[Technology-dependent children: the maternal care experience]

Delineating family needs in the transition from hospital to home for children with medical complexity: part 2, a phenomenological study

BACKGROUND

A systematic literature review on the transition from hospital-to-home (H2H) of families with a child with medical complexity (CMC), resulted in nine overarching themes. These demonstrated common needs and experiences despite the widely differing CMC diagnoses and family characteristics. However, none of the reported studies was conducted in the Netherlands, which hampers the creation of a tailored H2H care pathway, deemed essential for our recently established Transitional Care Unit in the Netherlands: the 'Jeroen Pit Huis'. Therefore, the aim of this study was to gain a deeper understanding of the needs and experiences of Dutch CMC parents on H2H transition and integrate these insights with the literature review into an evidence-based H2H care pathway for CMC and their families.

METHODS

A descriptive phenomenological approach was applied. Heterogeneous purposeful sampling methods were used to recruit participants according to the following criteria: parents of CMC from various regions in the Netherlands, who spoke Dutch fluently and who had been discharged home from a tertiary hospital within the previous five years. Semi-structured, open-ended interviews were conducted via video call by two researchers, who transcribed the audio recordings verbatim. Thematic analysis methods were used to identify emerging themes from the individual transcripts, involving a third and fourth researcher to reach consensus.

RESULTS

Between March and August 2021, 14 mothers and 7 fathers participated in 14 interviews. They elaborated on the H2H transition of 14 CMC with a wide range of underlying diseases: 7 male, 7 female, aged 6 months to 10 years. Eight overarching themes, consistent with the results of the systematic review, represent CMC parental needs and experiences during the H2H process in the Netherlands: (1) autonomy, (2) division of tasks and roles, (3) family emotions, (4) impact on family life, (5) communication, (6) coordination of care, (7) support system and (8) adaptation.

CONCLUSIONS

The H2H needs and experiences reported by the CMC families in this study align with the results of our systematic review. The H2H transition process is not linear but continuous, and should extend beyond the specific medical needs of the CMC to holistic care for the family as a whole. The overarching care needs and experiences, expressed by all CMC families, regardless of underlying symptoms and diagnoses, inform the H2H care pathway and its future evaluation. Our studies highlight the necessity to focus on the family needs rather than on the specific illness of the child, as well as the value of our interdisciplinary care team partnering with parents in the 'Jeroen Pit Huis' towards a safe and sustainable transition home.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 1, a meta-aggregation of qualitative studies

BACKGROUND

Advances in diagnostic and therapeutic interventions for rare diseases result in greater survival rates, with on the flipside an expanding group of children with medical complexity (CMC). When CMC leave the protective hospital environment to be cared for at home, their parents face many challenges as they take on a new role, that of caregiver rather than care-recipient. However, an overview of needs and experiences of parents of CMC during transition from hospital-to-home (H2H) is lacking, which hampers the creation of a tailored H2H care pathway. Here we address this unmet medical need by performing a literature review to systematically identify, assess and synthesize all existing qualitative evidence on H2H transition needs of CMC parents.

METHODS

An extensive search in Medline, PsychINFO and CINAHL (up to September 2022); selection was performed to include all qualitative studies describing parental needs and experiences during H2H transition of CMC. All papers were assessed by two independent investigators for methodological quality before data (study findings) were extracted and pooled. A meta-aggregation method categorized the study findings into categories and formulated overarching synthesized findings, which were assigned a level of confidence, following the ConQual approach.

RESULTS

The search yielded 1880 papers of which 25 met eligible criteria. A total of 402 study findings were extracted from the included studies and subsequently aggregated into 50 categories and 9 synthesized findings: (1) parental empowerment: shifting from care recipient to caregiver (2) coordination of care (3) communication and information (4) training skills (5) preparation for discharge (6) access to resources and support system (7) emotional experiences: fatigue, fear, isolation and guilt (8) parent-professional relationship (9) changing perspective: finding new routines and practices. The overall ConQual Score was low for 7 synthesized findings and very low for 2 synthesized findings.

