Factors influencing health promoting activities of mothers caring for ventilator-assisted children

Psychosocial factors affecting the quality of life of parents who have children with home mechanical ventilation

INTRODUCTION

Most children with medical complexity have to live with home mechanical ventilation (HMV). Undertaking the care of a child with HMV creates a psychosocial burden on parents. This study investigated the impact of selected potential determinants on the quality of life of parents who have children with HMV.

METHODS

A cross-sectional survey study was conducted using a structured questionnaire to determine the sociodemographic characteristics of the parents. The World Health Organization Quality of Life Assessment-Brief version, the Beck Depression Inventory (BDI), and the Multidimensional Scale of Perceived Social Support were applied.

RESULTS

A total of 35 participants responded to the questionnaires. Paired data from mothers and fathers were obtained from 12 families. A moderately significant positive correlation was found between the perceived social support levels of the parents and all domains of the quality of life scale (for the physical domain: r = .455, p = .006; for the psychological domain: r = .549, p = .001; for the social domain: r = .726, p = .000; and for the environment domain: r = .442, p = .008). A moderate negative relationship was found between parents' perceived social support levels and BDI scores (r = -.557, p = .001). The multivariate regression analysis determined that being a mother, quitting a job to become a caregiver, being the only caregiver at home, and having a neurological/neuromuscular disease as the primary disease of the child were associated with lower scores in more than one quality of life domain.

CONCLUSION

Our results emphasize that appropriate social support is important for improving the quality of life scores of parents of children with HMV.

Efficacy of a Resourcefulness Intervention to Enhance the Physical and Mental Health of Parents Caring for Technology-dependent Children at Home: A Randomized Controlled Trial

INTRODUCTION

Parent caregivers of children who require lifesaving medical technology (e.g., mechanical ventilation, feeding tubes) must constantly maintain vigilance. Poor physical and psychological health can negatively impact their ability to do so.

METHOD

A two-arm randomized controlled trial was conducted with 197 parent caregivers of technology-dependent children (aged < 18 years) to test the efficacy of Resourcefulness Training1, a cognitive-behavioral intervention that teaches social (help-seeking) and personal (self-help) resourcefulness skills, in improving key outcomes including mental health-related quality of life (HRQOL), depressive cognitions and symptoms, perceived and physiological chronic stress, burden, and physical HRQOL at five-time points.

RESULTS

Mixed-effects models using the intent-to-treat principle indicated statistically significant improvement with intervention participants at six and/or nine months postintervention for depressive cognitions, perceived stress, and physical HRQOL, controlling for covariates.

DISCUSSION

Study findings support the efficacy of Resourcefulness Training to significantly decrease perceived stress and improve psychological/physical outcomes with these vulnerable caregivers.

Sleep Quality of Family Caregivers of Children With Tracheostomies or Home Ventilators: A Scoping Review

Family caregivers of children with tracheostomies or home ventilators are more likely to experience poor sleep quality when undertaking the full responsibility of caring for fragile children. This scoping review aimed to identify the sleep quality, related factors, and their impact on the health of family caregivers of children with tracheostomies or home ventilators. The included studies (N = 16) were retrieved through PubMed, CINAHL, Cochrane Library, Embase, PsycINFO, and Web of Science. Family caregivers' sleep were low in quality, frequently disturbed, and insufficient. Their sleep quality was related to fatigue, anxiety, depression, family functioning, and health-related quality of life. The sleep disturbing factors were classified as child, caregiver, or environment-related, which were mutually interrelated. This review emphasizes the need to develop nursing interventions to both improve the sleep quality of family caregivers and the health of children with tracheostomies or home ventilators based on an in-depth understanding of the family's context.

Postal Delivery of Sleep Monitoring Devices: Research Implications

The purpose of this article is to describe the protocol development, feasibility, and lessons learned in the postal mail delivery of sleep monitoring devices to study participants. The original study protocol included four in-person visits with distribution of a sleep monitoring device (Actiwatch) and return of the Actiwatch via the postal service in a self-addressed, stamped envelope. The COVID-19 pandemic limited in-person research contact thus requiring a remote study protocol for application and return of the Actiwatches using postal delivery. While there were postal delivery and return challenges, the overall return rate of 94.4% confirmed remote protocol feasibility. Key lessons learned were: consistent and frequent communication via telephone calls and/or text; confirming required postage; and use of package tracking labels. All these strategies contributed to successful postal delivery/return and concomitantly decreased the potential loss of data and valuable research equipment.

