Nursing of Children and Families: A Selected State of the Science Marion E. Broome, PhD, RN, FAAN Sharron Crowder, MN, RN Sharron Crowder, MN, RN Mark

Nursing of Children and Families: Nursing of Children and Families:

A Selected State of the Science A Selected State of the Science

Marion E. Broome, PhD, RN, FAANMarion E. Broome, PhD, RN, FAAN

Sharron Crowder, MN, RNSharron Crowder, MN, RN

Mark J. Fisher, MS, RNMark J. Fisher, MS, RN

Lek Seal, PhD, RNLek Seal, PhD, RN

Indiana University School of NursingIndiana University School of Nursing

Indiana University School of NursingIndiana University School of Nursing

Purpose: what we will do here todayPurpose: what we will do here today

Describe the evolution of the knowledge

base in 3 foci of inquiry:

a)a)Interventions for children with asthma (Interventions for children with asthma (CrowderCrowder))

b)b)Health care provider-parent relationships (Health care provider-parent relationships (FisherFisher))

c)c) Interventions for overweight children (Interventions for overweight children (SealSeal))

Marion E. BroomeMarion E. Broome 22

State of the Science - 2009

• PubMed

• Pediatric 167,392

• Pediatric cancer 23,962

• Pediatric pain 7,094

• Parents 110,269

Criteria for this approach

• 1 family focused topic under investigated

• Chronic illness with long history of interventions

• Community based health problem with genetic association

Continued….PurposeContinued….Purpose

• Theoretical perspectives used to study the Theoretical perspectives used to study the area of inquiryarea of inquiry

• Methodological approaches usedMethodological approaches used

• Synthesis of what is knownSynthesis of what is known

• Challenges in the study of the Challenges in the study of the phenomenonphenomenon

• Recommendations for future inquiryRecommendations for future inquiry


Asthma Self-Management Asthma Self-Management Interventions for Children and Interventions for Children and

Adolescents with AsthmaAdolescents with Asthma

Sharron Crowder, MN, RNSharron Crowder, MN, RN

PhD Student, IUSONPhD Student, IUSON

NRSA 1F31NR010985-01NRSA 1F31NR010985-01

Literature ReviewedLiterature Reviewed

• Studies published – 2000-2008

• Sources– CINAHL, Cochrane, ERIC, Family and Society Studies Worldwide,

Humanities International, MEDLINE, PsycINFO databases and references from relevant articles from 2000 to 2008.

• Key terms– Adolescent, asthma, asthma education, child, intervention,

randomized controlled trials, self-care, self-management

Models and FrameworksModels and Frameworks

Common concepts across studies: adherence, asthma knowledge,Common concepts across studies: adherence, asthma knowledge,

quality of life, self-care, self-efficacy, and self-management quality of life, self-care, self-efficacy, and self-management


Theories, Models/Frameworks

11/30

Transtheoretical Transtheoretical ModelModel (n=1) (n=1)

PRECEDE-PROCEDEPRECEDE-PROCEDE Model (n=1) Model (n=1)Health Belief ModelHealth Belief Model (n=2) (n=2)

Social Cognitive Social Cognitive TheoryTheory (n=7) (n=7)

mbroome

Methods to Build KnowledgeMethods to Build Knowledge

Randomized Controlled TrialsRandomized Controlled Trials1980-1989: Comprehensive Asthma Education Interventions (n=10)1980-1989: Comprehensive Asthma Education Interventions (n=10)

1990-1999: Comprehensive Asthma Management Interventions 1990-1999: Comprehensive Asthma Management Interventions

+Peak Flow Monitoring +Asthma Action Plans (n=13)+Peak Flow Monitoring +Asthma Action Plans (n=13)

Our FocusOur Focus

2000-2008: Multifaceted, Multimedia Asthma Management 2000-2008: Multifaceted, Multimedia Asthma Management

Interventions (n=30)Interventions (n=30)◊ ◊ Asthma EducationAsthma Education

◊ ◊ Self-Management BehaviorsSelf-Management Behaviors

◊ ◊ Self-Monitoring SkillsSelf-Monitoring Skills

◊ ◊ Asthma Action PlansAsthma Action Plans

◊ ◊ Behavioral StrategiesBehavioral Strategies


Synthesis of FindingsSynthesis of FindingsParticipants Populations/

SettingsIntervention Delivery Medium/Target

Outcomes

Ages:

