Temperament and the hospitalized child

Temperament and the Hospitalized Child Mona Ruddy Wallace, EdD, RN

There is increasing evidence to support that temperament is an important variable in considering approaches to nursing care for the hospitalized child. Nursing admission assessment can be expanded to include temperament data from parent interviews. A number of case studies are highlighted to illustrate the relationship between temperament assessment, nursing interventions, and expected outcomes. It is recommended that pediatric nurses incorporate temperament information in all steps of the nursing process. Copyright 9 1995 by W.B. Saunders Company

CHANGES have occurred in D RAMATIC pediatric nursing during the last 25 years. Technological advances, emergence of new pathological conditions, and the changing needs of society have led to modifications in health care delivery as well as to the setting in which it occurs. In the past, the care of hospitalized children included rigid policies in regard to procedures, isolation, bed rest, and visitation. These policies were dictated in part by the nature of the prevalent diseases of the time and by the assumptions regarding the needs of sick children. Fortunately, the findings from studies of children's growth and development led to numerous changes within institutional health care settings (Petrillo & Sanger, 1980). Among the health care professionals to capitalize on this new knowledge were pediatric nurses. Many of the standards of care in acute care settings considered routine in the 1990s resulted from the leadership of nurses who were committed to excellence in the care of children and their families based on a developmental approach. For children and their families, illness creates a stressful experience. When accompanied by hospitalization, illness results in changes in routines. Both the child and family have a limited number of coping mechanisms to resolve the stresses associated with an illness and hospitalization. The child's reactions to these stressors are influenced by many factors, such as developmental stage, previous experience with illness, separation from family, and seriousness of the problem. Pediatric nurses are in a unique position to provide guidance and support for the hospitalized child and family. The expanding role of primary caregivers and managers of Journal of Pediatric Nursing, Vol 10, No 3 (June), 1995

the health team offers both opportunities and challenges for today's professional nurse. By using the nursing process, the nurse systematically assesses, plans, implements, and evaluates the plan of care to maximize positive outcomes and minimize stressors associated with illness and hospitalization. Pediatric nurses routinely collect information at admission to individualize the child's care. Questions that the nurse may ask pertain to the reason for hospitalization; family information; home routines, including bedtime, toilet behavior, food preferences, and security items; usual activities; fears; and reactions to school experiences. In some instances information related to comfort measures, reaction to separation, and personality characteristics also is solicited. Still, most nursing care plans focus predominantly on physiological needs with alterations in growth and development viewed as global and related to the child's chronological age (Gulanick, Puzas, & Wilson, 1992). Temperament theory can serve as an organizing framework to elicit more specific information about the individual characteristics of the child. The need to apply temperament theory to nursing practice began to appear in pediatric nursing journals in the mid-1980s From the School of Nursing, Southern Illinois University at Edwardsville, IL. Supported by grants from the Office of Research and Projects, Graduate School, Southern Illinois University at Edwardsville. Address reprint requests to Mona Ruddy Wallace, EdD, RN, School of Nursing, Southern Illinois Universityat Edwardsville, EdwardsviUe, 1L 62026. Copyright 9 1995 by WB. Saunders Company 0882-5963/95/1003-000753.00/0