Resourcefulness Intervention Efficacy for Parent Caregivers of Technology-Dependent Children: A Randomized Trial

Parent caregivers of children who require lifesaving technology (e.g., mechanical ventilation, feeding tubes) must maintain a high level of vigilance 24/7. A two-arm randomized controlled trial tested the efficacy of a resourcefulness intervention on parents' mental/physical health and family functioning at four time points over six months. Participants (n = 93) cared for their technology-dependent children <18 years at home. The intervention arm received teaching on social (help-seeking), personal (self-help) resourcefulness skills; access to the intervention video and skill application video-vignettes; four weeks of skills reinforcement using daily logs; four weekly phone contacts; and booster sessions at two- and four-month postenrollment. The attention control arm received phone contact at identical time points plus the current standard of care. Statistically significant improvement was noted; fewer depressive cognitions and improved physical health for the intervention participants than attention control participants over time after controlling for covariates. The findings support the resourcefulness intervention efficacy.

"Line care governs our entire world": Understanding the Experience of Caregivers of Children with Intestinal Failure on Long-term Parenteral Nutrition

BACKGROUND

Children with intestinal failure (IF) on long-term parenteral nutrition (PN) require significant medical care, including high risk procedures such as accessing a central venous catheter, with the majority provided by family caregivers in the home. This study sought to understand the experiences of family caregivers of children.

METHODS

This was a qualitative study of family caregivers of children with IF. Participants were recruited from an intestinal rehabilitation program to participate in virtual focus groups, which were recorded and transcribed. Thematic analysis was used to capture and describe experiences.

RESULTS

Thirteen caregivers providing care to eleven children participated in three virtual focus groups held between May to June 2020. Data analysis revealed five primary themes: 1) Caregiving as a 24/7 commitment; 2) facing constant risk of death, 3) chronic illness creates difficult feelings and emotions; 4) effects on all aspects of family life; 5) adapting and functioning as a family. The findings of this study pair well with the biopsychosocial model highlighting the need for multifaceted assessment and supports.

CONCLUSION

The impact of caring for a child with IF on long-term PN is significant for caregivers and their families and has implications for all aspects of their lives. A better understanding of the impact on caregivers and their coping strategies lays the groundwork for optimization of quality of life for caregivers and their family. This article is protected by copyright. All rights reserved.

A systematic concept analysis of 'technology dependent': challenging the terminology

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Depression and anxiety in mothers of home ventilated children before and during COVID-19 pandemic

BACKGROUND

Due to advances in technology, home ventilation in children has increased in recent years. The provision of proper care for a home-ventilated (HV) child can have a strong impact on the lifestyle of caregivers. The aim of this study was to evaluate the depression and anxiety levels of the mothers of HV children during the current COVID-19 pandemic and compare them to those of mothers of healthy peers.

METHODS

This cross-sectional study was conducted on HV children (n = 21) and a control group of healthy peers (n = 32) by means of a questionnaire completed by the mothers of the children of both groups. Psychometric scales, such as the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory-State (STAI-S), and the State-Trait Anxiety Inventory-Trait (STAI-T), were used to assess participants.

RESULTS

During the pandemic signs of depression were present in 8 (38.1%) of the case group and 8 (25%) of the healthy control group. Comparison of the BDI scores from before and during the pandemic showed no difference between mothers of the HV children (p = .09). Scores for BDI and STAI-T were higher in the case group than in the control group, whereas there was no significant difference in STAI-S scores.

CONCLUSION

Depression and anxiety levels of mothers of HV children were found to be higher during the COVID-19 pandemic. Economic, medical, and social support resources are needed to reduce levels of depression and anxiety and help mothers of those children dependent on technology.

Relationships among parenting stress, health-promoting behaviors, and health-related quality of life in Korean mothers of children with cerebral palsy

Health-promoting behaviors have been shown to enhance the quality of life across diverse populations. In this study, we examined the indirect effects of several health-promoting behaviors on the relationship between parenting stress and health-related quality of life in mothers of children with cerebral palsy (CP). A convenience sample of Korean mothers (N = 180) of children aged 10 months to 12 years with CP was recruited from clinical and school settings. Health-promoting behaviors were measured using the health-promoting lifestyle profile II, which is comprised of six subscales: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. Multiple mediation analyses were conducted to examine the mediating role of these behavioral categories. Spiritual growth (β = .56, p < .05) had an indirect effect on the relationship between parenting stress and physical health-related quality of life while spiritual growth (β = -1.00, p < .01) and stress management (β = -.80, p < .05) were found to mediate the association between parenting stress and mental health-related quality of life. The findings of multiple mediation analyses provide evidence of the influence of specific health-promoting behaviors on health-related quality of life, thereby informing the development of intervention programs for mothers of children with disabilities.

The impact of decision quality on mental health following periviable delivery

PURPOSE

To assess the relationship between decision quality and mental health outcomes for women and their important others (IO) 3 months following periviable birth.

METHOD

Mental health outcomes were assessed prior to delivery and at 3 months postpartum using depression (PHQ-9), anxiety (GAD-7), and post-traumatic stress disorder (PTSD) (IES-22) scales. Decision quality was measured in terms of Decisional Conflict, Control, Regret, and Satisfaction with Decision. Descriptive analyses and linear regression modeling were conducted using SAS version 9.4.

