Communication with young people in paediatric and adult endocrine consultations: an intervention development and feasibility study

BACKGROUND

Communication is complex in endocrine care, particularly during transition from paediatric to adult services. The aims of this study were to examine the feasibility of interventions to support young people to interact with clinicians.

METHODS

Development and evaluation of a complex intervention in 2 phases: Pre-intervention observational study; Intervention feasibility study. Purposive sample of recordings of 62 consultations with 58 young people aged 11-25 years with long-term endocrine conditions in two paediatric and two adult endocrine clinics. Proportion of time talked during consultations, number and direction of questions asked; Paediatric Consultation Assessment Tool (PCAT); OPTION shared decision making tool; Medical Information Satisfaction Scale (MISS- 21). Young people were invited to use one or more of: a prompt sheet to help them influence consultation agendas and raise questions; a summary sheet to record key information; and the www.explain.me.uk website.

RESULTS

Nearly two thirds of young people (63%) chose to use at least one communication intervention. Higher ratings for two PCAT items (95% CI 0.0 to 1.1 and 0.1 to 1.7) suggest interventions can support consultation skills. A higher proportion of accompanying persons (83%) than young people (64%) directed questions to clinicians. The proportion of young people asking questions was higher (84%) in the intervention phase than in the observation phase (71%).

CONCLUSIONS

Interventions were acceptable and feasible. The Intervention phase was associated with YP asking more questions, which implies that the availability of interventions could promote interactivity.

Mucopolysaccharidosis I; Parental beliefs about the impact of disease on the quality of life of their children

Background

Hematopoietic stem cell transplants, alongside enzyme replacement therapy and good multi-disciplinary care, have dramatically improved the life expectancy in children with Mucopolysaccharidosis (MPS) I, with better objective and functional outcomes. Despite these improvements, children with both the attenuated (non-Hurler) and severe (Hurler) variants of the disease have marked residual morbidity. Children with MPS I suffer with head and neck disease including obstructive sleep apnoea and hearing loss. The impact of these on quality of life has been poorly researched and no previous work has been published looking at patients’ perception of their own health, an important domain when considering the impact of treatment.

Methods

This exploratory qualitative study aimed to discover the effect of head and neck disease, alongside that of MPS I as a whole, on the quality of life of affected children.

A grounded theory approach was used to conduct this study. Children and their parents were invited to participate in semi-structured interviews. The transcribed interviews were coded and emergent themes explored until saturation occurred.

Results

The families of eleven children with MPS I were interviewed, five with Hurler’s and six with the attenuated non-Hurler’s. Important themes to emerge were- the fear of dying associated with obstructive sleep apnoea, difficulties communicating at school due to the delayed acquisition of language, chronic pain and restricted mobility, physical differences and restricted participation in social activities such as sports secondary to the musculoskeletal disease burden. The overall theme running through the analysis was the desire to fit in with ones peers.

Conclusion

Parents and children with MPS 1 worry about ‘fitting-in’ with broader society. The presence of airway disease has a profound impact on the emotional well being of parents whilst language delay and musculoskeletal disease have the biggest impact on the quality of life of the children themselves. It is important to understand the impact of MPS I on the quality of life of children and their families so that we may improve future treatment and management of this sub-group of children who have an increasing life span.

The use of qualitative methods to inform Delphi surveys in core outcome set development

Background

Core outcome sets (COS) help to minimise bias in trials and facilitate evidence synthesis. Delphi surveys are increasingly being used as part of a wider process to reach consensus about what outcomes should be included in a COS. Qualitative research can be used to inform the development of Delphi surveys. This is an advance in the field of COS development and one which is potentially valuable; however, little guidance exists for COS developers on how best to use qualitative methods and what the challenges are. This paper aims to provide early guidance on the potential role and contribution of qualitative research in this area. We hope the ideas we present will be challenged, critiqued and built upon by others exploring the role of qualitative research in COS development.

This paper draws upon the experiences of using qualitative methods in the pre-Delphi stage of the development of three different COS. Using these studies as examples, we identify some of the ways that qualitative research might contribute to COS development, the challenges in using such methods and areas where future research is required.

Results

Qualitative research can help to identify what outcomes are important to stakeholders; facilitate understanding of why some outcomes may be more important than others, determine the scope of outcomes; identify appropriate language for use in the Delphi survey and inform comparisons between stakeholder data and other sources, such as systematic reviews. Developers need to consider a number of methodological points when using qualitative research: specifically, which stakeholders to involve, how to sample participants, which data collection methods are most appropriate, how to consider outcomes with stakeholders and how to analyse these data. A number of areas for future research are identified.

