John S. Murray

Siblings of children with cancer: A review of the literature☆

Research on siblings of children with cancer during the past 40 years has clearly shown that the childhood cancer experience is a stressor that may increase subjective feelings of stress by well siblings and in some cases lead to decreased psychosocial competencies and increased psychopathologies. Research has expanded from identifying psychosocial problems experienced by the sibling after the patients death to identifying stressors during the illness experience. More recent studies have been targeted at identifying what action siblings take to cope with the stressors imposed since the cancer diagnosis and have addressed what interventions pediatric oncology nurses use in clinical practice to provide support to siblings of children with cancer. The current state of this body of literature, a review of 18 studies, is presented in this article along with a critique of the research studies and suggestions for future research.

THE LIVED EXPERIENCE OF CHILDHOOD CANCER: ONE SIBLING'S PERSPECTIVE

The demands of cancer on children and their parents have been studied and understood for many years now. However, very little focus has been placed on one other very important part of the family system--the siblings. In the health care profession today, there is a growing awareness that the psychosocial needs of siblings of children with cancer are less adequately met than those of other family members. Research suggests that siblings are particularly vulnerable to adjustment difficulties (depression, anger, anxiety, feelings of guilt, and social isolation), and they experience similar stress to that of the ill child Siblings have been identified as the most emotionally neglected and unhappy of all family members during serious childhood illnesses. The purpose of this study was to gain a better understanding of the lived experience of one 14-year-old siblings experience with childhood cancer. Through the qualitative research process of phenomenology, the researcher gained a greater understanding of the participants experience and how the childhood cancer experiences affected her and her family. Themes that emerged through the process of content analysis included emotional intensity, increased empathy for others, personal growth, need for support, and desire to help others.

Understanding sibling adaptation to childhood cancer

Clinical research conducted over the past 40 years has described adjustment difficulties healthy siblings face when they have a brother or sister with childhood cancer. Research on healthy siblings of children with pediatric malignancies has advanced over the past few years and has broadened from distinguishing psychosocial problems following the patient?s death to identifying stressors during the illness experience. More recent research endeavors have focused on recognizing what behaviors or interventions health care providers understand to be most significant in promoting the patient?s, parents?, and siblings? coping efforts with childhood cancer and its treatment. In addition, descriptive research is exploring interventions used by pediatric oncology health care providers to render social support to siblings of children with cancer (Murray, 1999). Despite the growing body of literature on sibling adaptation to childhood cancer, an understanding of this experience from a developmental perspective is lacking. This lack of theoretical understanding may contribute to inadequate care of siblings of children with cancer. Understanding the meaning cancer has for well siblings is critical. This article discusses the theoretical framework of child development in relation to understanding sibling adaptation to the childhood cancer experience.

Self-concept of siblings of children with cancer.

Childhood cancer can have detrimental effects on the psychosocial well-being of healthy siblings of children with cancer. The limited research done over the past 40 years has identified adjustment difficulties such as poor self-concept, depression, sorrow, anxiety, and feelings of loneliness in children who have a sibling with cancer. To date, clinical research investigating self-concept is scarce as it relates to siblings of children with cancer. The purpose of this study was to examine self-concept in siblings of children with cancer who attended summer camp. A nonprobability purposive sample consisted of 50 school-age siblings of children with cancer. Using the Personal Attribute Inventory for Children (PAIC) to measure childrens selfconcept, the researcher found that healthy siblings who attended summer camp scored higher on the PAIC than healthy siblings who did not attend camp. This research suggests that social support such as a camp experience may play an important function in coping with having a brother or sister with childhood cancer.

ATTACHMENT THEORY AND ADJUSTMENT DIFFICULTIES IN SIBLINGS OF CHILDREN WITH CANCER

The demands of the childhood cancer experience on children and their parents has been investigated for a number of years. Despite this research, very little emphasis has been placed on well siblings. In the health care profession today, there is a growing perception that the psychosocial needs of the healthy siblings of children with cancer are less sufficiently met than those of other members of the family system. Previous research proposes that well siblings are especially susceptible to a number of adjustment difficulties (such as depression, anger, anxiety, feelings of guilt, and social isolation) (Murray, 1999). Given these findings, the question arises as to whether the adjustment difficulties seen in siblings are a result of the loss of, or separation from, the attachment figure-the mother who is busy caring for the child with cancer. The purpose of this article is to use attachment theory as a conceptual framework to try to understand the effects of the childhood cancer experience on siblings. Recent findings regarding siblings of children with cancer and some speculations regarding clinical implications are provided.

Social Support for Siblings of Children with Cancer

This descriptive study investigated nursing interventions used by pediatric oncology nurses to provide social support to siblings of children with cancer. The study was guided by Houses conceptualization of social support which includes components of emotional, instrumental, informational, and appraisal support. A sample of 250 randomly selected pediatric oncology nurses were mailed the Sibling Social Support Questionnaire (SSSQ), developed by the researcher, to determine what interventions they use in clinical practice to provide social support to siblings of children with cancer. With 134 nurse respondents, the SSSQ demonstrated high internal consistency (Cronbachs alpha of .95). Results indicated that the two most frequently used nursing interventions to provide social support to siblings are: (1) encouraging parents to spend time with their other children and (2) providing honest responses to questions asked by siblings.

Medical Device-Related Hospital-Acquired Pressure Ulcers in Children: An Integrative Review

The management, cost, physical and emotional suffering associated with pressure ulcers have a significant impact on the health status of patients-especially infants and children. The purpose of this integrative review was to identify factors associated with medical device-related (MDR) hospital acquired pressure ulcers (HAPUs) in the pediatric population. Pediatric MDR HAPUs are becoming more prevalent and require further exploration in terms of describing devices which cause injury and preventive interventions to improve patient outcomes. Opportunities to uncover new methods for addressing this important problem and to inform and advance the state of the science in this evolving area exist.