RESULT

We recruited 30 eligible women and 16 IOs. Participants had mild anxiety and depression, and symptoms of PTSD were among bereaved parents. Participants with lower decision control had higher levels of depression (women: p = 0.014; IOs: p = 0.059) and anxiety (women: p = 0.053; IOs: p = 0.032). Depression was also associated with higher decisional regret (women: p = 0.073; IOs: p = 0.023).

CONCLUSION

Our findings suggest that decision quality is associated with mental health outcomes for families who experience periviable delivery.

Determinants of Health-related Quality of Life Among Mothers of Children With Cerebral Palsy

PURPOSE

Caring for a child with cerebral palsy (CP) can impact both the physical and mental health of parents. However, determinants associated with health-related quality of life (HRQOL) in these parents have yet to be adequately examined. The study aims were to identify the determinants affecting HRQOL among mothers of children with CP.

DESIGN AND METHODS

Participants in this cross-sectional study (N = 180) were mothers of children with CP recruited from clinical and school-based settings in Korea. Variables examined were characteristics of child (demographic factors and disability parameter), mother (demographic factors, number of chronic conditions, health-promoting behaviors (HPB), and parenting stress), and environmental factors (use of personal assistant care, leisure time and social support). Multivariate regression analysis was performed to examine the child, mother, and environmental factors associated with HRQOL.

RESULTS

The HRQOL results revealed that the physical HRQOL was higher than mental HRQOL in the sample. Longer length of disability of children and lower number of chronic conditions of mothers were significant factors of higher physical HRQOL. Lower parenting stress, more leisure time, engagement in HPB, and greater social support were significantly associated with higher mental HRQOL.

CONCLUSIONS

The levels of HRQOL of mothers of children with CP were very low and our findings suggest modifiable factors. Decreasing parenting stress, engaging in HPB, and providing social support should be considered when developing psychosocial intervention for this population.

PRACTICE IMPLICATIONS

Study results may inform programs aimed at health promotion, stress reduction, and QOL improvement among parents of children with disabilities.

Maternal Factors Associated With the Healthcare Utilization of Technology-Dependent Infants Following NICU Discharge

This study examined the relationship of mothers' psychological well-being (depressive symptoms, posttraumatic stress symptoms) and resourcefulness with their technology-dependent infants' healthcare utilization (rehospitalization, emergency department [ED] visits) following discharge from the neonatal intensive care unit (NICU). This descriptive, correlational study was conducted at a large Midwest level 4 NICU in the United States. Mothers (n = 19) with a technology-dependent infant (eg, supplemental oxygen, feeding tubes) to be discharged home from the NICU within 2 to 3 weeks were interviewed face-to-face using standardized instruments. Infant rehospitalization and ED visit data were collected from the electronic medical record (EMR) for the first 3 months following the infant's discharge. Analyses included descriptive statistics and negative binomial regression. A majority of infants (72.2%) required at least 1 hospitalization; 33% required at least one ED visit. Mothers' age and resourcefulness were significant predictors of ED visits while only resourcefulness predicted rehospitalizations. Neither depressive symptoms nor posttraumatic stress symptoms significantly predicted healthcare utilization. Maternal resourcefulness was the only main variable that significantly predicted both ED visits and hospitalizations and one of the few modifiable factors that could assist mothers with successfully coping with the complexity of caring for a technology-dependent infant. Future research should focus on interventions to enhance mothers' resourcefulness prior to their technology-dependent infant's NICU discharge.

Quality of life in home-ventilated children and their families

HMV (home mechanical ventilation) in children has increased over the last years. The aim of the study was to assess perceived quality of life (QOL) of these children and their families as well as the problems they face in their daily life.We performed a multicentric cross-sectional study using a semi-structured interview about the impact of HMV on families and an evaluation questionnaire about perceived QOL by the patient and their families (pediatric quality of life questionnaire (PedsQL4.0)). We studied 41 subjects (mean age 8.2 years). Global scores in PedsQL questionnaire for subjects (median 61.4), and their parents (median 52.2) were below those of healthy children. 24.4% received medical follow-up at home and 71.8% attended school. Mothers were the main caregivers (75.6%), 48.8% of which were fully dedicated to the care of their child. 71.1% consider economic and healthcare resources insufficient. All families were satisfied with the care they provide to their children, even though it was considered emotionally overwhelming (65.9%). Marital conflict and neglect of siblings appeared in 42.1 and 36% of families, respectively.

CONCLUSIONS

Perceived QOL by children with HMV and their families is lower than that of healthy children. Parents are happy to care for their children at home, even though it negatively affects family life. What is Known: • The use of home mechanical ventilation (HMV) in children has increased over the last years. • Normal family functioning is usually disrupted by HMV. What is New: • The aim of HMV is to provide a lifestyle similar to that of healthy children, but perceived quality of life by these patients and their parents is low. • Most of the families caring for children on HMV agree that support and resources provided by national health institutions is insufficient.

