UBC Theses and Dissertations

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UBC Theses and Dissertations

Ways parents help their preschool children with asthma Mitchell, Carol 1982

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WAYS PARENTS HELP THEIR PRESCHOOL CHILDREN WITH ASTHMA by CAROL MITCHELL B.N., U n i v e r s i t y of Manitoba, 1972 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES School of Nursing We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1982 © C a r o l M i t c h e l l , 1982 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t of the requirements f o r an advanced degree a t The U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s / h e r r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . School of Nursing The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, B r i t i s h Columbia Canada V6T 1W5 Date: A b s t r a c t T h i s study d e s c r i b e s ways t h a t parents attempt to h e l p t h e i r p r e -s c h o o l c h i l d r e n with asthma meet t h e i r b a s i c human needs. I n f o r -mation about such p a r e n t a l guidance i s l a c k i n g i n the l i t e r a t u r e and y e t parents need a s s i s t a n c e from h e a l t h p r o f e s s i o n a l s about how to accomplish the task of r e a r i n g t h e i r c h r o n i c a l l y i l l c h i l -dren. Ten couples with asthmatic p r e s c h o o l c h i l d r e n from the Lower Mainland r e g i o n of B r i t i s h Columbia were i d e n t i f i e d and i n t e r v i e w e d i n t h e i r homes. The couples were asked about the a c t i o n s they took to h e l p t h e i r p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r b a s i c human needs and the ways they p e r c e i v e d asthma and i t s treatment a f f e c t i n g t h e i r e f f o r t s t o h e l p these c h i l d r e n . An Interview Guide was developed based on the U n i v e r s i t y of B r i t i s h Columbia's Model f o r Nursing. I t i s a model with a b a s i c human needs and systems theory framework. A l l i n t e r v i e w s w i t h the couples were audiotaped and l a t e r analyzed f o r content of t h e i r communications. The a n a l y s i s r e v e a l e d 17 s p e c i f i c h e l p f u l a c t i o n s common to a l l of the couples, and a d d i t i o n a l emotions, d e c i s i o n s , a n d p h y s i c a l e f f o r t s to normalize t h e i r asthmatic c h i l -dren 's and f a m i l y ' s d a i l y l i v e s . I t was concluded t h a t the couples i n t h i s study assumed the r e s p o n s i b i l i t i e s of h e l p i n g t h e i r p r e s c h o o l c h i l d r e n , s i c k or w e l l , meet t h e i r needs to grow and develop a c c o r d i n g to p a r e n t a l t a s k s . The i n t e n s i t y of the h e l p i n g behaviours tended to i n c r e a s e d u r i n g the c h i l d r e n ' s a s t h -matic a t t a c k s . There are i m p l i c a t i o n s f o r h e a l t h p r o f e s s i o n a l s f o r d e v e l o p i n g programs t o a s s i s t parents to a c q u i r e the know-ledge, s k i l l s and a t t i t u d e s : t o f a c i l i t a t e the growth and develop-ment of t h e i r c h i l d r e n w i t h a c h r o n i c d i s e a s e such as asthma. i i i T able of Contents Page A b s t r a c t i i L i s t of Tables v i Chapter I I n t r o d u c t i o n 1 Background of the Study. . 1 Statement of the Problem 4 Purpose of the Study 4 D e f i n i t i o n s of Terms 5 Approach to the Problem 7 II T h e o r e t i c a l Framework and Review of the Re l a t e d L i t e r a t u r e 9 Tasks of Parenthood 10 Tasks of Parents Rearing P r e s c h o o l C h i l d r e n 11 Tasks of Parents C a r i n g f o r C h r o n i c a l l y 111 C h i l d r e n 12 C h i l d ' s B a s i c Human Needs: A Framework to Guide the Research. . . . 