How effective is a shortterm educational and support intervention for ...

Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

How effective is a short-term educational and support intervention for families of an adolescent with type 1 diabetes?

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Elisabet Konradsdottir and Erla Kolbrun Svavarsdottir Elisabet Konradsdottir, RN, MSC, is Clinical Nurse Specialist, Landspitali University Hospital Childrens’ Hospital Hringbraut; and Erla Kolbrun Svavarsdottir, RN, PhD, is Professor, Faculty of Nursing, University of Iceland Eirberg, Eiriksgata, Reykjavik, Iceland.

Search terms Adolescents with diabetes, coping and adaptation, experimental, families, pediatric.

Author contact [email protected], with a copy to the Editor: [email protected] Disclosure The authors report no actual or potential conﬂicts of interests. This research was funded by Icelandic Nurses Association research fund. First Received December 30, 2010; Revision received March 22, 2011; Accepted for publication May 16, 2011.

Abstract Purpose. To study adaptation and coping strategies of parents who had adolescents with diabetes and the effect of a short-term educational and support intervention. Design and Method. A quasi-experimental design was used in the study on 23 families of adolescents with diabetes. Results. A significant difference was found between parents’ coping patterns before the intervention. Fathers were, however, found to rate their coping patterns significantly more helpful after the intervention than before. The mothers demonstrated, nevertheless, a significantly greater use of all the coping patterns. Practice Implications. Educational and support intervention is helpful for parents of adolescents with diabetes.

doi: 10.1111/j.1744-6155.2011.00297.x

Type 1 diabetes is a serious illness that can have a detrimental effect on both the quality of life and life expectancy. The number of children and adolescents diagnosed with type 1 diabetes is rising. Worldwide, the overall annual incidence of type 1 diabetes is increasing at the rate of about 3% (The DIAMOND Project Group, 2006). The incidence of diagnoses of type 1 diabetes among Icelandic children and adolescents increases with age, peaking in the teenage years before dropping again (Thorsson, Franzson, Konradsdottir, & Helgason, 2001). Research has shown that when a child or adolescent is diagnosed with a serious chronic illness, the entire family is affected (Knafl & Gilliss, 2002; Wright & Leahey, 2009). The diagnosis of the disease comes as a shock, causing parents grief and a sense of loss, and creating a need to reassess the family’s situation before it can continue with anything resembling a “normal” life (Bowes, Lowes, Warner, & Gregory, 2009; Lowes, Gregory, & Lyne, 2005; Melseki, 2002). Parents need to adapt to new circumstances, such as coping with Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.

the treatment of the adolescent’s illness, supporting him or her in a new role, and considering his or her welfare in addition to that of the family as a whole. The regulation of blood sugar levels in adolescents with type 1 diabetes is difficult due to the major changes in physical and mental development typical of this age group, and metabolic control worsens during adolescence. However, the better the regulation of blood sugar levels, the less risk there is of experiencing the complications of type 1 diabetes (The Diabetes Control and Complications Trial Research Group [DCCT], 1996). Parents of children and adolescents with type 1 diabetes have a major influence on the regulation of blood sugar levels, and it has also emerged in research that they play a key role in supporting the adolescents when it comes to self-care. For example, parental support is important in terms of administering regular insulin injections and frequent monitoring of blood sugar levels on a daily basis, adaptation to a healthy lifestyle, and the correct response to blood sugar levels that are 295