Differences in physical health, and health behaviors between family caregivers of children with and without disabilities

BACKGROUND

Providing care for children with disabilities can negatively influence the physical health and health behaviors of family caregivers.

OBJECTIVES/HYPOTHESIS

The study purposes were to compare the prevalence of chronic conditions and health risk behaviors of family caregivers of children with and without disabilities and to examine associations between disability status of children and family caregivers' chronic conditions and health risk behaviors.

METHODS

This study compared chronic conditions and health risk behaviors across adult family caregivers of children with a disability (FCG-D) and family caregivers of children without a disability (FCG) living in a U.S. household using 2015 National Health Interview Survey data. Health risk behaviors were defined as heavy drinking, current smoking, physical inactivity, and unhealthy sleep. Multivariable logistic regression was conducted to compare chronic conditions and health risk behaviors between FCG-D and FCG with adjustments for demographic and healthcare coverage covariates.

RESULTS

FCG-D showed significantly greater likelihoods of chronic conditions (e.g., asthma, back pain, chronic bronchitis, heart conditions, migraine, and obesity) than FCG. FCG-D also exhibited significantly more smoking and unhealthy sleep.

CONCLUSIONS

Family caregivers of children with a disability reported significantly greater likelihoods of various chronic conditions and were more likely to engage in health risk behaviors (smoking and unhealthy sleep). Further study is needed to develop intervention programs for encouraging effective health-promoting behaviors among family caregivers of children with a disability as well as health policies for decreasing health disparities experienced by this population.

A necessary evil: Residential placement of people with intellectual disability among the Palestinian minority in Israel

Among the Palestinian minority in Israel, residential placement of people with intellectual disabilities [ID] is relatively new and steadily increasing, but poorly studied. A qualitative design was used to explore the process of residential placement decision by 18 parents of people with ID through semi-structured interviews. Sampling was purposive and data was analyzed thematically. Four main themes emerged representing parents' perceptions and experiences along the placement decision-making process, together indicating an experience of deeply 'conflicted parenting': (a) initial resistance to placement and its perception as abandonment and parental failure; (b) attrition following cumulative difficulties and lack of assistance; (c) resignation and reframing of placement as a necessary evil; (d) relief mixed with guilt, pain, and ambivalence following placement. Residential placement process proved to be linked primarily to lack of resources and of accessible culturally-competent services within the community. Parents' experience and behavior along the placement decision process reflect relentless efforts to practice "good parenting". This concept is culturally specific and in the present case entails commitment to consider the individual child's wellbeing together with the family's as a whole. Implications for practice are suggested.

Technology Dependence in Home Care: Impact on Patients and Their Family Caregivers

BACKGROUND

The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL).

METHODS

A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care.

RESULTS

Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience.

CONCLUSIONS

More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

Neonates and Infants Discharged Home Dependent on Medical Technology: Characteristics and Outcomes

BACKGROUND

Preterm neonates and neonates with complex conditions admitted to a neonatal intensive care unit (NICU) may require medical technology (eg, supplemental oxygen, feeding tubes) for their continued survival at hospital discharge. Medical technology introduces another layer of complexity for parents, including specialized education about neonatal assessment and operation of technology. The transition home presents a challenge for parents and has been linked with greater healthcare utilization.

PURPOSE

To determine incidence, characteristics, and healthcare utilization outcomes (emergency room visits, rehospitalizations) of technology-dependent neonates and infants following initial discharge from the hospital.

METHODS

This descriptive, correlational study used retrospective medical record review to examine technology-dependent neonates (N = 71) upon discharge home. Study variables included demographic characteristics, hospital length of stay, and type of medical technology used. Analysis of neonates (n = 22) with 1-year postdischarge data was conducted to identify relationships with healthcare utilization. Descriptive and regression analyses were performed.

FINDINGS

Approximately 40% of the technology-dependent neonates were between 23 and 26 weeks' gestation, with birth weight of less than 1000 g. Technologies used most frequently were supplemental oxygen (66%) and feeding tubes (46.5%). The mean total hospital length of stay for technology-dependent versus nontechnology-dependent neonates was 108.6 and 25.7 days, respectively. Technology-dependent neonates who were female, with a gastrostomy tube, or with longer initial hospital length of stay were at greater risk for rehospitalization.

IMPLICATIONS FOR PRACTICE

Assessment and support of families, particularly mothers of technology-dependent neonates following initial hospital discharge, are vital.

IMPLICATIONS FOR RESEARCH

Longitudinal studies to determine factors affecting long-term outcomes of technology-dependent infants are needed.

