Psychological support for hospital adaptation and positive attitude of the adolescents

Shumakova Ol'ga Alekseevna ORCID: 0000-0001-9928-0548 Doctor of Psychology Professor; Department of Psychology; South Ural State Medical University 454092, Russia, Chelyabinsk region, Chelyabinsk, Vorovskiy str., 66, room 220 olgash37@yandex.ru Ageeva-Podobed Irina Borisovna ORCID: 0000-0002-0777-1122 Head of the Pedagogical Department; Chelyabinsk Regional Children's Clinical Hospital 454087, Russia, Chelyabinsk region, Chelyabinsk, Blucher str., 42A, pedagogical department sib.psychologist@mail.ru Zhakupova Yana Turarovna ORCID: 0000-0002-2699-7430 PhD in Psychology Associate Professor; Department of Psychology; South Ural State Medical University 454092, Russia, Chelyabinsk region, Chelyabinsk, Vorovskiy str., 66, office 211 ps-gold@yandex.ru Shumakov Vadim Anatolevich ORCID: 0000-0002-7963-2320 PhD in Philosophy Associate Professor; Department of Psychology; South Ural State Medical University 454092, Russia, Chelyabinsk region, Chelyabinsk, Vorovsky str., 66, room 219 v.shumakov@inbox.ru

Titova Ekaterina Ivanovna ORCID: 0000-0001-7661-4330 PhD in Psychology Associate Professor; Department of Psychology; South Ural State Medical University 454092, Russia, Chelyabinsk region, Chelyabinsk, Vorovskiy str., 66, office 211 ddidd@inbox.ru

Introduction

During hospitalization, adolescents experience socio-psychological maladjustment, which affects a decrease in the productivity of communication with the attending physician and medical staff and leads to disorders of the child's emotional development. Adolescents have different attitudes towards hospitalization: 23.86% of adolescents consider it painful for themselves to stay in a hospital, some prefer to stay in multi-bed wards, and they feel more comfortable when they are next to older patients than with children, teenagers preferably spend time in the hospital reading and sleeping, as well as on conversations and walks ^{[1, 2]}. Hospitalized children, compared with non-hospitalized children, need more support ^[3], while the direct interaction of medical personnel with them is important for children in the hospital. At the same time, studies show that coping strategies in adolescents with disease-related pain vary depending on diagnosis and self-representations as part of the adaptive mode of the self-concept ^[5]. In fact, hospitalization narrows the socio-psychological space of a teenager's daily life and limits his self-realization. At the same time, a healthy lifestyle is not predominant in the daily life of a modern teenager, in particular, low medical activity was revealed, namely, only 13.4% try to pay attention to their health and 21.3% of adolescents follow the instructions of doctors for preventive purposes ^[6]. The psychological characteristics of hospitalized children are due not only to the exacerbation of a chronic disease or the emergence of new serious symptoms, but also to the fact that a teenager breaks away from his usual environment, from family and parents, his friends and from the usual routine of his life. Before the unknown, he experiences anxiety and fear, tries to avoid communication with medical personnel as a source of danger to himself and negatively perceives medical procedures. The study by E. A. Trifonova and E. A. Gerasimova revealed that in the first days of hospitalization, adolescents experience an increased level of anxiety, but after the first week of stay, anxiety gradually decreases, but by the middle of the hospital stay, anxiety increases, and this is primarily due to treatment and medical staff ^[7]. The study by E. Claridge and O. Powell (Amy M. Claridge, Olivia J. Powell) revealed stress factors in the hospital, such as pain, disorders of normal life and insecurity. The authors revealed that coping for children is associated with such factors as social support from parents and peers and leaving the hospital room as a distraction from medical routine ^[8]. It is noted that role-playing games ("pretend play") with children in the hospital affect pain, externalize behavior and adaptation to chronic diseases ^[8].

