Caregivers experiences in symptom management for their children who require medical technology at home

Using a longitudinal qualitative approach to understand the lived experiences of caregivers of infants with obstructive sleep apnea who require chronic noninvasive respiratory support

OBJECTIVE

Although positive airway pressure (PAP) is effective for treating obstructive sleep apnea (OSA) in infants, there is a lack of data on caregivers' experiences administering PAP at home. Understanding caregivers' perspectives may change health care professionals approach to PAP initiation. Our study aimed to gain comprehensive insight into caregivers' beliefs, perceptions, and challenges associated with implementing PAP for infants with OSA, considering the transition from inpatient hospitalization to home.

METHODS

In this single-center prospective longitudinal study, caregivers of infants with OSA less than 12 months old who were initiated PAP during inpatient hospitalization underwent two semi-structured interviews over 3 months. The interview data were analyzed using directed content analysis, utilizing the health belief and socioecological models as theoretical frameworks. Data were coded and clustered into themes that reflected the evolving perspectives and experiences of caregivers.

RESULTS

Eight caregivers completed semi-structured interviews, revealing three key themes. First, despite initial negative attitudes towards the equipment, caregivers recognized PAP benefits and through self-efficacy and cues to action, were motivated to use PAP at home. Second, caregivers encountered various barriers to adherence; however, caregivers' self-efficacy improved with time and practice. Lastly, interpersonal, organizational, and community support enhanced adherence while lack thereof hindered implementation.

CONCLUSION

Caregivers of infants with OSA understand the importance of PAP therapy. Providing family-centered care and targeted interventions helps caregivers maintain adherence to PAP for infants. By understanding the lived experiences of caregivers, health care professionals can better meet the needs of families and optimize the effectiveness of PAP.

Symptom and Technology Management Intervention Usefulness for Caregivers of Children With Tracheostomies and Feeding Tubes

BACKGROUND

Caregivers of children who require medical technology of tracheostomies and feeding tubes provide intensive and specialized care at home. They have extensive training in the hospital prior to their child's discharge; however, there is limited education about their child's care once they are at home. The Creating Opportunities for Personal Empowerment: Symptom and Technology Management Resources intervention focused on commonly experienced symptoms and technology used at home by caregivers.

OBJECTIVE

We present the findings from the intervention exit interviews to gain insight about the intervention from caregiver perspectives, notably their perceptions of usefulness, ease of use, and acceptability.

METHODS

A qualitative descriptive design was used to examine caregivers' perceptions of the intervention in exit interviews. These interviews were conducted upon completion of the intervention as part of feasibility testing.

RESULTS

Sixteen caregivers completed the study and participated in exit interviews. Caregivers described the themes of the best that you can do, a reminder that I am doing it the right way, and I wish I had these when my child first had the tracheostomy and feeding tube. Caregivers also provided feedback about the intervention's usefulness and suggestions for further refinement and future adaptations of the intervention.

CONCLUSIONS

Caregivers provided valuable insights about the intervention, describing its usefulness to them, the potential for usefulness for other caregivers of these children, and their experiences with care of their children at home. Future plans include efficacy testing and modifications to enhance the intervention based on caregiver feedback.

Enhancing caregivers self-management for their children who require medical technology: A feasibility study for the COPE-STAR intervention

PURPOSE

To test feasibility of the Creating Opportunities for Personal Empowerment: Symptom and Technology Management Resources intervention for caregivers of children who require medical technologies of tracheostomies and feeding tubes.

DESIGN AND METHODS

Quasi-experimental one group design with measures at baseline and at 4 weeks. Intervention feasibility was tested from August 2019-June 2021, including recruitment, retention, and adherence, and caregiver satisfaction. Caregiver and child characteristics and outcomes were assessed.

RESULTS

Caregivers were enrolled (n = 22) and completed (n = 16) the study. Caregivers were primarily female (n = 21), were predominately Caucasian (n = 14, 64%) followed by African-American (n = 8, 36%), and Non-Hispanic/Latino (n = 18, 82%). Feasibility indicators of recruitment (92%), retention (73%), and adherence (100%) were satisfactory. Outcome measures of management of child's chronic condition, caregiver beliefs about managing their child's symptoms and medical technology, anxiety, and depressive symptoms remained stable. Caregivers agreed that the intervention was useful, easy to use, and acceptable, and had positive feedback.

CONCLUSIONS

This is a feasible and acceptable intervention. With further development and efficacy testing, the intervention has potential for use and expansion to a larger population of caregivers of children who require medical technology.

PRACTICE IMPLICATIONS

Children who require medical technology have multiple complex chronic conditions and complex care needs at home. This intensive and focused care is provided by informal caregivers who need education and resources for their child's care. This intervention addressed caregiver management of common symptoms and medical technologies of children in the home setting.

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.

