Transition to Adulthood for Young People with Medical Complexity: An Integrative Literature Review

Technology-based parent school: A randomized controlled trial

OBJECTIVE

This study was conducted as a randomized controlled trial to evaluate the technology-based parent school program.

DESIGN

The study was conducted in the well-child care outpatient clinic of a hospital in Turkey. Data were collected between October 31, 2022 and February 17, 2023. The parent school was prepared based on Meleis' transition theory.

SAMPLE

Forty-eight parents participated in the study. Parents in the intervention group participated in a 10-week parent school program (five website modules, five online interactive group trainings, and counseling).

MEASURES

Data were collected before the program, after the program, and 1 month after the program.

RESULTS

There were increases in the mean scores of the "Parent Skill Assessment Form" and "Skills Assessment Form for the Toddler Development" items in the intervention group compared to the control group. The difference between the groups in the mean scores of the Self-Efficacy for Parenting Task Index Toddler Scale (1-3 years) was not statistically significant. However, the difference between the times was statistically significant.

CONCLUSION

It was concluded that the technology-based parent school training program could guide parents with children aged 1-3 years on child-rearing.

TRIAL REGISTRATION

It was registered at ClinicalTrials.gov in May 2022 (NCT05370989).

Development and psychometric analysis of care needs scale for mothers of children with congenital heart disease

PURPOSE

This cross-sectional study aimed to create and evaluate a care needs scale for mothers of children with congenital heart disease (CHD) to determine its psychometric properties.

DESIGN AND METHODS

This methodological research was conducted with 155 mothers whose children were diagnosed with CHD and were treated at a university hospital. The study's methodology included scale development, specialist opinions, and a pilot test. Data analysis involved descriptive statistics, exploratory and confirmatory factor analyses, and reliability assessments.

RESULTS

The 11-item scale was created using component analysis, expert comments, and pilot testing. It was divided into two categories: Information Needs Regarding Disease and Treatment and Needs Regarding Care. The Exploratory Factor Analysis revealed a 2-factor structure, explaining 41.5% of the variance. Reliability analysis showed reliable dimensions, and Tukey's scalability test indicated the scale requires separate dimension evaluation. The model fit indices were obtained as CMIN/DF (72.751/41) = 1.774, GFI = 0.925, IFI = 0.923, TLI = 0.893, CFI = 0.920, RMSEA = 0.071, SRMR = 0.063. The Cronbach's alpha coefficient for subdimension 1 was 0.758, and for subdimension 2 was 0.678, indicating reliable dimensions.

CONCLUSION

The developed scale provides a valuable tool for assessing the care needs of mothers of children with CHD, contributing to enhancing maternal support programs in pediatric cardiology clinics.

PRACTICE IMPLICATIONS

Assessment of the care needs of mothers who have children with CHD is promising for the development of educational programs on this subject and to ensure the competence of mothers for care.

Scoping Review on Transitions in the Context of Pediatric Palliative Care

Background: Children with complex and chronic conditions receiving palliative care will likely experience many transitions during their life and their treatments. Transition periods for children with life-limiting conditions and their families can be bewildering and highly anxiety-inducing. However, clinical observations seem to point to a more heterogenous care offer, including a lack or discontinuity of services, at the expense of their quality of life. Objective: This paper aims to establish a portrait of the existing literature and identify research gaps on the multiple transitions experienced by this population. Design: A scoping review is provided, following a PRISMA protocol. MEDLINE, PubMed and CINAHL were consulted. The search strategy is based on three key concepts: (1) palliative care/complex condition, (2) child/adolescent, and (3) transition. Articles were screened with the help of Covidence. Results: A total of 72 articles are included for analysis. The aimed population is either identified by age group or by medical status. Respondents are most often parents rather than the children themselves. Transitions include: reaching adulthood, changes in care environment, changes in medical status, and school integration. Conclusion: The discussion notices a definitional murkiness about transitions and highlights the fact that the multifaceted and complex nature of transition over time is largely ignored. New research should involve a diversity of participants and include children's voices. Recommendations include clearer concept definitions, health care policies that adopt an ecosystemic approach, and professional training in the systemic family approach in palliative care.

Exploring fathers' experiences of caring for a child with complex care needs through ethnography and arts-based methodologies

BACKGROUND

Although the number of children living with complex care needs (CCN) is increasing worldwide, there is limited data on the experience of fathers caring for children with CCN. This paper reports on findings specific to fathers' experiences of caring for their child with CCN and highlights recommendations provided for parents of children with CCN, service providers, and policymakers. The findings emerged from a larger study designed to examine how Canadian families of children with CCN participate in society.

METHODS

We used the qualitative research approach of ethnography and arts-based methodologies (ecomaps and photovoice) as well as purposive and snowball sampling techniques. Four parents were engaged as advisors and twenty-nine fathers participated in interviews (all were married or in a relationship; age range of 28 to 55 years). In line with an ethnographic approach, data analysis involved several iterative steps including comparing data from the first, second, and third set of interviews and refining themes.

RESULTS

One overarching theme, striving to be there for the child with CCN, was identified. Five supporting themes further exemplified how fathers strived to be there for their child: 1) contributing to the parental team through various roles; 2) building accessibility through adaptation; 3) engaging in activities with the child; 4) expressing admiration and pride in their children; and 5) meaning making. Recommendations for parents included making and nurturing connections and asking for help while recommendations for healthcare and social service providers included communicating authentically with families and listening to parents. Fathers also indicated that leadership and funding for programs of families of children with CCN should be priorities for policymakers.

CONCLUSIONS

In addition to documenting fathers' active involvement in their child's care and development, our findings provide new insights into how fathers make participation in everyday life accessible and inclusive for their children. Study findings also point to 1) priority areas for policymakers (e.g., accessible physical environments); 2) factors that are critical for fostering collaborative care teams with fathers; and 3) the need for complex care teams in the adult health care system. Implications for those providing psychosocial support for these families are noted as well as knowledge gaps worthy of future exploration such as the role of diversity or intersectionality in fathering children with CCN.