Support Intervention for Families of an Adolescent

too high or too low (Kyngäs, Hentinen, & Barlow, 1998; Wysocki et al., 2006). The complexity of type 1 diabetes treatment can result in family stress, which can in turn contribute to poor metabolic and health outcomes. However, including the family in diabetes care has been found to play an important role in the successful management and adaptation of type 1 diabetes in children and adolescents (Chesla, 2010; Wysocki et al., 2006). An adaptation is defined as the degree to which an individual responds both physiologically and psychosocially to the stress of living with chronic illness (Whittemore, Jasper, Guo, & Grey, 2010). Each family member uses his or her coping strategies to adapt to the chronic illness. Confidence in type 1 diabetes management is crucial to successful adaptation, but family functioning and parental adaptation is also acknowledged to be an important factor in childhood adaptation to type 1 diabetes (Whittemore et al., 2010). Differences in coping strategies have been found between mothers and fathers. When a child suffers from a chronic illness, mothers have been found to use a wider range of coping strategies directed at family duties, and commitments and care of the child, whereas fathers are primary providers for the family and supporters for the healthy children and for their wives (Goble, 2004; Hovey, 2005; Rayens & Svavarsdóttir, 2003; Svavarsdottir, 2005). This information is important to take into consideration when assisting parents to cope with their children’s chronic illness. Interventions directed toward recognizing and accepting differences between parents in the same family may contribute to successful family adaptation. In a recent literature review on family-centered interventions to enhance the health outcome of children with type 1 diabetes, McBroom and Enriquez (2009) found nine publications that investigated the effectiveness of the interventions. Findings indicated that family-centered interventions significantly improved HbA1C, enhanced family dynamics, and decreased family conflict. A positive correlation has also been identified between the good adaptation of parents to their child’s chronic illness and the child’s own adaptation (Canam, 1993; McCubbin, McCubbin, Nevin, & Cauble, 1996b). Further, families with higher incomes and higher caregiver knowledge have been found to be associated with lower HbA1C (Stallwood, 2006). However, Wennick, Lundqvist, and Hallström (2009) have interestingly pointed out that in assisting families to adapt to childhood type 1 diabetes, healthcare providers emphasize controlling the 296

E. Konradsdottir and E. K. Svavarsdottir

blood sugar level, rather than emphasizing assisting families in their everyday lives (living with the illness). In actuality, families need support and solutions when successfully adjusting to having one family member with a chronic illness (Fisher, 2001; Leonard, Jang, Savik, & Plumbo, 2005). Parents and siblings of juveniles with chronic illnesses should be considered, therefore, to be the nurse’s clients, just as the child or the adolescent with the illness (Wright & Leahey, 2009). The Calgary Family Assessment Model (CFAM) and the Calgary Family Intervention Model (CFIM; Wright & Leahey, 2009) formed the theoretical framework for the present study. These models were chosen to guide the study as well as the intervention because of their strengths in focusing on clinical issues in such a way that a clinician can help family members to deal with a complex and often difficult life situation (Chesla, 2010; Wright & Leahey, 2009; Wysocki et al., 2006). The basic components of the Calgary models are that illness impacts every member of the family. Family assessment according to the CFAM provides comprehensive information about the family, which then enables the nurse to highlight each family’s coping behavior and strengths. In our study, a brief family assessment according to the Calgary model was made for each family. A nursing intervention grounded in the CFIM is based on mutual cooperation between the family and the nurse. Such a nursing intervention is used to enhance, improve, and sustain a family’s functioning in the cognitive, affective, and behavioral domains of this conceptual framework. The goal is to facilitate change or adjustment to the family’s health problem. One of the most powerful nursing interventions for families adapting to a chronic health problem is the use of “interventive” questions (Wright & Leahey, 2009, p. 145–150). Interventive questions invite family members to share concerns, information, challenges, and problems. Listening to answers and discussing them can help family members to discover new solutions in adapting to the chronic illness or eventually accept the differences between mothers’ and father’ perspectives. In the support interviews in this study, the parents (mothers and fathers) were asked interventive questions like: What are your greatest concerns about having an adolescent with type 1 diabetes? What has been helpful for you to adapt to your child’s illness, and what has been least helpful? These questions were asked to gain an insight into parents’ coping strategies. Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.



