Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation

OBJECTIVE

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence.

HYPOTHESIS

Moral distress will be significant in a dedicated pediatric trach/vent unit.

METHODS

The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed.

RESULTS

Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively).

CONCLUSIONS

Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

A novel behavioral health program for family caregivers of children admitted to a transitional chronic ventilator unit

BACKGROUND

The care of mechanically ventilated pediatric patients is complex and burdensome. It is essential to adequately support the family caregivers of these children to optimize outcomes; however, there is no literature describing interventions for caregivers in this population.

RESEARCH QUESTION

This study described a novel behavioral health program and examined its impact on family caregiver engagement and psychological distress on a pediatric inpatient chronic ventilator unit.

STUDY DESIGN AND METHODS

Electronic chart review was completed with retrospective and prospective participant enrollment for the purposes of longitudinal evaluation of caregiver engagement. For analytic purposes, participants were grouped into three categories: (1) preprogram, (2) postprogram, and (3) postprogram with completion of psychotherapy.

RESULTS

The behavioral health program was associated with increased caregiver participation in rounds, t = 7.76, p = < .001. Parents who completed a course of psychotherapy within the behavioral health program demonstrated reduced time to training completion (F = 5.89; p < .01), higher staff-rated caregiver engagement (F = 3.69; p < .05), and significantly reduced levels of caregiver distress (t = 2.09; p < .05).

Executive functioning in pediatric cystic fibrosis: A preliminary study and conceptual model

BACKGROUND

Research has shown that broad cognitive functioning in individuals with CF is intact. Specific executive functioning (EF) deficits have been identified, however, and adults with CF report more symptoms of ADHD than the general population. EF skills are critical to the management of a complex disease like CF although studies have not adequately examined EF mechanisms in CF. This manuscript (a) described EF in a small sample of children with CF, (b) summarized relations found between EF and psychosocial variables, and (c) presented a conceptual model by which to understand EF's impact on adherence in CF.

METHODS

Data for this preliminary study were collected from 19 children with CF and their caregivers (ages, 6-18). Caregivers completed questionnaires assessing their child's physical and mental health, their own functioning, and overall family functioning. EF was measured using a parent-report rating scale. Patient health data were collected from the electronic medical record.

RESULTS

This sample did not demonstrate elevated levels of EF impairment. Worse EF was related to poor family communication/cohesion, as well as higher treatment burden, worse lung function, poorer adherence, and older age. From these findings, a preliminary model was developed describing EF in the context of CF and adherence.

CONCLUSIONS

Findings from this preliminary study suggest that the CF regimen and associated symptoms may overload otherwise adequate EF skills. Reducing disease burden and preventing burnout should be a focus of treatment. A better understanding of EF in CF and the impact on adherence would allow for better clinical management and effective design of interventions.

Psychological predictors of nutritional adherence in adolescents with cystic fibrosis

BACKGROUND & AIMS

The CF medical regimen is notoriously burdensome, comprised of respiratory treatments, oral medications, and nutritional demands. Adequate caloric intake has been identified as a challenge over the lifespan; however, we lack detailed information about nutritional adherence in teens, and the contextual drivers of these behaviors. Adolescence is a time of increased responsibility, reduced parental monitoring, and growing peer connections. There is no literature examining the impact of familial attitudes (e.g., privacy, disease disclosure) and the social milieu (e.g., friendships) on teen nutritional adherence behavior. We hypothesized that better teen nutritional adherence behaviors would be predicted by more favorable familial privacy attitudes, better relationship quality, and greater comfort in disease disclosure.

METHODS

Assessment included questionnaires of caregiver privacy attitudes, relationship quality, and disease disclosure. Teens tracked PERT adherence for 1 month and logged daily caloric intake for 2 weeks. This produced detailed information on daily enzyme adherence, caloric intake, and eating frequency.

RESULTS

Average PERT adherence, caloric intake, and eating frequency were suboptimal in this sample. More comfort in disease disclosure and less teen/mother discord predicted better PERT adherence. Higher caregiver privacy and lower teen closeness with friends predicted greater caloric intake and eating frequency.

CONCLUSIONS

Results suggest that comfort in disease disclosure supports consistent PERT adherence across environments. Adolescents with close friendships may have less time for self-management (e.g., eating). Future research should collect more detailed information about friendships of teens with CF. Results suggest that daily structure and positive, appropriately supportive relationships should be encouraged by care teams.

Caregiver Daily Experiences Associated with Child Asthma Symptoms

OBJECTIVE

In this study, we used ecological momentary assessment (EMA) delivered via smart- phones to determine how the daily experiences (comfort in neighborhood, ability to manage child's asthma, positive/negative affect) of 59 caregivers (90% African-American/black) living in an urban setting are associated with asthma symptoms in children ages 7-12 years (M = 9.56 years).

METHODS

Caregivers and their children with asthma completed a baseline research ses- sion, followed by 14 days of EMA surveys completed on smartphones. EMA enables researchers to examine within-person processes while preserving the ecological validity of the data and re- ducing retrospective recall bias.

