David Nicholas, PhD, MSW, RSW
Dr. David Nicholas is an Associate Professor, Faculty of Social Work, University of Calgary.
Dr. Donna Koller is an Associate Professor, Department of Early Childhood Education,
Ryerson University. Dr. Robin Gearing is an Associate Professor, School of Social Work,
Columbia University. Each of these researchers brings extensive clinical and research
experience in pediatric health and mental health. Their interest in SARS research solidified
after the SARS outbreak in Toronto, during which time this team embarked on an active
program of research examining psychosocial impacts of SARS, and potential means to foster
effective pediatric pandemic planning. The Principal Investigator, Dr. David Nicholas, served
for several years as a social worker in pediatric Respiratory Medicine, and he was extensively
involved as a volunteer in the Ontario Respiratory Care Society prior to his transition from
Ontario to the University of Calgary. He continues to work in respiratory care research, with a
focus on pandemic preparedness and social support. This study, which was supported by an
ORCS Research Grant, is currently being prepared for publication, and the team has published
several manuscripts related to SARS and pandemic preparedness (see publication list in
The Long-Term Psychosocial Impact of SARS: Perceptions of Families in which a Child
was Hospitalized with SARS
Principal Investigator: Dr. David B. Nicholas
Co-Investigators: Dr. Donna Koller & Dr. Robin E. Gearing
The outbreak of SARS was a health emergency with unprecedented scope in recent Canadian
history. SARS, which is characterized by fever, respiratory distress as well as other
nonspecific symptoms (Booth and Stewart, 2005), spread rapidly throughout the world and
resulted in a total of 251 probable cases and 43 deaths in Canada alone (WHO). In an attempt
to quell virus spread, aggressive infection control precautions were implemented including the
isolation of hospitalized patients and the cancellation of elective clinics and surgeries (Booth
and Stewart, 2005). Research by members of this team revealed that there were substantial
emotional impacts on children being treated for SARS as well as on those with other conditions
who were affected by related infection control procedures (Koller, Nicholas, Gearing & Kalfa,
2010; Nicholas, Patershuk, Koller, Bruce-Barrett, Lach, Zlotnik-Shaul & Matlow, 2010;
Nicholas, Gearing, Koller, Salter & Selkirk, 2008; Koller, Nicholas, Salter Goldie, Gearing &
Selkirk, 2006; Koller, Nicholas, Salter Goldie, Gearing & Selkirk, 2006; Nicholas & Koller,
In order to adequately respond to the future needs of children and families in potential infection
outbreaks, research is needed that assesses both the immediate and long-term impacts of
such health crises. Our early research on the immediate pediatric impacts of SARS offered an
important foundation upon which we could further examine potential lingering or long-term
effects, within this study.
Purpose of the Study
This study explored the long term impacts of SARS on the experiences of families in which a
child was hospitalized with suspected or probable SARS. More specifically, the study explored:
(1) post-traumatic type responses to the SARS outbreaks, (2) key issues pertaining to the
psychosocial needs of families, and (3) future recommendations for practice and policy.
Ethnographic interviews were conducted. Interviews were analyzed using McCracken’s ‘long
interview’ analytical framework that proceeds from line-item review within single transcripts to
the ultimate development of inter-transcript patterns and themes. N-Vivo qualitative analysis
software was utilized and data saturation was achieved, based on guidelines outlined by
Participants comprised a qualitative sample of seven families in which a child was hospitalized
with suspected or probable SARS. While a larger sample was initially expected, families either
could not be located due to the time lapse since the SARS outbreak or they were unwilling to
participate in the study. Participants varied in terms of their hospitalization experiences and the
demands placed on the child and family regarding quarantine. Some parents were able to stay
with their child while in hospital, while others were required to leave their child. Participants
conveyed a variety of emotions during and after the SARS outbreak. The following themes
were identified: (i) inconsistent admission procedures and guidelines during SARS such as
some parents being allowed into the hospital with their children while others were denied
access; (ii) negative impacts on the parent(s) including isolation and stigma in the community;
and (iii) negative impacts on the hospitalized child including, in a few cases, long-term
psychosocial responses such as being unable to sleep without parental comfort or
reassurance, and demonstrating what one parent viewed as an extended anxiety reaction
related to separation and isolation. Negative impacts on the family as a whole and other family
members were reported in some but not all cases, and parents described varying means by
which they grappled with challenges related to SARS. In a few cases, positive outcomes were
identified such as families working together effectively or more tightly bonding. On balance,
participants were concerned over the lack of resources to help them deal with the crisis.
This study raises several key practice and policy issues, most notably, the importance of
family-centred care in pandemic crises. To augment communication in a pandemic or similar
time of heightened risk, use of technology may be beneficial for fostering family-centred care
(e.g., video or web-based tools). Technology potentially supports infection containment by not
requiring face-to-face contact while enabling family-centred communication. Accordingly,
hospitalized children can remain in close contact with family members despite isolating
conditions. Given participant reports of inconsistent procedures and rules implemented during
the pandemic, there appears to be a need for reasonable uniformity through formalized
processes. This invites a careful balance of policy adherence, yet transparent review, as
needed. Although information may frequently change throughout a health crisis, participants
recommended strong leadership and decisiveness on the part of health care professionals.
Meeting complexity, uncertainty and change with a health care policy and practice response of
consistency, transparency and effective communication, was viewed to potentially ease the
burden on families.
This study builds on previous research conducted by this team, by identifying long-term
impacts of SARS on families who were directly affected by the virus. It identifies the risk of
possible post-traumatic issues for children and families, which in turn informs planning and
policy development in the possible event of a future health outbreak.
Booth CM & Stewart TE (2005). Severe acute respiratory syndrome and critical care medicine:
The Toronto experience. Critical Care Medicine. 33(1): S53-S60.
Koller D, Nicholas DB, Gearing RE & Kalfa O (2010). Paediatric pandemic planning: Children's
perspectives and recommendations. Health and Social Care in the Community. 18, 4, July:
Koller D, Nicholas DB, Salter Goldie R, Gearing R & Selkirk E (2006). Bowlby and Robertson
revisited: The impact of isolation on hospitalized children during SARS. Journal of
Developmental and Behavioral Pediatrics, April, 27(2): 134-140.
Koller D, Nicholas DB, Salter Goldie R, Gearing R & Selkirk E (2006). When family centered
care is challenged by infectious disease: Pediatric health care delivery during the SARS
outbreaks. Qualitative Health Research, 16(1): 47-60.
McCracken G (1988). The Long Interview. Thousand Oaks, CA: Sage.
Nicholas DB, Gearing RE, Koller D, Salter R & Selkirk E (2008). Pediatric epidemic crisis:
Lessons for policy and practice development. Health Policy, 88: 200-208.
Nicholas DB, Patershuk C, Koller D, Bruce-Barrett C, Lach L, Zlotnik-Shaul R & Matlow A
(2010). Pandemic planning in pediatric care: A website policy review and national survey data.
Health Policy, 96, 2: 134-142.
Nicholas D & Koller D (2003). The Experience of SARS from a pediatric perspective. Ontario
Respiratory Care Society Update, Ontario Lung Association, 19(3): 10.
World Health Organization. Summary of probable SARS cases with onset of illness from 1
November 2002 to 31 July 2003. Retrieved August 18, 2011 from:
Research Review 2011; Volume 8