Nurses are now more than ever required to demonstrate the effectiveness of their work and have, because of that, increasingly been engaging in developing interventions and testing their impact (Burns & Grove, 2001). Helping a family to adjust to complex chronic illnesses involves many factors, such as education, support counseling, and providing family members with the opportunity to express their feelings about the impact of the illness on their lives (Marshall, Fleming, Gillibrand, & Carter, 2002; Sullivan-Bolyai, Knafl, Sadler, & Gilliss, 2003; Wright & Leahey, 2009). Nurses, who work with families of chronically ill children and adolescents, must assess each family individually, emphasize its strengths, and assist it in developing its own problem-solving abilities. It is vital that interventions under development are tested for the benefit of the client and his or her family, as well as the effectiveness for the healthcare service in general. In recent years, the adaptation to chronic illnesses has attracted the attention of researchers (Chesla, 2010; Svavarsdottir, 2005). Less is known, however, about how to intervene with parents of chronically ill children. Family-based interventions are being recommended and further research on parents’ adaptation is needed. Parents’ adaptation and strategies for coping with their adolescents’ type 1 diabetes has received little attention. A Finnish study, however, demonstrated insufficient adaptation by the parents of children and adolescents with type 1 diabetes (Hentinen & Kyngäs, 1998). The overall purpose of this quasi-experimental study was to evaluate the effectiveness of a nursing intervention for families of adolescents with type 1 diabetes as well as to evaluate how these families adapt to and cope with living with the illness. Based on the review of the literature and the theoretical framework that guided this study, the following hypotheses were tested: (a) the adaptation of mothers and fathers will have changed significantly 6 months after a short-term education and support intervention, and (b) the coping patterns (family solutions, parental solutions, and illness-related solutions) of mothers and fathers will have changed significantly 6 months after a short-term education and support intervention. Further, the following research questions were posed: (a) How do mothers and fathers adapt to their adolescent’s type 1 diabetes? (b) What coping patterns do mothers and fathers use? (c) Is there a correlation between background variables, such as the age of the adolescent, the age of the adolescent at diagnosis, the adolescent’s admissions to hospital, serious incidences of Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.

hypoglycemia, and the education and income of the parents, on the one hand, and the adaptation and coping patterns of the parents, on the other? METHOD Procedure

This intervention study was part of a larger research project and used data collected in Iceland over the winter of 2002–2003. In the larger research project, the parents’ perspectives of adapting to and coping with type 1 diabetes was studied as well as selfefficacy from the adolescents’ perspectives and siblings’ behavior. However, the study presented here gives only the parents’ perspectives regarding adaptation and coping strategies of having an adolescent ages 13–18 with type 1 diabetes. Furthermore, results regarding the evaluation of the impact of a short-term education and support intervention from the parents’ perspectives are identified. The intervention in the larger research project was divided into three sessions: (a) group education for parents and adolescents with type 1 diabetes, (b) single support interviews with the parents, and (c) support groups for the adolescents (see Table 1). Only the results from the intervention offered to the parents (sessions a and b) are presented here. The data collector, a study nurse who was not working at the diabetic clinic, invited participants to participate in the study. If the parents agreed to participate, a questionnaire and a consent form were mailed to their home address before the first session (N = 23 families; 22 mothers and 19 fathers). At the

Table 1. The Short-Term Education and Support Intervention Session A: Educational lectures for parents and adolescents • The impact of chronic illness on adolescents and their families, and adaptation to chronic illness • The impact of chronic illness on siblings and sibling relationships • The teenage years and the support of adolescents by parents and healthcare professionals Session B: Support interviews for parents • Engage parents in dialogue about their illness experience • Assess the impact of the illness on family • Comment on the family’s strengths • Identify possible resources Session C: Support groups for adolescents • Chance to meet other adolescents with diabetes and reflect on their experiences • Discuss their experiences of having a chronic illness • Give one another support