In hospital pediatric practice, psychological and social technologies are increasingly being used to improve the child's adaptive resources in inpatient treatment, ensuring coping with hospital stress and successful compliance. For example, the use of games in the hospital has proven to be an effective tool for providing substantial assistance to hospitalized children ^[9]. It has been proven that technologies using digital educational tools and gaming activities with a robot are an effective way to reduce anxiety in children and protect their emotional sphere during hospitalization ^{[10, 11]}. Clownadotherapy performed by specially trained clown volunteers has proven itself well in both domestic and foreign hospital practice ^{[12, 13, 14]}.

However, despite the practical actions taken, the psychological problems of staying in hospital conditions in adolescents are relevant to this day. This means that the search for their solution must be localized in the scientific and practical plane, taking into account the specific characteristics of adolescent children and modern possibilities of psychological and social support in hospital practice ^{[15, 16, 17]}. Hospital psychological support programs should be focused on the psychological characteristics of the child's age, individual needs for psychological and social support, experience of staying in hospital conditions and personal strategies for coping with stress.

All of the above suggests that adolescent patients in a pediatric hospital are among the most difficult both in terms of behavioral difficulties and the organization of interaction in the treatment process. And it is extremely important to take a number of adaptation measures that allow a teenager to get used to a new space and new interpersonal relationships, thereby creating a positive attitude towards the treatment process.

The purpose of the study: to identify clinical and psychological features in the conditions of hospitalization as a "target" of preventive support for the socio-psychological adaptation of adolescents in the hospital.

The subject of the study is the psychological features of the hospital adaptation of adolescents, depending on the profile of the disease (gastroenterological and neurological).

Research base: Chelyabinsk Regional Children's Clinical Hospital, Chelyabinsk.

Materials and methods of research

In consultation with parents, children aged 10-14 years old who were hospitalized due to neurological and gastroenterological diseases were included in the study.

Psychodiagnostic methods were applied: the CMAS scale of explicit anxiety (authors A. Castaneda, V. Msandless, D. Palermo, adaptation by A.M. Parishioners); the questionnaire of socio-psychological adaptation, SPA (authors K. Rogers, R. Diamond, adaptation by A. K. Osnitsky); the Kettell test, 14PF / HSPQ (adolescent version); the Spielberger anxiety scale- Hanina.

The methods of mathematical statistics are applied: correlation analysis (Spearman's rank correlation coefficient, rs) between indicators of anxiety, personal characteristics, socio-psychological adaptation; Student's T-criterion for indicators of maladaptivity (YES), integral indicator of socio-psychological adaptation (ISPA) and overt anxiety (YT) at the stage of analyzing the results of the study.

Empirical research procedure: a pilot study was conducted (120 people), based on the results obtained, two groups of subjects (neurological and gastroenterological departments of the hospital) with an equal number of participants (14 in different treatment periods) with the same composition of boys and girls, equal average age in the groups were selected for the formative experiment.

Research plan:

Stage 1 – the first week of hospital stay – conducting entrance diagnostics, conversations of a medical psychologist with adolescents, observation;

Stage 2 – implementation of the adaptation program, repeated psychodiagnostics;

Stage 3 – analysis of the research results.

The results of the study and their discussion

Diagnosis of socio-psychological adaptation (K. Rogers, R. Diamond) revealed a high level of maladaptivity in 67% of adolescents (YES=130± 2), which is an important signal when organizing the treatment process in a hospital. The integral adaptation index in 52% of adolescents was manifested at an average level (IA=44 ± 1), in 33% of adolescents adaptation is at a low level (A=28 ± 1) and only in 5% – at a high level (A=62±1). That is, in fact, out of the entire analyzed sample (120 people), only 6 people show successful adaptation in the hospital and may not have risks of further maladaptation.

According to the Kettell test (14PF/HSPQ, adolescent variant), indicators of emotional stability (C), passivity/dominance (E), acceptance of moral norms (G) were analyzed. 62% of the subjects showed low results of emotional stability (boys C=11±0.2; girls C=9±0.3); 14% of adolescents have a low degree of acceptance of moral norms (boys G= 12± 0.2; girls G=12± 0.4); 57% have high dominance (boys E=15.1± 0.1; girls E=14.3±0.1).