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(Cherry, Hayes, & Feeg, 1987; Chess, 1985; Ruddy-Wallace, 1987). This article discusses the clinical significance of children's temperament as it relates to the hospital setting. An illustration of how temperament information can be incorporated into the steps of the nursing process also is presented. CLINICAL SIGNIFICANCE OF TEMPERAMENT IN THE HOSPITAL SETTING It is generally accepted within the temperament field that the origin of temperament is genetic, but its final outcome depends on modification by the environment (Chess & Thomas, 1986). When the properties of the environment and its expectations and demands are in accord with the individual's characteristics and style of behaving, goodness of fit results. Conversely, if there is poorness of fit, distorted behavior is likely to result. The term temperament risk factors refers to the temperament characteristics that predispose a child to a poor fit within a specific environment. For the developing child, a supportive environment that matches the capacities of the child reduces stress and ultimately leads to mastery (Chess & Thomas). This is especially relevant to the hospital experience, which is stressful for children and their families. Common problems confronting children who are hospitalized are loss of control, fear, separation from family members, the need to adjust to an unfamiliar environment, and the threat of pain. Maladaptive behaviors displayed by children in the hospital may be explained in part by a lack of sensitivity to the vulnerable child's temperament and the demands of the hospital environment (Ruddy-Wallace, 1987). A study by McClowry (1990) demonstrated the value of temperament theory in explaining children's responses to hospitalization by identifying the temperament dimensions of mood and approach as predictors of their behavioral response. Reported case studies have demonstrated the clinical application of temperament to the care of hospitalized children (Chess, 1985; McLeod & McClowry, 1990; Ruddy-Wallace, 1987). The focus of these case studies has been on planning individual interventions that are designed to match the child's temperament with hospital environment variables, thus resulting in a goodness of fit. Other investigators have related temperament

to adaptation to chronic illness. Sick children have been found to display more difficult temperaments than healthy children (LaVigne, Nolan, & McLone, 1988; Rovet & Ehrlich, 1988; Varni, Ruhenfeld, & Setoguchi 1989). For example, infants and toddlers with cardiac disease were rated as more withdrawn, more intense, and having lower thresholds than their healthy counterparts (Marino & Lipshitz, 1991). Chess and Thomas (1986) studied individual responses of children to physical symptoms of illness and concluded that temperamental differences are critical in managing all aspects of child health care. Certain temperament characteristics have been found or suspected to predispose to organic problems, such as accidents and child abuse; functional disorders, such as colic, abdominal pain and enuresis; and failure to thrive syndromes (Carey & McDevitt, 1989; Davison, Faull, & Nichol, 1985). A pervasive physical symptom associated with illness and disease is pain. Because of its recognized personal nature, pain would appear to be closely associated with temperament variables. The influence of temperament on pain management differences in hospitalized 3- to 7-year-oldchildren has been examined (Ruddy-Wallace, 1989). Young children undergoing similar surgical procedures varied greatly in the amount of analgesics received. The number of analgesic medications administered to each subject in the postoperative period ranged from 0 to 24 doses. Children rated as high intensity by the Behavioral Style Questionnaire, a temperament rating scale, received a significantly greater number of postoperative analgesic medications than did children rated as low intensity. Although not significant predictors, there were trends in other dimensions that appeared to influence pain management, such as activity, rhythmicity, approach, mood, distractibility and threshold. Children with high activity tended to receive less medication than children with low activity; children who were rated as arrhythmic tended to receive less medication than rhythmic children; children with high approach tended to receive less medication than withdrawn children; children with positive mood tended to receive less medication than those with negative mood; children who were nondistractible tended to receive less medication than distractible children; and children with high thresholds tended to receive less medication than children with lower thresholds. Lee (1993) also explored the

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role of temperament in pediatric pain response and reported that activity, adaptability, approach, intensity, mood, and threshold were related to pain perception. Children who were less approachable, more active, and more intense in their responses had lower oxygen saturation levels after venipuncture. A related study focused on nurse variables and the management of children's pain. A survey of 273 practicing pediatric nurses was conducted to determine their philosophies and beliefs regarding pain management in children (Wallace, 1991). More than 70% of the nurses relied most heavily on the child's behavior when assessing pain, with less than 1% using assessment tools. Restlessness was identified as the best predictor of pain by the majority of nurses surveyed. From a temperament perspective, an assessment based primarily on restlessness is inadequate, because some children increase their physical activity as a way to distract themselves from pain, whereas others sleep for long periods after a painful event. Nurse variables also were evident when school-age children concluded that administration of pain medication depended entirely on the initiative of the nurse (Alex & Ritchie, 1992). Nurses in this instance provided analgesics primarily when the child displayed outward manifestations of discomfort rather than acknowledging variations in pain behaviors. Although family-centered care is the stated philosophy of many of the pediatric health care facilities in the United States, relatively little is reported on how parents are included in meeting the needs of the hospitalized child. From a nursing viewpoint, much of the information necessary for formulating an individualized care plan depends on parent-communicated assessment data. There is a lack of information in the literature to provide direction for nurse clinicians related on how to best include parents in their child's care. However, it appears theoretically sound to conclude that parents are valuable members of the health care team and can contribute significantly to planning care that considers the unique behavioral characteristics of the child. For example, in a recent parent survey, parents selected "having an IV" and "having pain/discomfort" equally in response to the question, "What was the most difficult part of hospitalization for your child?" (Wallace, 1992). Eighteen percent of the parents stated that "going to the operating room" was