Composing adult lives with a ventilator at the intersection of developmental and neoliberal discourses of time

This paper explores temporalities and experiences of time drawn from an analysis of interview data from a critical narrative inquiry of the experiences of young adults living with home mechanical ventilation (HMV). The analysis centers the ideological effects of dominant discourses that shape understandings of time in the Euro-Western world and the ways in which young adults' stories prompt a rethinking of time in health research and praxis. Data generation involved interviews and photo-elicitation with five young adults (ages 18-40). A critical narrative analysis of participants' stories surfaced the influence of ableist, developmentalist, and neoliberal discourses of time and the creative resistance that points to the potential of crip orientations to time in opening up possibilities for living. Implications for practice and research are offered.

Challenges, Complexity, and Developments in Transition Services for Young People with Disabilities, Mental Health, and Long-Term Conditions: An Integrative Review

Transition to adulthood for young people is complex and multi-faceted, with additional hurdles for young people who have disabilities, long-term, or life-limiting conditions or mental health problems. The challenges in providing effective transition support are not new; researchers, policymakers, commissioners, and service providers have been grappling with the problem for several decades, with varying degrees of success. The aims of this integrative review were firstly to build on previous research to synthesize and evaluate recently published evidence. Secondly to provide an overview of the effectiveness of interventions (in one or a combination of health, social care, and education transitions) designed to support transition to adulthood in these groups of young people. A search of a range of databases retrieved published literature from January 2015 to January 2021 demonstrating global interest in the topic. Fifty-one articles were included following an appraisal of quality and eligibility. Qualitative, quantitative, mixed methods studies, and evidence synthesis were included. Some studies were clinically orientated whilst others examined the impact of the transition process, or utilized participatory approaches which give young service-users and families a voice. Transition between children's and adult health or care services as well as other life-course trajectories, such as life-skills development, education transitions, social inclusion and employability were evaluated. Thematic analysis and synthesis of articles retrieved in this review highlighted themes identified in previous reviews: timing of, and preparation for transition; perceptions and experience of transition; barriers and facilitators; transition outcomes. Additional themes included special considerations; dealing with complexity; advocacy, participation, autonomy, aspirations, and young people's rights; future work, research, and evaluation. Novel perspectives and diverse data sources contributed to holistic understanding of an ongoing priority for international policy, service development, and research: the complexity of providing effective transition support and achieving positive outcomes for young people with long-term and life-limiting health conditions, disabilities, and mental health difficulties.

Health Care Transition: The Struggle to Define Itself

Health care transition is an expanding field of health care practice and research focused on facilitating adolescents and emerging adults with long-term conditions to transfer uninterruptedly from pediatric to adult health care services and to transition successfully into adulthood and beyond. There is a widespread need to develop and implement service models as approximately one million adolescents and emerging adults with long-term conditions transfer their care into the adult system and enter adulthood. The purpose of this article is to explore major issues associated with the current state of health care transition practice, research and ultimately policymaking and systems change. The prominent issues addressed in this article include the following. Defining clearly what constitutes models of health care transition practice as ambiguity exists with terminology used with concepts integral to health care transition. The indistinct meanings of health care transition terminology commonly used, such as transition, transfer, readiness, and preparation, need to be operationalized for widespread application. Furthermore, questions remain as to what goal-directed outcomes are expected within this field of practice and science.

'Struggling to participate in everyday life': emerging adults' experiences of living with long-term health challenges

AIM

To gain a deeper understanding of the experiences of participation in the everyday life of emerging adults living with long-term health challenges and how this influences their own quality of life.

METHODS

Using an explorative study design, data were collected through in-depth interviews with a sample of 12 young people aged 18-29 years living with long-term health challenges in Norway.

FINDINGS

The analysis identified one overarching theme of struggling to participate in everyday life, and four subthemes: the notion of being independent but also dependent, experiencing mismatch between needs and support, experiencing deprivation of spontaneity and feeling uncertain about the future. The emerging adults experienced difficulties with participation in key areas of life such as education, employment and leisure activities. Associated symptoms of their diagnosis, limited physical abilities and lack of sufficient support made it hard to participate in everyday life the way they aspired to.

CONCLUSION

The challenges of living with a long-term health challenge as an emerging adult contributed to limitations in participation in different areas of life that was perceived as important for their quality of life.

The role and the composition of a liaison team to facilitate the transition of adolescents and young adults: an umbrella review

Adolescents and young adults (AYAs) benefit from healthcare transition (HCT) programs. Despite the well-established literature reviewing HCT, a considerable heterogeneity exists on the involved healthcare professionals. This review aims to explore systematic reviews on the practices and recommendations on which disciplines of professionals should be involved in HCT. An umbrella review was performed using the MEDLINE, EMBASE, and Web of Science databases. To be eligible, systematic reviews had to report on the composition and/or the rationale of members of a transition team. Seventeen reviews were included in this systematic review. A healthcare professional that coordinates HCT was identified as a key caregiver in all reviews. Other reported members of a HCT team were nurses (75% of the reviews), social workers (44%), and peers/mentors (35%). The reported key responsibilities of a HCT team were to (i) manage communication, (ii) ensure continuity of care, and (iii) maintain contact with community services.  Conclusions: A team responsible for HCT should be active on the organizational, medical, and social levels. Key members of a HCT team vary little between diseases and included a coordinator, social worker, and nurse. A coordinating physician could facilitate transition in complex conditions. At all times, the condition and needs of the AYA should determine who should be involved as caregiver. What is Known: • The psychosocial needs of adolescents and young adults during healthcare transition are largely similar between chronic diseases. What is New: • Coordinators, nurses and social workers were the most involved, independent of the condition. • A liaison team should be active on organizational-, medical- and social-levels.

