Hospitalised Children: Reactions of Siblings

Nouran Katooa RMIT University School of Health Science Disciplines of Nursing and Midwifery, Melbourne Australia

Summary of Project Hospitalisation of a sick child is perhaps one of the most traumatic events a family can face. Parents react swiftly to the trauma of a sick child, and there is a considerable body of research on the effects of hospitalisation on the child and its parents. However, there is extant research on the effects of hospitalisation, on the child's siblings. There is little understanding of the connection of the siblings to this traumatic occurrence whereby they can become confused and frightened when seeing their parents' sad and angry and frustrated reactions (Barlow & Ellard, 2006). The following project explores reactions and coping mechanisms of siblings and parents of hospitalised children. The aim of this project is to critically review the literature in relation to the environment and the effects of hospitalisation on the siblings' psychological and physiological health, their behaviours and attitudes, and responses to the illness of the brother or sister. There is much evidence in the literature supporting the relationship between hospitalised children and their parents and siblings. Recommendations have been formulated to improve and develop a set of guidelines that assist the parents to find the best approaches that can be used to help the siblings cope with the change of circumstance. These recommendations include the anticipation of health care provides of the challenges that might be experienced by parents and siblings, the active participation of parents and children in caring of the ill child and the seeking of professional counselling services by parents and siblings.

INTRODUCTION
It is only natural for parents of hospitalised children to want to be actively involved in activities aimed at ensuring the well being of their children. A family is the basic unit of every society and it provides members with the sense of comfort, belonging and identity. It is well documented that the role played by parents of children in paediatric care is significant for the psychological and emotional well being of the children. Additionally, parental involvement has also been identified to be beneficial to the parents (Lam, Chang & Morrissey, 2006).

In addition to those children under paediatric care due to curable diseases, there are also the children who are admitted with chronic diseases where the chances of survival are slim or they might require extensive hospitalisation. Some of these diseases require a greater emphasis on the quality of life. Provision of the quality life to the child requires that the parents invest more emotionally on the child. The implication is that the parents are prone to become worn out emotionally. Furthermore, there is also the danger of other siblings being deprived of emotional support. Studies outlined by Foster et al. (2009), more than half a million of the children in the United States are currently living with life threatening diseases. Furthermore, the study indicated that close to 50% of the children living with life threatening diseases are suffering from cancer. According to Foster et al. (2009), substantial evidence actually indicates that the siblings of children hospitalised for chronic illnesses are at risk of being emotionally ignored by parents and being taken for granted by health care providers. Nursing require the provision of support services to both parents and siblings of the chronically ill children to ensure that they are conversant with the patient's condition. The support to the children should be done with consideration of their capacity to understand and absorb the shock and grief.

The project will identify an introduction of hospitalised children, hospitalised children effects on parents and siblings, the relationships between siblings, the factors influencing parents and siblings to cope with hospitalisation, and well critically review the changes in siblings' cognitive and emotional behaviour in respect to hospitalised children and the responses of their parents. In undertaking this project, an extensive literature review was conducted using the RIMT library database, ProQuest, Science Direct, PubMed and Google.

Statement of Problem
Children are weak and vulnerable. They establish great psychological and emotional attachment to family, to their parents and relatives, and especially to their brothers and sisters. Any change in the normal setting, particularly a traumatic change when a child falls ill or has an accident, can be devastating to their self-confidence, can realign their relationships with parents and siblings, and can have lasting effects on the growing individual (Bhat & Rawat, 2004).

Most parents with terminally ill children usually become confused and frustrated, uncertain how to respond to the situation and they devote the majority of their time and energies to attempting to resolve the situation at hand (Jones & Weisenfluh, 2003). In the process, they may fail to notice the changes and challenges their other children are undergoing. Even if the parents recognise the disintegration of the family relationships, they may not be in an emotional state to attend to their other children's psychological and sometimes physical needs. Treats and recreational activities are dispensed with; children cannot or will not seek their parents' reassurances in times of great trial (Aujoulat, Simonelli & Deccache, 2006; Kyle & Kyle, 2007). Some parents however may notice the change but find no time to talk to them or find a lot of difficulty in addressing the issue.