The Adaptation of Mothers of Children With Intellectual Disability in Lebanon

In many Middle Eastern countries, including Lebanon, there is a stigma attached to families who have an intellectually impaired child. These families complain of isolation and lack of community resources that could help them cope with their circumstances to optimize the child’s abilities. Health professionals and researchers should be cognizant of factors related to the process of stress adaptation to help families cope with their circumstances. The aim of this cross-sectional study was to identify factors that play a role in mothers’ adaptation to the care of their intellectually impaired children. The results, based on a sample of 127 mothers from Lebanon, reveal that a high percentage of mothers had depressive symptoms. Multiple regression analysis demonstrates that by order of importance, the factors that determine maternal depression are family strain, parental stress, and family income. The conclusions about nursing implications from a cultural perspective are discussed and recommendations proposed.

Chronic respiratory failure: Utilization of a pediatric specialty integrated care program

OBJECTIVE

Describe utilization and satisfaction in a specialty integrated care program for children with severe, chronic respiratory insufficiency (CRI).

SUBJECTS

Enrollees of the Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program.

METHODS

Children with CRI received home visits, care coordination, and "on-demand" 24/7 access to physicians. Program activity and outcomes were recorded for 3 years using an adapted Care Coordination Measurement Tool© version. Parents completed the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Patient characteristics, program activity, clinical outcomes, utilization, and satisfaction were summarized using descriptive statistics.

RESULTS

CAPE provided care for 320 patients from 2012 to 2014 with a median of 7 encounters per year. Neuromuscular (n=132, 41%), chronic lung disease (n=37, 12%), and congenital heart disease (n=13, 4%) represented the majority of underlying conditions. Services included 905 home, 504 clinic, and 3633 telephone encounters, of which 43.6% included a care coordination activity. CAHPS (n=102) revealed that 92.1% (n=93) of children had at least one non-urgent (i.e., routine) visit and nearly two-thirds (64.7%, n=66) reported the need for urgent or emergency care. Overall, parents were highly satisfied with CAPE, with a mean satisfaction rating of 9.3 (±1.3) out of 10. Most parents reported that the CAPE team understood the child's (96.0%, n=95) and family's day-to-day life (86.9%, n=86).

CONCLUSIONS

When given open access to an intregated care program, children in our highly complex population required a median of 7 encounters per year. We believe that this experience is scalable and may inform other organizations contemplating similar services.

Outcomes of Depression in Black Single Mothers

Despite suggestions in the literature that depression has serious consequences, few studies have examined specific health and psychosocial outcomes of depression in Black single mothers. The purpose of this study was to estimate paths in a just-identified theoretical model of outcomes of depression for Black single mothers based on theoretical propositions and empirical findings. The model included the variables, depressive cognitions, depressive symptomatology, perceived social support, and positive health practices. Five direct and two indirect hypothesized relationships were estimated using structural equation modeling. A nonprobability sample of convenience of 159 Black single mothers aged 18 to 45 years was recruited for the study. This study used a cross-sectional correlational design. The participants responded in person or via the U.S. mail to the Center for Epidemiologic Studies-Depression scale, the Depressive Cognition Scale, the Personal Resource Questionnaire 85-Part 2, and the Personal Lifestyle Questionnaire. Beta and Gamma path coefficients were statistically significant for four out of five hypothesized direct relationships within the model ( p < .01). The direct path between depressive cognitions and positive health practices was not supported (Gamma = -.11, p > .05). The two indirect paths were weak but statistically significant ( p < .01). Depressive symptoms and perceived social support were outcomes of depressive cognitions. Positive health practices was not a direct outcome of depressive cognitions. Perceived social support and positive health practices were outcomes of depressive symptoms.

Factors Related to Depressive Symptoms in Mothers of Technology-Dependent Children

Mothers caring for technology-dependent children at home often suffer clinically significant and unrecognized depressive symptoms. The study aim was to determine factors related to elevated depressive symptoms and provide information to target interventions that assists mothers in self-management of their mental health. Secondary data analysis from a descriptive, correlational study of 75 mothers was performed. Hierarchical multiple regression analysis results indicate that younger, unpartnered mothers with lower normalization efforts and personal resourcefulness, and less care hours, had increased depressive symptoms. The importance of personal resourcefulness and the potential for a resourcefulness training intervention to reduce depressive symptoms are discussed.

Sleep patterns, sleep instability, and health related quality of life in parents of ventilator-assisted children

STUDY OBJECTIVES

Parents of children with chronic illnesses have poorer health related quality of life (HRQoL), shorter sleep duration, and poorer sleep quality than parents of healthy children. However, night-to-night variability of sleep in parents has not previously been considered. This study compared the sleep patterns of parents of ventilator-assisted children (VENT) and healthy, typically developing children (HEALTHY), and examined the relationship between sleep variability and perceived HRQoL.