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first data collection point in November 2002, the family members were asked to complete the questionnaires and bring them to the Time 1 session along with the signed consent form. Six months later (at Time 2, May 2003), family members were asked again to answer the same set of questions. Twentyfive parents completed the questionnaire at Time 2. Several parents failed to answer all the items on the questionnaire (at Time 1, n = 22 mothers and n = 19 fathers participated [23 families]; at Time 2, n = 12 mothers and n = 13 fathers participated). The fact that more mothers withdrew from the study was taken into consideration during subsequent analysis of the data. Ethical considerations

Permission was granted by the hospital ethical review board, and notice was sent to Iceland’s Data Protection Authority. Permission was also granted from the director of the Outpatient Clinic for Children with Diabetes and the director of nursing in the pediatric ward at the University Hospital in Reykjavik. Participants

The study population was comprised of all families of Icelandic adolescents with type 1 diabetes, ages 13–18 at the time of the study (N = 46 families). Half of these or a total of 23 families (22 mothers, 19 fathers, and 23 adolescents) consented to take part in the study. The conditions for inclusion in the study were that parents or guardians had a 13- to 18-year-old adolescent child with type 1 diabetes (see Table 2), and that participants had to be able to read, speak, and write Icelandic. The sample included 13 male (56.5%) and 10 female (43.5%) adolescents. The average age was 14.8 years (range 13–17 years). The children’s age at diagnosis ranged from 13 months to 16 years, with an average age at diagnosis of 10 years. Every family of an adolescent who was receiving active treatment at the diabetic clinic was invited to participate in this study because, on average, only 13 children are diagnosed in Iceland each year with type 1 diabetes, and the investigators were hesitant to exclude some families that might benefit from the study. Instruments

All the instruments used in this study were originally developed in English but translated (forward 298


Table 2. Parent Demographics

Age of participants 32–42 43–51 52–64 Marital status of mothers and fathers Cohabiting/married Single parent Employment status of mothers and fathers Full-time Full-time + second job Part-time Stay-at-home parent Didn’t answer Years of education 2–10 years 11–14 years 15–21 years Didn’t answer Family income < ISK 400,000 > ISK 400,000

Mothers (n = 22)

Fathers (n = 19)

n

%

n

9 10 3

40.5 45.5 13.5

7 8 4

36.8 42.1 21.1

17 5

77.3 22.7

18 1

94.7 5.3

14 1 5 2

63.6 4.5 22.7 9.1

13 5 0 0 1

72.2 26.3 0 0 5.3

7 9 4 2

31.5 40.5 18.9 9.1

8 2 4 5

44.8 10.6 21.2 26.5

13 9

59.1 40.9

9 10

47.4 52.6

%

and backward) into Icelandic. The following four questionnaires were used in the study. The Family Profile Inventory (McCubbin, 1991) was used to obtain background information about the mothers, the fathers, and the family as a whole. Questions focused on parents’ gender, age, education, and income, as well as the family’s circumstances, length of cohabitation, and number of children. General Information About the Adolescent with Type 1 diabetes (Svavarsdóttir & McCubbin, 1999) was used to obtain information about the adolescent with type 1 diabetes. The questionnaire consists of 13 items, including the age and gender of the child and when the child was diagnosed with diabetes, and questions related to monitoring of blood sugar levels and the administration of insulin injections. Other items include where the family is receiving health care, whether others in the family have been diagnosed with type 1 diabetes, and whether the family belongs to an association for families of children and adolescents with type 1 diabetes. The Family Adaptation Scale (Antonovsky & Sourani, 1988) was used to investigate the family’s adaptation. The questionnaire consists of 11 items featuring multiple choice questions with seven options (from “I’m completely satisfied” to “I’m not Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.


