Elevated Parental Stress Is Associated With Lower Self-Efficacy in Provider Communication During a Pandemic Free

This cross-sectional study occurred at an urban quaternary-level children’s hospital in a large city. Parents, defined for the purpose of this study as the legal caretaker or guardian, were recruited for this study between January and August 2020. This time frame coincided with the onset of the COVID-19 pandemic within the United States. The initial cohort of patients, termed the “pre-COVID-19” cohort, was interviewed between January 1 and March 9, 2020, whereas the “post-COVID-19” cohort was enrolled after COVID-19 was declared a national emergency, between May 4 and August 6, 2020. The hospital institutional review board approved this study.

We conducted in-person surveys of parents during their child’s hospitalization. Parents of children aged 3 months to 17 years who admitted to the inpatient pediatric hospitalist teams were eligible. Parents were excluded if (1) they were unable to complete the survey tool in English without an interpreter or (2) their child had a significant developmental delay rendering them noncommunicative. The rationale for this exclusion was that the Parenting Stress Index-Short Form (PSI-SF) tool, although validated in diverse populations, is limited to parents who can verbally communicate with their children at the expected developmental age, or (3) they were not present on rounds or had <2 instances of parent-physician communication during the hospitalization. In the pre-COVID-19 cohort, parent-physician interactions were as follows: communication on rounds took place in the patient’s room, with team members presenting medical data and updates to the parent at bedside, allowing them to make clarifying comments or ask questions. A previous study done at this hospital estimated that teams typically consisting of an attending, fellow, resident, interns, and medical students, spent around 10 minutes in each room on rounds.²²  Occasionally, medical students or interns revisited the rooms after rounds to give verbal updates. In the post-COVID cohort, medical presentations took place outside of the patient’s room, after which the attending and hospitalist fellow entered the room to provide a summary of clinical updates and plan, allowing families to voice concerns and provide input.

Eligible parents were chosen to participate using a consecutive sampling method on the day of discharge or after at least 48 hours of admission, giving them enough time to have been updated on rounds by the primary team and establishing a working relationship with the person they perceived to be their child’s physician. Participants were recruited during the weekdays to allow for more continuity of care between the resident and attending staff because the care model allowed for the same team of physicians to attend to patients from Monday through Friday. For long-stay patients, parents were asked to evaluate the team with which they spent the most time communicating. If more than 1 parent was at the bedside, we surveyed the parent who, by his or her own assessment, spent more time interacting with the child’s team. In-person surveys were conducted from January through March 2020. However, on resumption of data collection after COVID-19, participants whose child was under isolation precautions were surveyed via telephone while the investigator stood outside of the room, within the participants view.

Data were collected using an electronic survey, administered via the RedCAP^23,24  secure online application. Two validated tools were used. The PSI-SF was used to determine the level of parenting stress. The Perceived Efficacy in Parent-Physician Interactions (PEPPI) was used to determine their perceived self-efficacy in communicating with physicians.

The PSF-SF, version 4, is a 36-item tool designed to be an accurate measure of parenting stress.^25,26  It is based on Castaldi’s factor analysis of the original tool and has a validity scale built in.²⁷  The “parent” characteristics assessed include presence of depression, isolation, attachment, role restriction, competence, parenting-partner relationship, and health.²⁸  The “child” characteristics include adaptability, acceptability, demandingness, mood, distractibility, hyperactivity, and reinforcement of parent.^25,27,28  Based on these data, the PSI-SF produces 3 subscale scores in the areas of: (1) Parental Distress, (2) Parent-Child Dysfunctional Interaction, and (3) Difficult Child. A Defensive Responding subscale is also included that indicates whether the parents are presenting a minimizing bias to their responses, rendering them invalid; these participants were removed from the analysis. We analyzed all 4 scores as both continuous and categorical variables; the latter was based on the classification as being elevated or normal.

The PEPPI is a tool initially developed to measure adult patients’ self-efficacy in obtaining medical information and drawing attention to their medical concerns from physicians.²⁹  It was modified to measure the parent’s personal sense of effectiveness in obtaining health care when communicating with physicians and was initially adapted for use in pediatrics by Tarini et al.³⁰  The self-efficacy scores on this scale were used as a continuous variable.

Socioeconomic data were also collected using a brief 4-question survey and partially from the electronic medical record (EMR) and PSI-SF tool.

1. Socioeconomic status tool: Annual earnings above federal poverty, self-placement on socioeconomic ladder, insurance status, and education level.