Conclusions

Qualitative research has the potential to increase the research community’s confidence in COS, although this will be dependent upon using rigorous and appropriate methodology. We have begun to identify some issues for COS developers to consider in using qualitative methods to inform the development of Delphi surveys in this article.

Risks and benefits of ventilation tubes and hearing aids from the perspective of parents of children with cleft palate

OBJECTIVE

To understand parents' experiences of treatment of otitis media with effusion (OME) for children with cleft palate.

METHODS

Qualitative interviews with parents of 37 children who had non-syndromic cleft palate (with or without cleft lip). They were recruited from two cleft centres in northern England. Participants talked about choices, information, decision-making and satisfaction with ventilation tubes (VTs) and/or hearing aids (HAs). Interviews were recorded and transcribed verbatim. Themes were developed using Framework Analysis.

RESULTS

VTs and HAs were not considered as equal treatments by interviewees, due to physical risks associated with the former and social consequences with the latter. The inequality was explained within three main themes: (1) treatment recommendations - most parents did not recall being offered options when OME was first treated; VTs tended to be presented initially followed by HAs if VTs had been inserted more than once. Treatment recommendations came from medical specialists, although participants could also be influenced by other parents' stories; (2) beliefs about mechanisms of treatments - interviewees believed VTs could address the underlying cause of OME by draining fluid. Some parents felt HAs signified a deterioration in hearing and an escalation of care. Improvements in hearing were reported by interviewees with VTs and HAs; (3) demands on parents - participants often saw the insertion of VTs as opportunistic, alongside another procedure (e.g. palatal closure). They could feel disappointed when VTs fell out or were perceived to have caused ear infections. Parental involvement was on-going for HAs (e.g. ordering batteries and tubes). Parents expressed fears about the potential for social stigma of HAs, although none reported significant teasing of children because they wore HAs.

CONCLUSIONS

Parents' views about treatment for OME were shaped by differing perceptions about anticipated risks and benefits. VTs may have been seen as a simple fix, inserted alongside another procedure, but some interviewees had concerns about possible physical consequences. Others were more worried about anticipated social stigma associated with HAs. However, parents of children who wore a HA described them as easy to manage and well tolerated, at least until children got older and started to comment on their appearance.

Supporting the care of children with diabetes in school: a qualitative study of nurses in the UK

AIMS

Intensification of diabetes management in children and young people has implications for schools. The aim of this study was to examine the role of nurses in supporting care of children with diabetes in schools and early years settings.

METHODS

The qualitative design incorporated focus groups and individual telephone interviews with nurses who were unavailable to participate in focus groups. A purposive sample of 47 nurses from acute and community settings, participated in eight focus groups and eight telephone interviews. Data were analysed through a process of constant comparison.

RESULTS

Nurses identified an ambiguous and inadequate legal and policy framework. The responses of schools were variable and unpredictable because the views of head teachers determined the level of cooperation. School staff could lack basic knowledge about Type 1 diabetes. Relationships between school staff and parents could also affect their willingness to provide support for diabetes care. The skills of negotiating appropriate support for children with diabetes were learnt by experience rather than through formal training or evidence-based guidance. Nurses' accounts demonstrated uncertainties about: what could be required of schools; how schools would respond; individual responsibilities; and about what constituted best practice.

CONCLUSIONS

There is a need for more evidence about how healthcare providers can influence schools and about the most cost-effective use of nurses to support the management of children with diabetes in schools.

The effectiveness of self-care support interventions for children and young people with long-term conditions: a systematic review

Children's health policy has highlighted the need to develop self-care programmes. However, there is a lack of evidence on which to base the development of such programmes. This paper reviews the published research on the effectiveness of self-care support interventions for children and young people with asthma, cystic fibrosis and diabetes. A systematic search was conducted of a range of electronic databases, supplemented by searching the reference lists of retrieved papers and published reviews. Retrieved studies were assessed against quality and eligibility criteria by two independent reviewers. The results were narratively synthesized to examine the effectiveness of self-care support interventions on health status, psycho-social well-being, condition-related knowledge, health service use and participant satisfaction. The search strategy identified 4261 papers which were screened against the review inclusion criteria. A total of 194 papers were assessed as being potentially eligible for inclusion with 15 papers being judged as adequate to include in the review. There is strong evidence of the effectiveness of interventions that target children/young people; use e-health or group-based methods; that are delivered in community settings. There is no evidence that interventions that focus on parents alone or are delivered only in hospital settings are effective. While there is some evidence to inform the development of self-care support programmes, there is a need for well-designed trials of interventions that are feasible to transfer into real-life settings and which involve parents and children in their development.