The diagnosis of anxiety (Spielberger-Khanin) showed that upon admission to the hospital, 38% of adolescents had a high level of situational (reactive) anxiety (CT=47± 1) and 34% had a high level of personal anxiety (LT=48±1). It should be noted that personal anxiety is a basic personality trait that is formed throughout a person's life, while in combination with manifestations of reactive (situational) anxiety can become the basis for the occurrence of psychosomatic diseases, emotional breakdowns, and also provoke neurotic pathology. Based on this, it is understood that adolescents who are admitted to treatment are easily traumatized by their emotional background, in fact, "fragile", tend to show anxious reactions to uncomfortable situations, as well as high maladaptivity with negative emotional colors.

The results on the CMAS anxiety level scale show the formation of a very high and clearly elevated level of anxiety in 30% of adolescents (T=8.6±0.4), that is, every third teenager has experience of anxiety reactions, and they are chronic.

The correlation analysis of the studied indicators confirmed the relationship of the results obtained (Fig. 1.).

Fig.1. Interrelations of psychological indicators of hospital adaptation of adolescents

The integral index of adaptability (K. Rogers, R. Diamond) positively (rs≥0.5) correlates with anxiety (CMAS) and personal anxiety (Spielberger-Khanin), emotional stability (R. Kettel) negatively (rs ≥ - 0.5) correlates with situational and personal anxiety (Spielberger-Khanin), maladaptivity (K. Rogers, R. Diamond), anxiety (CMAS); maladaptivity (K. Rogers, R. Diamond) positively correlates (rs≥ 0.5) with anxiety (CMAS) and situational anxiety (Spielberger-Khanin).

Emotional stability has a greater number of connections with indicators. Emotionality as one of the key age characteristics of adolescents affects the occurrence of maladaptivity with a negative correlation: the higher the emotional regulation, the more stable the emotions, the lower the maladaptivity. At the same time, the integral indicator of adaptation is not directly related to emotions, their relationship is mediated by anxiety (reactive and personal). This means that ensuring the normative level of adaptation of adolescents in the hospital should occur simultaneously with the regulation of anxiety indicators.

Thus, upon admission to the hospital, adolescents experience a high psychoemotional load, manifested in emotional instability, personal and situational anxiety, and use habitual worries, anxieties and fears, and vivid emotional reactions as a protective form. With such characteristics, it is very important for medical personnel to find an approach to adolescent patients that would contribute to the successful course of the treatment process, a comfortable psychological environment in the department and prevent the development of socio-psychological maladaptation of adolescents. It is important to note that the implementation of this task is aimed at ensuring that adolescent patients treat the hospitalization period constructively, tune in to treatment adherence and thereby preserve and strengthen their psycho-emotional health.

Further, based on the results obtained, experimental work was carried out on psychological support for the adaptation of adolescents in the hospital. Two groups of subjects (neurological and gastroenterological departments) with an equal number of participants (14 people each) with the same and equal number of boys and girls, equal average age in the groups (11.6±0.3 years) were selected. The division into two groups ensured the identification of specific psychological characteristics of adolescents being treated in different departments, and further consideration of these features in the development and implementation of the adaptation program.

In the first group (patients of the neurological department), on the basis of correlation analysis, the interrelations between the studied indicators of anxiety, personal characteristics, and socio-psychological adaptation were revealed: adaptability negatively correlates with personal anxiety (rs = - 0.6), situational anxiety (rs = - 0.85), positively correlates with emotional stability (rs = 0.5) and acceptance of moral norms (rs = 0.78), maladaptivity negatively correlates with the indicator of passivity/dominance (rs = - 0.78). Adolescents of the neurological department experience situational anxiety, which is associated with hospitalization and, therefore, makes it difficult to adapt in a hospital. In addition, adolescents show personal anxiety as a well-established personal characteristic, which is clearly manifested in situations of danger and fear. This means that teenagers perceive the fact of hospitalization as a situation of danger and react to it with increased anxiety.