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most difficult and 13% indicated that "being away from home" was most difficult. The majority of parents indicated that the child verbalized to them when they had pain, and 35% of the nurses asked the parent if the child needed a pain medication. In the subject group rated by parents as having "more than expected" pain, there was a greater frequency of children whose temperament had been rated as negative mood. Children whose parents perceived them as experiencing pain "as expected" were more often rated as high in the dimension of distractibility. Although these results are preliminary, there is evidence to support that temperament is an important variable in considering approaches to nursing care for the hospitalized child and that parents play a valuable role in actualizing this concept in the acute care setting.

TEMPERAMENT DATA AND CLINICAL NURSING PRACTICE Interest in temperament by the author grew out of (a) clinical experiences that repeatedly showed that individual children respond differently to hospitalization along with (b) the subsequent haunting question, "How different is different?" An important goal for nurses in the hospital setting is to facilitate mastery and decrease anxiety in the child and family. Nurses are in a unique position to identify individual differences in children and to promote those behaviors that produce smooth and effective mastery of environmental expectations. Initially the author's research focused on describing the behavioral responses of 3-7-year-old children to the same-day-surgery experience, followed by assessing the temperament of children admitted to an acute care unit in a pediatric hospital. The descriptive nature of these investigations was directed primarily at identifying each child's temperament profile to formulate a nursing care plan. For example, in instances where the child with high activity needs was restricted to bed rest, the nurse could anticipate the unreasonableness of such a request to the child and institute nursing interventions to provide for a goodness of fit. Such play activities as bean-bag toss, finger painting, and clay modeling proved therapeutic to the child and resulted in positive outcomes related to nursing actions. Other examples included the need for children with low adaptability to be introduced slowly into the hospital environment; the advisability of using quiet rooms for teaching children with high

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distractibility; and the likelihood that children with low approach respond better to parent, rather than nurse, requests. The results of these clinical observations led to the formal inclusion of temperament information into all phases of the nursing process. Adapted from the scientific approach to problem solving, the nursing process is central to nursing actions in any setting. The steps in the nursing process are assessment, planning, implementation, and evaluation (Carpenito, 1983). Nursing process enables the nurse to individualize care and potentiates the probability that optimal patient satisfaction will be achieved. NURSING ASSESSMENT Assessment, the first phase of the nursing process, involves the systematic collection of data by means of observation, examination, interviewing, and record review. Nursing diagnoses are derived from these assessments, which are followed by the formulation of nursing plans of care. The resultant care plans provide direction and continuity of care by facilitating communication among nurses and other caregivers as well as providing guidelines for documentation. Because of the time-consuming nature of writing nursing care plans, many agencies rely on standardized care plans. Although these care plans provide direction for managing patient care, they fall short of achieving optimal outcomes when measured against individuality and the unique characteristics presented by each child and family. An initial step in efforts to individualize care is to collect temperament data. Temperament can be measured through parent interviews, parent questionnaires, and observations of children. Although some researchers have been skeptical about the ability of mothers to report accurately how their children behave, every appropriately designed study has supported the validity of mothers' reports (Carey, 1986). In clinical practice, most professionals supplement questionnaire data with interviews and observation. Commonly used temperament scales are the Early Infancy Temperament Questionnaire (1 to 4 months), the Infant Temperament Questionnaire (4 to 8 months), the Toddler Temperament Scale (1 to 3 years), the Behavioral Style Questionnaire (3 to 7 years), and the Middle Childhood Temperament Questionnaire (8 to 12 years). Johnson (1992) has developed an interview format for