School children's own views, roles and contribution to choices regarding diet and activity in Spain

BACKGROUND

  Behaviours regarding food and activity are learned during childhood and continue throughout life. Children can be very important agents in making decisions concerning their own well-being and care and their perspective is essential to understanding how they and/or others make choices for them to achieve a healthy lifestyle. However, their perspectives remain under-researched. This study provides an insight into school children's own perspectives, behaviours and contribution to food and activity choices.

METHODS

  The paper reports on the findings from an ethnographic study with 38 Spanish children aged 5-7 years. Information was obtained through participant observations, diaries kept by children and group interviews. Data were analysed using techniques of analytical induction and constant comparison.

RESULTS

  The children who took part in this study described choices about activities with enthusiasm. Children saw activity as a way of learning new things, mastering skills and socializing. They were willing to try and experience new activities and games. However, the activities performed depended on parents' agendas and security issues. In contrast, children reported less interest in and active involvement in food choices. They contributed to family food choices indirectly through the expression of their preferences, not wanting to eat what they disliked or tasting new foods.

CONCLUSION

  Children had strong preferences and motivations, particularly about activities which could be harnessed in interventions to prevent obesity and promote healthy diet and activity. Parental involvement and commitment is also important both to encourage exercise according to children's interests and active informed food choices, including introduction to unfamiliar foods.

Parenting children requiring complex care: a journey through time

BACKGROUND

Parents of children requiring complex care provide intense and demanding care in their homes. Unlike professionals who provide similar care in institutions, parents may not receive regular breaks from care giving. As a result, parents, over time, experience health and social consequences related to care giving. Respite care, one form of a break from care giving, is frequently cited as an unmet need by such parents.

METHOD

Given the paucity of literature on the impact of care giving over time, an ethnographic approach that involved in-depth interviews, participant observation, eco-maps, and document review was used. Parents of children requiring complex care, nurses and social workers participated in the study.

RESULTS

A developmental map of care giving over time was constructed from the parents' retrospective accounts of parenting a child requiring complex care. The developmental map describes the trajectory of care for the children from infancy through young adulthood and the parents' evolving needs for respite care.

CONCLUSION

Existing literature focuses on the day-to-day experiences of parents, who are carers, rather than their experiences over time. As parents of children requiring complex care are providing care from infancy through the death of either child or parent, respite needs will change. This developmental map identifies how a group of parents reported these changes in care giving and their perceived needs for respite care.

Weight and energy: parents' and children's perspectives on managing cystic fibrosis diet

AIMS

To explore the meanings that parents and children attach to food and eating, and how these influence their approaches to dietary management of cystic fibrosis (CF).

METHODS

Ethnographic design using in-depth interviews with 32 children with CF (aged 6-14 years) and their parents, and participant observations during visits to CF clinics with a sub-group of 21 children. Data were analysed using the constant comparative method and theoretical sampling was used to further explore and develop emergent themes.

RESULTS

Dietary management was found to be a demanding task for children and their parents, and priorities differed between them. A priority of feeding for parents was to protect their children's long term physical health and survival by keeping their weight up. A challenge for parents was to ensure their children's cooperation with eating. A priority for children in being healthy was to have energy for physical activities and so energy rather than weight was of immediate relevance to their daily lives. These differences between parents and children gave rise to tensions and conflicts in their interactions with one another in managing diet.

CONCLUSIONS

Healthcare professionals should take account of the meanings that children and their parents attach to food and eating that can influence their decisions about implementing CF dietary recommendations. The role of children in making food choices has implications for acknowledging them as active participants in their dietary care and for adopting child centred approaches to dietary advice for CF.

Re-thinking family-centred care across the continuum of children's healthcare

BACKGROUND

The terms family-centred care (FCC) and family-centred services (FCS) are used interchangeably across the continuum of children's healthcare to encompass concepts of: parental participation in children's healthcare; partnership and collaboration between the healthcare team and parents in decision-making; family-friendly environments that normalize as much as possible family functioning within the healthcare setting; and care of family members as well as of children. However, authors from different professional and policy perspectives have used different definitions and literatures when arguing the evidence for FCC and FCS.

METHOD

A critical literature review and theoretical discussion exploring common concepts and issues forming the basis for a research agenda further strengthening of the evidence base for FCC. A systematic identification of constructs, concepts and empirical indicators is developed and applied to exemplars in pain and asthma that span the continuum of children's healthcare across acute and community settings.