satisfied”). The reliability (Cronbach’s alpha) of this evaluation tool has been measured in studies as .89 for the entire scale (Svavarsdottir, Rayens, & McCubbin, 2005). The Coping Health Inventory for Parents (CHIP; McCubbin, McCubbin, Nevin, & Cauble, 1996a) was used to discover what parents found helpful or less helpful in overcoming problems in family functioning caused by the illness of a child (family member). The questionnaire consists of 45 items with four response categories from extremely helpful to not helpful. For each item where the participants chose not helpful, they were asked to select either the option “Chose not to use it” or “Not possible.” The questionnaire is divided into subscales consisting of three categories of principal coping behaviors or patterns. Coping pattern I (family solutions) involves maintaining the family’s stability, cooperation, and optimism. This subscale consists of 19 items focused on enhancing family functioning and interaction between family members and maintaining optimism in spite of the child’s/adolescent’s chronic illness. A typical answer for this category of coping strategies is, “trying to maintain family stability.” Coping pattern II (parental solutions) involves maintaining social support and self-esteem. This subscale consists of 18 items focused on interaction outside the nuclear family, which gives family members strength and increases their sense of selfconfidence. This subscale also includes solutions that mitigate stress. A typical answer to an item in this subscale is “concentrating on hobbies.” Coping pattern III (illness-related solutions) consists of eight items about receiving counseling and support from professionals and from the parents of other children and adolescents with chronic illnesses. A typical answer for this subscale is “reading more about the medical problem which concerns me.” The reliability or internal consistency (Cronbach’s alpha) for coping pattern I (family solutions) has been reported as .79, for coping pattern II (parental solutions) .79, and for coping pattern III (illnessrelated solutions) .71 (McCubbin et al., 1996a). The Cronbach’s alpha for the list of coping patterns calculated for this study was, CPI (family solutions) .97, CPII (parental solutions) .94, and CPIII (illnessrelated solutions) .93. Intervention

The short-term education and support intervention was designed by the research team, which included a nurse with a PhD, a clinical nurse specialist, and a Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.


master’s student in nursing. The intervention was based on the Calgary Family Assessment and Intervention Models. The short-term education and support intervention consisted of three sessions: (a) educational lectures for the 23 families, the adolescents and parents together; (b) support interviews for the parents; and (c) support groups for the adolescents. Session A, the educational lecture, occurred at a 3-hour afternoon meeting at which the researchers held three 45-minute lectures. Parents and adolescents were given opportunities to meet and talk during the 30-minute breaks between lectures. A coffee-house atmosphere was created to stimulate open dialogue between the parents, adolescents, and researchers. Before the first lecture, the researchers collected the completed questionnaires that the families had brought along with them. The three lectures dealt with (a) adolescence, the parental role, family dynamics, the impact of chronic illnesses on adolescents and their families, and adaptation to the illness situation, (b) the impact of chronic illnesses on siblings and sibling relationships, and (c) the impact of risk factors, such as smoking and alcohol, on the control of blood sugar levels, adolescents’ perceptions of having type 1 diabetes, and the support for adolescents from parents and healthcare professionals. In session B, support interviews lasting 60–90 min were conducted with parents of the adolescents. The parents (in one instance, one parent and one guardian) attended together. The aims of the support interview were to give parents the chance to express their feelings about their experiences of having an adolescent with type 1 diabetes, to hear about other families’ experiences, and to support parents by emphasizing the family’s strengths and problemsolving abilities. At the beginning of each interview, the parents were greeted and made comfortable. A family assessment was carried out using the CFAM (e.g., questions such as who belongs to your family?) Parents were encouraged to talk about their experiences from the diagnosis of the child and throughout the adolescent years, and the main concerns of each parent were explored. The researchers commented on the family’s strengths, and potential resources for each family were identified. Session C, which comprised the third part of the education and support intervention used support groups for the adolescents. Five groups were formed, each consisting of five to seven adolescents of a similar age, who met on a single occasion for 299


60 min. The main aim of the support groups was to give the adolescents a chance to meet other adolescents with type 1 diabetes, to discuss their experiences of having a chronic illness, and to give one another support. An attempt was made to get all the adolescents to talk about their experiences of having type 1 diabetes. The researchers asked the adolescents interventional questions grounded in the theoretical framework of Wright and Leahey (2009), such as what were the adolescents’ greatest worries, what was the most difficult thing about having type 1 diabetes, and what had they found most helpful in regulating their blood sugar levels and, in general, their daily lives. The points raised in each case were explored, such as the adolescents’ experiences in administering self-care at school, friends’ attitudes to type 1 diabetes, and risk factors in adolescence. The adolescents also spoke extensively about relationships with their parents and their experiences of hypoglycemia (see Table 1). As indicated above, only the results from the intervention offered to the parents (sessions A and B) are presented here.