CONCLUSIONS

Despite the variability in CMC symptoms and underlying (rare disease) diagnoses, overarching themes in parental needs during H2H transition emerged. We will augment this new knowledge with an interview study in the Dutch setting to ultimately translate into an evidence-based tailored care pathway for implementation by our interdisciplinary team in the newly established 'Jeroen Pit Huis', an innovative care unit which aims for a safe and sustainable H2H transition for CMC and their families.

FACTORS ASSOCIATED WITH DE-HOSPITALIZATION OF CHILDREN AND ADOLESCENTS WITH COMPLEX CHRONIC CONDITION

Objective:

To assess the factors associated with the de-hospitalization of children and adolescents with complex chronic condition.

Methods:

This cross-sectional and retrospective study investigated a sample of children and adolescents admitted to the Dehospitalization Training Unit, from January 2012 to December 2017. Data were collected by consulting medical records and patient record books, from November 2018 to June 2019. The length of stay in the unit, de-hospitalization, readmissions, frequency and cause of death, age, sex, diagnosis, place of residence, number of caregivers and kinship, and use of devices were studied. The chi-square test was used to verify the association between the dependent variable (de-hospitalization) and the independent variables (age, sex, place of residence, use of devices, and clinical diagnosis).

Results:

A total of 93 patient records were analyzed, 37.6% aged between 7 months and 2 years old, 58.1% boys, 95.7% used tracheostomy, 92.5% gastrostomy, and 71% invasive mechanical ventilation. Hypoxic-ischemic encephalopathy was the diagnosis of 40.3% of the sample. Average hospitalization time was 288 ± 265 days; 60.2% were hospitalized between 31 days and one year, representing 50% of deaths. Of those de-hospitalized, 76.3% were discharged to the Ventilatory Assistance Homecare Program. De-hospitalization was associated with the child or adolescent's place of residence (p=0.027) and use of ventriculoperitoneal shunt (p=0.021).

Conclusions:

This study identified that de-hospitalization may be associated with the place of residence of the child or adolescent, with the highest number of discharges to the state capital, and non-dehospitalization when using ventricular-peritoneal shunt.

ENCONTRO EDUCATIVO DA ENFERMAGEM E DA FAMÍLIA DE CRIANÇAS COM NECESSIDADES ESPECIAIS DE SAÚDE

RESUMO Objetivo: conhecer as dúvidas dos familiares de crianças com necessidades especiais de saúde quanto aos cuidados domiciliares relacionados aos dispositivos tecnológicos; e analisar o uso da roda de conversa como estratégia de educação em saúde no preparo de alta hospitalar dos familiares de crianças com dispositivos tecnológicos. Método: pesquisa descritiva e exploratória, com abordagem qualitativa, realizada no setor de internação pediátrica de um hospital federal no Rio de Janeiro entre maio e junho de 2014. Seis familiares participaram de entrevistas semiestruturadas e rodas de conversa. Os dados foram submetidos à análise temática. Resultados: os familiares destacaram dúvidas no aprendizado e na adaptação à tecnologia durante a transição do hospital para o domicílio e em possíveis situações de emergência após a alta hospitalar. Essas dúvidas versaram, principalmente, sobre os cuidados procedimentais com a traqueostomia e a gastrostomia. Entretanto, a estratégia da roda de conversa com uso de um boneco com dispositivos tecnológicos acoplados foi bem aceita pelos familiares, pois favoreceu o diálogo e a troca de conhecimentos e experiências entre os participantes, além da promoção da segurança no cuidado. Conclusão: a roda de conversa é uma estratégia de educação em saúde, que pode ser utilizada pela Enfermagem no preparo de alta hospitalar de crianças com necessidades especiais de saúde, dependentes de tecnologia. Todavia, esse preparo deve acontecer de forma processual durante a hospitalização.