Long term and persistent unaddressed suppressed fears caused by a hospitalised child are a danger to the health and social behaviour of siblings. Frequently this is manifested by withdrawal, where a child retains concerns because of fears of adding to parents' anxiety or through perceptions of being ignored. Psychological stress can be present through aggressiveness and fear. Siblings of sick children become overactive or restless, can feign or actively seek sickness as a means to retrieve parents' attention (Craft, Sandel, & Wyatt, 1985). According to Morgan and Attfield (2006), siblings of children with autism are always worried that their parents will give the ill child more attention.

It is therefore important to assess the environment that a sick child creates in family relationships. The social and psychological processes involved with those coping with sick children can be determined through data-gathering and analysis to identify causative factors which in turn can lead to coping strategies in managing these distressing family environments. The intention of this project is to identify and promote better communication paths which parents could adopt to move toward cognitive resolution of the hospitalised child by the siblings by providing them with relevant information that would assist them to handle delicate matters for the benefit of their children.

Aims of the Project
The objective of this project is to establish the emotional, psychological, and health changes that siblings of hospitalised children undergo. This is supported by the following goals:

- To identify coping strategies for parents so that the sick child's siblings are not alienated and suffer harm the family's unfortunate experiences with illness.
- To identify what the recommendation and approaches of coping strategies are found in the literature that will assist the parents and siblings in such difficult situations.

Background to the Study / Rationale
As outlined previously in this study is the fact that the chronically ill child will draw much emotional and physical support from family members. The support should be devoid of any grudges or complaints, so that the child does not develop feelings of being indebted to those providing support. Therefore, the emotional condition of the family members is important towards the provision of support to the child. Studies to pertaining to the challenges faced by family members of chronically ill patients have been conducted and the results have been documented as well.

In a study conducted by Glasper and Richardson (2006), to outline the experiences of siblings of sick children in the paediatric care, it was established that a significant number of children in the United States are spending time under paediatric care and that around 3 million families were affected by the need to provide care to the children. Unlike other studies where data collection and analysis are always based on vague and poorly defined options, the study grouped the results into; "increased risk, no risk, and positive and negative outcomes". The findings of these studies realized that family members are significantly important in the well being of a chronically ill child. It also realized that siblings of chronically ill child may be affected especially when the roles and responsibilities have to be adjusted for the sake of the ill child. The two areas where siblings were affected are having to take part in taking care of the ill child during feeding, dressing and in some instances assuming adult responsibilities, and siblings who may be affected by the fact that the ill child is being given most of the attention and the parents may have little or no time to address the concerns of the siblings.

In a related study by Lindblad, Rasmussen and Sandman (2005), that sought to establish the ways in which parents taking care of disabled children may be empowered, the findings realized that parents respond in varied ways some of which may be unhealthy for the child and the parents. For instance, some parents may develop the feeling that the child does not deserve to be taken care of. The study analysed the responses by 10 mothers and 6 fathers caring for 11 children between the age of 6 and 11. Qualification to participate in the study required that children under care were significantly dependent on their parents due to some physical or mental disability. Although, the children were not chronically ill, the study would provide insight as to how parents may respond to children who required extensive care due to one reason or another.

Another research conducted by Broome and Snethen (2001), the response of siblings when their brothers or sisters were placed under clinical research was documented. Various factors were realized and one significant factor was that certain factors determined the level of understanding of the situation that their brother or sister was going through. Age of the sibling and the medical condition were identified as the two most recurring determinants. The study realized that siblings played an important part in the alleviation of stress among themselves. This occurred as a natural response that was not only eminent during illness, but also during normal conditions. The research adopted favourable conditions where siblings were interviewed by paediatric specialists and the age of the siblings were between 7 and 21 years. The research also realized that there were three areas of concern for the siblings whose brothers or sisters were undergoing research. The areas included their overall understanding and interpretation of the research, ethical implications of the research, communication methodology employed by the health care and the way the research affected the normal routines in their respective families. This research provides evidence that siblings require attention by care givers to help them in understanding of the medical condition affecting their brother or sister. Furthermore, the siblings are always concerned how the illness of a brother or sister may affect the family routine in general.