Understanding Zika virus.

PURPOSE This article describes what pediatric healthcare professionals should know about Zika virus (ZIKV). LITERATURE REVIEW ZIKV is classified as an arthropod-borne, single-stranded RNA virus of the Flaviviridae family and genus Flavivirus. ZIKV is not new. The virus was first discovered almost 70 years ago in Uganda. The first isolate of the virus was found in rhesus monkeys in the Zika Forrest, hence the nomenclature. The primary route of ZIKV transmission to humans is through the bite of an infected Aedes species mosquito-primarily Aedes aegypti. When the mosquito bites individuals infected with the virus, mosquitos then become the vector of transmitting the infection to others. Women can also pass ZIKV to their fetus during pregnancy and at the time of delivery. ZIKV can also be transmitted through sexual activity from an individual who is infected with the virus to his or her partners. It is estimated that approximately 18% of individuals infected with ZIKV will go on to develop symptoms. When symptoms develop, it is usually within 3-12 days, although this may vary. Most often, symptoms are mild and self-limited. The most common symptoms are fever, arthralgia, maculopapular rash, and conjunctivitis lasting up to seven days. Less frequent symptoms include headache, vertigo, myalgia, vomiting, and diarrhea. At present, there is no vaccine available to prevent ZIKV and no specific antiviral treatment. Supportive care consisting of rest, hydration, analgesics, antihistamines, and antipyretics is recommended as needed. Given that there is no vaccine or treatment for ZIKV, considerable efforts must be focused on prevention. One of the most effective ways of preventing ZIKV infection is through avoiding mosquito bites, especially when traveling to or residing in areas where transmission is present. Precautions should include wearing appropriate attire with the objective of having as little skin exposed as possible, use of screens for windows and doors, and use of insect repellent. PRACTICE IMPLICATIONS What is known about ZIKV changes continually. An infectious threat that was relatively obscure just a few months ago has now become a topic of heightened interest worldwide. Pediatric healthcare professionals must remain cognizant of evolving developments and emerging new evidence.

Re: Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age.

As clinicians and researchers interested in hospitalacquired pressure ulcers (HAPUs) in children, we continually seek collaborative opportunities nationally and internationally to address this important issue and advance the state of the science as it relates to this evolving area of pediatric nursing. We appreciate the ongoing efforts by AnnaBarbara Schlüer, MScN, and colleagues to identify factors related to the development of HAPUs in the pediatric population. In a JSPN early view (online version of record published before inclusion in an issue) publication, Schlüer, Schols, and Halfens (2014) conducted a multicenter, cross-sectional, descriptive study to explore factors associated with HAPUs in children and adolescents. The authors used the Braden Scale vs. the Braden Q Scale for predicting pediatric pressure ulcer risk, which is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool (Noonan, Quigley, & Curley, 2006). It is unclear why Schlüer and colleagues would use the original Braden Scale, which has never been psychometrically tested with any age group in the pediatric population. Instead, it was developed and tested for the adult population. It is also unclear why the authors did not use the Braden Q Scale, which has been translated into German (Die Braden Q-skala: Dekubitus-risiko bei kindern, 2005). Additionally, Schlüer and colleagues (2014) did not separate traditional immobility-related from devicerelated pressure ulcers. The Braden Scale does not predict device-related injuries. Researchers have emphasized the importance of clinicians recognizing that riskassessment,prevention,andmanagementof immobility-related and medical device-related pressure ulcers are different (Kohr & Curley, 2010). In order to avoid confusion regarding implementation of best practice recommendations for HAPU prevention and quality monitoring, it is critically important to differentiate the two phenomena (Murray, Noonan, Quiqley, & Curley, 2013). As nursing experts continue to contribute to the science of HAPUs in the pediatric population, greater collaboration and open dialogue is needed so that the experiencesofallwhoare interested in this important issue are considered. The enduring commitment to refining a psychometrically sound risk assessment tool forHAPUs iscritical to informingnursingpractice and optimizing prevention and treatment (Murray et al., 2013).

Toxic stress and child refugees

The purpose of this article was to describe the phenomenon of toxic stress and its impact on the physical and mental health of child refugees. Almost two decades ago, researchers found that recurring adverse childhood events (ACEs; e.g., physical, psychological, and sexual abuse, neglect, and household dysfunction such as substance abuse, mental illness, and criminal behavior) were associated with a significant increase in serious illnesses during adulthood. Illnesses include heart, lung, and liver disease, cancer, and bone fractures. The scientists reported that experiencing four or more ACEs during childhood significantly increases the risk for toxic stress. Toxic stress is defined as the exposure to extreme, frequent, and persistent adverse events without the presence of a supportive caretaker. There is a paucity of literature related to toxic stress and child refugees. However, it has been clearly established that the prolonged brutal and traumatizing war in Syria is having a profound impact on the physical and mental health of child refugees at a distressing rate. Prevention of toxic stress should be a primary goal of all pediatric healthcare professionals working with child refugees. While this seems daunting given the population, and the seemingly insurmountable stressors they experience, some basic interventions should be considered. Providing basic anticipatory guidance to parents and caregivers of child refugees, to encourage positive parenting and strengthening support networks, will be highly effective in developing the requisite buffers that mitigate the effects of stress and avoid toxic stress. Efforts should also be focused on addressing caregiver stress and improving their ability to provide safe, reliable, and nurturing care that will help to mitigate any stress response experienced by a child. PRACTICE IMPLICATIONS It is critical that greater awareness be placed on the effects of toxic stress on child refugees who are exposed to significant adverse events early in life.