ContentslistsavailableatScienceDirect
Australian
Critical
Care
jo u r n al hom e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / a u c c
Research
paper
Development
of
a
screening
measure
of
stress
for
parents
of
children
hospitalised
in
a
Paediatric
Intensive
Care
Unit
Rocío
Rodríguez-Rey
MA
∗,
Jesús
Alonso-Tapia
PhD
1UniversidadAutónomadeMadrid,DepartmentofBiologicalandHealthPsychology,PsychologyFaculty,C/IvanPavlov,6,CP28049,Madrid,Spain.
a
r
t
i
c
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Articlehistory:
Received27March2015
Receivedinrevisedform20July2015 Accepted18November2015
Keywords:
Parentalstress Assessmentofstress PaediatricIntensiveCareUnit PICU
Psychometricproperties
a
b
s
t
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a
c
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Background:Havingachildadmittedtointensivecareisahighlystressfulexperienceforparents;however thereisalackofscreeninginstrumentsofparentalstressinthatcontext,whichwouldbeusefulforboth, researchandclinicalpurposes.
Objectives:(1)TovalidateabriefmeasureofparentalstressbasedontheParentalStressorScale:Paediatric IntensiveCareUnit(PSS:PICU),(2)tostudywhichenvironmentalfactorsofthePICUaremorestressfulin asampleofSpanishparents,and(3)tostudywhichvariablesarerelatedtohigherlevelsofstressamong thisgroup.
Method:196SpanishparentscompletedtheAbbreviatedPSS:PICU(A-PSS:PICU)andageneralstress scale(thePerceivedStressScale)upontheirchild’sdischargetotesttheconvergentvalidityofthetool. Threemonthslater,theywereassessedanxietyanddepressionusingtheHospitalAnxietyandDepression Scale,andposttraumaticstresswiththeDavidsonTraumaScaleinordertotestthepredictivevalidityof theA-PSS:PICU.
Results:TwofactorsemergedfromConfirmatoryFactorAnalyses,(1)stressduetochild’sconditionand(2) stressrelatedtoPICU’sstaff.TheA-PSS:PICUshowedadequatereliabilityandconvergentandpredictive validity.Themoststressfulaspectswerethebehavioursandemotionalresponsesoftheirchildand thelossoftheirparentalrole.Age,gender,child’scondition,lengthofadmission,spiritualbeliefs,and mechanicalventilationwereassociatedtoparentalstressscores.
Conclusion:TheA-PSS:PICUisareliableandvalidmeasure.Parentalstressshouldbescreenedduringa child’sPICUadmissiontoidentifyparentsatriskofpost-dischargedistress.
©2016AustralianCollegeofCriticalCareNursesLtd.PublishedbyElsevierLtd.Allrightsreserved.
1. Introduction
Having a child admitted to a Paediatric Intensive CareUnit
(PICU)haslongbeenrecognisedasahighlystressfulexperience
forparents.1–3Thisisunderstandableifwetakeintoaccountthat
childrenunderintensivecareareusuallyacutelyillorinjured,and
consequentlytheyareatincreasedriskofdeath.Furthermore,the
PICU’senvironmentitself,withitsrapidpace,noises,brightlights,
∗ Correspondingauthor.Contactaddress:UniversidadAut ´onomadeMadrid, DepartamentodePsicolog´ıaBiol ´ogicaydelaSalud,C/IvanPavlov,6,CP28049, Madrid,Spain.
E-mailaddresses:[email protected](R.Rodríguez-Rey),
[email protected](J.Alonso-Tapia).
1 Address: Universidad Aut ´onoma de Madrid, Departamento de Psicolog´ıa
Biol ´ogicaydelaSalud,C/IvanPavlov,6,CP28049,Madrid,Spain.
andcrisis-focusedinterventionspresentsagreatchallengefor
par-entswhoarealreadystressed.
Somepreviousstudieshaveexploredwhatarethesourcesof
parentalstressduringtheirchild’shospitalisationinthePICU.4–6
Commonlyidentifiedparentalstressorsincludedthelossof the
parentingrole,uncertaintyover thechild’soutcome,being
sep-arated from their child, a feeling that the quality of care the
childwasreceivingwaspoor,notbeingabletounderstand
med-icalinformation4–6orhavingcommunicationproblemswiththe
medical staff,7 feelings of uncertainty and helplessness,8 and
seeing their child in pain and discomfort. Also, parents can
becomedistressedas aresult oftheirexposuretoother
paedi-atricpatients’ lifethreateningconditions,traumaticprocedures,
anddeath.9
Somestudieshaveusedinterviewstodetectparentalsourcesof
stress4,5;howevermostofthemhaveusedquestionnaires.Thebest
knownmeasuretoassessparents’responsestostressinthePICU
istheParentalStressorScale:PaediatricICU(PSS:PICU).10,11The
http://dx.doi.org/10.1016/j.aucc.2015.11.002
original79-itemscalewasdevelopedbyCarter,Miles,Buford,and
Hassanein.10Followingfactoranditemanalysis,CarterandMiles11
revisedthescale,reducingitto37 itemsmeasuringthe
follow-ingsevendimensionsintheICUenvironment:Child’sappearance,
Sights and sounds, Painful procedures conducted on the child,
Alterationinparentingrole,Behavioursandemotionalresponses,
Staff’sbehaviourandStaff’scommunication.