"They go hand in hand": a patient-oriented, qualitative descriptive study on the interconnectedness between chronic health and mental health conditions in transition-age youth

BACKGROUND

Transition-age youth (TAY) with chronic health conditions frequently experience co-occurring mental health conditions. However, little is known about the perspectives of TAY with co-occurring diagnoses preparing to exit pediatric health and mental health services. Research is needed to understand the impact of a mental health condition on transition readiness and self-management in TAY with chronic health conditions.

METHODS

TAY (aged 16-20 years) with co-occurring chronic health and mental health conditions were recruited in Alberta, Canada. Nine semi-structured individual interviews were completed by phone or videoconference, and transcribed verbatim. Guided by qualitative description, we analyzed the data using thematic analysis in partnership with five young adults with lived experience in the health/mental health systems.

RESULTS

Participants shared their experiences living with simultaneous physical and mental health concerns and preparing for transition to adult care. Our analysis revealed three overarching themes: 1) "they're intertwined": connections between chronic health and mental health conditions in TAY, 2) impact of mental health on transition readiness and self-management, and 3) recommendations for service provision from the perspectives of TAY.

CONCLUSIONS

Our findings highlighted the myriad ways in which physical and mental health are connected as TAY prepare for service transitions using specific examples and powerful metaphors. TAY endorsed the importance of providers discussing these connections in routine clinical care. Future research should involve co-designing and evaluating educational material addressing this topic with diverse TAY, caregivers, and service providers.

Transitions Theatre: Creating a Research-Based Reader's Theatre With Disabled Youth and Their Families

Transition to adult life can be a challenging time for disabled youth and their families. This article describes the collaborative creation of Transitions Theatre, a research-based reader's theatre activity based on narrative interviews with eight disabled youth (aged 17-22) and seven parents. Analysis of these interviews generated two opposing yet interrelated themes. On one hand, youth and families felt lost in transition facing multiple gaps in healthcare, financial support, education, and opportunities for social participation after having "aged out" of the pediatric system. On the other hand, they started cripping "normal" adulthood to envision more inclusive futures wherein disabilities are understood as integral to society. These two themes were transformed into two reader's theatre scripts, one featuring a youth, the other featuring a parent. Seven youth and four parents (six of them were original interview participants) then participated in a Transitions Theatre workshop to read the scripts together and discuss the authenticity and relatability of the scripts. Participant feedback suggested that the reader's theatre method was effective in sharing findings with research participants and stimulating a critical dialogue on how to (re)imagine transition to adulthood. We discuss the importance of implementing inclusive design strategies to make reader's theatre accessible to participants with diverse abilities and preferences.

Experiences of siblings of children with congenital heart disease during Coronavirus disease 2019; A qualitative interview study

PURPOSE

To explore siblings' perceptions of having a brother or sister with congenital heart disease in the UK during the COVID-19 pandemic.

DESIGN AND METHODS

Siblings of children with congenital heart disease aged 8-17 years old were interviewed via video call technology between September 2020 and February 2021. We conducted reflexive thematic analysis of these interviews to generate themes.

FINDINGS

Interviews took place with 17 siblings, predominantly of white ethnicity n = 15 (86%). Most siblings interviewed were first born in the family n = 15 (88%), and most children with CHD were the youngest n = 15(88%). Four themes were generated; My sibling is vulnerable, what does this mean for my family, I have a responsibility to protect my brother or sister, our family time during the pandemic and adjustment and adaptations to pandemic life.

CONCLUSIONS

Siblings identified difficult aspects of the pandemic and these related to concerns about their brother's or sister's vulnerability, family impact, and keeping their sibling safe. They also identified adjustments they made to keep their family functioning throughout the COVID-19 pandemic. Despite the worry and uncertainty siblings experienced, they valued increased family cohesion which helped to mitigate some challenges of the restrictions imposed in the UK.

PRACTICE IMPLICATIONS

Honest and open communication is valued by siblings. It is vital to ensure siblings receive the support they need to ensure they keep up with their schooling and social commitments as pandemic related restrictions ease.

A Comparison of Young Adults With and Without Cancer in Concurrent Hospice Care: Implications for Transitioning to Adult Health Care

Purpose: Concurrent hospice care provides important end-of-life care for youth under 21 years. Those nearing 21 years must decide whether to shift to adult hospice or leave hospice for life-prolonging care. This decision may be challenging for young adults with cancer, given the intensity of oncology care. Yet, little is known about their needs. We compared young adults with and without cancer in concurrent hospice care. Methods: Retrospective comparative design used data from 2011 to 2013 U.S. Medicaid data files. Decedents were included if they were 20 years of age, enrolled in Medicaid hospice care, and used nonhospice medical services on the same day as hospice care based on their Medicaid claims activity dates. Results: Among 226 decedents, 21% had cancer; more than half were female (60.6%), Caucasian (53.5%), non-Hispanic (77.4%), urban dwelling (58%), and had mental/behavioral disorder (53%). Young adults with cancer were more often non-Caucasian (68.7% vs. 40.4%), technology dependent (47.9% vs. 24.2%), had comorbidities (83.3% vs. 30.3%), and lived in rural (58.3% vs. 37.6%), southern (41.7% vs. 20.8%) areas versus peers without cancer. Those with cancer had significantly fewer live discharges from hospice (5.7 vs. 17.3) and sought treatment for symptoms more often from nonhospice providers (35.4% vs. 14.0%). Conclusions: Young adults in concurrent hospice experience medical complexity, even at end-of-life. Understanding care accessed at 20 years helps providers guide young adults and families considering options in adult-focused care. Clinical and demographic differences among those with and without cancer in concurrent care highlight needs for research exploring racial and geographic equity.