13 Review of the Re l a t e d Research 13 I I I Research Design and Methods 20 Overview of the Research Plan 20 D e s c r i p t i o n of the Sample 21 Interview Guide 24 Procedure f o r C o l l e c t i n g the Data 27 Procedure f o r A n a l y z i n g the Data 28 E t h i c a l C o n s i d e r a t i o n s Encountered i n the Research 30 i v Page C h a p t e r IV P r e s e n t a t i o n o f t h e F i n d i n g s . . 33 D e s c r i p t i o n o f t h e Sample 33 The c o u p l e s 33 The p r e s c h o o l c h i l d r e n w i t h asthma. . 35 The H e l p P r o v i d e d by t h e C o u p l e s 36 Need: t o b r e a t h e 37 Need: t o e a t and d r i n k 40 Need: t o e l i m i n a t e w a s t e p r o d u c t s . . 41 Need: t o have a b a l a n c e between r e s t and a c t i v i t y 42 Need: t o f e e l s a f e and s e c u r e . . . . 43 Need: t o f e e l l o v e d 44 Need: t o f e e l s e n s o r y s a t i s f a c t i o n . . 44 Need: t o have a s e n s e o f a c c o m p l i s h -ment 45 Need: t o d e v e l o p s e l f - r e s p e c t . . . . 46 The Impact o f Asthma and I t s T r e a t m e n t . . 46 V D i s c u s s i o n o f t h e F i n d i n g s 49 T a s k s o f P a r e n t s R e a r i n g P r e s c h o o l C h i l d r e n w i t h Asthma and N u r s i n g I m p l i c a t i o n s . . . 49 V I Recommendations and Summary 59 Recommendations f o r N u r s i n g P r a c t i s e . . . 59 Recommendations f o r N u r s i n g R e s e a r c h . . . 60 Summary . ^0 R e f e r e n c e s ^2 A d d i t i o n a l R e f e r e n c e s 6 8 Page Appendices A. S e l e c t e d Assumptions from The UBC Model of Nursing 70 B. Developmental Tasks of P r e s c h o o l C h i l d r e n . . 73. C. I n t e r v i e w Guide 77 D. L e t t e r t o the P h y s i c i a n s 8.2 E. W r i t t e n consent from the P h y s i c i a n s 83 F. L e t t e r t o the Parents 84 G. Interview Procedure 86 H. Consent from the Parents 88 I. C e r t i f i c a t e of Approval f o r Research I n v o l v i n g Human Subjects . . . . 89 L i s t o f Tables v i Table Page 1. The UBC Model f o r Nursing: Subsystems and the Corresponding Needs . 6 2. Demographic Data of Couples of P r e s c h o o l C h i l d r e n w i t h Asthma 34 3. Demographic Data D e s c r i b i n g the P r e s c h o o l C h i l d r e n w i t h Asthma 36 4. The Couples' H e l p i n g Behaviours 38 1 CHAPTER I I n t r o d u c t i o n Background of the Study In ..Western s o c i e t y , p arents assume the major r e s p o n s i b i l i t y f o r g i v i n g t h e i r c h i l d r e n , s i c k or w e l l , support, guidance, and care u n t i l they reach m a t u r i t y ( D u v a l l , 1977, p. 26; Hymovich, 1976, p. 11; Le Masters, 1977, p. 6). T h i s r e s p o n s i b i l i t y has a s i g n i f i c a n t impact on parents of s i c k c h i l d r e n . Parents who r e a r c h i l d r e n w i t h c h r o n i c d i s e a s e s such as asthma have a m u l t i -tude of complex and d i f f i c u l t t a sks t o perform. Furthermore, parents f r e q u e n t l y change t h e i r way of l i v i n g t o accomodate the needs of the asthmatic c h i l d and experience f e e l i n g s of g u i l t , g r i e f , and a n x i e t y because of the e f f e c t s of the i l l n e s s (Crummette, 1979, p. 23; Kapotes, 1977, pp. 7-8). Some mothers of asthmatic c h i l d r e n have r e f e r r e d t o the tasks of parenthood as being burdensome and demanding (Crummette, 1979, p. 25; Reddihough, Landau, Jones, & R i c k a r d s , 1978, p. 324). Despite the e f f e c t s of i l l n e s s , parents m a i n t a i n the major r e s p o n s i b i l i t y f o r c h i l d r e a r i n g i n our s o c i e t y . Obviously parents must a l t e r t h e i r ways to support, guide, and care f o r i l l c h i l d r e n . There i s a l a