temperament assessment that can easily be combined when the nurse obtains the admission health history and nursing admission assessment. In other words, the typical form nurses use to record admission information can be expanded to highlight temperament data. Following are examples of temperament data that were collected by parent interview using a modified nursing admission assessment form: Mary, 2 years old (pulmonary stenosis): intense, a sweetheart, demanding at times Christopher, 4 years old (cervical adenitis): very adaptable Kelsie, 5 years old (fractured femur): tomboy who likes running and playing rough; happy, active, bold Julie, 6 years old (cystic fibrosis): quiet and gentle Rebecca, 7 years old (cochlear implant): happy but stubborn Tommy, 11 years old (multiple trauma): playful, friendly; won't talk unless he knows you Lisa, 12 years old (ventricular septal defect): sweet, caring, kind, compassionate Greg, 14 years (cardiac catheterization): cocky, stubborn, pretty good guy

These behavioral indicators communicated by parents give valuable information to the nurse as the nursing process is actualized. The very adaptable child usually fits into new environments with minimal stress, whereas the quiet and gentle child requires a period of time, repeated explanations, and parental support for effective coping. Stubborn is an interesting descriptor, and in Rebecca proved to be a dimension of high persistence. On the other hand, the descriptors of cocky and stubborn in the adolescent were linked more closely to the developmental characteristics typical of that age, although Greg displayed an unusual amount of stoicism when managing his pain. Viewed within the framework of temperament, these personality differences form the basis for the next step in the nursing process, the formulation of nursing diagnoses. NURSING DIAGNOSIS Nursing diagnosis is the summary judgment that the nurse makes about the data gathered during the nursing assessment. It provides a framework for using nursing process and gives nurses a common language for communicating patient problems and nursing interventions. However, the art related to nursing diagnosis is still in a state of evolution. Consequently, the clinical nurse often is faced with situations that

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are not completely addressed by the nursing diagnoses approved by the North American Nursing Diagnosis Association (Gulanick et al., 1992). How then does one subsume temperament into the language of nursing diagnosis? The category of "growth and development, altered" is broad in scope and is intended to include physical and biological, motor and selfcare, sensory, cognitive and intellectual, language, psychosocial, psychosexual, and spiritual and moral as defining characteristics. Because admission of a child to an acute care facility causes disruption of the normal patterns of growth and development, the need to include temperament dimensions as defining characteristics becomes even more crucial. Because an expected outcome of nursing assessment and interventions is that the child and families' abilities will be maximized, the nursing diagnosis of "At risk for alteration in growth in development" is recommended. For example, when the nurse assesses high activity in a child and then provides nursing interventions that adequately meet this need, the nurse has used temperament as a basis for nursing care and has provided a goodness of fit between the child's individual temperament and the environmental and hospital demands. In accepting temperament differences as neither right or wrong, the focus of nursing diagnosis and subsequent interventions is on modifying the environment to support the difference as opposed to attempting to change how the child will respond.

NURSING INTERVENTIONS The case studies in Table 1 illustrate the relationship between temperament assessment, nursing interventions, and expected outcomes. Although the child's activity level has the potential of interfering with normal growth and development while hospitalized, this is not a risk factor for all children. Children with low activity accomodate quite readily to the limitations of bed rest, especially if family members are present and a television is available. Conversely, children with high activity pose real challenges for achieving positive outcomes! The role of rhythmicity in children has been suspected to relate to the occurrence of colic and other functional physical problems (Carey, 1986). Marino and Lipshitz (1991) demonstrated that in their study group toddlers with cardiac disease were less rhythmic than the