ThePSS:PICUwasbasedSelye’stheoryonstress,12 Lazarus’s
cognitive-phenomenologicaltheoryonstress,13Roy’sadaptation
modelofnursing14and Moos’stheoryoncoping withillness.15
These authors support the idea that the stress response is
theresult of a complex interaction betweenmultiplevariables
such as environmental stimuli, characteristics of the
situa-tion, personal factors and the perception of the individual of
the power of the stressors. So, while a child is hospitalised
in a PICU, a multiplicity of environmental stimuli could be
sourcesofparentalstress.Somepersonal/familyvariables (such
as age of the parent) and situational factors (such as child’s
illness) can also interact with these stimuli to affect their
overall stress response.16,17 Based on that idea, the PSS:PICU
was developed to measure the environmental stressors of the
PICU.
ThePSS:PICU hasshown reliability, validity, and stability in
numerousresearchstudies10,11,18 andhasproveditsefficacyto
measuretheeffectofinterventionstoreduce parentalstressin
the PICU.19,20 It has shown adequate psychometric properties
whenusedinavarietyofpopulations,suchasIndian,21Spanish,22
Malay23andChinese.24
In spiteof thefact that thePSS:PICUis a reliable and valid
measure,itisnotfreeoflimitations.First,althoughatotalstress
scorecanbecalculated inadditiontosevensubscale scores,no
confirmatoryfactoranalysishasbeenconductedtotestthe
adjust-mentofamodelwithasecondorderfactor.Second,withregardto
theSpanishvalidation,thesmallsamplesize(N=20)isan
impor-tant limitation,as it shouldhave been fivetimes larger asthe
poweranalysisrevealed.Third,andmostimportant,ittakesaround
30minutestocompletethePSS:PICU,whichmakesitnotpractical
touseonadailybasis25ifweconsiderthedifficultyofthesituation
thattheseparentsareexperiencing,andthehighburdenofwork–
andconsequentlythelackoftime–ofstaffworkingincriticalcare.
Instead,inthecontextofthePICU,professionalsneedtohave
effec-tiveandfastscreeningtoolstomeasureparentalstress,whichare
notavailablecurrently.Ifwehadtheseshortermeasures,parents
withahighlevelofdisturbancecouldbedetectedforanearly
inter-vention.Ashortermeasurewouldbeusefulforresearchpurposes
too,asawayofreducingthedemandonparticipants’time.
Inpreviousstudies,stressassessedthroughthePSS:PICUhas
beenfoundtoberelatedtoseveralpsychologicalvariables,such
asgeneralstress,26 anxiety11,24,27,28 depression28 and
posttrau-maticstress.7,29 Thus, thesevariables couldbeusedas external
criteriontotestthevalidityofthenewtool.PSS:PICUscoreshave
alsofoundtoberelatedwithsomemedicalandsociodemographic
variables, such as child’s mechanical ventilation6,23,30,31
unex-pectedadmission,32 higherseverityofthechild’scondition,21,23
lackof previousPICU’sexperience,23 prior parental
psychologi-calproblems32orparentalsocioeconomicdifficulties33whichare
associatedwithhigherstress.
Evenwhen,asithasjustbeendescribed,thereisawidebody
ofusingthePSS:PICU,thismeasurehassomeproblems,mainlyits
length.Therefore,thepurposesofthisstudywerethefollowing:
(1)todevelopashortquestionnairebasedonthePSS:PICUthat
couldbeusedwithparentsofcriticallyillchildrenasascreening
measureofthedegreeandsourcesofstressproducedbythePICU
environment,(2)tostudywhicharethemoststressfulaspectsof
thePICUinoursampleofSpanishparents,and(3)tostudywhich
variablesarerelatedtohigherlevelsofstressinourSpanishsample.
2. Method
2.1. Sample
Participantswereparentswhosechildhadbeendischargedin
theprevious48hoursfromaPICUinMadrid,Spain.ThePICUis
locatedinatertiarylevelhospitalandhas16beds,8physicians
andatotalof49nursingstaff.Thenurse-to-patientratiois2:1.
RegardingpsychosocialservicesprovidedatthePICU,there isa
SocialWorkerwhoattendsfamiliesatrequestfortheentire
paedi-atricwardwherethePICUislocated.ApsychologistfromanNGO
providespsychologicalsupporttothechildrenwithheart
condi-tionsandtheirfamiliestwotimesaweek.
Theparentswereexcludedfromeligibilityinthestudyifthey
didnotspeaksufficientSpanishtocompleteaquestionnaire,ifthey
wereadmittedforlessthan12hoursinthePICUorifchildabuse
orneglectwassuspectedasaprecipitanttotheadmission.Atotal
of196parentsof130childrenagreedtoparticipate,61.2%women
and38.8%men.Theiraverageagewas37.80years(SD:6.58)for
theparentsand 56.58months(SD: 61.92)for thechildren.The
primaryreasonsforadmissionwereplannedsurgery(65.3%),
emer-gencymedicaltreatment(16.8%),accidentalinjuryandemergency
surgery(11.1%)andrelapseofachronicdisease(6.6%).Themore
prevalentdiagnoseswereheartconditions(26.2%),cancer(16.2%)
andrespiratoryconditions(12.3%).Theaveragelengthofadmission
was6.12days.Threemonthsafterthechild’discharge158parents
completedthefollowing-upassessment.
2.2. Materials
AbbreviatedParentalStressorScaleforPaediatricIntensiveCare
Unit(A-PSS:PICU).Inordertodevelopthisscale,twopsychologists
summarisedthecontentofeachofthesevensubscalesofthe
Span-ishversionoftheSpanishPSS:PICU22inoneitemforeachsubscale.
Todoso,forexample,insteadofaskinghowstressfulwere6
differ-entmedicalprocedures,withanitemforeachprocedure,weasked
inoneitemhowstressfulweremedicalproceduresconductedon
thechildingeneral,andwegavethemsomeexamplesofsuch
pro-cedures,sosixitemswerereducedtoone.Thus, thebriefscale
designedcontains7items(oneforeachofthesevensubscalesof
thePSS:PICU).Theresponseformatisa5pointLikertscaleranging
from1“Notstressful”till5“Extremelystressful”,or0“Not
expe-rienced”.ItwasdevelopedinSpanishlanguageanditisincluded
inAppendixAalongwithitsEnglishtranslation.Totranslateitto
English,twonativeSpanish-speakingbilingualpsychologists
trans-lateditindependentlyandagreedonafinalcommontranslation.