The positive relationship of adaptability with emotional stability gives an understanding that the success of adaptation is possible through the activation of emotional mechanisms: for example, through a change in attitude to a problem, a positive interpretation of difficult experiences, enrichment of life with positive emotional situations and positively tuned emotional contacts. A positive correlation with the acceptance of moral norms also gives an understanding that teenagers are ready to learn the rules of life in a hospital, follow the established rules and this will well facilitate the period of adaptation to hospital conditions and the treatment process.

Of particular interest is the revealed negative correlation of maladaptivity with the indicator of passivity / dominance: the more the indicator of dominance is manifested, the weaker the indicators of maladaptivity are expressed, and vice versa: the more clearly dominance is revealed in adolescents, the lower the risks of maladaptation. At this point, the peculiarity of adolescent children in general is manifested: dominance is manifested both in terms of interest in their personality ^[18], and in the motivational sphere ^[19], and in the need to be considered and be an adult, to assert themselves ^[20]. Therefore, maladaptation will be less likely to manifest itself when these moments in the organization of a teenager's life activity are taken into account by all participants in the treatment process.

So, the analysis shows that in a group of adolescents of the neurological department, psychological work can be carried out in the direction of activating self-presentation, creating situations with vivid impressions and interesting facts, supporting the positioning of a teenager as an adult, independent and responsible for his behavior, and a clear lifestyle during hospitalization.

A number of significant correlations between indicators of emotional stability, adaptability, maladaptivity, personal and situational anxiety were established in the group of adolescents of the gastroenterology department. The maladaptivity index positively correlates with indicators of situational anxiety (rs=0.8) and personal anxiety (rs = 0.56). Maladaptivity correlates negatively with emotional stability (rs= - 0.56). Unlike the group of the neurological department, significant correlations of adaptability with all the studied indicators were not revealed. Adolescents in this group have greater risks of maladjustment, primarily associated with increased anxiety. It is anxiety, suspiciousness, hypersensitivity to changes and unfamiliar situations that become a trigger for the deterioration of the psychological state of adolescents. But the negative correlation with emotional stability makes it possible to determine the psychological mechanism in interaction with adolescents with gastroenterological diseases: positive emotional attitude and emotional reinforcement (praise, recognition of achievements, approval). Ensuring a stable positive emotional climate of interaction with adolescents will reduce maladaptation and generally form hospital adaptability.

Attention is drawn to the strong connection of maladaptivity with situational anxiety, since this can lead to the accumulation of negative, negative experiences. It should be noted that in adolescents, anxiety often performs the function of psychological protection, they feel the need for an anxious experience, as this allows them to turn to themselves in a familiar way, to self-esteem and exacerbate their well-being. Thus, in certain events related to a difficult situation, the manifestation of anxiety in adolescents can be considered the norm. Communication tactics related to persuasion, stigmatization, and categorical rhetoric against adolescents in the hospital are not advisable, therefore, it is necessary to find productive ways to establish contact with this group of patients and, most importantly, create a favorable communicative environment leading to a positive perception of the treatment process.

Thus, the analysis conducted in a group of adolescents of the gastroenterology department shows that psychological work should be aimed at reducing increased manifestations of situational and personal anxiety, providing mechanisms for emotional reinforcement in the interaction between adolescents and medical staff.

Based on the conducted psychological research and the establishment of psychological correlates of hospital adaptation, a hospital adaptation program was developed and implemented.

The program consisted in the implementation of psychological support for individual settings for the treatment process in adolescent children in the hospital. The psychologist's active work with adolescents consisted of daily meetings lasting no more than 30 minutes during the first week of stay and individual meetings during the subsequent stay of adolescents in the hospital (if necessary, upon request). According to the content, the program consisted of two blocks: the first block – games for communicative activity (this block was common to all adolescents, the work was carried out in microgroups of 4-5 people); the second block – meetings of a psychologist with adolescents of each department, taking into account the results of psychological research (for adolescents of the neurological department – role–playing, theatrical situations; for adolescents of the gastroenterology department – psychohymnastics, relaxation, relief of psycho-emotional tension).