The role of family adaptation in the transition to adulthood for youth with medical complexity: a qualitative case study protocol

Background

For youth with medical complexity and their families, the transition to adulthood is a stressful and disruptive period that is further complicated by the transfer from relatively integrated and familiar pediatric services to more fragmented and unfamiliar adult services. Previous studies report that families feel abandoned, overwhelmed, and unsupported during transition. In order to provide better support to families, we need to understand how families currently manage transition, what supports they need most, and how key factors influence their experiences. The aim of this study is to understand how families of youth with medical complexity adapt to the youth’s transition to adulthood and transfer to adult health care, social, and education services, and to explain how contextual factors interact to influence this process.

Methods

Informed by the Life Course Health Development framework, this study will use a qualitative explanatory case study design. The sample will include 10–15 families (1–3 participants per family) of youth with medical complexity (aged 16–30 years) who have lived experience with the youth’s transition to adulthood and transfer to adult services. Data sources will include semi-structured interviews and resources participants identified as supporting the youth’s transition. Reflexive thematic analysis will be used to analyze interview data; directed content analysis will be used for documentary evidence.

Discussion

While previous studies report that families experience significant challenges and emotional toll during transition, it is not known how they adapt to these challenges. Through this study, we will identify what is currently working for families, what they continue to struggle with, and what their most urgent needs are in relation to transition. The anticipated findings will inform both practice solutions and policy changes to address the needs of these families during transition. This study will contribute to the evidence base needed to develop novel solutions and advance policies that will meaningfully support successful transitions for families of youth with medical complexity.

Transition to adult care for youth with medical complexity: Assessing needs and setting priorities for a health care improvement initiative

BACKGROUND

Technological advances have led to more youth with medical complexity (YMC) who are living into adulthood and being transferred from pediatric to adult care. The transition to adult care is a complex and challenging process, partly due to differences in how pediatric and adult systems deliver health care. YMC and their families need support from their health care providers to ease this transition. To identify how to better support transitioning YMC, a needs assessment was conducted to examine the current state of transitional support for youth and families cared for by a pediatric Complex Care Program.

AIMS

The aims of this needs assessment were to understand the transition practices of pediatric Complex Care Programs, explore transition-related needs of YMC and their families, and identify priorities for future quality improvement.

METHODS

This project involved three components: a literature review, a benchmarking survey of pediatric Complex Care Programs in Ontario, and key informant interviews.

FINDINGS

The benchmarking survey identified transition planning and transfer of care as areas of strength in the Complex Care Program, while transition readiness and transfer completion provided opportunities for improvement. Stakeholder collaboration, an early start, and knowledgeable providers facilitated a successful transition. Barriers included lack of time, poor access to adult services and resources, higher medical complexity, and inadequate support for adult health care providers.

CONCLUSIONS

Recommendations for improving transitional care for YMC are provided, along with resources, tools, and considerations for implementation.

Health Care Transition for Children with Medical Complexity: Challenges and Lessons Learned

BACKGROUND

Transition from pediatric to adult health care is a pivotal process for young adults, especially those with complex medical needs. Despite advancements in the medical care provided to children with medical complexity (CMC), there is a lack of systematic approaches and guidance for patients and families transitioning from pediatric to adult health care.

METHODS

Health care providers and nurse case managers in the Complex Care Program (CCP) evaluated health care transition practices prior to 2019, and initiated quality improvement efforts to standardize transition guidance, planning, and documentation from 2019 to 2020 within the CCP.

FINDINGS

Challenges identified with transitioning CMC include: 1) Varied approaches and timelines for health care providers, 2) Documentation in the EMR, and 3) Connecting to adult health care systems. Throughout this work, CCP staff have learned lessons to effectively transition CMC. Themes included: 1) Transition from a pediatric to an adult primary care provider first, 2) Start transition conversations early, 3) Identify a universal location to document transition planning, and 4) Importance of family involvement.

IMPLICATIONS FOR PRACTICE

To effectively transition CMC, health care staff must start conversations early, engaging all primary and specialty providers, patients, and families to create safe transition plans.

Successful healthcare transition for youth with special healthcare needs is a team effort

ABSTRACT

NPs care for persons across the age continuum and transitions commonly occur. Some are unexpected, like hospitalizations for acute illness or injury. Others are an expected consequence of growing up, like moving from pediatric to adult care models. Understanding the factors impacting healthcare transition is critical for successful outcomes.

Canadian Resources for Siblings of Youth With Chronic Health Conditions to Inform and Support With Healthcare Management: A Qualitative Document Analysis

Background: As children and adolescents with a chronic health condition (CHC) age and transition to adulthood, many will increasingly assume responsibilities for the management of their healthcare. For individuals with CHCs, family members including siblings often provide significant and varied supports. There are a range of resources in Canada to support siblings of individuals with a CHC, but these resources are not synthesized and the extent to which they relate to healthcare management remains unclear.

Purpose: The purpose of this document review was to identify, describe, and synthesize the types of resources currently available to provide general information and healthcare management information about how siblings can provide support to individuals with CHCs in Canada.

Methods: Print and electronic resources were systematically identified and retrieved from the websites of organizations, treatment centers, and children's hospitals that are part of Children's Healthcare Canada. Each unique resource was treated as a text document. Documents that met the following inclusion criteria were included: addressed the topic of siblings of individuals with a CHC and written in English. Data were extracted from included documents and qualitative conventional content analysis was conducted. Throughout the process of this review, we partnered with a Sibling Youth Advisory Council.