TheSpanishversionwasfirstadministeredto4parents(2mothers
and2fathers)inordertotestwhetherunderstandingdifficulties
emerged.Withthispurpose,weaskedthese4parentstocomplete
themeasureandalsotoindicatewhethertheyhadhadany
diffi-cultyinunderstandingeachoftheitems.Asnoneofthemreported
anydifficulty,weadministeredthescaletothe196-parents
sam-pleabovedescribed withtheaimof assessingitspsychometric
properties.
PerceivedStressScale(PSS).34 ThePSS isa globalmeasure of
stressthatwasdevelopedwiththeaimofmeasuringthedegree
towhich situations in one’slife are appraised as stressful. We
usedtheEuropeanSpanishversion.35Thisisa14-item
question-nairethatdemonstratedadequatereliability(internalconsistency,
˛=.81,andtest–retest,r=.73),concurrentvalidity,andsensitivity.
DavidsonTrauma Scale(DTS).36 It is a 17-itemmeasure that
assesses the 17 DSM-IV symptoms of PTSD. It wasadapted to
Spanishlanguage37showinghighinternalconsistency(˛=.90)and
test–retestreliability(ICC=87).
HospitalAnxietyandDepressionScale(HADS).38Itisa14-item
onefordepression.WeusedtheSpanishversion39thatshowed
test–retestreliability(presentedcorrelationcoefficientsabove.85),
highinternalconsistency(˛=.86),andhighconcurrentvalidity.
Medical variables. The physician responsible for every child
respondedthePaediatricIndexof MortalityII (PIM 2)40 a rating
indexdevelopedtopredictmortalityriskinthePICUduringthe
first24hofadmissionwhichdiscriminatedbetweendeathand
sur-vivalwell[areaunderthereceiveroperatingcharacteristic(ROC)
plot.90(.89–.91)].Wealsoregisteredthelengthoftheadmission,
mechanicalventilationonthechild,beingtheadmissionelective
orurgent,previousadmissionsonPICUandprevioushealthstatus
ofthechild.
Subjectiveperceptionoftheseverityofthechild’scondition.We
askedeveryparentthefollowingtwoquestions:(1)Howsevere
doyouthinkthatyourchild’sconditionhasbeenduringhis/her
hospitalisationinthePICU?(0–7)and(2)Didyouthinkthatyour
childcoulddieatanypointofhis/herPICU’sadmission?(Yes/No).
Socio-demographicandculturalvariables:Weassessedageand
sexoftheparentsandthechild,maritalstatus,numberof
chil-dren,workstatus,financialtrouble,educationlevel,nationality,
andspiritualorreligiousbeliefs.
2.3. Procedures
ThestudywasapprovedbytheInstitutionalReviewBoardof
thehospital.Theparentsofeverychildthathadbeenadmittedto
thePICUformorethan12handsurvivedtheadmissionwereasked
toparticipateinthefirst48hafterthechild’sdischargefromthe
PICU.Datacollectionwasmadebyatrainedresearcherin
psychol-ogy.Parentsweregivenaninformedconsentformthatdescribed
thestudyanditspurposes,potentialriskandbenefits,and
confi-dentiality.Then,thosewhoagreedtoparticipateandsignedthe
writtenconsentcompletedtheA-PSS:PICU,thePSSanda
socio-demographicandmedicalquestionnaire.Wealsoaskedthemto
provideuswithapreferredwaytobecontactedinthefollow-up
(telephone,emailorpost).Threemonthslaterwecontactedthem
againviatheirpreferredmethodofcontactandweaskedthemto
completetheHADSandtheDTS,which theycouldcompleteby
email,telephoneorpost.
2.4. Dataanalysis
First, two models were tested through confirmatory
fac-tor analyses (CFA) to study the A-PSS:PICU factor structure.
An inter-category correlation matrix was used in
compu-tation of the factor matrix to help compensate for “Not
experienced”responses.Estimateswereobtainedusingthe
max-imum likelihood method after examining whether data were
adequate for the analysis. In order to assess model fit,
abso-lute fit indexes (2, 2/df, SRMR), relative fit indexes (IFI)
and non-centrality fit indexes (CFI, RMSEA) were used, as
well as criteria for acceptance or rejection described by Hair
etal.41
Second,thereliability–internalconsistency–ofthesubscales
andthegeneralscalewascalculated.
Third,togetinformation ontheconcurrentvalidity,Pearson
correlationcoefficients werecomputedbetweentheA-PSS:PICU
scoresandgeneralstressassessedthrough thePerceivedStress
Scale(PSS). Toexplorethepredictivevalidity, wecalculatedits
correlationwithPTSD,anxietyanddepression.
Fourth,toexaminethelevelofstressproducedbyeachstressor
and thescoresinthetotal scale andeach subscale, themeans,
rangesandstandarddeviationswerecalculated.
Fifth, withthe aimof testing which socio-demographic and
medicalvariableswereassociatedwithparentalstressinthePICU,
wecalculatedPearsoncorrelationswiththecontinuousvariables
assessed,andthepoint-biserialcorrelationcoefficient(rpb)with
thedichotomisedvariablesassessed.
3. Results
3.1. Confirmatoryfactoranalyses
The fit indexes of the two models tested through CFA are
shown in Table1.Within thefirst model tested we attempted
toprovewhethertheA-PSS:PICUhasamono-factorialstructure.