Caring for children with new medical technology at home: parental perspectives

OBJECTIVES

This qualitative descriptive study explores the experiences of family caregivers (FCs) of children with medical complexity who are initiated on new medical technology in the hospital and transition to new daily life at home. The study aims to investigate FCs' response and readiness for medical technology use, the value of education and transition support and the challenges associated with managing new medical technology in the home.

STUDY DESIGN

A qualitative descriptive approach was used to conduct and analyse 14 semistructured interviews with a group of FCs composed of 11 mothers and 3 fathers. Content analysis was used to analyse transcripts of the caregiver interviews. The study was conducted at a tertiary paediatric hospital in Toronto, Canada.

RESULTS

Our study revealed three main themes: FC's response and readiness for medical technology use, the value of education and transition support for initiation of new medical technology and the challenges associated with managing new medical technology in the home. FCs expressed emotional distress related to coping with the realisation that their child required medical technology. Although the theoretical and hands-on practice training instilled confidence in families, FCs reported feeling overwhelmed when they transitioned home with new medical technology. Finally, FCs reported significant psychological, emotional and financial challenges while caring for their technology-dependent child.

CONCLUSIONS

Our study reveals the unique challenges faced by FCs who care for technology-dependent children. These findings highlight the need to implement a comprehensive education and transition programme that provides longitudinal support for all aspects of care.

Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals

OBJECTIVES

To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.

DESIGN

Qualitative semistructured interview study.

SETTING

One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.

PARTICIPANTS

A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.

INTERVENTION

Interviews undertaken by telephone or video link.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative reflexive thematic analysis with QSR Nvivo 12.

RESULTS

This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.

CONCLUSIONS

Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

Parents' process of recognition and response to clinical deterioration of their children with medical complexity at home: A grounded theory

AIM

To explore the process of recognition and response to clinical deterioration of children with medical complexity at home by their parents.

BACKGROUND

Children with medical complexity are characterised by known chronic conditions associated with frailty and functional limitations, dependence on healthcare services and high use of technology and resources. Their medical complexity often leads to the onset of complications. Targeted care ensures timely recognition and response to clinical deterioration at home, thus avoiding serious sequelae, inappropriate hospitalisations and improving quality of life. Evidence on parents' process of the recognition and response to clinical deterioration at home is limited.

DESIGN

Qualitative study using a Grounded Theory methodology.

METHOD

Seven online focus groups were conducted with parents and healthcare providers experienced in their care. The interviews were transcribed verbatim and analysed through open, axial and selective coding, using a constant comparative iterative method. The COREQ guidelines guided the reporting of this work.

RESULTS

Four categories and one core category were identified: (1) Awareness of the unique and shared characteristics of children with medical complexity; (2) Parents' care maintenance and management; (3) Parents' care monitoring; (4) Parents' response to clinical deterioration and (5) Seeking the Shift of Agency, the core category as the foundation of the Process of Recognition and rEsponse of PAREnts to Deterioration (PRE-PARE-D) theory.

CONCLUSION

The role of parents of children with medical complexity is evolving into active care leaders, by developing care management and care monitoring competences and negotiating care with healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

The shift of agency from healthcare providers to parents requires education and counselling pathways to promote the development of parent's self-efficacy, competencies and empowerment in the care management of their children. Home care delivery for children with medical complexity should aim at sustaining this partnership between healthcare providers and parents.

Effects of the Discharge Education Program on Family Caregivers Caring for Patients on Mechanical Home Ventilation in Korea: A Pilot Test

Patients on home ventilators rely on mechanical ventilation until their death; hence, family caregivers should perform additional caregiving, including tracheostomy, equipment management, and positive pressure ventilation by ambu-bag in emergencies. Therefore, a systematic discharge education program and evaluation of actual caregiver performance are necessary for safe home management. The program consists of suction and tracheostomy management, home ventilator management, emergency management, fundamental caregiving, and video material. To test clinical validity, family caregivers of patients about to be discharged to their homes from S hospital in Seoul, Korea, were selected by convenience sampling with a non-equivalent control group design. Of 18 participants, one refused, one died, and two became unstable after their agreement; therefore, 14 participants were finally included. To compare caregiving performance scores between the groups, we ran repeated measures ANOVA. Intergroup and period interaction of suction ( F = 6.08, p = .001) and tracheostomy management ( F = 3.00, p = .038) crucial for airway management, showed significant statistical differences. In short, the intervention group showed a faster increase in suction and tracheostomy management than the control group. Home ventilator management ( F = 22.53, p < .001), emergency management ( F = 12.01, p < .001), and fundamental caregiving ( F = 7.88, p < .001) showed significant differences within the group regarding the period. According to the results of the clinical validity test, the discharge education program increased the family caregiver’s suction and tracheostomy management performance scores. Further research is needed to demonstrate long-term effects of the program with a larger sample.

Death review of children receiving medical care at home

BACKGROUND

Children receiving home medical care need special attention to prevent unexpected death. The aim of this study was to clarify the factors contributing to death in children receiving home medical care from the child death review database.