CONCLUSIONS

The extent to which the concepts are supported by research and applied in practice remains unclear. We propose that re-thinking of FCC is required in order to develop a more coherent programme of research into the application of FCC theory in children's healthcare.

Different meanings of respite: a study of parents, nurses and social workers caring for children with complex needs

AIM

To examine the meaning of respite care to parents of children with complex conditions and providers.

METHODS

In-depth interviews, participant observation and document review were used to collect data from nineteen mothers and seven fathers of children between the ages of 8 and 16 years who required complex care and from their respite providers, including thirteen nurses, and four social workers from three counties in North-west England.

RESULTS

Parents described three categories of respite: short breaks provided by the extended family or friends, short breaks (3-4 h) by an outside agency, and overnight respite outside of home. They highly valued overnight respite outside the home. There was some overlap but also notable differences between parents' and providers' categorizations of respite care and the value attached to different forms of respite provision. Parents and nurses valued overnight respite outside the home unlike social workers who preferred to provide respite without separating children from their families.

DISCUSSION

Appropriate provision of respite care and communication with parents requires understanding of the meaning of respite to parents. The meanings attached to respite care by parents and providers should be considered in attempts to understand and address problems of inappropriate provision and/or dissatisfaction with respite services.

Involvement and fragmentation: a study of parental care of hospitalized children in Brazil

Parental involvement in the care of children who are hospitalized has been encouraged by the government in Brazil, as it has in the United Kingdom (UK). In this paper, key aspects of the UK, North American, and Latin American literature concerning parental participation are discussed, and implications for hospital care of children in Brazil are considered. A study of the division of work between nurses and the mothers (or other relatives) of 10 children hospitalized with chronic illnesses is reported. Data were collected by participant observation of child care in a Brazilian hospital. The results highlight some of the difficulties that arise in the integration of the work of mothers and nurses in hospital care of children and the fragmentation of care into "manual" and "intellectual" work. The results are considered within the theoretical framework of the model of technologic organization of work (Gonçalves, 1979, 1994). Implications for the organization of child care in the hospital are discussed.

Enhancing the rigor of grounded theory: incorporating reflexivity and relationality

Some proponents of the grounded theory method appear to treat interview and participant observation data as though they mirror informants' realities. Others claim that grounded theory incorporates reflexivity. It is claimed in this article that the principal texts on grounded theory do not attend to the effects of interactions between researchers and participants in interview and participant observation contexts. Descriptions of the effects of interactions on interview data and attention to relationships between interviewers and interviewees are necessary for attending to the rigor of grounded theory findings. Therefore, it is argued that reflexivity and relationality, which are defined as attending to the effects of researcher-participant interactions on the construction of data and to power and trust relationships between researchers and participants, should be incorporated into grounded theory.

Training and education: an analysis of quality assurance in teaching and nursing education

There is a continuing tension between training and education in vocational higher education courses. The debate in nursing has been heightened by the transfer of courses into higher education and staffing problems in the NHS. Comparisons with other occupations can help prevent introspection in analysis of policy issues in nursing. Teacher training is a particularly useful comparator because it entered higher education before nursing, and teachers have failed to maintain a level of autonomy that nurses would once have envied. This paper compares nursing and teacher training with particular reference to quality assurance. The UK government has adopted a centralized quality assurance and funding system for teacher training. Nursing is included in higher education quality assurance systems but funding is devolved. The tensions between training and education within nursing and teacher training are examined, and implications for the development of nursing considered.

Caring for parents of hospitalized children: a hidden area of nursing work

Children are the recognized patients when admitted to hospital but their parents can also present demands for care by nurses. Involvement in care can be stressful for parents, particularly when children are required to undergo unpleasant procedures. Parents turn to their families for support in the first instance but some also look for care from nurses. Consequently parents can present a need for care of themselves to nurses whose primary patients are children. In this paper the experiences of a group of parents who became co-clients of nurses are considered along with the views of nurses working on the same ward. The discussion arises out of a larger study of the experiences of the parents of children admitted to a surgical ward in a children's hospital. The principal purpose of the study was to examine parents' and nurses' perceptions of their participation in the care of hospitalized children. The work of caring for parents is found to be ad hoc and unpredictable. The implications of the study for practice and policy are considered.

Paying to participate: financial, social and personal costs to parents of involvement in their children's care in hospital

Parental participation now has become an accepted feature of the care of children in hospital. However, the costs to parents of their involvement in the care of their hospitalized children have received little attention. In this paper the financial, social and personal costs to a group of parents of children admitted to a surgical ward are described. Financial costs included loss of earnings, travel and subsistence. Parents' financial commitment was open-ended and the burden of financial costs was inequitable. The organization of alternative care for siblings carried social costs including loss of privacy and autonomy in family relationships. Participation in care could be distressing and so result in personal costs. Differences between the socialization of parents and health care professionals explain some of these personal costs. Implications for policy makers and practitioners are considered.