Results: The systematic search yielded 1,628 non-duplicate documents, of which 163 documents met the inclusion criteria. Of the total of 163 documents, they were delivered in the following formats: 17 (10%) general informational products (e.g., booklets, videos) about a CHC and sibling relationships, 39 about support programs and workshops (24%), 34 news articles (21%) that described the roles of siblings, and 6 (3%) healthcare management informational products (e.g., toolkit, tipsheets), 31 blogs (19%) and 39 interviews (24%) with parents and siblings. In the blogs and interviews, siblings and parents described how siblings developed knowledge and skills for healthcare management, as well as their role and identity over time.

Significance: This study identified that there are limited resources available about healthcare management for siblings of CHC in Canada. Resources are needed to facilitate conversations in the family about the role of siblings with healthcare management of their sibling with a CHC.

Investigating Specialized Chronic Pain Care Among Emerging Adults

BACKGROUND

  AIMS: To investigate characteristics of emerging adults accessing a specialized chronic non-cancer pain clinic and describe interventions offered and utilized by this group.

DESIGN

A retrospective chart review was conducted of emerging adults and middle-aged adults with chronic pain receiving care over a six-month period.

SETTING

A chronic pain clinic in Southeastern Ontario.

PARTICIPANTS

82 participants comprised of 41 emerging adults (aged 18-29) and 41 middle-aged adults (aged 30-64) METHODS: Groups were matched on sex and number of pain sites. Demographic and pain characteristics, interventions, referrals, and clinic utilization were examined using bivariate and multivariate analysis.

RESULTS

Emerging adults reported lower pain severity scores (t(80) = -2.15, p = .035), were more likely to receive referrals for additional consultation and/or diagnostic investigations (X²(1, n = 82) = 4.97, p = .026) and to have at least one psychology visit (X² = 7.29, p = .007). Moreover, emerging adults with higher depression scores were more likely to see a psychologist (OR 1.23, 95% CI 1.014-1.492).

CONCLUSIONS

Pain presentation and care patterns differed between emerging adults and middle-aged adults. Increased use of non-pharmacologic interventions in emerging adults may reflect differences in pain presentations as well as clinician's sensitivity to emerging adult's particular developmental needs but further research is needed. Further research is needed to contribute to nurses' understanding of the quality and efficacy of pain management approaches.

Children with medical complexity: A concept analysis

AIM

The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity."

BACKGROUND

Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications.

DESIGN

This analysis relied upon the framework described by Walker and Avant.

DATA SOURCE

The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity."

REVIEW METHODS

This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences.

RESULTS

This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology.

CONCLUSIONS

The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.

Using telehealth to assess depression and suicide ideation and provide mental health interventions to groups of chronically ill adolescents and young adults

Telehealth distance health care is a significant resource for young, chronically ill patient populations given their numerous medical complexities and their concomitant depression and/or suicide ideation experiences. This manuscript shares the telehealth methods used to prepare for a larger study of interventions for increasing adolescents' and young adults' chronic care resiliency and skills for preventing depression. The young patients in this study were prescribed lifelong home parenteral nutrition infusions, treatment for those with short gut bowel diseases. The training methods for our mental health nurse and psychologist to conduct depression and suicide ideation assessments from a distance are presented. The study implementation methods of group facilitated interventions and discussion are reviewed. The group discussions were conducted via audiovisual telehealth devices over encrypted firewall-protected connections with patients in their own homes and professionals in an office. The results of assessments of the 40 participants, 25% (n = 10) with depressive symptoms or suicide ideation, are described. Following participants' assessments, their subsequent depression measures were all in the normal range, without any suicide ideation, across the year of the study. Patient evaluation ratings were high in the areas of being able to connect with other young patients in similar situations, using the audiovisual equipment, and learning new useful information from the interventions. The methods developed for the study ensured that the safety and well-being of participants were supported through telehealth.

Young people with long-term health challenges experiences in transition to adulthood: A qualitative metasynthesis

AIMS

The aim of this study was to describe the experiences of the transition to adulthood for young people with long-term health challenges.

DESIGN

The metasynthesis approach was based on the guidelines by Sandelowski and Barroso for synthesizing qualitative research.

DATA SOURCES

Seven electronic databases: CINAHL, Medline, Embase, PsycINFO, Web of Science, Scopus, and SocIndex were searched on 6-10 February 2020.

REVIEW METHODS

Studies were critically appraised using the Joanna Briggs critical appraisal tool. Qualitative data were extracted, meta-summarised, then meta-synthesized.

FINDINGS

Nineteen qualitative studies were included in this review. Six themes illustrated experiences in the transition to adulthood: wishing for an 'ordinary' life, significance of close network, working towards independence, in need of systemic resources and services, psychosocial challenges and keeping a positive attitude.

CONCLUSION

Young people with long-term health challenges wished for as 'ordinary' a life as possible in the future. In the transition to adulthood, they gradually gained more competence in self-management skills and knowledge and strived to become more independent. By having a positive attitude and using other coping strategies, young people can work on some of the difficulties they experience in this phase. However, to achieve and maintain independence young people with long-term health challenges are dependent on the support of a close network and systemic support and services.

IMPACT

The findings highlight the need to help alleviate the fears and worries of young people with long-term health challenges and create opportunities for successful transition to adulthood by increased awareness and interventions from policy-makers and professionals in the health and social system.