METHODS

Children receiving home medical care were enrolled from the child death review database from 2014 to 2016 in Aichi prefecture, Japan, with a population of one million children. Types of medical care and factors contributing to death were examined.

RESULTS

Of the 631 children who died, 40 children (6%) were receiving home medical care (21: tracheostomy; 19: ventilator; 26: suctioning of naso-oral secretions; 19: oxygen inhalation; 32: tube feeding; 6: urethral catheterization; and 1: peritoneal dialysis). The death rate was 50 times that in the general population of children. Ten children had contributory factors that seemed to be preventable. In four children, the families could not replace the tracheostomy tubes during an accident. In three, oxygen saturation or ventilator alarms were not set appropriately. In two, an oxygen cylinder became empty. One child fell down from a seat in a car.

CONCLUSIONS

Improvement of devices and correct guidance to caregivers may reduce the death rate in children receiving home medical care.

IMPACT

Children receiving home medical care, such as tracheostomy care, mechanical ventilation, or tube feeding, need special attention to prevent unexpected death. In this population-based child death review, 6% of children received home medical care, and it was estimated that 1 of 100 children receiving home medical care died per year. One-quarter of the deaths could be preventable by caregiver education or development of devices.

Establishing fidelity for the creating opportunities for personal empowerment: Symptom and technology management resources (COPE-STAR) intervention

AIM

To establish intervention fidelity for the Creating Opportunities for Personal Empowerment: Symptom and Technology Management Resources web-based intervention to assist caregivers of children aged 1-5 years in managing their child's symptoms and medical technology of tracheostomies and feeding tubes at home.

DESIGN

Descriptive study of the strategies used to establish intervention fidelity, specifically using expert and caregiver reviewers.

METHODS

To establish fidelity of the intervention, experts and caregivers were asked to evaluate the usefulness, ease of use, and acceptability of the intervention and provide any suggestions for the modules. Caregivers provided caregiver and child characteristics and were administered a health literacy measure, the Newest Vital Sign. Intervention fidelity was established from April 2019-July 2019.

RESULTS/FINDINGS

Expert and caregiver reviewers (N = 13) all agreed or strongly agreed that the intervention was useful, easy to use, and acceptable. In addition, caregiver reviewers provided care to children who required multiple technologies and a variety of care needs at home and confirmed adequate health literacy (N = 5).

CONCLUSION

The use of expert and caregiver reviewers was very beneficial in establishing intervention fidelity. Caregivers are experts in the care of their child and provide valuable feedback based on their daily experiences at home. Experts provided evidence-based feedback.

IMPACT

This nursing intervention addresses caregivers of children who require medical technology by targeting caregiver management for common symptoms, related technologies, and resources for the child and caregiver in the home setting. Intervention fidelity was established and expert and caregiver reviewers confirmed the usefulness, ease of use, and acceptability of the intervention. This study is essential to nursing, other healthcare providers, and healthcare systems in planning and implementing programmes and services for children and their caregivers and for nurse researchers establishing intervention fidelity.

TRIAL REGISTRATION

This study is not designated as a clinical trial per NIH/NINR study and grant proposal guidelines.

Creating opportunities for personal empowerment: Symptom and technology management resources (COPE-STAR) for caregivers of children who require medical technology

AIM

This research protocol addresses the development of web-based modules for the 'creating opportunities for personal empowerment: symptom and technology management resources' intervention with caregivers of children who require medical technology. The commonly experienced symptoms of fever and increased respiratory symptoms (coughing, wheezing, increased secretions), and the care of technologies (tracheostomy tubes, respiratory equipment and feeding tubes) are addressed in this nurse-led and nurse-developed intervention.

DESIGN

The purpose of this study was to develop web-based intervention modules and obtain review by expert and caregiver reviewers using a systematic, structured process and form.

METHODS

The intervention includes evidenced-based, theory-based, modules that address the child's most common emotions and behavioural responses with the management of their symptoms and technologies using a web-based format. To establish fidelity of the intervention, expert and caregiver reviewers (e.g. caregivers of children with multiple complex chronic illnesses and technologies) will review the modules that will then be refined prior to feasibility testing. Funding for the study began in July 2018.

DISCUSSION

The intervention development led by nurses entails an evidence-based literature review; development of scripts with appropriate health literacy level; and content by experts, photography, and videography; production of video modules and creation of a website for modules.

IMPACT

This nursing intervention addresses the educational needs and skills considered essential and most applicable to caregivers of children who require medical technology to improve self-management of their child's symptoms and technology in the home setting. The information obtained from this study will be valuable to nursing, other healthcare providers and healthcare systems in planning and implementing programs and services for these children and for nurse researchers designing intervention studies for children with multiple complex chronic illnesses.

TRIAL REGISTRATION

This study is not designated as a clinical trial per NIH/NINR study and grant proposal guidelines.