A study by Mitchell and Courtney (2004), which sought ways to reduce the anxiety and uncertainty experienced by family members due to transfer to or from the Intensive Care Unit (ICU), realized that the anxiety and uncertainty experienced were due to a number of reasons. The first one was that most families were not conclusively aware of the reasons behind the transfer and the implications following such transfers. Secondly, in the ICU and the other normal wards were characterized by different conditions ranging from the level of care provided to the children and the equipments used. Therefore, family members may feel that the children will not be catered for properly after being moved from the ICU. Among the findings of the research was that the anxiety experienced had nothing to do with the physical environment, but as due to the diagnosis conducted. The implication of the research is that family members need clarification on certain medical procedures to alleviate anxiety and uncertainty that may ensue. This study implies that even in instances where siblings are not actively involved, they may sense the anxiety and concern being experienced by parents and subsequently become depressed especially when the situation is not explained to them.

In a study conducted by Huizinger et al. (2004), to establish the factors that enabled adolescents and siblings to cope with cancer more effectively and thereby improving their quality of life, it was realized that the environment played a critical role. Analysis of the responses realized that the siblings were also affected by the environment where their brother or sister was in. Therefore, it is also to take into account the environment of hospitalisation when seeking to address the needs, concerns and siblings. The hospital environment may either alleviate or worsen the anxiety felt by siblings. Anxiety may be evidenced by refusal of the siblings to visit their hospitalised brother or sister.

An additional study conducted in Sweden by Kristofferzon, Lofmark and Carlsson (2005), to establish how men and women respond differently one month after myocardial infarction of their child, it was realized that both men and women were affected socially and emotionally by the condition of the child. However, the two groups differed in terms of where they mostly got their social support and how they coped with the situation. Women employed a more evasive and supportive coping mechanism and perceived that psychological dimensions of the disease as presenting a major challenge as compared to men. Therefore, such varied mechanisms of response as dictated by age should be placed into account when seeking to provide holistic support to parents with chronically ill children.

These studies substantially provide evidence that parents and siblings of a chronically ill child are significantly affected by the child's condition. Parents and siblings are affected physically, emotionally and even socially. The parents are affected in terms of not being able to cater for the child effectively as a result of the illness, anxiety and concern for the child's condition and the way the hospital is responding to the condition, balancing between taking care of the child, being available for other children an attending to their work, and having the capacity to hold the family together during the challenging experience. However, the siblings are also experience challenges in terms of anxiety on whether the medication being given is appropriate, concern over how the condition is going to affect the family routine, having to depend on their parents less and less in terms of emotional support and other forms of support, development of anger towards the ill child and finally having to revert to unhealthy ways for coping with the situation.

Hospitalised Children Effects on Parents and Siblings
Parents' Reactions
Most chronically ill children require specialised care due to the delicate nature of children and due to the condition that the disease puts the child in (Bhat & Rawat, 2004). Some chronic illnesses incapacitate children either fully or partially and parents are often required to take extra care when performing duties such as; breastfeeding, changing and washing. In addition, parents are also required to ensure that they adhere to medication in instance where the child is recovering at home. Apart from the physical support the child may also require is additional emotional support to prevent depression that may be associated with the medication. As outlined by Smith (2004), parents of children in Hip Spicas face difficulties ranging from breastfeeding and having close physical contact and therefore they are at risk of experiencing social and emotional problems due to frustrations.