Experiences of youth with medical complexity and their families during the transition to adulthood: a meta-ethnography

Youth with medical complexity (YMC) are a small subset of youth who have a combination of severe functional limitations and extensive health service use. As these youth become adults, they are required to transition to adult health, education, and social services. The transition to adult services is especially difficult for YMC due to the sheer number of services that they access. Service disruptions can have profound impacts on YMC and their families, potentially leading to an unsuccessful transition to adulthood. This meta-ethnography aims to synthesize qualitative literature exploring how YMC and their families experience the transition to adulthood and transfer to adult services. An in-depth understanding of youth and family experiences can inform interventions and policies to optimize supports and services to address the needs of this population at risk for unsuccessful transition to adulthood. Using Noblit and Hare’s approach to meta-ethnography, a comprehensive search of Medline, CINAHL, Embase, PsycINFO, Social Sciences Index, and Sociological Abstracts databases, supplemented by hand searching, was conducted to identify relevant studies. Included studies focused on the transition to adulthood or transfer to adult services for YMC, contained a qualitative research component, and had direct quotes from youth or family participants. Studies were critically appraised, and data were analyzed using meta-ethnographic methods of reciprocal translation and line of argument synthesis. Conceptual data from ten studies were synthesized into six overarching constructs: (1) the nature and process of transition, (2) changing relationships, (3) goals and expectations, (4) actions related to transition, (5) making sense of transition, and (6) contextual factors impacting transition. A conceptual model was developed that explains that youth and families experience dynamic interactions between their goals, actions, and relationships, which are bounded and influenced by the nature, process, and context of transition. Despite the tremendous barriers faced during transition, YMC and their families often demonstrate incredible resilience, perseverance, and resourcefulness in the pursuit of their goals. Implications for how the conceptual model can inform practice, policy, and research are shared. These implications include the need to address emotional needs of youth and families, support families in realizing their visions for the future, promote collaboration among stakeholders, and develop policies to incentivize and support providers in implementing current transition guidelines.

"Transition from children's to adult services for adolescents/young adults with life-limiting conditions: developing realist programme theory through an international comparison"

BACKGROUND

Managing transition of adolescents/young adults with life-limiting conditions from children's to adult services has become a global health and social care issue. Suboptimal transitions from children's to adult services can lead to measurable adverse outcomes. Interventions are emerging but there is little theory to guide service developments aimed at improving transition. The Transition to Adult Services for Young Adults with Life-limiting conditions (TAYSL study) included development of the TASYL Transition Theory, which describes eight interventions which can help prepare services and adolescents/young adults with life-limiting conditions for a successful transition. We aimed to assess the usefulness of the TASYL Transition Theory in a Canadian context to identify interventions, mechanisms and contextual factors associated with a successful transition from children's to adult services for adolescents/young adults; and to discover new theoretical elements that might modify the TASYL Theory.

METHODS

A cross-sectional survey focused on organisational approaches to transition was distributed to three organisations providing services to adolescents with life-limiting conditions in Toronto, Canada. This data was mapped to the TASYL Transition Theory to identify corresponding and new theoretical elements.

RESULTS

Invitations were sent to 411 potentially eligible health care professionals with 56 responses from across the three participating sites. The results validated three of the eight interventions: early start to the transition process; developing adolescent/young adult autonomy; and the role of parents/carers; with partial support for the remaining five. One new intervention was identified: effective communication between healthcare professionals and the adolescent/young adult and their parents/carers. There was also support for contextual factors including those related to staff knowledge and attitudes, and a lack of time to provide transition services centred on the adolescent/young adult. Some mechanisms were supported, including the adolescent/young adult gaining confidence in relationships with service providers and in decision-making.

CONCLUSIONS

The Transition Theory travelled well between Ireland and Toronto, indicating its potential to guide both service development and research in different contexts. Future research could include studies with adult service providers; qualitative work to further explicate mechanisms and contextual factors; and use the theory prospectively to develop and test new or modified interventions to improve transition.

Palliative care for young adults with life-limiting conditions: public health recommendations

Objective

To engage young adults (18–35 years of age) with life-limiting neuromuscular conditions, their parents, and health and community providers in the development of a public health approach to palliative care. A public health approach protects and improves health and wellness, maximises the quality of life when health cannot be restored and improves the quality, scope and accessibility of age-appropriate care and services.

Methods

Group concept mapping (GCM) was used to determine the most important priorities for these young adults. GCM involves three district phases: (1) brainstorming ideas, (2) sorting and rating ideas based on level of importance and (3) analysing and interpreting concepts maps. Online software was used to collect information for phases 1 and 2 and develop concept maps. In phase 3, a face-to-face workshop, participants analysed and interpreted the concept maps. The combination of online and face-to-face research activities offered the needed flexibility for participants to determine when and how to participate in this research.

Results

Through this three-phase patient engagement strategy, participants generated 64 recommendations for change and determined that improvements to programming, improvements to funding and creating a continuum of care were their most important priorities. Five subthemes of these three priorities and development of the concept map are also discussed.

Conclusion

This research demonstrates the unique perspectives and experiences of these young adults and offers recommendations to improve services to enhance their health and well-being. Further, these young adults were integral in the development of recommendations for system changes to match their unique developmental needs.

Themes of Stressors, Emotional Fatigue, and Communication Challenges Found in Mobile Care Discussion Sessions With Patients Requiring Lifelong Home Parenteral Nutrition Infusions

BACKGROUND

The purpose of this article is to examine themes and topics that emerged from 35 discussion sessions with teens and young adults requiring long-term home parenteral nutrition (HPN) intravenous infusions. The goal was to gain a more detailed understanding of participants' challenges and successes of living with HPN.

METHODS

These patients were invited to attend 3 discussion group sessions facilitated by health professionals. A secure iPad Mini was selected as the mobile tablet device for hosting these encrypted audio-visual group discussions. Content analysis, a standard research data-sorting technique, was used to summarize the anonymous data. Words, phrases, and topics in patients' discussions were coded and grouped together with similar concepts and subsequently categorized into themes.

RESULTS

Themes in these discussions were related to patients' daily, complex management of HPN. These "themes" included having multiple repetitive illness-related stressors and how those stressors were managed; managing emotions; communication challenges with professionals, family, friends, and using social media; and lastly, the least frequent but no less important theme discussed was how HPN effects their daily lives.

CONCLUSION

Teens and young adults living with lifelong HPN face a variety of unique psychological, physical, and emotional stressors and may benefit from numerous methods for managing these challenges.