Care for technology dependent children and their relationship with the health care systems

OBJECTIVE:

to understand the experience of care delivery to technology dependent children based on the mothers' experience.

METHOD:

exploratory study with qualitative approach, based on the theoretical framework of medical anthropology and the narrative method. Twelve mothers participated and, as the technique to obtain the narratives, open interviews were held at the participants' homes.

RESULTS:

the narratives were organized into three thematic categories: the family system, identifying the care forms, the association between popular and scientific knowledge and the participation of the social network; the professional system, which discusses the relations between professionals and family, the hegemony of the biomedical model and the role of nursing; and the popular system, presenting popular care practices like spirituality and religiosity.

CONCLUSION:

the study provided support for a health care project that takes into account the families' moral and symbolic values and beliefs in view of the illness of a technology-dependent child. The results found can contribute towards changes in the health work process, so that its foundation is guided not only by the biomedical model, allowing the integration of the sociocultural dimensions into the health care movement.

Criança dependente de tecnologia e a demanda de cuidado medicamentoso

RESUMO Objetivo: compreender a vivência de mães de crianças dependentes de tecnologia em relação ao cuidado medicamentoso. Método: pesquisa qualitativa do tipo descritivo-exploratória, desenvolvida por meio de entrevistas abertas e aplicação de instrumento estruturado para caracterização, com 12 mães cuidadoras de crianças dependentes de tecnologia durante visita domiciliar. Os dados foram submetidos à análise de conteúdo indutiva. Resultados: organizados em dois temas: a sobrecarga materna diante do cuidado medicamentoso, que revelou a necessidade da administração de medicamentos de forma contínua e as repercussões desse cuidado exaustivo para as cuidadoras; e as dificuldades e facilidades no acesso aos medicamentos, apontando as estratégias informais e redes de apoio. Conclusão: o cuidado medicamentoso configura-se um desafio diário expresso pela sobrecarga materna e dificuldade de acesso aos medicamentos, potencializado por falhas na constituição da rede de atenção e coordenação do cuidado.

Families' concerns about the care of children with technology-dependent special health care needs

OBJECTIVE

To identify concerns of family members of Children with Special Health Care Needs (CSHCN) as far as care related to using technology, and to discuss nurses' performance in the face of these concerns.

METHODOLOGY

Qualitative descriptive research, developed through February and March 2014, through semi-structured interviews with six family members, caregivers of technology-dependent CSHCN who are followed at a University Hospital in Rio de Janeiro. The setting chosen was the family members' home. Data were submitted to content analysis.

RESULTS

Concerns were distributed in a timeframe, divided between those occurring the moment the family members received the information about the technological device needed, then those which arose while accompanying the child during hospitalization, and finally those that remained after the hospital discharge.

CONCLUSION

The family needs information and support from nurses, because different concerns emerge throughout the treatment and accompaniment of a technology-dependent child.

A enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia

Objetivos: identificar os desafios enfrentados pela família na alimentação da criança em quimioterapia antineoplásica e descrever as estratégias utilizadas pela família para superação dos desafios e as possibilidades de atuação da enfermagem. Método: pesquisa qualitativa descritiva, realizada em maio de 2013, por meio de entrevista semiestruturada com 12 familiares de crianças em tratamento quimioterápico, internados na enfermaria de um hospital público pediátrico do Rio de Janeiro. Os dados foram submetidos à análise temática. Resultados: dentre os desafios enfrentados pelas famílias na alimentação da criança em quimioterapia, estão os efeitos adversos das medicações no sistema gastrintestinal e a adaptação às mudanças alimentares em casa e no hospital. As estratégias utilizadas por eles para superação desses desafios são perguntar e oferecer o que a criança gosta e deixar a refeição mais atrativa. Dentre as principais formas de atuação da enfermagem destacadas pelos familiares, encontram-se a orientação e o apoio à família e à criança. Conclusão: que é importante a realização de cuidados de enfermagem para minimizar os danos resultantes do processo do adoecimento e do tratamento.