system with health professionals is undeniably important for family members, as it helps them deal with and adapt to the child's illness, reducing stress symptoms and the feeling of fear. Effective communication between health professionals and the family can reduce the anxiety felt in the face of illness and hospitalization, so the nursing team aims to promote the adaptation of the family, contributing to their health and quality of life ²¹.

For Doupnik et al.²⁹, there are three essential categories of nursing interventions in this field. Beginning with education, the authors focus on the importance of teaching about parental skills and beneficial knowledge in caring for children. As far as emotional regulation is concerned, these point out that the focus is on emotional self-care, and include such interventions as activities to promote relaxation or distraction, teaching parents strategies for coping with anxiety and stress, and encouraging adaptive emotional expression. Finally, social and structural support focuses on identifying resources for social support and practical considerations related to hospitalization. This study shows that adaptation support interventions are effective in reducing parents' anxiety and stress and consequently in improving children's anxiety, as they increase parents' ability to participate in child care, to receive information and to participate in shared decision making ²⁹.

Reflecting on the effectiveness of an adaptation scale to hospitalization, based on the nursing evaluation of the effectiveness of coping mechanisms, it is concluded that this leads to the implementation of realistic support interventions. This scale facilitates the successful identification of families most at risk of ineffective adaptation during their child's hospitalization ³⁰.

A schematic representation of the analysed results, with the nursing interventions promoting adaptation to hospitalization addressed to the child and family highlighted by the articles analysed in Scoping Review is presented below (Figure 2).

Figure 2.  Nursing interventions that promote adaptation to hospitalization for children and their families. 

To point out the limitations of this study, it should be mention that only articles published in Portuguese and English were included and research was conducted in three databases. The same search criteria may be applied in the future to more databases and to articles in other languages, in order to increase the theoretical sample and test the results.