Maternal knowledge and professional knowledge: co-operation and conflict in the care of sick children

Although it is common-place to describe mothers as 'experts' about their own children there has been little examination of the nature of mothers' expertise in the assessment of their sick children. In this paper mothers' accounts of occasions when they believed that they knew that their children were unwell are reported. Mothers also described how it could be difficult to convince health professionals that their concerns were justified. These accounts were obtained during a qualitative study of the experiences of parents of 24 children hospitalised on a surgical ward. The nature of maternal and professional knowledge is considered and it is suggested that conflicts arise from the different nature of maternal knowledge, which develops in the 'private' domain of intimate contact and professional knowledge which is based in the 'public' domain of the world of work. These differences are illustrated by problems experienced by mothers and nurses in the integration of their different knowledge in assessments of children's pain. Implications for practitioners involved in the care of sick children are considered.

The use of qualitative methods in the study of parents' experiences of care on a children's surgical ward

User satisfaction with the care of hospitalized children is examined in this paper. It is argued that parents are proxy consumers but that their status is conditional on the way in which they exercise choices. Parents' involvement in the care of their children means that the term 'user' is more appropriate than 'consumer'. Methodological problems in the assessment of user satisfaction are discussed. A study of the experiences of parents of 24 children discharged from a surgical ward of a children's hospital is described and the implications for the assessment of user satisfaction reviewed. The study demonstrates that qualitative methods have value in the assessment of user satisfaction with care. A particular strength of qualitative methods of inquiry is that limitations of users' choice in care can be assessed.

A study of role negotiation between nurses and the parents of hospitalized children

The role of the parent of a hospitalized child has changed considerably over the past 30 years. Where parents were previously expected to had responsibility for care over to their child's nurses, there is now an expectation that parents will be extensively involved in the care of their hospitalized children. The negotiation of roles between nurses and parents has been advocated by workers concerned about conflicts between nurses and parents. However, it is not known whether such negotiation takes place between nurses and parents. It is clear that power is not evenly distributed between nurses and parents: issues of territory, stress, anxiety, uncertainty, control and conflicts arising from parental competence all place the parent in a weaker position. It is argued that the nurse holds the initiative in the decision about whether negotiation takes place. A small study is described in which nurses were invited to describes their response to their perception that a parent wanted to increase or decrease her or his involvement in her or his child's care. The critical incident technique (Flanagan 1954) was used to collect data. Nurses' responses were categorized into categories of 'encouragement', 'explanation/advice' and 'negotiation'. Responses were then placed in more specific subcategories. The inter-rater reliability of the categorization was measured. Owing to the limitations of the study, the results can only be regarded as suggestive. Nevertheless, significant association was found between the category of response and the grade of staff, with a stratified pattern of category of response demonstrated. The implications of the study for future research are discussed.

Moral learning in nursing education: a discussion of the usefulness of cognitive-developmental and social learning theories

The preparation of students for ethically sound practice is an essential concern for nurse educators. The theories of cognitive development and social learning theory are discussed as explanations of moral learning. The implications of the application of each of these theories to nursing education are discussed and the usefulness of each theory to nurse educators is reviewed. It is argued that neither theory is entirely satisfactory for application to nursing education and it is concluded that a pragmatic eclecticism is desirable in the approach to moral education in nursing.

Development of new radiopharmaceuticals based on N-substitution of iminodiacetic acid

A new approach to radiopharmaceutical design is demonstrated, in which small chelating groups capable of binding gamma-emitting radiometals are attached to biologically active molecules, thus producing radiopharmaceuticals based on bifunctional drug and biochemical analogs. The chelating group iminodiacetic acid has been evaluated for this role by examining two N-substituted iminodiacetic acids: methyliminodiacetic acid (MIDA) and N-(2,6-dimethylphenylcarbamoylmethyl)iminodiacetic acid (HIDA). Radiochemical and biologic studies showed that both agents were obtained in high radiochemical purity, were stable in vitro and in vivo, and possessed biologic distributions governed almost exclusively by the N-substituted group. These characteristics of 99mTc-labeled N-substituted iminodiacetic acids, prepared using an "instant kit" method, provide the basis for a valuable new class of radiopharmaceuticals based on bifunctional drug and biochemical analogs.