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normative group. Because physical illness and hospitalization disrupt usual sleeping, waking, eating, and elimination patterns, it would appear that the rhythmic child would have greater difficulty accomodating to the hospital routines, as was characterized by Bradley. Whenever he was awakened for breakfast at 8 a.m. when the trays arrived, he would cry, throw temper tantrums, and refuse to eat. This was followed by negative behavior for many hours later. "Miraculous results" (mother's words) were achieved by tuning into Bradley's sleeping, waking, and eating cycles. Nurses are encouraged to interpret variations in physiological function, such as decreased appetite, wakefulness, and elimination patterns, in relationship to the child's usual routines in the home setting rather than to hospital convenience or preconceived norms. Although there is a relationship between chronological age and initial approach to new situations, temperament theory suggests significant variations within age groups. The dimension of approach is extremely relevant when anticipating a child's response to the hospital experience. When Kelsie was admitted to the Same-Day Surgery Unit and immediately unclothed and placed in hospital pyjamas, her response was one of screaming, intense fighting, and physical distress. Had nursing interventions been based on the nursing diagnosis "potential alteration in growth and development related to low approach," the probability of fostering a sense of security would have been enhanced. As with approach, adaptability greatly influences the child's response to hospitalization. Children of all age groups with low adaptability benefit greatly from parental presence. Christopher responsed to parent absence by withdrawal, refusing to talk, eat, or drink. In addition, he initially refused to visit the playroom until assurances were made that his parents would be able to find him when they came back to the hospital. A long-term nursing goal related to Christopher was to promote positive experiences so that his future hospitalizations would be met with a greater sense of trust. As discussed earlier in this article, the dimensions of threshold, intensity, and mood have implications for nursing interventions related to the clinical manifestation of pain. In the case studies cited, both Brian and David needed optimum pain relief. The use of pain self-report scales as well as relying on parent information

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MONA RUDDY WALLACE Table 1. Temperament Data and Nursing Process CaseStudy

Temperament Assessment

Nursing Interventions

ExpectedOutcome

Cassie, 3 yr Nephrotic syndrome

Low activity

Age-appropriate board games Wagon rides

Usual activity level supported

Steven, 5 yr Fx femur/traction

High activity

Frequent therapeutic play Overhead punching bag Bean bag toss Paper airplane game

Activity needs met consistently Call light on less frequently

Melissa, 5 yr Urinary tract infection

Arrhythmic

Offer fluids every 2 h Modify criteria for evaluating urinary tract infection Do not expect regular voiding

Bacteruria will resolve

Bradley, 3 years Fxfemur/traction

High rhythmicity

Breakfast offered after awakening on own schedule (9 a.m.) Do not awaken for meals

Usual home pattern supported Negativism avoided

Kelsie, 4 yr Myringotomy

Low approach

Time for play activities when admitted before interventions Promote parent participation in all activities, including carrying to the operating room

Heightened sense of security Anxiety decreased

Theresa, 6 yr Mitral valve replacement

High approach

Provide peroperative medical play Encourage child's participation in nursing interventions

Trust established Sense of control fostered

Christopher, 4 yr Irrigate and drain neck abscess

High adaptability

Plan group play in playroom Support parents' need to return to work

Easyadjustment to hospital routines

Clinton, 7 yr Colostomy

Low adaptability

Encourage parent presence Leave note for parents when leaving for playroom Keep bed and unit environment the same Do not transfer to another bed or room during hospitalization

Reduced stress Increased sense of trust

Brian, 7 yr Renal transplant

High threshold Low intensity Positive mood

Use pain scale to evaluate comfort level Administer pain medications regularly

Optimum pain relief

David, 5 yr Ureteral reimplant

Low threshold High intensity Negative mood

Administer pain meds on a set schedule Use parent information to promote comfort Evaluate pain response based on past history

Optimum pain relief

Tammy, 6 yr Diabetes mellitus, type 1

High distractibility

Teach urine testing in quiet room Individual teaching sessions Use teaching strategies that are focused Include active participation