Data analysis

To process the data and answer the research questions, descriptive statistics such as mean, standard deviation, and range were used along with the inferential statistics of an independent-samples t-test and Pearson correlation. A dependent-samples t-test was used to analyze the impact of the short-term education and support intervention. Statistical significance was set at p < .05.


RESULTS Hypothesis testing

In this study, no significant difference was found between the adaptation of mothers and fathers at baseline and 6 months after they received the shortterm education and support intervention. However, the adaptation of mothers and fathers declined between the two periods. Nor was any significant difference found in the subscales of mothers’ coping patterns after 6 months or after they had received the short-term education and support intervention. On the other hand, fathers were found to rate all the subscales of the coping patterns more helpful after the intervention than before the intervention: coping pattern I (family solutions; n = 10, t = -4.37, p = .002), coping pattern II (parental solutions; n = 11, t = -2.35, p = .041), and coping pattern III (illnessrelated solutions; n = 10, t = -2.481, p = .035; see Figure 1). Parental adaptation

The mean adaptation score for mothers (n = 18) was 62.9, and the mean adaptation for fathers (n = 16) was 65.9 (Table 3). The gap between the lowest and highest value (range) for the mothers was 39–77, and for the fathers 48–77, suggesting that some mothers do not adapt as well as fathers. When the adaptation of parents (N = 35) was examined together (mothers and fathers), the mean adaptation score was 64.3 Although fathers scored higher than mothers in adaptation, no significant difference was demon-

Figure 1 Use of mothers’ and fathers’ coping patterns (CPI, CPII, and CPIII) before short-term education and support intervention.

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Journal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.



Table 3. Mean Value of Adaptation of Mothers and Fathers M Adaptation of mothers (n = 18) Adaptation of fathers (n = 16) Adaptation of parents (n = 34) Adaptation of mothers Time 1 (n = 12) Adaptation of mothers Time 2 (n = 12) Adaptation of fathers Time 1 (n = 13) Adaptation of fathers Time 2 (n = 13)

SD

Range df

t

p

Table 5. Subscale of Coping Patterns (CPI, CPII, CPIII) Most Used by Mothers and Fathers in Session 1

62.9 10.4 39–77 65.7

8.2 48–77

64.3

9.2 39–77

64.4

8.9

61.3 10.0 65.8

8.5

61.5

9.3

Coping patterns CPI (family solutions) CPII (parental solutions) CPIII (illness-related solutions)

Mothers (n = 17) Mean/number of items

Fathers (n = 15) Mean/number of items

48.3/19 = 2.52 38.1/18 = 2.11 19.4/8 = 2.42

23.4/19 = 1.23 19.1/18 = 1.06 9.1/8 = 1.13

11 1.87 .089

12 1.65 .126

strated between the adaptation of mothers (M = 62.9) and fathers (M = 65.7, n = 34, t = .860, p = .72). When the correlation between the mothers’ background variables and adaptation was examined, a significant positive correlation emerged between family income and mother’s adaptation (n = 18, r = .553, p = .017). Parental coping strategies