METHODS

Seventy-nine mothers and 33 fathers from 42 VENT families (n = 56) and 40 HEALTHY (n = 56) families completed the SF-36 and wore an actigraph for 2 weeks. Reported bedtime and wake time, along with actigraphic total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) were examined using both average values and night-tonight instability (mean square successive differences).

RESULTS

VENT parents showed significantly later bedtimes, shorter TST, longer WASO, and lower SE than HEALTHY parents. VENT parents also exhibited greater instability in their reported wake time, WASO, and SE. Adjusting for family type and gender, greater instability of wake times, WASO and SE were related to poorer SF-36 subscale scores, while averaged sleep values were not.

CONCLUSIONS

Many parents of ventilator-assisted children experience deficient sleep and show significant instability in their sleep, which was related to HRQoL. Similar to shift workers, variable sleep schedules that may result from caregiving responsibilities or stress may impact parental caregivers' health and well-being. Additional studies are needed to determine how support and other interventions can reduce sleep disruptions in parental caregivers.

Proceedings of the fourth international conference on central hypoventilation

Central hypoventilation syndromes (CHS) are rare diseases of central autonomic respiratory control associated with autonomous nervous dysfunction. Severe central hypoventilation is the hallmark and the most life-threatening feature. CHS is a group of not-fully defined disorders. Congenital CHS (CCHS) (ORPHA661) is clinically and genetically well-characterized, with the disease-causing gene identified in 2003. CCHS presents at birth in most cases, and associated with Hirschsprung's disease (ORPHA99803) and neural crest tumours in 20% and 5% of cases, respectively. The incidence of CCHS is estimated to be 1 of 200,000 live births in France, yet remains unknown for the rest of the world. In contrast, late-onset CHS includes a group of not yet fully delineated diseases. Overlap with CCHS is likely, as a subset of patients harbours PHOX2B mutations. Another subset of patients present with associated hypothalamic dysfunction. The number of these patients is unknown (less than 60 cases reported worldwide). Treatment of CHS is palliative using advanced techniques of ventilation support during lifetime. Research is ongoing to better understand physiopathological mechanisms and identify potential treatment pathways.The Fourth International Conference on Central Hypoventilation was organised in Warsaw, Poland, April 13-15, 2012, under the patronage of the European Agency for Health and Consumers and Public Health European Agency of European Community. The conference provided a state-of-the-art update of knowledge on all the genetic, molecular, cellular, and clinical aspects of these rare diseases.

Families with children with medical complexity and self-management of care: a systematic review of the literature

This review analyzes the quantitative literature on children with medical complexity (CMC). Using the Pediatric Self-Management Model, evidence is summarized into facilitators and barriers to self-management. Current quantitative research focuses on the caregiver burden in families with CMC. A model for social work with families with CMC was introduced in response to these findings. A re-envisioned model allows the child with medical complexity to be seen as whole rather than focusing on typically deficit-based areas of medical specialty or service provision.

Nursing's contribution to research about parenting children with complex chronic conditions: an integrative review, 2002 to 2012

Children with complex chronic conditions (CCC) need extensive, costly care, usually provided at home by parents. These children often rely on technology to survive or avoid complications. Children with CCC receive nursing care in hospital, community, and home settings. An integrative review of 22 nursing studies, from 2002 to 2012, of parenting for children with CCC was conducted to synthesize nursing research addressing parenting a child with a CCC and identify promising areas for future inquiry and development of supportive interventions and policies. Criteria for sampling in these studies were reviewed, and an updated definition for children with CCC is offered to replace an outdated definition of "medically fragile" children. Findings include the extensive impacts of providing complex care at home, including the tension between the difficulties and recognition of the rewards of providing that care. Disruptions occurred in emotional, role development, social, and moral realms.

Explicating caregiving by mothers of children with complex needs in ireland: a phenomenological study

This qualitative phenomenological study explored mothers' experiences of caring for a child with complex needs. After ethical approval was obtained, data were collected through 11 diaries and 48 interviews with 17 mothers in Ireland. Caring for a child with complex needs involves the delivery of care in an inside world of the home, the world outside the home, and a "going-between" world. Caregiving, 1 of 8 closely linked dimensions, is presented, including its 4 categories. These are normal mothering, technical caregiving, preemptive caregiving, and individualized caregiving. Professionals require a greater understanding of the experiences of mothers caring for children with complex needs at home.

Biopsychosocial risks of parental care for high-risk neonates: implications for evidence-based parental counseling

OBJECTIVE

Provide an evidence base for counseling parents of high-risk neonates about the biopsychosocial impact of providing long-term care.

STUDY DESIGN

A review of the effects of long-term care on families of high-risk neonates. Our search was limited to 1993-2010. We used the terms 'long-term care,' 'family,' 'neonate' and 'technology dependence.' Results were organized based on Engel's biopsychosocial model.