2. PSF-SF tool: Parental sex, marital status, ethnicity, and race.

3. Hospitalization related factors from EMR: Length of stay, disease complexity (based on the Pediatric complex chronic conditions classification system version 2), and medical diagnosis.

We used descriptive statistics with proportions used to describe categorical variables and means and standard deviations used for quantitative variables. Parenting stress and PEPPI variables were assessed overall and stratified by onset of COVID-19. These differences in era were formally tested with either a t test for continuous variables or a Fisher exact test for dichotomous variables.

The association of parental stress and the total PEPPI scores were further tested using a regression analysis using a univariate as well as a multivariate race and poverty adjusted model. Results were presented both overall and stratified by COVID-19 era. All analyses were performed in SAS V9.4 (Cary, NC) with 2-sided tests and an α < 0.05 deemed statistically significant.

Forty-nine participants were interviewed. Three participants were excluded before statistical analysis because their score fell into the “defensive response” range. Of the 49 respondents, 30 were enrolled before and 19 after onset of COVID-19. Although most caregivers identified as female in both groups, there were more male caregivers at the bedside during the pandemic (Table 1). Overall, the majority of participants in either cohort self-identified as non-White. In the post-COVID-19 cohort, Black participants accounted for the largest groups of subjects (41%).

Fewer than one-half of respondents had received a high school education or equivalent in the pre-COVID-19 group. In contrast, they accounted for almost two-thirds of the post-COVID-19 cohort (Table 1). Families living under the federal poverty level rose from 55% to 71% during the pandemic.

Both tools demonstrated good internal consistency and reliability in our population (Cronbach α, PSI-SF 0.892; PEPPI 0.79). An increase in the mean total stress score (TSS) was observed when comparing the before and after COVID-19 cohorts; however, only the means for subscores of Parent-Child Dysfunctional Interaction (PCDI) and Difficult Child showed a statistically significant increase over this time (P = .016, P = .019; Table 2). A rise in the number of participants reporting clinically significant stress (a value >85% on the PSI-SF report) was seen in the overall TSS as well as for the subscores of PCDI and Difficult Child; however, this increase was not statistically significant (Table 2). The average PEPPI scores were 86.5 prepandemic and 83.6 during COVID-19 (P = .431), signaling no statistical difference.

The total cohort (n = 46) showed an inverse relationship between the TSS and PEPPI in both univariate and multivariate models, after adjusting for race and poverty level (P = .018, P = .02) (Table 3). The strongest statistically significant association was seen between the TSS and the PEPPI scores after COVID-19 onset, with an estimate of –0.368, meaning that that for every incremental point increase in total parental stress score, the self-efficacy score decreased by –0.368 points (standard error, 0.139, P = .018; Table 4). The only subscale score to gain statistical significance in the multivariate model during the pandemic was the PCDI (P = .046, Table 4).

This study was initially intended to examine the relationship between parental stress and self-efficacy when parents were communicating with their child’s physicians. However, unprecedented conditions introduced by the COVID-19 pandemic allowed us compare how the new conditions of presumed increased parental stressors and altered modes of interaction impacted this prepandemic baseline. Our study provides evidence that parenting stress in the acute care setting impairs a parent’s self-efficacy in exchanging information with physicians. Parenting stress, as described in current literature, depends on many preadmission factors that relate to socioeconomic standing and the family dynamic, such as financial stability, parent- child relationship and availability of a support system.^31–34  During the COVID-19 pandemic, key drivers of parenting stress, including economic and psychosocial factors, were exacerbated by sudden imposed drastic measures that increased stress levels. Several observational studies that examined COVID-19–induced lockdowns across different continents showed strained parent-child relationships.^7,35–38 

We found that family-related drivers contributed to the overall increase in parental stress observed during pandemic times. The PCDI score consistently showed a predictable relationship with the parental self-efficacy scores. The mean value was significantly increased in the COVID-19 cohort and was inversely related to the PEPPI score. This observation aligns with psychosocial research that emerged on how stress affected family dynamics during COVID-19–induced lockdowns.^7,35–38  One such study in US adults showed reduced closeness and greater parent-child conflict compared with a national sample from prepandemic times.⁷  Their tool produced 2 subscales; a “conflict” score assessing the parent’s perceived negativity in their parent-child relationship and a “closeness” score assessing the perception of open communication. Increased conflict was associated with higher caregiver burden and reduced perception of their child’s stress.⁷  This aligned with Achterberg et al, who showed COVID-19–related stress to mediate worsening “parental negative feelings” and children’s externalizing behavior, both associated with negative coping strategies. This may be related to “stress contagion,” a phenomenon describing how psychosocial stress experienced by 1 family member can spread and how its proliferation in 1 domain impairs the ability to function optimally in another.³² 