Aswe can seein Table1, this model isnot welladjusted.
Ini-tialconfirmatorystandardisedsolution thismodel showedthat
theitemsthatassessedhowstressfulwerethe“inadequatePICU’s
staffbehaviour”andthe“communicationproblems”havealower
relationtothegeneraltotalscorethantherestofitems,sothey
couldbeassessingadifferentfactor.Thus,inthesecondmodelwe
attemptedtoprovewhetherthequestionnairehasabi-factorial
structure,inwhichonefactorcontainsitemsrelatedtostressors
producedbythechild’ssituationinthePICU(child’sappearance,
procedures,etc.)andtheotheritemsrelatedtodifficultiesinthe
relationwithPICU’sstaff.Thismodelalsocontainsasecondorder
factortoexplainallcovariancebetweenthetwofirstorderfactors.
ThismodelispresentedinFig.1.AswecanseeinTable1allthefit
indexesareacceptable,sotheA-PSS:PICUhasa2-factorstructure
Thefirstfactorhasfiveitemstoassesshowstressfulareforparents
thefollowingstimuli:child’sappearance,sightandsounds,
proce-dures,parentalroles,andbehavioursandemotionalresponsesof
thechild.Thesecondfactorhastwoitems,toassesshowstressful
areaspectsrelatedtoPICU’sstaff.Thismodelalsoallowscalculating
atotalscoreinthequestionnaire.
3.2. Internalconsistency
InternalconsistencyoftheA-PSS:PICUwas.76.Internal
consis-tencyofthefactor“Stressrelatedtochild’ssituationinthePICU”
was.81,andthatofthefactor“Stressrelatedtodifficultiesinthe
relationshipwithPICU’sstaff”was.77.Internalconsistenciesofthe
remainingquestionnairesusedforvalidationpurposes(thePSS,the
DTSandtheHADS)wereallover.80.
3.3. Concurrentandpredictivevalidity
AsitisshowninTable2,correlationsofthetotalscaleandthe
factor“Stressrelatedtochild’ssituationinthePICU”withperceived
stress,anxiety,depressionandPTSDareinthedirectionthatwe
hadexpected.Thisfactprovidesevidenceoftheconcurrentand
predictivevalidityofthistool.Howeverallcorrelationsofthefactor
“StressrelatedtodifficultiesintherelationshipwithPICU’sstaff”
withthecriterionarenotsignificant.
Table1
FitindexesofthetwomodelstestedthroughConfirmatoryFactorAnalysis.
2 df Sig 2/df IFI CFI RMSEA SRMR
Model1 51.294 14 .000 4.235 .863 .860 .129 .083
Fig.1.Initialconfirmatorystandardisedsolutionforthetwo-factormodeloftheAbbreviatedParentalStressorScalePaediatricIntensiveCareUnit(A-PSS:PICU).
3.4. Stressorsforparentsofchildrenadmittedtointensivecare
Todeterminethegreatestsources ofstressamong our sam-ple,firstwecalculatedthepercentageofparentswhoexperienced eachofthesevenpotentiallystressfulsituationswhichareincluded intheA-PSS:PICU.Around95%ofparentsexperiencedsituations assessedbyItem1[Physicalappearanceofthechild(wounds,changes inskincolour,appearancetobecold,etc.)],Item2(Soundsofmonitors, seeingtheheartrateonmonitorsorhearingsuddenalarmsounds.)and Item3[Medicalproceduresconductedonmychild(needles,tubes, incisions,etc.)],whilearound50%ofparentsexperiencedsituations assessedbyItem4(Notbeingabletoseemychild,beingwithmychild andtakingcareofhimandholdhimwheneverIwhish.),Item5(Seeing mychildcryingconfused,inpain,unabletospeak,sadorangry.),Item 6[SeeingthestafffromPICUbehavinginawaythatIconsider inad-equate(e.g.Laughing,speakingtooloud,nottellingmetheirnames, etc.)]andItem7[Communicationproblemswiththedoctors (explain-ingmethethingsinawaythatIdonotunderstand,expressing contra-dictoryopinions,talkingtoolittletome,etc.)].Secondly,groupmeans werecalculatedfortheitems,thesubscalesandthetotalscale.The meanscorewascomputedbydividingthesumofthetotalscoreson everyitembythenumberofitemsrated“1”orabove.Thus,wedo notconsiderdifficultiesthathavenotbeenexperiencedbyparents
Table2
CorrelationsbetweentheA-PSS:PICUscoresandthecriterionvariablesselected.
Totalscore A-PSS:PICU
“Stressrelatedto child’ssituationon PICU”
“Stressrelatedto difficultiesinthe relationshipwith PICU’sstaff”
PerceivedStress (PSS)(N=196)
.25** .29** .02
Anxiety(HADS)at 3months (N=158)
.17* .24** −.03
Depression(HADS) at3months (N=158)
.15 .19* .00
PTSDat3months (DTS)(N=158)
.22** .27** .02
* Sigatp≤.05. ** Sigatp≤.01.
tocalculatethemeans.Themoststressfulaspectswhen
consider-ingonlythoseparentswhohaveexperiencedeachsituationwere
theChild’sbehaviourandemotions,thelossoftheirparentalrole
andtheChild’sappearance.ThesedataarepresentedinTable3.
3.5. CorrelationsbetweentheA-PSS:PICUandsocio-demographic
andculturalvariables
Asit’sshown in Table4, higher stressscoresare negatively
relatedtoageoftheparentandthechild.Womenandthosewho
havespiritualorreligiousbeliefsaremorepronetohavehigher
levelofstress.Thenumberofchildrenisnegativelycorrelatedwith
thesubscale“StressrelatedtoPICU’sstaff”.Nocorrelationhasbeen
foundbetweenparentalstressandthefollowingvariables:
eco-nomicandeducationlevel,child’sgender,nationalityandmarital
andworkstatus.