Mothers demonstrated a significantly greater use of all the coping patterns on the questionnaire: coping pattern I, maintaining the family’s stability (n = 31, t = -4.51, p < .001); coping pattern II, social and personal support (n = 32, t = -3.813, p = < .001); and coping pattern III, seeking advice and support from professionals and other parents in the same situation (n = 31, t = -4.170, p = < .001; Table 4). Both fathers and mothers used coping pattern I the most, namely, maintaining family stability (Table 5). Examination of subscale CPIII (seeking advice and support from professionals and other parents in the same position) revealed that mothers and fathers did not regard specific coping patterns as equally helpful (see Table 5). Mothers found it extremely helpful or

moderately helpful to talk to healthcare professionals (e.g., nurses, social workers) when visiting a medical center with the adolescent in 100% of cases (n = 22), whereas fathers found it so in only 41.1% of cases (n = 7). Additionally, for the mothers, 95.3% found it extremely or moderately helpful to talk to a doctor about their concerns, while 41.2% of the fathers indicated talking with the doctor was helpful for them. All of the mothers found it also to be extremely or moderately helpful to take the adolescent regularly to the doctor (n = 22), whereas this was true for only 41.7% of the fathers (n = 5). The solution that fathers found most helpful in this subscale (CPIII) was “reading more about the medical problem which concerns me,” which they rated extremely or moderately helpful in 60.0% of cases (n = 9). Mothers rated the same solution as extremely or moderately helpful in 81.8% of cases. The solution fathers rated as least helpful in this subscale (CPIII) was “reading about how other persons in my situation handle things,” which they rated as minimally helpful or not helpful in 66.2% of cases, whereas mothers rated the same solution extremely or moderately helpful in 95.5% of cases. DISCUSSION

The main findings of this study indicated fairly good adaptation among Icelandic mothers and fathers

Table 4. Coping Patterns (CPI, CPII, CPIII) and Total Score of Mothers and Fathers in Session 1 Mothers (n = 17) M Coping patterns CPI (family solutions) CPII (parental solutions) CPIII (illness-related solutions) Total score

Fathers (n = 15) SD

Range

M

SD

Range

48.3 38.1 19.4

19.7 6.9 19.1

30–56 28–50 11–24

23.4 19.1 9.1

19.7 18.0 9.0

0–57 0–51 0–25

105.8

17.9

69–127

51.6

46.8

0–123


301


who have an adolescent with type 1 diabetes. Some mothers rated their adaptation as poor, and it emerged that the lower the family’s income, the worse the mother’s adaptation. This finding is in harmony with findings presented by Whittemore et al. (2010) and Stallwood (2006), who found families with higher incomes to report better blood sugar control. Special consideration should be given to the adaptation of mothers when it is known that a family is in difficult financial circumstances. At this time in particular, given the level of the recession in Iceland, mortgage foreclosures, the unemployment rate, and rising costs, family income needs to be taken into consideration. Another finding of this research indicated that parents’ adaptation had decreased after 6 months (even though it had not decreased significantly compared to Time 1, see Table 3). One possible explanation for the decreased adaptation is that adaptation can vary due to temporary problems or stress factors, such as difficulties in daily metabolic control and major changes in the physical and mental development of the adolescent. Type 1 diabetes treatment is a very complex and demanding therapy that affects fundamental aspects of daily family life, and metabolic control often worsens during the adolescent years (McCubbin et al., 1996b). It has been shown that there are more conflicts in families where a child suffers from type 1 diabetes than in the families of children with other chronic illnesses such as rheumatoid arthritis or asthma (Hentinen & Kyngäs, 1998; Wysocki et al., 2006). It is, therefore, very important for health professionals such as nurses who support the families of adolescents with type 1 diabetes to check regularly on the families’ needs for further emotional and educational support. Parents may need increased information about the impact of type 1 diabetes on adolescents and their families, and professionals need to assist mothers and fathers in their parenting roles. Interestingly, when the coping patterns were evaluated, a significant difference was found between mothers and fathers before the education and support intervention. Mothers found it extremely helpful or moderately helpful to talk to healthcare professionals, whereas 41.2% of the fathers found talking to healthcare professionals to be helpful. Other research also supports the result that mothers are more likely to use coping strategies related to the management of the illness, whereas fathers are more likely to use coping strategies that distance themselves from the stressors related to the type 1 diabetes (Azar & Solomon, 2001; Dashiff, 302