As our observations showed, adolescents from the gastroenterology department showed more concern and concern about psychological meetings, demonstrated unwillingness to join the game or lack of interest in interaction; it was always difficult to involve them in work, but after three meetings the anxiety disappeared and involvement in psychological work improved.

Teenagers of the neurological department immediately showed interest in psychological meetings, demonstrated activity and mobility. In the process of working with them, a regular change of activities was required (for example, drawing was replaced by dance improvisations, then speech exercises, relaxation, listening to music followed by discussion in a group, etc.).

During the period of the adaptation program, there were quantitative and qualitative changes in the indicators of SPA and overt anxiety in adolescents.

The effectiveness of the work was assessed by indicators of maladaptivity (YES), an integral indicator of socio-psychological adaptation (ISPA) and overt anxiety (YT) using the T-criterion:

the integral indicator of socio-psychological adaptation (questionnaire of socio-psychological adaptation, SPA) at the average and above average levels was recorded in all adolescents (IA =75±2; p≤0,01);

indicators of maladaptivity in the sample showed up at minimum values (YES=38±2; p≤0,01);

overt anxiety (CMAS overt anxiety scale) in 91.6% manifested itself at a normal level (p≤0.01), necessary for adaptation and productive activity.

The attitude to the treatment process was studied in a simple, uncomplicated way for adolescents by choosing an emoticon appropriate to their mood and attitude. Three variants of emotions were offered – positive (smile), neutral (without emotions), negative (discontent). In the group of adolescents of the neurological department, the positive and neutral attitude at the entrance control was 28.6 %, at the exit control – 92.8 %. In the group of adolescents of the gastroenterology department, the positive and neutral attitude at the entrance control was 21.4 %, at the exit control – 100 %. Thus, the attitude towards the treatment process among adolescents has improved, communication with the medical staff has acquired positive emotional shades.

The work also allowed the medical psychologist to formulate sound practical recommendations to the hospital medical staff on the specifics of interaction with adolescents: regardless of their mood or workload, observe a friendly tone of communication, call the teenager respectfully by name (without using diminutives), do not stigmatize (do not create labels); in case of observation of complex behavior on the part of a teenager, immediately contact to a psychologist to receive targeted recommendations; on the first day of the teenager's stay in the hospital, familiarize them with the daily routine and kindly monitor its observance; if the teenager shows vivid emotions, but does not create disciplinary violations, react gently, with understanding, do not interrupt, continue interaction calmly, in an adult way and as with an adult; if in personal interaction with a teenager, focus on the inviolability of his personal boundaries ("if you don't mind", "let me do it", "I think you will agree", etc.); pay attention to the free time of teenagers, suggest fixing different types of activities for the period of free time: reading, drawing, playing with moving elements, mental games (for memory, attention, imagination), board games, strategy games, watching movies with subsequent analysis and discussion, caring for plants in the department, vocal group singing (karaoke); when organizing free time in the hospital adaptation program, take into account the psychological characteristics of adolescents according to the profile of the disease.

Conclusions

The presence of psychological support for the process of hospitalization of children in a hospital makes it possible to reduce anxiety, improve attitude to the treatment process, consolidate a positive emotional state and stabilize the overall socio-psychological adaptation of adolescents for the period of stay in the hospital.

It is advisable to implement a hospital adaptation program taking into account the psychological characteristics of adolescents, depending on the disease profile.

In adolescent patients with a neurological profile of the disease, hospital adaptation is provided by the characteristics of anxiety, personal characteristics, and socio-psychological adaptation. Psychological support can be carried out in the direction of activating self-presentation, creating situations with vivid impressions and interesting facts, supporting the positioning of a teenager as an adult, independent and responsible for his behavior and a clear mode of life during hospitalization.

In adolescent patients with a gastroenterological profile of the disease, hospital adaptation is provided by the characteristics of emotional stability, adaptability, maladaptivity, personal and situational anxiety. Psychological support can be aimed at reducing increased manifestations of situational and personal anxiety, providing mechanisms for emotional reinforcement in the interaction between adolescents and medical staff.