3.6. CorrelationsbetweentheA-PSS:PICUandmedicalvariables
Higherstressscoresareassociatedtohigherobjectiveseverity
ofthechild’smedicalconditionassessedthroughthePIM2,with
thesubjectivechild’sseverityasperceivedbytheparents,withthe
beliefthatthechildcoulddieduringtheadmissiontoPICU,with
lengthoftheadmission,and withmechanicalventilationofthe
child.Previoushealthstatusofthechild,previousadmissionand
beingtheadmissionunexpectedwerenotrelatedtostress.These
correlationsarealsoshowninTable4.
4. Discussion
First, we can conclude that the A-PSS:PICU is an adequate
screening measure to assess parental sources of stress while
theirchildisadmittedtothePICU.Startingwithitspsychometric
properties,two factorsemergedthrough factoranalysis,“Stress
related to child’s situationin thePICU”, and “Stress related to
difficulties in the relationship with PICU’s staff”. As they are
significantlycorrelated, a score forthewholescale canalsobe
obtained. The scale and its two factors showed good internal
consistency. The total scale and the first factor showed good
Table3
Averagescores,ranges,andstandarddeviationsofthesubscalesandthetotalinstrument.
N %ofparentswho experiencedthat stressor
Range Mean SD
Item1–Child’sappearanceinthePICU 185 94.38 1–5 3.19 1.14
Item2–PICU’ssightsandsounds 187 95.41 1–5 2.74 1.17
Item3–Proceduresconductedonthechild 188 95.92 1–5 2.59 1.21 Item4–LossofparentalroleinthePICU 106 54.08 1–5 3.45 1.28 Item5–Behaviours&emotionalresponsesofthechild 107 54.59 1–5 3.98 1.10 Item6–InadequatebehaviourofPICU’sstaff 106 54.08 1–5 2.82 .95 Item7–CommunicationwithphysiciansinthePICU 96 48.97 1–5 2.73 .86 Factor1–Stressrelatedtochild’ssituationonPICU
subscale(items1–5)
196 – 1–5 3.14 .96
Factor2–Stressrelatedtodifficultiesintherelationship withPICU’sstaffsubscale(items6and7)
120 – 1–5 2.58 1.17
A-PSS:PICUtotal 196 – 1–5 3.05 .87
didn’tshowsignificantcorrelationswithanyofthecriteriathatwe assessed.Wehypothesisethatthismaybebecause,evenwhenthe difficultiesintherelationshipwithPICU’sstaffcanbeasourceof stress,itisatemporaryone,asdisappearsoncethechildhasbeen dischargedfromintensivecare.However,thefactorrelatedtoa child’ssituationin thePICUcomprisesstimuli (suchasmedical procedures)thatmayhave a longer-termimpactonthechild’s healthand,consequently,inparentalmentalhealth.Inanycase, anoteofcautionisneededonthefactthatthesecondfactorhas onlytwoitems.Thisfactlimitsthevariabilityofscores,whatmight affectthemanifestationofitsrelationwithothersvariables.
Second,regardingmoreprevalentstressorsforparentsatPICU, Child’sappearanceinthePICU,PICU’ssightandsoundsand Proce-duresconductedonthechildwerethemostfrequentlyexperienced aspectsbyparents,asaroundof95%ofthemreportedhaving expe-riencedthesesituations.Regardingmoststressfulaspects,when onlyparents who had experiencedeach situation were consid-ered,child’sbehaviourandemotionsandthelossoftheirparental rolewerefoundtobethemoststressfulaspects,evenwhenonly
Table4
Pearsonandpoint-biserialcorrelationsbetweentheA-PSS:PICUpunctuationsand socio-demographic,culturalandmedicalvariableschosen.
Totalscore A-PSS:PICU
“Stressrelated tochild’s situationon PICU”subscale
“Stressrelatedto difficultiesinthe relationshipwith PICU’sstaff” subscale
Age −.31** −.30** −.19*
Child’sage −.20** −.22** −.11
Gender .24** .24** .02
Child’sgender .09 .10 .02 Numberofchildren −.10 −.13 .06 Economicdifficulties .12 .11 .09 Educationlevel .03 .07 −.12 Spiritualbeliefs .24* .26** −.03
Maritalstatus .06 .07 .04 Workstatus −.05 −.06 .01 Livinginthecity
wherethePICUis located
−.13 −.15* −.00
PIM2 .14* .16* −.01
Subjectivechild’s severity
.42** .45** .09
Beliefchildcoulddie .26** .28** −.03
Lengthofadmission .23** .23** .13
Previoushealth status
.08 .11 −.17 Previousadmissions −.04 −.07 .10 Electivevsurgent −.09 −.11 .08 Intubatedornot .23** .21** .16
*Sigatp≤.05. **Sigatp≤.01.