Empowering Young Persons with Congenital Heart Disease: Using Intervention Mapping to Develop a Transition Program - The STEPSTONES Project

PURPOSE

Describe the implementation of intervention mapping in the development of a transition program that aims to empower adolescents with congenital heart disease.

DESIGN AND METHODS

To gain a better understanding of the problem, we conducted a literature review, focus group and individual interviews, and a cross-sectional survey. This information helped us decide on the scope of the intervention, relevant theories, determinants, formulate performance and change objectives and identify adequate evidence-based change methods. Once the transition program had been designed, effectiveness and process evaluation studies were planned.

RESULTS

Young persons with congenital heart disease have insufficient disease-related knowledge, self-management skills and high parental involvement. The transition program involves three meetings with a trained transition coordinator over a two-and-a-half-year period and targets young persons with congenital heart disease and their parents. The transition coordinators use change techniques such as goal-setting, modeling and active learning in order to target three personal determinants (knowledge, self-efficacy and self-management).

CONCLUSIONS

The use of intervention mapping may lead to designing interventions tailored to the needs of the targeted population. The transition program described in this paper is currently being evaluated in a hybrid experimental design with simultaneous undertaking of the process evaluation.

PRACTICE IMPLICATIONS

This transition program can lead to the empowerment of young persons with congenital heart disease and help them in the process of becoming more responsible for their care. If proven effective, it can be implemented for other chronic conditions.

The potential contribution of critical theories in healthcare transition research and practice

BACKGROUND

Healthcare transition has been established as a significant topic of interest in pediatric rehabilitation. Healthcare transition research has primarily focused on barriers to self-management and achievement of a productive adulthood. Healthcare transition experts have recently called for further attention to social structural factors. Theoretical approaches are, therefore, needed to account for how such factors shape the lives of youth with disabilities, particularly those who experience marginalization and social exclusion.

PURPOSE

Taking up this call, the aim of this paper is to examine the potential contributions of two critical theories to healthcare transition research and practice.

METHODS

Review two theories - intersectionality and critical discourse analysis.

RESULTS

Intersectionality highlights how multiple intersecting social locations and social structures interact with youth's experiences, choices and health care needs. Critical discourse analysis focuses on how discourses and assumptions in healthcare transition research and practice contribute to marginalization and can be resisted and changed by youth, families, researchers, and clinicians.

CONCLUSIONS

The uptake of critical theories within health care transition research and practice can account for the complex interplay of social structures, power relations and youth's experiences. Such analysis can contribute to refining assessments and developing interventions that reflect how marginalization and exclusion impact youth's well-being.IMPLICATIONS FOR REHABILITATIONWhile critical theories have been applied in health and rehabilitation, there has been limited uptake of these theories in healthcare transition research and practice.Critical theories can promote awareness of how youth's experiences, choices and actions throughout the healthcare transition process are shaping and shaped by structural factors and assumptions about a productive adulthood.Applying critical theories in healthcare transition practice involves being responsive to the structural factors that may be shaping youth's experiences, choices and opportunities.Intersectional and critical discourse analyses can surface how to reduce social exclusion and marginalization for youth transitioning to adulthood through analyses of language, power, dominant discourse and practices amenable to change.

Ready for Transfer to Adult Care? A Triadic Evaluation of Transition Readiness in Adolescents With Congenital Heart Disease and Their Parents

Transfer to adult care for adolescents with chronic conditions ought to be determined by transition readiness. The aims of this study were (a) to describe the level of readiness for transition in adolescents with congenital heart disease, (b) to compare adolescents' assessment of transition readiness with their parents' assessments, and (c) to study potential correlates of transition readiness. A total of 157 triads of adolescents aged 14 to 18 years and their parents completed the Readiness for Transition Questionnaire. Adolescents scored higher on overall readiness than their parents. Multivariable analyses revealed that higher levels of adolescents' overall readiness were associated with a less threatening view of the illness, a higher level of empowerment, and with higher mothers' and fathers' overall readiness scores. Adolescents' responsibility scores were positively associated with age and parental adolescent responsibility scores. Parental involvement scores were negatively associated with adolescents' age and positively with the mothers' parental involvement scores. By using a triadic evaluation, the results of the present study significantly extend what is currently known about this population.

Conflicting realities experienced by children with life-limiting and life-threatening conditions when transitioning to adult health services

AIMS

The aim of this study was to report a secondary qualitative analysis exploring the cultural and practical differences that young people and parents experience when transitioning from children's to adult services.

BACKGROUND

Despite two decades of research and quality improvement initiatives, young people with life-limiting and life-threatening conditions still find transition unsatisfactory.

DESIGN

Secondary analysis: 77 qualitative interviews with children and young people (20), parents (35), siblings (1), professionals (21).

METHODS

Qualitative framework analysis completed 2017.

FINDINGS

Six conflicting realities were identified: Planning to live and planning to die with different illness trajectories that misaligned with adult service models; being treated as an adult and the oldest "patient" in children's services compared with being treated as a child and the youngest "patient" in adult services; being a "child" in a child's body in children's services compared with being a "child" in an adult's body in adult services for those with learning impairments; being treated by experienced children's professionals within specialist children's services compared with being treated by relatively inexperienced professionals within generalist adult services; being relatively one of many with the condition in children's services to being one of very few with the condition in adult services; meeting the same eligibility criteria in children's services but not adult services.

CONCLUSION

Inequity and skills deficits can be addressed through targeted interventions. Expanding age-specific transition services, use of peer-to-peer social media, and greater joint facilitation of social support groups between health services and not-for-profit organizations may help mitigate age dilution and social isolation in adult services.

S.M.A.R.T. Transitions: A Program Evaluation

INTRODUCTION

Various programs have been proposed to facilitate more successful transitions from pediatric to adult care for children with special health care needs. Few have been evaluated for their effectiveness. The purpose of this project was to systematically evaluate the Duke Complex Care Clinic using the social-ecological model of adolescent and young adult readiness for transition (SMART).