The feelings of frustrations originate from the fact that the parents are not able to effectively care for their children and also due to the detachment from their children (Barlow et. al, 2008). In cases where the chronic illness is associated with disability, the parents are required to balance on emotionally and physically being available for the sick child and attending to the needs of the siblings and attending to their normal duties such as going to work. All these responsibilities may leave the parents fatigued and emotionally drained. Therefore, parents find themselves not being able to effectively care for the other siblings and they may also not be able to be productive in their work places. Frustration may also stem from the fact the parent may feel that the health care providers are not giving the child the care deserved (Hardy & Prior, 2001). Concerns may be in form of the environment the child has been placed. This is because some environments worsen the symptoms in terms of pain and discomfort. Different conditions require specialised care and it is important that this fact is put into consideration. The parent may also be frustrated when their questions are ignored or are not answered conclusively (Ramritu & Croft, 2009, Rutter & Taylor, 2002).

According to Ramritu and Croft (2009), the most frustrating aspect of a child's illness to the parents is the state of uncertainty and the fluctuating condition of the child. The parents might experience anxiety and even fear for the child. This is because the condition of the child that may fluctuate in terms of progress and the parent may also experience the fluctuation between hope and hopelessness. According to Cullen and Barlow (2004), parents with children with disabilities are more prone to depression as compared to their counterparts whose children are experiencing normal development. The psychological and physiological condition of the parents is expected to affect the siblings significantly. Although much research has been on the affect of hospitalisation children on their parents, emerging evidence suggest that children are even more affected (Armstrong-Dailey & Zarbock, 2009). Research has established that siblings are affected by their parents' condition, the condition of the sick child and the resultant disruption in family routine. Knowingly or unknowingly parents continually find themselves overlooking the needs of the siblings while concentrating on the sick child (Kyle & Kyle, 2007).

The realization by the parents that they have a child that has been hospitalised generally goes through stages. First, there is the aspect of denial, followed by self blame and then acceptance. Denial is always characterized by the perception that it is impossible for their child to have such an illness. As outlined by Brannon and Feist (2009), this is a general reaction when people are faced with a challenge they feel is beyond their capacity. During the denial stage, both parents are usually draw strength from one another. However, during the self blame stage, the parents are always taking their frustrations upon each other. It is during this instance that the fear of the family breaking up is most evident on the siblings. During this period, the parents will concentrate more on attacking each other and striving to be the innocent one in the situation. In most instances, the sick child and the siblings may be drawn into the tension.

Siblings' Reactions
Sibling reaction to hospitalised brothers or sisters may be subtle and therefore prone to be ignored by the parents and caregivers. In most instances, siblings are left in the dark as the parents and care givers assume that they would not understand or it would be better for them if they do not know (Doherty, 2009; Jolley, 2010).

There is substantial evidence supporting the fact that when a child is hospitalised, it is not only the hospitalised children and the parents who are affected with this condition, but the siblings as well (Stoneman, 2005). A family is a close knit society where members derive identity and support of different kinds. The family is the ultimate place that a person turns to during trying emotional and psychological times due to the high levels of understanding and intimacy (Glasper & Richardson, 2006).

According to Bhat & Rawat (2004), siblings of a hospitalised children may be at a risk of contracting the same disease in a situation when the disease in contractible. This is because when parents visit their sick child, they usually allow siblings to accompany them. The situation is further worsened by the fact that siblings share the same hereditary and environmental factors. Instances, where the disease is not communicable, siblings may experience feelings of fear and anxiety of contracting the disease during visits when the situation is not explained to the conclusively by their parents and nurses.

There are strong emotional foundations that members build by the virtue that they share in their moments of grief and happiness (Giallo & Gavidia-Payne, 2006). Therefore, when a member of the family becomes ill, it becomes the responsibilities of all family members to gather all their emotional strength in support of the ill member. The situation places stress upon the foundation and it is important that all family members understand that things will have to be change. Siblings are bound to respond differently to an ill child and various factors have been identified as contributory. These factors include age and sex. For instance, during adolescent when children are already experiencing hormonal fluctuations and dealing with emotional conflicts, it is unlikely that they will participate actively. The participation by siblings may occur in various aspects and various behaviours may be observed. The constructive behaviours include; being worried of the condition of the ill child, sharing in sorrow with other family members and the ill child, providing assistance to the ill child and to other family members, finding information on the condition and sharing it with other members, showing maturity in dealing with the situation, and showing responsibility being obedient to the parents (Johansson, Fridlund & Hildingh, 2004). Destructive behaviours that may be adopted by the siblings include; anger projected at the ill child, complaining of lack of attention from the parents because much attention has been directed to the ill child, getting overtly anxious about losing the ill child or the family being disintegrated, being emotionally destabilized and as documented siblings may also revert to increased appetite as a way of responding to the situation (Johansson, Fridlund & Hildingh, 2004).