around50%ofparentsexperiencedthesesituations.Thismeans
that,whenexperienced,thesesituationscanbeextremely
stress-fulforparents,soeffortsshouldbemadebyPICU’sstaffinorder
todecreasethedegreein whichtheparentsperceivethattheir
childissuffering,andinordertomaintaintheirparentalroleby
involvingtheminthechild’scare.Thefactthatthemorestressful
aspectswhenexperiencedwerethechild’sbehaviourand
emo-tionsandthelossoftheirparentalroleisconsistentwithdatafrom
English-speakingNorthAmericanparents,10,18butnotwithresults
fromHispanicNorthAmericanparents22andIndianparents31for
whomtheSightsandSoundsandProceduressubscaleswerethe
moststressfulaspects.Thissuggeststhattherearecultural
differ-encesinwhatparentsconsidertobethemoststressfulfactorsofthe
PICUenvironment.LikeNorthAmericanEnglish-speakingparents,
SpanishparentsfoundphysicalaspectsofthePICUlessstressful
thanHispanicNorthAmericanparentsandIndianparents
possi-blybecauseoftheirpreviousexposuretocomponentsoftheICU
throughthemedia,orthehospitalisationofarelative.17
Third,withregard tovariables associated withstressin our
study,thefactthattheparentalstresswaspositivelyand
signifi-cantlycorrelatedwithanxiety,depressionandPTSDassessedthree
monthspost-dischargeisrelevant,asitshowsthattheA-PSS:PICU,
which takes a few minutes to be completed, couldpotentially
contribute topredict psychopathology monthsafter the child’s
admissionhasended.Regardingsocio-economicandmedical
vari-ables,youngerparents,women,thosewithspiritualbeliefs,and
thosewhosechildisintubated,admittedforlongerandwhose
med-icalconditionwasmoreseverereportedhigherstress.Thus,special
attentionshouldbepaidtothisgroup,astheyhaveahigh-risk
pro-filetoexperiencehighstressrelatedtoPICUenvironment.Thefact
thathigherseverity,mechanicalventilation,youngerageand
fem-ininegenderwasrelatedtostresswasanexpectedresulttous,as
thesedataareconsistentwithliterature.21–23However,evenwhen
previousstudiesfoundthatparentsfeelthatprayerishelpfulin
reducingtheirstress21,42ourresultsshowedthatparentswith
spir-itualorreligiousbeliefshavehigherratesofstress.Also,evenwhen
previousstudiesfoundthathavingpreviousPICU’sexperienceswas
associatedtolowerstress23wefoundthattheoccurrenceof
previ-ousadmissionstoPICUwasunrelatedtotheparentalstressscore.
Finally,evenwhenpreviousstudiesfoundthatparental
socioeco-nomicdifficultieswererelatedtohigherstress,33wefoundthat
economic difficultiesand workstatus wereunrelated to stress.
Theseunexpectedresultsshouldbefurtherexplored.
Regardinglimitationsofthiswork,weareawarethatreducing
thenumberofitemsofthePSS:PICUmaycausealossofdetailin
theinformationcollected.However,bothscalesarenot
incompat-ible:theA-PSS:PICUcouldworkasanscreeningtoolthatmight
becomplementedbythePSS:PICUwhenmorepreciseinformation
abbreviatedscale.First,itwouldbeinterestingtoadministerour
scalealongwiththePSS:PICU,inordertoexploretowhatextentthe
abbreviatedversionisassessingthesamegroupsofstressorsasthe
longerone.Second,itwouldbeconvenienttotestthepsychometric
propertiesoftheEnglishversionofthisscale.
Inspiteofitslimitations,theA-PSS:PICUisanewinstrument
toeffectivelyassessparentalsourcesanddegreeofstressduring
achild’scriticalhospitalisation.Itsmainstrengthisthatittakes
afewminutestocompleteit,whichmakesthisscalepracticalto
beusedinaroutinewaybynursingstaff.Itcanalsobeusedto
detectparentswithahighlevelofstressforanearlypreventive
intervention,because,aswementioned,thescoresonthisscale
arerelatedtoparentalpsychopathologymonthspost-discharge.
Also,thisinstrumentcouldbeusedtodetectwhichimprovements
wouldbenecessarytomakeinaparticularPICU,andtotestthe
effectivenessofinterventionstoreduceparentalstressinthat
con-text.Consequently,theA-PSS:PICUcouldbecomeanadditionto
theinventoryofquestionnairesusefulinpaediatric criticalcare
nursing.
Fundingandfinancialdisclosure
ThisworkwassupportedbyUniversidadAutónomadeMadrid
underaFPI-UAMfellowship.
Acknowledgments
TheauthorswouldliketoacknowledgeLidiaCasanueva,
Victo-riaRamos,AlbaPalacios,AnaLlorente,SilviaBelda,OlgaOrd ´o ˜nez
andMartaOlmedillaaswellastoallthenursingstaffofthePICU
ofHospital12deOctubre,andespeciallyEvaValandRaquel
Vina-gre,fortheirhelpwiththedatacollection.Wealsowouldliketo
acknowledgeHelenaHernansaiz-Garridoforreviewingthewriting
styleofthisarticle.
Bothauthorshavemadeequallysignificantcontributionstothe
articleinallofthefollowingaspects:(1)theconceptionanddesign
ofthestudy,acquisitionofdata,andanalysisandinterpretation
ofdata,(2)draftingthearticleorrevisingitcriticallyfor
impor-tantintellectualcontent,(3) final approvalof theversiontobe
submitted.
AppendixA. TheA-PSS:PICU(Spanish)anditsEnglish translation
INSTRUCCIONES:Las siguientes preguntas serefieren
aspec-tos dela UCIP quepueden resultarestresantespara los padres
duranteelingresodesuhijo.Conestresante,nosreferimosaque
laexperienciatehahechosentiransioso,preocupadootenso.Te
pedimosquerodeeselnúmeroquemejorexpresecuántohasido
deestresantelaexperiencia parati,deacuerdoconlasiguiente
escala:
INSTRUCTIONS:ThefollowingitemsdescribeaspectsofthePICU
environmentthatmightbestressfulforparentsduringtheirchild’s
hospitalisation.“Stressful”meansthattheexperiencehasmadeyou
feelanxious,worriedortense.Weaskyoutocirclethenumber
whichbetterexpresshowstressfuleachexperiencehasbeenfor
youaccordingtothefollowingscale:
0
Noheexperimentado estasituación
Notexperienced
1
Noestresante
Notstressful
2
Mínimamente estresante
Minimallystressful
3
Moderadamente estresante
Moderatelystressful
4
Muyestresante
Verystressful
5
Extremadamente estresante
Extremelystressful
1.Aspectofísicodelni ˜no(heridas,cambiosenelcolourdesupiel,aparienciadeestarfrío,etc.)