1993; Svavarsdottir, 2005). It has been demonstrated that fathers have difficulties in adjusting to a child’s chronic illness and they are not being educated about the illness (Katz & Krulik, 1999). This may result in fathers being at increased risk of becoming isolated from the child and the rest of the family due to lack of communication and negative perception of the child’s chronic illness (Deatrick & Knafl, 1988; Hovey, 2005). However, in modern society, the role of fathers is changing, perhaps because of the increasing participation of women in the workforce and the introduction of paternal leave in Iceland. In this study, 91% of mothers worked outside the home, with 68.1% working in a full-time job. It is generally accepted that it is important for the well-being of a family with a chronically ill child that both parents are equally involved in providing care for the child. It is important, therefore, to understand how fathers adapt to their children’s illnesses and which coping strategies they find most helpful. Interestingly, the impact of the short-term education and support intervention that was developed and used in this research was evident among fathers since 6 months after the intervention, they found it more helpful to use all the coping strategies that experts believe may improve adaptation to a child’s chronic illness. Nurses who work with the families of chronically ill adolescents in clinical settings must pay attention to each family member individually, emphasize their strengths, and assist them in developing their own problem-solving abilities. It is also important to point out different coping strategies between parents in order to improve their communication with each other and enhance mutual support. An appropriate nursing intervention like the support conversations used in this study (which gave the parents a chance to express their thoughts and feelings about having an adolescent with type 1 diabetes) may have increased parents’ understanding of each other’s feelings and their adaptation to the adolescent’s health problem. In this Icelandic study, both parents (mothers and fathers) indicated using coping pattern I the most, which is aimed at maintaining family stability. This emphasis on maintaining the stability of the family cannot be ignored by healthcare professionals. Therefore, nurses need to focus on the family system in their practices when caring for adolescents with type 1 diabetes and their families. LIMITATIONS

The findings from this study indicate that the shortterm educational and support intervention is feaJournal for Specialists in Pediatric Nursing 16 (2011) 295–304 © 2011, Wiley Periodicals, Inc.


How Do I Apply This Evidence to Nursing Practice?

The study, which was based on the Calgary Family Assessment and Intervention Models, implies that short-term educational and support intervention can be helpful for parents in the adaptation phase to life with type 1 diabetes, although larger studies are needed to confirm these results and to relate the results to disease outcomes. This information is important for clinicians who assist the families of children and adolescents with type 1 diabetes in adapting to the condition. The differences observed in this study between mothers and fathers needs to be addressed in the design and implementation of nursing interventions for families of children and adolescents with type 1 diabetes. Further, although metabolic control is important, the well-being of family members must not be forgotten. Both parents need to be encouraged to take part in conversations within the clinical setting about their own coping strategies, well-being, and adaptation to their child’s illness. Therefore, a future vision for clinicians is to increase support for the family as a whole in order to facilitate change or adjustment to the family’s health problem and enhance, improve, and sustain the family’s functioning.

sible, particularly for fathers. However, the coping patterns of parents of adolescents with type 1 diabetes need to be studied further. The results suggest that mothers and fathers use different coping patterns when coping with their adolescents’ chronic illnesses. It should be noted, however, that it is not possible to generalize about the findings due to the small sample size, nor is it possible to predict the usefulness of the intervention used in the study. Further research is needed, using a larger sample, to investigate the effectiveness of this type of educational and support intervention and to measure whether its effects can be observed over a longer time period. Future research also needs to focus specifically on fathers’ coping and adaptation. References Antonovsky, A., & Sourani, T. (1988). Family sense of coherence and family adaptation. Journal of Marriage and Family, 50, 79–92. Azar, R., & Solomon, C. R. (2001). Coping strategies of parents facing child diabetes type 1 mellitus. Journal of Pediatric Nursing, 16(6), 418–428. doi:10.1053/jpdn. 2001.27878



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