Relationships between Siblings
Critical illness of a child affects all members of the family, including well brothers and sisters. Stress in siblings lives results from changes in parental behaviors, care giving arrangements, and family relationships (Barlow & Ellard, 2006). These changes, along with limited understanding and information about the crisis, create feelings of confusion, loneliness, jealousy, and sadness, as well as physical symptoms and behaviour changes. They may also notice increased moodiness, behaviour changes and school difficulties.

When a child in the hospital, everyone is affected, especially brothers and sisters. Children who are hospitalised often receive more attention, special treatment and gifts. Brothers and sisters can experience many feelings as they try to understand and deal with the change in family life and routines (Young, 2007).

It's normal for healthy siblings to undergo the following reactions:

- Worry that his/her sister or brother will die.
- Fear that they or other loved ones will catch the sibling's disease
- Feel guilty because they are healthy and can enjoy activities that the sibling cannot
- Be angry because parents are devoting most of their time and energy to the sick sibling
- Feel neglected and worried that no one in the family cares
- Resent the sibling who never has to do chores
- Resent that the family has less money to spend now because the sibling is sick
- Be nostalgic for the past (wishing things could be like they were before the illness)
- Feel residual guilt for being "mean" to the sibling in the past
- Experience generalized worry and anxiety about an uncertain future

The way siblings express their needs will vary considerably; some may act out, some may try be the perfect child, and many will do both. Most studies find that siblings of children with cancer are not at any increased risk for mental illness, although they may be at greater risk for behavioural and emotional manifestations of their distress (Huizinga et. al, 2005).

Factors Influencing Coping with Hospitalisation

Factors Influencing Response by Parents

Nature of the Illness
Different illnesses present different challenges and require varied level of emotional and physical care by parents. Some illnesses limit the level which the child and the parent can interact and will therefore has an effect on the relationship between the two. For instance, some chronic illnesses may limit the contact that the child can have with the parent due to reduced immune capacity, which places the child at risk. According to Rutter and Taylor (2002), any condition that severs or reduces the relationship between the parent and the child may place the esteem of the parent at risk. For example, some conditions place challenges on the mother during breast feeding while other may lead to pain by the child when close contact s established. The nature of the disease may also determine the parents' response because some chronic diseases are well documented and researched and the parent may already be aware of the challenges that they may encounter when providing care. However, other diseases are not well documented and the parents may constantly need to consult doctors with regard to the progress and the medication. Such situation may cause the parents to be anxious and uncertain. In addition, different conditions may require different levels of physical, social and emotional support. Illnesses that incapacitate the child will require much physical support than an illness that predisposes the child to social stigma such as mental illness (Ramritu & Croft, 2009).

Age of the Child
The age of the child is important in the sense that children at different ages exhibit varied levels of dependency when they are chronically ill. Furthermore, the children may also have different levels of understanding for their condition. A chronically ill child of 12 years may have the capacity to control bowel movement and may therefore not require the parents to continually change them. However, a 2 year old child with the same condition will not have control and therefore the parents will be constantly required to change the child in the case where the children are being taken care of at home. Furthermore, as outlined by Hardy and Prior (2001), attachment of children with their parents reduced by an increase in the child age. Therefore, younger children who are more attached to their parents will require more attention than older children who are comparatively less attached.

Gender of the Parent
As outlined by Kristofferszon, Lofmark and Carlsson (2005), mothers and fathers of chronically ill children respond differently to the condition of their child. The differences come in terms of the coping mechanisms they adopt, their perception of the disease and the social support they are bound to seek.