METHODS

Cross-sectional data were acquired from surveys of 23 patient/parent dyads and from retrospective chart reviews for 50 patients. After the initial program evaluation, a pilot transition readiness tracking tool was implemented.

RESULTS

Documentation of compliance with the SMART domains was high. Despite high satisfaction with the clinic and a focus on transition, many of the patient/parent dyads expressed low confidence in their ability to transition successfully.

CONCLUSIONS

Transition beliefs and expectations should be further assessed and addressed in transition care visits. Further modification of the patient tracking tool and clinic flow may improve patient transition outcomes.

Pediatric Nurse Practitioners' Perspectives on Health Care Transition From Pediatric to Adult Care

INTRODUCTION

This study examined the perspectives of pediatric nurse practitioners (PNPs) regarding the needs of adolescents, parents/caregivers, clinicians, and institutions in the health care transition (HCT) process for adolescents/young adults.

METHODS

PNPs (N = 170) participated in a luncheon for those interested in transition at an annual conference. Small groups discussed and recorded their perspectives related to health care transition from adolescent to adult services. Content analysis was used to analyze responses (Krippendorff, 2013).

RESULTS

Four themes, Education, Health care system, Support, and Communication, emerged from the data analysis. PNPs identified health care informatics and adolescents' use of technology as additional critical aspects to be considered in health care transition.

DISCUSSION

Opportunities and challenges identified by the PNPs are discussed to improve the quality and process of transitioning adolescents to adult services. This report will help National Association of Pediatric Nurse Practitioners formulate a new Health Care Transition Policy Statement for the organization.

Adolescents' experiences of obesity surgery: a qualitative study

BACKGROUND

The positive effects of behavioural treatment and weight management in adolescents with severe obesity are modest. Obesity surgery can be an option for adolescents, but is not the first-hand choice of treatment. The knowledge about adolescents' own experiences of having undergone surgery and their thoughts and feelings of the follow-up period are limited.

OBJECTIVES

To describe adolescents' decision to go through obesity surgery as teenager and their experiences of the follow-up period.

SETTING

National Childhood Obesity Centre at Karolinska University Hospital in Stockholm, Sweden.

METHODS

Phone interviews with 20 young adults that went through obesity surgery as teenagers. Interviews were analysed with qualitative systematic text condensation.

RESULTS

"Lost in the healthcare system" and "A rough but well worth journey to a healthier life" were the categories that appeared in our analysis. The participant had a feeling of uncertainty about contacts with the healthcare system and the transition to primary care was confusing. Most of the participants were happy with the decision to go through obesity surgery as teenager, despite it had been a difficult time.

CONCLUSIONS

Our results show implications for improving the clinical care of adolescents undergoing obesity surgery, which should be offered as a last choice. Information and individualized supports should be offered more often during first year postsurgery and should be given by a multidisciplinary team. This multifaceted population should be given priority for a successful transition.

Adolescents with congenital heart disease: their opinions about the preparation for transfer to adult care

The aim of the study was to explore what adolescents with congenital heart disease (CHD) view as important in the preparation for the transfer to adult care. We performed interviews in four focus groups with adolescents (14-18 years old) at four university hospitals in Sweden. Data was analysed using qualitative content analysis. The analysis revealed one main category; Becoming a manager of the condition and four subcategories; Sufficient knowledge about the health, Be a participant in the care, Parental support, and Communicate with others about the health. The adolescents' ages differentiated the discussion in the groups. The older adolescents seemed to have more interest in transition planning, information and transfer. The younger described more frustrations about communication and handling the disease.

CONCLUSION

To become a manager of the CHD in daily life, the adolescents want disease specific knowledge, which should be communicated in a developmentally appropriate way. Adolescents want to participate and be involved in the transition process. They need support and guidance in how to communicate their CHD. Parental support is fundamental but it change over time. Moreover, peer-support is becoming more significant during the transition process. What is Known: • Transition during adolescence and transfer to adult care for adolescents with CHD is complex, and there is a shift in roles. • Adolescents often have poor knowledge and understanding about their heart condition and the consequences. What is New: • Adolescents call for disease specific information regarding health issues of importance for them in daily life. • Communicating the disease with other is a challenge- peer support from other adolescents with CHD could be a facilitator.

Stressors in Teens with Type 1 Diabetes and Their Parents: Immediate and Long-Term Implications for Transition to Self-Management

Teens with Type 1 diabetes and their parents experience every day and illness-related stress; however, understanding of how these stressors relate to the transition to adulthood is limited. The purpose of this study was to identify stressors of teens with Type 1 diabetes (T1DM) and their parents related to the impending transition to adulthood.

DESIGN AND METHODS

This study used open-ended questions to identify every day and illness-related stressors among 15 teens with T1DM and 25 parents seen in one pediatric diabetes clinic. Qualitative descriptive analysis identified themes in interview transcripts.

RESULTS

The primary teen stressor related to impending transition centered on ineffective self-management, often when they were taking over responsibility for T1DM management. Parents' concerns included immediate and long-term negative outcomes of teen self-management as well as financial resources and health insurance for the teen. Teens and parents both expressed specific concerns about outcomes and prevention of nocturnal hypoglycemia, and identified uncertainties related to teen health and diabetes-focused health care when no longer living in the parent's home.

CONCLUSIONS

Teens with Type 1 diabetes and their parents understand that independent teen self-management is a component of transition to adulthood, but worry about teen self-management outcomes. Concerns specific to health care transition included health insurance, T1DM resources, and teens' abilities to handle new situations.

PRACTICE IMPLICATIONS

Identifying current and future self-management concerns of individuals and families can facilitate targeted education and interventions to support successful transition to adulthood.