RESULT

Physical-parental caregivers reported more health problems, had fewer health-promoting behaviors and lower vitality.Psychological-parental caregivers had higher rates of post-traumatic stress disorder and depressive symptoms, although some improved with time. Siblings reported greater stress and depression. Social-parental caregivers achieved fewer years of education, higher unemployment and lower incomes. Couples reported greater family strain. The effect on divorce was mixed. Siblings reported disruption in their academic and social lives.

CONCLUSION

Providing long-term care involves biopsychosocial risks. Counseling of parents should identify them and advocate strategies for prevention.

Families with children who are technology dependent: normalization and family functioning

This cross-sectional study examined family functioning and normalization in 103 mothers of children ≤16 years of age dependent on medical technology (mechanical ventilation, intravenous nutrition/medication, respiratory/nutritional support) following initiation of home care. Differences in outcomes (mother's depressive symptoms, normalization, family functioning), based on the type of technology used, were also examined. Participants were interviewed face-to-face using the Demographic Characteristics Questionnaire, the Functional Status II-Revised Scale, the Center for Epidemiological Studies-Depression Scale, a Normalization Scale subscale, and the Feetham Family Functioning Survey. Thirty-five percent of the variance in family functioning was explained primarily by the mothers' level of depressive symptoms. Several variables were significant predictors of normalization. Analysis of variance revealed no significant difference in outcomes based on the type of technology used. Mothers of technology-dependent children are at high risk for clinical depression that may affect family functioning. This article concludes with clinical practice and policy implications.

The relationship between home nursing coverage, sleep, and daytime functioning in parents of ventilator-assisted children

This descriptive study examined the relationship between home-care nursing support, sleep, and daytime functioning in familial caregivers of ventilator-assisted children. Thirty-six primary caregivers (27 mothers, 7 fathers, 1 foster mother, and 1 grandmother) of ventilator-assisted children completed measures of home nursing support, sleep, depression, fatigue, and daytime sleepiness. Daytime nursing coverage was not related to caregiver sleep or daytime functioning, but caregivers with less nighttime nursing coverage had significantly shorter sleep onset latency than caregivers with some night nursing (16-48 hours/week). Caregivers with regular night nursing (>48 hours/week) had a total sleep time of almost 1 hour more than caregivers without regular night nursing ( Collapse

Key Words

• home care nursing
• caregivers
• ventilator-dependent
• sleep
• functioning

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MESH Headings

• Adult
• Attitude to Health
• Caregivers/psychology
• Child
• Cost of Illness
• Cross-Sectional Studies
• Depression/etiology
• Fatigue/etiology
• Female
• Health Services Needs and Demand
• Home Care Services/organization & administration
• Home Nursing/organization & administration
• Home Nursing/psychology
• Humans
• Male
• Middle Aged
• Night Care/organization & administration
• Nursing Methodology Research
• Parents/psychology
• Pennsylvania
• Respiration, Artificial/nursing
• Sleep Deprivation/diagnosis
• Sleep Deprivation/etiology
• Sleep Deprivation/psychology
• Social Support
• Surveys and Questionnaires

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Grants

• K23 MH077662 NIMH NIH HHS
• K23MH077662 NIMH NIH HHS

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Affiliation(s)

Lisa J Meltzer University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
Deborah S Boroughs
John J Downes

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Collaborators Collapse

Predictors of coping in parents of children with an intellectual disability: comparison between Lebanese mothers and fathers

This cross-sectional study was designed to assess the predictors of coping behaviors of 147 Lebanese parents (101 mothers and 46 fathers) with a child with intellectual disability. It assessed the contribution of child's and parent's characteristics, informal social support, and stress on the coping behaviors of fathers and mothers. Multiple regression analysis confirmed that the father's education, informal social support, and stress were the best predictors of coping. The child's age, severity of illness, and parental health did not significantly contribute to predicting coping behaviors. Contrary to expectations in a Middle Eastern culture, both fathers and mothers reported similar levels of stress, perceived informal social support, and coping. Although informal social support cannot be forced on parents, health professionals can mobilize resources that are culturally sensitive, such as home visitation by nurses or support from other parents. This may especially be beneficial in developing countries with limited resources.

A Transcultural Strengths Assessment Interview Guide for Parent Caregivers

The Haley Transcultural Strengths Assessment interview guide for parent caregivers is an instrument for nurses and related health care providers to identify, better understand, and promote the development of strengths of parents for children with ongoing, complex health needs. Assisting these caregivers to build on their strengths, as identified through their own cultural perspective, is crucial not only to promote their health and well-being, but also to the quality of care they deliver to their child. The development of the instrument is discussed. The interview guide and description of how to use it are presented. This is a versatile instrument that may be used across cultures in the home or clinical setting, or in research. It frames the strengths of the parent caregiver, so these strengths can be encouraged and woven into the parent's life, promoting a positive sense of energy, empowerment, and harmony.