Extent of Participation
Giallo and Gavidia-Payne (2006) emphasize on the participation of parents during the hospitalisation of their chronically ill child, as a way of alleviating anxiety in both the child and the parents. The participation ensures that care givers have the opportunity of discussing the condition of child continuously and therefore the parents will have a greater understanding of the condition of their child. Furthermore, parents will be conversant of the medication, the procedures and other activities done by caregivers and will be therefore less prone to anxiety. For the parents whose participation is limited, anxiety is usually caused by the diminishing level of understanding of the efforts of the health care and of the illness.

Number of Children
The number of children the parents will have to take care of is also determines the pressure that will be placed upon the parents and subsequently the response (Giallo & Gavidia-Payne, 2006). This correlation is drawn from the fact that level of response is affected by the extent to which the ill child requires care by parents. When there are other children to take care, pressure will be increasing with increase in the number of children.

Factors Influencing Response by Siblings
Nature of Illness
The nature of the chronic illness determines the response of the siblings to the situations pertaining to the illness (Stoneman, 2005). Some diseases are more prone to stigmatization and siblings may have a much difficult time accepting the condition of their brother or sister. Furthermore, varied illnesses disrupt the normal routines of families to different degrees.

Age of the Siblings
Children develop understanding of situations as they grow older. Therefore, age is an important factor determining the way children respond to different challenging circumstances. Studies have identified adolescents as contributing the least towards the care of a critically ill brother or sister (Hardy & Prior, 2001). During the adolescent age, children are already dealing with varied emotions due to hormonal changes and this may affect how they respond. Temperament of a sibling determines to a greater degree how he/she will respond to the illness of a brother or a sister and the reduced parental attention. In essence each child will respond differently to the various circumstances that emanate when their brother or sister has been hospitalised. Some of them will respond very positively when called upon to offer assistance to the ill child but will not take it very well when the parents concentrate most of their attention to the ill child (Stoneman, 2005).

Coping Mechanisms
As explained by Kiernan, Guerin and MacLachlan (2005) and Koopman et al. (2004), during the periods of extensive emotional stress, individuals are prone to developing psychological and even physiological complications. It is therefore important that health care providers strive to ensure that parents adopt healthy coping mechanisms that encourage positive behaviour by the siblings. Furthermore, the siblings can also be educated and encouraged to develop a more positive approach during hospitalization of their brother or sister.

Due to the extensive researches that have been documented concerning the response of siblings and parents of children who are chronically ill, it is obvious that coping mechanisms have been documented. However, one important realization is that health care providers are the major driving force towards the awareness of holistic care for parents and siblings (Koopman et. al, 2004). Health care providers are already conversant with various medical conditions and may anticipate the kind of response adopted by parents and siblings. It is therefore upon health care providers to extend their services to parents and siblings aimed at equipping them with behavioural approach when responding to the circumstances presented when a child is chronically ill. Furthermore, the lack of experience by parents and siblings require nurses to identify the possibility of destructive behaviours and recommend treatment (Lam, Chang & Morrissey, 2006).

Working hand in hand with care givers has been identified as one of the important mechanisms that may help the parents deal with the condition of their child (Lam, Chang & Morrissey, 2006). Therefore, it is proposed that parent adopt a close contact with care givers. Getting adequate information from care givers relating to the progress of the child is also important and this is usually obtained when the parents work together with care givers. In most instances, parents who develop anxiety due to the condition of their child do so because they adopt a negative approach towards the care givers. The negative approach is usually nurtured by a prolonged period of misinformation or lack of information. The parents are therefore subjected to speculation which emanates to anxiety and uncertainty (Mitchell, 2004; Ramritu & Croft, 2009).

Parents are also coping with the situation by seeking of support services from various quarters. According to Ramritu and Croft (2009), the sources of support as revealed by parents were spouse, other family members, the church and other parents undergoing the same challenging moments. Other sources of support also included literature that has documented information concerning the condition of the child. A significant number of parents also revealed that they seek for sought professional help (Lindblad, Rasmussen & Sandman, 2005).