Teaching-learning objectives achieved

Leah, 5 yr Diabetes mellitus, type 1

Low distractibility

Group teaching sessions Test urine and finger sticks at the bedside

Teaching-learning objectives achieved

Julie, 5 yr Cystic fibrosis

High persistence

Schedule respiratory therapy around planned activities Allow time to complete current task without interruption Include Julie in planning day's activities Design a daily calendar of events and times

Reduced stress Self-esteem fostered

Richard, 5 yr Body cast

Low persistence

Provide short-term activity projects Reintroduce noncompleted projects Vary stimuli (television, music, reading, painting) on a daily basis

Reduced stress Self-esteem fostered

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describing the child's past responses to pain provide data on which the child's needs can be met. The recognition of differences in a child's affect, predominantly positive or negative, also can influence nursing interventions. In the case of David, he never appeared happy. Consequently, if pain relief was determined on behavioral assessment alone the expected outcome of care would not be achieved. This finding was highlighted in a study group of 75 hospitalized children where the majority of parents viewed their children as happy (positive mood), whereas the parents who rated their children as negative mood perceived them as experiencing more postoperative pain than their counterparts (Wallace, 1992). Nursing interventions commonly focus on patient teaching, both for the child and the family. An assessment of the child's learning capacity, including the effects of environmental stimuli, is necessary before actual teaching is initiated. The case studies illustrate that children with the same medical diagnosis of diabetes mellitus attain successful learning with quite different teaching strategies and nursing interventions. This observation may explain in part why children with diabetes who have easy temperaments are more successful in controlling their blood glucose levels than are children with difficult temperaments, as reported by Rovet and Ehrlich (1988). Other considerations that have relevance for the teaching-learning process is the level of a child's persistence. Persistence characteristics also are thought to influence the attainment of psychological attributes, such as self-concept and self-esteem, which have been shown to be related to learning and achievement in school-age children (Carey, 1986). In the hospital setting, the child with high or low persistence potentially is at risk and can benefit from nursing interventions that recognize this characteristic and provide appropriate interventions. The nursing interventions formulated in Table 1 are meant to be additions to currently used standard nursing care plans. The entries are intended to serve as a blueprint on which nursing approaches that recognize temperament differences can be patterned. More documentation and study are necessary to validate that temperament theory has important implications for nursing clinical practice. It also has been cautioned that there may not be one

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standard approach for developing a plan of care based on temperament but rather that plans must consider the uniqueness of each child, each parent, and the setting involved (Johnson, 1992).

SUMMARY The quality of care provided for the hospitalized child is related directly to the commitment of health care professionals to individualize all aspects of the hospital experiences. Nursing assessment, nursing plans of care, nursing interventions, and nursing evaluations play a key role in determining optimal outcomes. Along with expert knowledge related to physiological, developmental, and environmental factors, nurses are encouraged to include individual difference considerations in the plan of care. Studies in other disciplines have validated the usefulness of temperament in predicting behavior as well as in formulating plans of action for learning, medical interventions, and parenting skills (Carey & McDevitt, 1989). There is evidence that more nurse researchers are focusing on temperament as an important nursing care variable. Nursing journals have reported studies between the relationship of temperament and development, temperament and social relationships, stress and temperament, and measurement issues (McClowry, 1992). However, there are limited data to specifically prescribe how temperament can best be used in everyday practice. In the hospital setting, pediatric nurses can begin by formalizing the collection of temperament data as an integral part of the admission history. Once this information is available, nursing care plans can be formulated that direct nursing interventions specifically to the temperament of each child in striving for a goodness of fit between the needs of the child and family and environmental demands. The pediatric nurse functions both as a primary caregiver as well as a client advocate who buffers a sometimes unfriendly health care setting. Nurse clinicians who use temperament theory in their daily practice contribute to a body of knowledge that may lend itself to further scrutiny and formal validation. Just as pediatric nurses in the past were risk takers who spearheaded creative change, the challenge for the future remains. Nurse clinicians have a unique opportunity to transform theory into practice and attain yet a higher level of nursing excellence.

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