Daily living with distress and enrichment: the moral experience of families with ventilator-assisted children at home

OBJECTIVE

The growing shift toward home care services assumes that "being home is good" and that this is the most desirable option. Although ethical issues in medical decision-making have been examined in numerous contexts, home care decisions for technology-dependent children and the moral dilemmas that this population confronts remain virtually unknown. This study explored the moral dimension of family experience through detailed accounts of life with a child who requires assisted ventilation at home. This study involved an examination of moral phenomena inherent in (1) the individual experiences of the ventilator-assisted child, siblings, and parents and (2) everyday family life as a whole.

METHODS

A qualitative method based on Richard Zaner's interpretive framework was selected for this study. The population of interest for this study was the families of children who are supported by a ventilator or a positive-pressure device at home. Twelve families (38 family members) were recruited through the Quebec Program for Home Ventilatory Assistance. Children in the study population fell into 4 diagnostic groups: (1) abnormal ventilatory control (eg, central hypoventilation syndrome), (2) neuromuscular disorders, (3) spina bifida, and (4) craniofacial or airway abnormalities resulting in upper airway obstruction. All 4 of these diagnostic groups were included in this study. Among the 12 children recruited, 4 received ventilation via tracheostomies, and 8 received ventilation with face masks. All of the latter received ventilation only at night, except for 1 child, who received ventilation 24 hours a day. Family moral experiences were investigated using semistructured interviews and fieldwork observations conducted in the families' homes.

RESULTS

Data analysis identified 6 principal themes. The themes raised by families whose children received ventilation invasively via a tracheostomy were not systematically different or more distressed than were families of children with face masks. The principal themes were (1) confronting parental responsibility: parental responsibility was described as stressful and sometimes overwhelming. Parents needed to devote extraordinary care and attention to their children's needs. They struggled with the significant emotional strain, physical and psychological dependence of the child, impact on family relationships, living with the daily threat of death, and feeling that there was "no free choice" in the matter: they could not have chosen to let their child die. (2) Seeking normality: all of the families devoted significant efforts toward normalizing their experiences. They created common routines so that their lives could resemble those of "normal" families. These efforts seemed motivated by a fundamental striving for a stable family and home life. This "striving for stability" was sometimes undermined by limitations in family finances, family cohesion, and unpredictability of the child's condition. (3) Conflicting social values: families were offended by the reactions that they faced in their everyday community. They believe that the child's life is devalued, frequently referred to as a life not worth maintaining. They felt like strangers in their own communities, sometimes needing to seclude themselves within their homes. (4) Living in isolation: families reported a deep sense of isolation. In light of the complex medical needs of these children, neither the extended families nor the medical system could support the families' respite needs. (5) What about the voice of the child? The children in this study (patients and siblings) were generally silent when asked to talk about their experience. Some children described their ventilators as good things. They helped them breathe and feel better. Some siblings expressed resentment toward the increased attention that their ventilated sibling was receiving. (6) Questioning the moral order: most families questioned the "moral order" of their lives. They contemplated how "good things" and "bad things" are determined in their world. Parents described their life as a very unfair situation, yet there was nothing that they could do about it. Finally, an overarching phenomenon that best characterizes these families' experiences was identified: daily living with distress and enrichment. Virtually every aspect of the lives of these families was highly complicated and frequently overwhelming. An immediate interpretation of these findings is that families should be fully informed of the demands and hardships that would await them, encouraging parents perhaps to decide otherwise. This would be but a partial reading of the findings, because despite the enormous difficulties described by these families, they also reported deep enrichments and rewarding experiences that they could not imagine living without. Life with a child who requires assisted ventilation at home involves living every day with a complex tension between the distresses and enrichments that arise out of this experience. The conundrum inherent in this situation is that there are no simple means for reconciling this tension. This irreconcilability is particularly stressful for these families. Having their child permanently institutionalized or "disconnected" from ventilation (and life) would eliminate both the distresses and the enrichments. These options are outside the realm of what these families could live with, aside from the 1 family whose child is now permanently hospitalized, at a tremendous cost of guilt to the family.

CONCLUSIONS

These findings make important contributions by (1) advancing our understanding of the moral experiences of this group of families; (2) speaking to the larger context of other technology-dependent children who require home care; (3) relating home care experiences to neonatal, critical care, and other hospital services, suggesting that these settings examine their approaches to this population that may impose preventable burdens on the lives of these children and their families; and (4) examining a moral problem with an empirical method. Such problems are typically investigated through conceptual analyses, without directly examining lived experience. These findings advance our thinking about how we ought to care for these children, through a better understanding of what it is like to care for them and the corresponding major distresses and rewarding enrichments. These findings call for an increased sensitization to the needs of this population among staff in critical care, acute, and community settings. Integrated community support services are required to help counter the significant distress endured by these families. Additional research is required to examine the experience of other families who have decided either not to bring home their child who requires ventilation or withdraw ventilation and let the child die.