Coping mechanisms of children mostly relate to how the specific condition has affected the family in general. In a study conducted by Appleton and Hames (2009), on the perception of siblings of a child with epilepsy, it was realized that most children perceived and responded to the condition positively. However, the research also revealed that very few of the siblings who perceived and responded to the condition negatively were willing to participate in the research. Siblings first responded by protesting to the apparent concentration of the parents on the condition of the ill child, secondly the siblings resort to withdrawal and finally to total detachment.

According to Cullen and Barlow (2004), parents should be encouraged to enrol in training and support programme. They realized that parents who enrolled in training programmes had the capacity to manage well children with various forms of disability.

Although disability is just one aspect that can lead to hospitalisation, the challenges faced by parents are roughly similar in terms of the extent of care required. The increase in confidence during care giving reduces parental anxiety and therefore the parent is able to manage the situation effectively. This will ensure that the parent has the time, energy and mental capacity to address the concerns of the siblings of the sick child effectively.

Interventions & Recommendations
In most instances, parents and siblings of the chronically ill child are inexperienced and are completely unaware of what to expect and how to respond. It is therefore upon the health care provider to anticipate the challenges that might be experienced by parents and siblings, and offer specialized advice. It is also important that nurses offer information that would be beneficial to parents and siblings instead of waiting to be asked. This not only demonstrates holistic care but also gives the parents and siblings with confidence in the care provided.

Parents on the other hand are required to work together with health care providers in terms of seeking clarification on the child's illness. Furthermore, they should also seek advice on how to respond positively to the situation and even offer assistance to the other siblings. In addition, they should look for professional help when they feel that the situation might get out of hand (Lam, Chang & Morrissey, 2006).

Health care providers need to take such factors into account when providing services to families with a chronically ill child. This is because some of these factors may have negative effects on the well being of the child. Furthermore, an approach that also cares for the needs and concerns of the siblings is more holistic.

With regard to the findings of a research conducted by Kiernan, Guerin and MacLachlan (2005), the importance of letting children encourage one another cannot be overemphasized. The research sought to identify the recommendations of children during their stay in a hospital. The concerns of most children were that during hospitalisation they would not be able to do the interesting things that they used to do. Extrapolating these findings to the siblings of hospitalised children, implies that among their fears is being deprived of the time to undertake interesting activities, either because their parents are busy taking care of the sick child or because everybody is so sad to engage in any activity. Siblings of hospitalised children should therefore be allowed time for play. For instance, a health institution can organize outdoor activities for siblings of hospitalized children as a way of creating the platform where they can share their fears and concerns. Such an initiative can relieve the parents of a significant load while at the same time being therapeutic for the siblings. Furthermore, the nurses and the health care institution can also seek for the views of siblings of hospitalised children on ways in which both the parents and the hospital can ensure that they are psychologically and physiologically healthy (Cohen et. al, 2008).

This research has established that environment play a very key role on how siblings of hospitalised child respond to the situation. According to Aujoulat et al. (2006), it was recommended that the health care facility where a child is hospitalised has the responsibility of ensuring that the environment is sensitive to siblings of all developmental stages. Such an environment should include playrooms where siblings can play during visits. This will help the parents manage the siblings and the sick child more effectively (Brannon & Feist, 2009).

Finally, it is important for the siblings to be granted consideration when dealing with the challenges facing the parents. In most instances; care givers assume that siblings are not affected and when they are the parents can easily handle they problems. However, the findings of this study indicate that the siblings may even suffer more in silence. With regard to their developmental stages and their level of understanding, Nurses may involve the siblings by addressing their concerns with regard to the illness, shedding more light concerning the illness and perhaps explaining to them the psychological situation faced by their parents. In return siblings will develop greater understanding and will even offer each other comfort in addition to offering comfort to parents (Koopman et. al, 2004). (See Appendix 1)