Physicalappearanceofthechild(wounds,changesinskincolour,appearancetobecold,etc.)
2.Sonidodelosmonitores,verloslatidosdelcorazónenlosmonitoresoescucharpitidosdealarmarepentinos.
Soundsofmonitors,seeingtheheartrateonmonitorsorhearingsuddenalarmsounds.
3.Procedimientosmédicosquelehanhechoamihijo(inyecciones,tubos,incisiones,etc.)
Medicalproceduresconductedonmychild(needles,tubes,incisions,etc.)
4.Nopoderveramihijoyestarconélycuidarleycogerlecuandoyoquiera.
Notbeingabletoseemychild,beingwithmychildandtakingcareofhimandholdhimwheneverIwhish.
5.Veramihijollorando,confundido,teniendodolor,incapazdehablarollorar,tristeoenfadado.
Seeingmychildcryingconfused,inpain,unabletospeak,sadorangry.
6.VeralpersonaldelaUCIPcomportándosedeunmodoqueconsideroinadecuado(riendo,hablandomuyalto,nodiciéndomesusnombres,etc.)
SeeingthestafffromPICUbehavinginawaythatIconsiderinadequate(e.g.Laughing,speakingtooloud,nottellingmetheirnames,etc.)
7.Problemasdecomunicaciónconlosmédicos(explicarmelascosasdeunmodoquenolasentiendo,diciéndomeopinionescontradictorias,hablandopococonmigo,
etc.)
References
1.BalluffiA,Kassam-AdamsN,KazakA,TuckerM,DominguezT,Helfaer M. Traumaticstressinparentsofchildrenadmittedtothepediatricintensive careunit.PediatrCritCareMed2004;5(6):547–53,http://dx.doi.org/10.1097/ 01.PCC.0000137354.19807.44.
2.Casanueva-MateosL,Ruiz-LópezP,Sánchez-DíazaJI,Ramos-CasadoV, Belda-HolfheinzS,Llorente-delaFuenteA,etal.Cuidadosalfinaldelavidaenla unidaddecuidadosintensivospediátricos.Empleodetécnicasdeinvestigación cualitativaparaelanálisisdelafrontamientodelamuerteysituacionescríticas [End-of-lifecareinthepediatricintensivecareunit.Useofqualitativeresearch techniquesforanalyzingcopingwithdeathandcriticalsituations].RevCalid Asist2007;22(1):36–43.
3.BerenbaumJ,HatcherJ.Emotionaldistressofmothersofhospitalizedchildren. JPediatrPsychol1992;17:359–72.
4.HayesVE,KnoxJE.Theexperienceofstressinparentsofchildrenhospitalized withlong-termdisabilities.JAdvNurs1984;9:333–41.
5.LaMontagneLL,PawlakR.Stressandcopingofparentsofchildreninapediatric intensivecareunit.HeartLung1990;19(4):416–21.
6.HainesC,PergerC,NagyS.Acomparisonofthestressorsexperiencedby par-entsofintubatedandnon-intubatedchildren.JAdvNurs1995;21(2):350–5,
http://dx.doi.org/10.1111/j.1365-2648.1995.tb02533.x.
7.ColvilleG,DarkinsJ,HeskethJ,BennettV,AlcockJ,NoyesJ.Theimpacton parentsonachild’sadmissiontointensivecare:integrationofqualitative findingsfromacross-sectionalstudy.IntensiveCritCareNurs2009;25:72–9,
http://dx.doi.org/10.1016/j.iccn.2008.10.002.
8.JeeRA,ShepherdJR,BoylesCE,MarshMJ,Thomas PW,RossOC. Evalua-tionandcomparisonofparentalneeds,stressors,andcopingstrategiesin apediatric intensivecareunit. PediatrCrit CareMed2012;13(3):e166–75,
http://dx.doi.org/10.1097/PCC.0b013e31823893ad.
9.Ward-BegnocheW.Posttraumaticstresssymptomsinthepediatricintensive careunit.JSpecPediatrNurs2007;12(2):84–92.
10.CarterMC,MilesMS,BufordTH,HassaneinRS.Parentalenvironmentalstressin pediatricintensivecareunits.DimensCritCareNurs1985;14(3):181–8.
11.CarterMC,MilesMS.Theparentalstressorscale:pediatricintensivecareunit. MaternChildNursJ1989;18(3):187–98.
12.SeyleH.Thestressoflife.NewYork:McGraw-Hill;1956.
13.LazarusRS,LaunierR.Stress-relatedtransactionsbetweenpersonand environ-ment.In:PervinlaO,LewisM,editors.Perspectivesininternationalpsychology. NewYork:PlenumPress;1978.
14.RoySC.Introductiontonursing:anadaptationalmodel.EnglewoodCliffs,NJ: PrenticeHall;1976.
15.MoosRH,BillingsAG.Conceptualizingandmeasuringcopingresourcesand pro-cesses.In:GoldbergenL,BregnitzS,editors.Handbookofstress:theoreticaland clinicalaspects.NewYork:TheFreePress;1982.
16.MilesMS,CarterMC.Assessingparentalstressinintensivecareunits.Matern ChildNursJ1983;8:354–60.
17.MilesMS,CarterMC,HennesseyJ,EberlyTW,RiddleI.Testingatheoretical model:correlatesofparentalstressresponsesinthepediatricintensivecare unit.MaternChildNursJ1989;18(3):207–19.