Children 2-12 years (n=13)

Children/Adolescents 2-18

Parents/Children 2-12

Adolescents 13-18 (n=3)

Gender:

Males >Females (n=17/30)

Races:

White, African American, Hispanic, Other (n=19)

Minorities: (n=11)

African American

Hispanics

African American & Hispanics

Urban (n=8) Rural

Outpatient (n=12)

School

Home

ER

Inpatient

Computers: (n=11)

Videos

Diaries

Games

Telephone Prompts

Peak Flow Meters (n=8)

Individual (n=21/30)

Group

Individual + Group

Healthcare Utilization: (ER, Acute Care Visits,

Hospitalizations (n=15))

Asthma Symptoms

Knowledge

Asthma Self-Management

Lung Function

Medication

Self-Efficacy

QOL

School Absences

Behavioral Strategies

Cost-effectiveness

Limitations and ChallengesLimitations and Challenges

LimitationsLimitations• Models or theoretical frameworks used in few studies Models or theoretical frameworks used in few studies

• Small sample sizes, specific populations, and settings decrease generalizabilitySmall sample sizes, specific populations, and settings decrease generalizability

• Small sample sizes limit the statistical power to detect significant differencesSmall sample sizes limit the statistical power to detect significant differences

• Short term follow-up can only assess immediate gainsShort term follow-up can only assess immediate gains

ChallengesChallenges• Recruitment of children/adolescents, especially low SES, minoritiesRecruitment of children/adolescents, especially low SES, minorities

• Compare effectiveness of interventions using new and existing instrumentsCompare effectiveness of interventions using new and existing instruments

• Multimedia interventions used for broad age rangesMultimedia interventions used for broad age ranges

• Determine the most effective theory-based interventions for diverse populations Determine the most effective theory-based interventions for diverse populations and settingsand settings


Future ResearchFuture Research

Multifaceted Asthma Self-Management Programs:

1. Incorporate multiple behavioral strategies into interventions

2. Identify specific program components that improve asthma outcomes.

3. Determine sustainability of intervention effects through longer follow-up.

Interventions:

1. Develop and evaluate effectiveness of tailored, theoretically-based, multimedia

interventions.

2. Identify moderators and mediators of intervention effectiveness.

3. Determine cost-effectiveness of interventions for translation into care.

Collaborative Research:

Multidisciplinary teams are needed to develop effective interventions to improve asthma

self-management.


Health Care Provider-Parent Health Care Provider-Parent RelationshipsRelationships

Mark J. Fisher, MS, RN

PhD Student IUSON

Literature ReviewedLiterature Reviewed

• Key terms: parents; providers including nurses, physicians, and others; professionals; relations-relationships; chronic condition-disease-illness; communication-interaction

• Years covered: 1999-2008• Sources: CINAHL, MEDLINE, PsycINFO, Health

and Psychological Instruments, Evidence Based Medical Reviews – Cochrane Database of Systematic Reviews, reference lists from articles

• Many theories, models, and frameworks identified– Three examples used, cited, or referenced most commonly

• Nursing Mutual Participation Model of Care– Curley in the late 1980’s and early 1990’s– Reducing and/or alleviating parental stress

• Stages of health care relationships– Thorne and Robinson in the mid-late 1980’s– Naïve trusting, disenchantment, and guarded alliance

• Patient and Family-Centered Care– Referenced in late 1960’s – late 1980’s and early 1990’s– Core principles: dignity and respect, information sharing,

participation, and collaboration– Nine elements of family-centered care based on principles

Models and FrameworksModels and Frameworks

• Quantitative– Very few quantitative

studies noted in the literature

– One randomized controlled trial – satisfaction

• Qualitative– Grounded theory,

phenomenology, ethnography

– Descriptive, exploratory, convenience samples

– Interviews, questionnaires, and surveys

• Reviews: Systematic, Integrative, & Metasynthesis– Parents/families:

• Parent participation, decision making, support, presence

• Parent’s needs, trust, and experiences/interactions

• Chronic illness• Negotiation• Interpersonal skills of doctors• Stress and coping• Family-centered care

– Health care providers:• Collaboration• Team collaboration• Family-centered care

Methods to Build KnowledgeMethods to Build Knowledge

Synthesis of FindingsSynthesis of Findings• Health care providers

– Partnership, collaboration, negotiation– Technically capable and empathetic– Expectations, decision-making, medical home– Communication

• Parents– Respect, support, satisfaction, – Needs, expectations, uncertainty– Participation, involvement, decision-making, medical home– Education, experience with hospitalization– Communication

• Measurement tools– Working Alliance Inventory– Concepts related to family-centered care (Practice Continuum Tool)– Patient/Parent Information and Involvement Assessment tool

Limitations and ChallengesLimitations and Challenges

• Sample– Small sample sizes– Cross-sectional– Convenience samples– Other sampling issues

• Methods– Interviews– Questionnaires– Surveys

• Self-reported data – behaviors and actions

• Tools and measurement methods– Adapted from adult for

pediatric application– Minimal testing– Family-centered care

• Limited pre-existing evidence

Future ResearchFuture Research• Phenomena: alliance, partnership, collaboration, relationship• Gender-related issues

– Creative methods of getting fathers involved in research• Family-centered care

– Measurement methods – tool development and testing• Parents’ participation in care

– Stages of child’s chronic illness (diagnosis, short-term, long-term)– Medical home

• Relationship-centered care– Self-awareness, patient/parent experience, caring relationships, and

effective communication• Outcome measures in addition to satisfaction

– Cost, quality of care, and safety• Multiple disciplines/individuals involved in same study

– Nurses, physicians, other disciplines, children, and parents

Interventions for Childhood ObesityInterventions for Childhood Obesity

Nuananong Seal, PhD, RNAssistant Professor, University of North Dakota

Post Doctoral Fellowship,

Indiana University

T32NR7066-18

20

Trends in Overweight* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2004

*Overweight is defined as at or above the 95th percentile for body mass index by age and sex based on reference data. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004: Ogden CL, et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA 2006; 295 (13): 1549-55.

54

65

7

5

7

11 1110

16 16

14

19

17

0

5

10

15

20

2 to 5 years 6 to 11 years 12 to 19 years

Pre

va

len

ce

(%

)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2004

Model of Childhood Obesity Development

22

Literature review and Literature review and Methodological approachMethodological approach

Synthesis of FindingsSynthesis of Findings• The majority of programs targeted children

aged 6–11 years, while only 6% of programs addressed the 0–5 years old

• Fewer than 3% programs were implemented in the home setting,

• Few programs addressed gender-specific differences. 11% of programs targeted girls and only 3% targeted boys.

• Only ¼ of programs follow up over than 1 year

• The majority of the programs included health education on diet, physical activity or both (69%) and engagement in physical activity (64%).

• Few programs focused on subgroups of children e.g., American Indians, and Hispanics.

Challenges & Future Directions Challenges & Future Directions in Obesity in Childhood in Obesity in Childhood

ResearchResearch• Must address biological, behavioral and environmental factors

• Integrate emerging knowledge in genomics into primary prevention and treatment of obesity

• Translate these research-informed models into practice by using them to guide multi-level prevention approaches that reach into health care, school, workplace, and community settings.

• Evaluate the potential for innovative individual behavioral approaches for weight control or maintenance in the context of diverse environments.

• Collaborate with experts from academic, medicine, other health care providers, and federal government

• More research on parental lifestyle factors and their effects on child body weight as well as family-based interventions

• More research on subgroups of children (e.g. American Indians, Hispanics)

• Refinement and innovation in the measurement of diet,

physical activity, body composition, and other

physiological states and processes.• More research on health care providers and systems to

better understand obesity care practices as well as

barriers in obesity care.

Documents

Nursing of Children and Families: A Selected State of the Science Marion E. Broome, PhD, RN, FAAN Sharron Crowder, MN, RN Sharron Crowder, MN, RN Mark