Conclusion
Parents should take more responsibility to have a close monitoring of their hospitalised child and also at the same time should maintain the balance between siblings, so that the bonds between siblings remains in a healthy manner and there won't be any negative changes or reactions in the siblings of hospitalised child . They should also obtain that siblings must involve in caring of their hospitalised child where ever possible and maintain good environment between them. It is only natural for parents of hospitalised children to want to be actively involved in activities aimed at ensuring the well being of their children. A family is the basic unit of every society and it provides persons members with the sense of comfort and belonging and identity. Extensive literature has covered the psychological effects experienced by the hospitalised child, but the effect of hospitalisation of one child has on the parents and the siblings have not been well recognized. However, it is well documented that the role played by parents of children in paediatric care is significant for the psychological and emotional well being of the children. In addition, parental involvement has also been identified to be beneficial to the parents. Children perceive illnesses differently and it is important that this aspect is taken into consideration when seeking ways to help the parents address the needs of siblings of a hospitalised child. Siblings are also affected when their brother or sister has been hospitalised or is revering from a chronic illness. Children are the mostly ignored when providing health care. In most instances, the welfare of children is usually left aside and only the parents are considered. However, this project has revealed that children also experience physical and other emotional challenges. Therefore, it is important that the health care facility take care of the chronically ill child, address the needs of parents, and keep into consideration the needs of siblings as well. This will ensure that health care to the ill child and the family is provided in a holistic manner. This report strives to identify the relationship between hospitalised children and their parents and siblings, and to critically review the literature in relation to the environment and the process of hospitalisation on the siblings' psychological and physiological health, their behaviours and attitudes, and responses to illness of the brothers or sisters.

Appendix 1
Recommendations

Meet Siblings Needs
- Recognize that illness and hospitalization affects the whole family in different ways.
- Remember that honest and ongoing communication helps children understand the events or situation affecting their family.
- Reassure siblings that they most likely will not also become sick or injured.
- Continue daily routines as much as possible. Children do better keeping their usual schedules and rules for home, school and other activities.
- It's the little things that count. Help children feel valued, loved and remembered as an important part of their family, whether you are in the hospital or at home.

Communicating With Children
- Give them information they can understand.
- Talk to them about how they feel about their brother or sister being in the hospital.
- Discuss their concerns about visiting the hospital.
- Acknowledge how hard the situation is and let them know you appreciate their efforts.
- Keep your kids connected. Ways to do this include:

Call or write emails
Share drawing or photos
Make videos or voice recordings of stories, songs or messages
Create and exchange CDs of favourite music
Make a get-well banner

School & Community Support
When you are not able to be with your other children, arrange for a caring adult such as; grandparent, neighbour or friend, to spend time with them.

Choose someone at your children's school, like a teacher, counsellor or coach, to help support them during this time.

Let others help your family by running errands, making meals or driving carpools. This may allow you more free time to spend with all of your children.

Helping Siblings Feel Included
During the hospitalisation, siblings can participate in activities at home, while visiting my let them feel more included.

Home Activities
- Choose photographs of family, friends, favourite trips or any other familiar objects to bring to the hospital to decorate their brother or sister's room.
- Create artwork for their brother or sister's hospital room.
- Help pick their brother or sister's favourite things to send to the hospital such as; stuffed animals, clothes, movies or pictures.
-Write letters and cards to keep their brother and sister informed about news at home or at school.
- Design a door sign with their brother or sister's name and messages for visitors.
- Record favourite songs, stories, jokes and greetings to send to the hospital. Voices of familiar people can be comforting.
- Put together care packages to send to the hospital. They can include notes, drawings, gifts or pictures from home.

Hospital Activities:
- Invite siblings to visit whenever possible and appropriate.
- Prepare siblings for what they will see and hear. If their brother or sister's behaviour and appearance are different than normal, describe how their brother or sister may look or act. Child life specialists can help provide support for visits.
- Encourage siblings to visit the Child Life Department's Activity Rooms such as; the Playroom, - - School Room, All-Stars Technology Room and Teen Lounge. They can attend with their brother or sister, or visit on their own if appropriate.
- Create opportunities for siblings to engage with their brother or sister if appropriate. They can create art projects together, read books, attend programming and play together.
- Introduce siblings to familiar figures in the hospital who are involved with their brother or sister's care. These may include doctors, nurses and child life specialists.

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