RESULTS

On days when caregivers reported more child asthma symptoms, they also reported feeling less comfortable in their neighborhoods and less able to control their child's asthma at home. Baseline reports of caregiver quality of life were also associ- ated with child asthma symptoms.

CONCLUSIONS

Findings highlight the need for researchers and clinicians to recognize that both asthma (ie, ability to control asthma) and non-asthma related factors (ie, factors related to neighborhoods) may be associated with caregivers' perceptions of their children's asthma symptoms. Perceptions of child symptoms have important consequences for daily asthma care, including decisions related to healthcare utilization.

The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder

OBJECTIVE

The current study examined the association between asthma and attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample.

METHODS

Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a co-morbid asthma diagnosis were identified and matched by age to a group of 71 patients with only ADHD.

RESULTS

Children with asthma and ADHD were more likely to display clinically elevated levels of hyperactivity, externalizing behaviors, anxiety, and hyperactive/impulsive behaviors compared to children with ADHD alone. Boys with asthma and ADHD had more symptoms than boys with only ADHD of somatization and emotional internalizing, while girls with asthma and ADHD had more symptoms of hyperactivity/impulsivity, conduct problems, anxiety, and emotional internalizing compared to girls with only ADHD.

CONCLUSIONS

Findings suggest that in children with ADHD, co-morbid asthma is associated with increased behavioral and internalizing symptoms, with distinct gender differences present. Increased behavioral and internalizing symptoms seen in children with both asthma and ADHD may be due to the burden of their medical condition. No difference was found on cognitive variables, suggesting chronic hypoxia may be less influential in explaining these differences. Future research should determine the specific mechanisms of these differences.

Acculturation and quality of life in urban, African American caregivers of children with asthma

OBJECTIVE

Racial/ethnic minority caregivers of children with asthma are at risk for low levels of quality of life (QOL). Limited research has identified factors that contribute to lower QOL among African American caregivers. This study examined associations between acculturation (e.g., engaging in values/beliefs traditional of one's culture versus adopting mainstream cultural views) and caregiver QOL in low-income, urban African American families of children (7-12 years) with persistent asthma. We also investigated the association between caregiver QOL and child emergency department (ED) use.

METHODS

Fifty-five caregivers and their children completed interview-based questionnaires in a single research session. Caregivers completed the Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ), the African American Acculturation Scale-Revised (AAAS-R), and reported on child asthma variables. Children completed items assessing asthma control.

RESULTS

Higher overall QOL and emotional function subscale scores were associated with more traditional African American religious beliefs/practices (r = .288, p = .033; r = .333, p = .013). Higher emotional function subscale scores were associated with more traditional values of African American families (r = .306, p = .023). Lower QOL was found among caregivers of children who had visited the ED three or more times in the last year.

CONCLUSIONS

Less acculturation tied to religious beliefs/practices and family values (as measured by the AAAS-R) may serve a protective role in reducing the burden low-income, urban African American caregivers experience in managing child asthma. This study is the first of its kind to study acculturation in African American caregivers of children with asthma.

Disease disclosure in individuals with cystic fibrosis: Association with psychosocial and health outcomes

BACKGROUND

This study aimed to quantify cystic fibrosis (CF) disclosure and examine associations between disclosure and psychosocial and health outcomes.

METHODS

Participants completed measures assessing disease disclosure and psychosocial outcomes. Data from chart reviews and pharmacy records were obtained.

RESULTS

Participants (N=128; ages 16-63) were more likely to disclose to romantic partners (97%) and close friends (94%) than to casual friends (79%), bosses (71%), or co-workers (53%). Participants reported more comfort discussing CF with and doing treatments in front of romantic partners and close friends than other groups. Disclosure was associated with higher social support, social functioning, and medication adherence self-efficacy. Lower lung-function was associated with disclosure to bosses and co-workers.

CONCLUSIONS

Clinicians should consider discussing disclosure with patients, as limited disclosure may have a negative impact on psychosocial outcomes.

Quality of Life in Children With Asthma: A Developmental Perspective

OBJECTIVE

The current study investigated whether factors associated with quality of life (QOL) in children with asthma (e.g., family functioning, asthma routines, asthma severity) differed by child age.

METHODS

Participants included 192 children with asthma (5-12 years) and their caregivers. Both children and caregivers completed questionnaires at an initial research session. Family functioning was determined from a mealtime observation that occurred in family homes.

RESULTS

Child age moderated the association between asthma severity and child QOL and between routine burden and QOL in children with asthma. Post hoc probing analyses revealed that among older children, QOL levels were lower in the presence of worse asthma severity and more routine burden.

CONCLUSIONS

Findings suggest that associations between asthma severity, routine burden, and QOL may differ by child age. Treatment programs and health-care recommendations addressing QOL in children with asthma may need to be tailored to address differences in factors associated with QOL by child age.