Within the pediatric hospital medicine setting, research has shown that sharing responsibility for the medical decision-making process with parents increases their satisfaction with care, and this has been linked to better medical knowledge retention.^4,21  Sharing of information by physicians has been cited as a valuable subcategory of communication by caregivers, which productively drives parent-physician conversations.³⁹  The literature suggests that when faced with an acute stressor, persons who experience chronic stress tend to show a bias toward their established behavior, rather than considering new information that may lead to behavioral change.⁴⁰  This aligns with our findings; participants with higher levels of ongoing parenting stress reported lower levels of self-efficacy when communicating with their child’s physician in the domains of information-gathering and advocating on behalf of their child, as measured by the PEPPI instrument.

The COVID-19 pandemic exacerbated disparities in health care delivery.⁴¹  The percentage of participants reporting household earnings below the federal poverty level increased and, within our population, socioeconomic and racial differences were associated with a higher burden of infection in children.⁴²  Our results showed that the proportion of people experiencing clinically significant stress did not increase during the pandemic; however, the degree of stress measured by subscales did, as evidenced by increased mean scores. Although the literature showed that COVID-19–related lockdowns led to economic drivers of stress that exacerbated the socioeconomic situation,^43–45  we speculate that overall levels of measured individual stress were similar in both groups because of 2 main factors: reserves of resources and a tipping point that had not yet been crossed.⁴⁶  This study was conducted early in the pandemic, when individuals were starting to adjust to new conditions, allowing most to access financial, emotional, and social resources, maintaining their ability to cope. In addition, independent interpretation of the subscale scores adds insight into types of stressors in the parent-child system and can inform more specific targets for early intervention.⁴⁷ 

It is considered a public health crisis when parental stressors contribute to long-term adverse child health outcomes by affecting the familial dynamic when the mental health burden becomes pathologic.⁴⁸  Notably, 10% to 12% of our participants reported clinically significant levels of stress (Table 2), indicating that the respondents had a high chance of having a clinically diagnosable mental health condition according to the PSI-SF scoring manual. One similar public health example was when postpartum depression was recognized as a medical condition that affected families. Consequently, the US Preventative Health Task Force and the American College of Obstetricians and Gynecologists started advocating for universal screening to improve the identification of at-risk individuals.^48,49  At the time of implementation, an estimated 12% to 15% of new mothers were believed to be affected. The authors agree that universal screening for parental mental health issues should be done while their children are inpatient because the numbers of those affected are significant.

Limitations to this study include the small sample size at a single center and heterogeneity in diagnoses. We did not account for the severity of illness on admission; however, participants all were parents of patients on the acute care floor. Furthermore, the rounding structure adapted during the pandemic engendered limited opportunities for communication and altered the typical structure for parent-physician interactions. Learners were not allowed into rooms of patients who were under investigation for COVID-19. Physicians started communicating with parents at the bedside while wearing personal protective equipment, which theoretically presented an impediment to the free flow of dialogue. Additionally, multiple analyses were run on this small sample size, raising the possibility of a type I error.

Our study showed that parental stress was associated with decreased parental self-efficacy in communicating with physicians about their child’s medical needs. In this small sample size, ∼ 1 in 10 parents was found to have a clinically significant level of stress. This has several implications, one of which leads us to advocate for universal parental stress screens on admission as inpatients. Universal depression screens for parents are limited throughout childhood. Many factors can contribute to parental stress and potentially poor parental mental health; therefore, screening may be beneficial in identifying at-risk individuals and referring them for further care. Additionally, there is a need for a more robust social support system for parents of hospitalized children. The way in which physicians and other health care providers communicate with parents has evolved to a model-of-care delivery that accommodates the patient within the family unit and includes a more empathetic and respectful approach through practices that focus on cultural sensitivity. We recommend that future studies examine the effect of different styles of physician-parent communication on both parental stress and self-efficacy during hospitalization.

The authors thank Neha Shah, MD, MPH, and Priti Bhansali, MD, MEd, for their contributions.