18.MilesMS,CarterMC,RiddleI,HennesseyJ,EberlyTW.Thepediatricintensive careunitenvironmentasasourceofstressforparents.MaternChildNursJ 1989;18(3):199–206.
19.CurleyMAQ.Effectsofthenursingmutualparticipationmodelofcareon parentalstressinthepediatricintensivecareunit.HeartLung1988;17(6):682–8.
20.CurleyMAQ,WallaceJ.Effectsofthenursingmutualparticipationmodelofcare onparentalstressinthepediatricintensivecareunit:areplication.JPediatrNurs 1992;17(6):377–85.
21.PooniPA,SinghD,BainsHS,MisraBP,SoniRK.Parentalstressinapaediatric intensivecareunitinPunjab,India.JPaediatrChildHealth2013;49(3):204–9,
http://dx.doi.org/10.1111/jpc.12127.
22.ReiRM,FongC.TheSpanishVersionoftheParentalStressorScale:Pediatric IntensiveCareUnit.JPediatrNurs1996;11(1):3–9,http://dx.doi.org/10.1016/ S0882-5963(96)80033-9.
23.NizanM,NorzilaMZ.Stressamongparentswithacutelyillchildren.MedJ Malaysia2001;56(4):428–34.
24.YamBM,LopezV,ThompsonDR.TheChineseversionofthePSS:PICU.NursRes 2004;53(1):19–27.
25.AldridgeMD.Decreasingparentalstressinthepediatricintensivecareunit:one unit’sexperience.CritCareNurse2005;25(6):40–50,http://dx.doi.org/10.1002/ 9781444345186.ch37.
26.AgazioJB,BuckleyKM.Revisionofaparentalstressscaleforuseonapediatric generalcareunit.PediatrNurs2012;38(2):82–7.
27.MilesMS,FunkSG,KasperMA.Theneonatalintensivecareunitenvironment: sourcesofstressforparents.AACNClinIssuesCritCareNurs1991;2(2):346–54.
28.BusseM,StromgrenK,ThorngateL,ThomasKA.Parents’responsestostressin theneonatalintensivecareunit.CritCareNurse2013;33(4):52–60.
29.ColvilleG,GraceyD.Mother’srecollectionofthePaediatricIntensiveCareUnit: associationswithpsychopathologyandviewsonfollowup.IntensiveCritCare Nurs2006;22:49–55,http://dx.doi.org/10.1016/j.ccn.2005.04.002.
30.EberlyTW,MilesMS,CarterMC,HennesseyJ,RiddleI.Parentalstressafterthe unexpectedadmissionofachildtotheintensivecareunit.CCQ1985;8(1):57–65,
http://dx.doi.org/10.1007/s10880-012-9328-x.
31.AamirM,MittalK,KaushikJS,KashyapH,KaurG.Predictorsofstressamong parentsinpediatricintensivecareunit:aprospectiveobservationalstudy.Indian JPediatr2014;81(11):1167–70,http://dx.doi.org/10.1007/s12098-014-1415-6. 32.BronnerMB,PeekN,KnoesterH,BosAP,LastBF,GrootenhuisMA.Course and predictorsof posttraumatic stress disorder in parentsafter pediatric intensivecaretreatmentoftheirchild.JPediatrPsychol2010;35(9):966–74,
http://dx.doi.org/10.1093/jpepsy/jsq004.
33.FranckLS,McquillanA,WrayJ,GrocottMPW,GoldmanA.Parentstresslevels duringChildren’shospitalrecoveryaftercongenitalheartsurgery.PediatrCardiol
2010;31(7):961–8,http://dx.doi.org/10.1007/s00246-010-9726-5.
34.CohenS,KamarckT,MermelsteinR.Aglobalmeasureofperceivedstress.JHealth SocBehav1983;24:385–96.
35.Remor E. Psychometric Properties of a European Spanish Version ofthe PerceivedStressScale(PSS).SpanJPsychol2006;9(1):86–93,http://dx.doi.org/ 10.1017/S1138741600006004.
36.DavidsonJRT,BookSW,ColketJT,TuplerLA,RothS,DavidD,etal. Assess-mentofanewself-ratingscaleforpost-traumaticstressdisorder.PsycholMed
1997;27:153–60,http://dx.doi.org/10.1017/S0033291796004229.
37.BobesJ, Calcedo-BarbaA,GarcíaM,etal. Evaluationofthepsychometric propertiesoftheSpanishversionof5questionnairesfortheevaluationof post-traumaticstresssyndrome.ActasEspPsiquiatr2000;28(4):207–18.
38.ZigmondAS,SnaithRP.Thehospitalanxietyanddepressionscale.ActaPsychiatr Scand1983;67:361–70.
39.QuintanaJM,PadiernaA,EstebanC,ArosteguiI,BilbaoA,RuizI.Evaluation of the psychometric characteristics of the Spanish versionof the Hospi-talAnxietyandDepressionScale.ActaPsychiatrScand2003;107(3):216–21,
http://dx.doi.org/10.1034/j.1600-0447.2003.00062.x.
40.Slater A, Shann F, Pearson G, PaediatricIndex of Mortality (PIM) Study Group,&PIMStudyGrp.PIM2:arevisedversionofthepaediatricindexof mortality.IntensiveCareMed2003;29(2):278–85,http://dx.doi.org/10.1007/ s00134-002-1601-2.
41.HairJF,BlackWC,BabinBJ,AndersonRE,TathanRL.Multivariatedataanalysis. UpperSaddleRiver,NJ:Pearson-PrenticeHall;2006.
42.MilesMS,CarterMC.Copingstrategiesusedbyparentsduringtheirchild’s hospitalizationinanintensivecareunit.ChildHealthCare1985;14(1):14–21,