c k o f i n f o r m a t i o n about p a r e n t s ' behaviours which help c h i l d r e n w i t h asthma meet t h e i r needs to grow and develop. Such a d e s c r i p t i o n of p a r e n t s ' behaviours c o u l d be use-f u l f o r nurses i n p l a n n i n g care. Such i n f o r m a t i o n i s an adjunct f o r s e t t i n g a p p r o p r i a t e and r e a l i s t i c g o a l s (Neuman, 1974, p. 107; The U n i v e r s i t y of B r i t i s h Columbia Model f o r Nursing, 1980, p. 2). I t was t h e r e f o r e decided to design a d e s c r i p t i v e study w i t h the i n t e n t i o n of adding to a knowledge base about the 2 p a r e n t s ' b e h a v i o u r s w h i c h were p e r c e i v e d as h e l p f u l t o t h e i r a s t h m a t i c c h i l d r e n . The r e s u l t s o f t h i s s t u d y w o u l d seem t o c o n t r i b u t e t o i n f o r m a t i o n u s e f u l f o r n u r s e s i n p l a n n i n g c a r e f o r c h i l d r e n w i t h asthma and t h e i r f a m i l i e s . I n t h i s c h a p t e r , t h e s i g n i f i c a n c e o f t h e p r o b l e m , t h e p r o b l e m s t a t e m e n t , p u r p o s e o f t h e s t u d y , d e f i n i t i o n s o f t h e c o n c e p t s , and a p p r o a c h t o t h e r e s e a r c h w i l l be p r e s e n t e d w i t h t h e meaning and i m p o r t a n c e o f c h i l d h o o d asthma as a c h r o n i c d i s e a s e b e i n g d i s c u s s e d f i r s t . C h i l d h o o d asthma i s a s i g n i f i c a n t p r o b l e m a f f e c t i n g t h e h e a l t h o f c h i l d r e n o f a l l ages (Bro n h e i m , 1978, p. 310; G u e n t e r , 1979, p. 3 ) . Asthma i s a d i s e a s e m a n i f e s t e d by h y p e r r e s p o n s i v e b r o n c h i w h i c h r e s u l t s i n a i r w a y o b s t r u c t i o n . As a r e s u l t , t h e a s t h m a t i c c h i l d may cough, wheeze, and be s h o r t o f b r e a t h ( B r o n h e i m , 1978, p. 3 1 7 ) . The c o n d i t i o n v a r i e s i n e a c h c h i l d f r o m t h e o c c a s i o n a l e p i s o d i c a t t a c k t o p e r s i s t e n t symptoms o f asthma (Gr e g g , 1977, p. 240; Kuzemko, 1976, p. 1; T s e , 1979, p. 7 ) . Some c h i l d r e n e x p e r i e n c e symptoms o f asthma o n l y once o r t w i c e a y e a r ; o t h e r c h i l d r e n may s u f f e r f r o m asthma e v e r y day. Asthma i s t h o u g h t t o be one o f t h e m a j o r c h r o n i c r e s p i r a t o r y d i s e a s e s o f c h i l d h o o d . I t i s e s t i m a t e d t h a t t h e d i s e a s e a f f e c t s 5% t o 10% o f a l l c h i l d r e n l i v i n g i n t h e W e s t e r n c o u n t r i e s o f t h e w o r l d ( P l e s s & D o u g l a s , 1971, p. 405; T o n k i n , 1979, p. 8 3 ) . Of t h e s e c h i l d r e n , 80% show symptoms o f asthma b e f o r e t h e y r e a c h 5 y e a r s o f age ( G o d f r e y , 1977, pp. 324-325; G o r d i s , 1973, p. 27; K e s l i n , 1979, p. 8 3 ) . A p p r o x i m a t e l y 70% o f a s t h m a t i c c h i l d r e n a r e a s y m p t o m a t i c by 10 y e a r s and 90% o f a s t h m a t i c c h i l d r e n have no c l i n i c a l symptoms by t h e t i m e t h e y a r e a d o l e s c e n t ( G o l d , 1976, 3 p. 1; Kattan, 1979, p. 527). From t h i s data, i t i s apparent t h a t asthma i s a common c h i l d h o o d d i s e a s e a f f e c t i n g a l l age groups of c h i l d r e n , but there i s a tendency f o r more p r e s c h o o l c h i l d r e n t o be symptomatic. I t was t h e r e f o r e d e c i d e d to focus on the parents of p r e s c h o o l c h i l d r e n . Rearing p r e s c h o o l c h i l d r e n can be a d i f f i c u l t task f o r par-ents and i t i s even more d i f f i c u l t when these c h i l d r e n have a c h r o n i c d i s e a s e l i k e asthma ( T r a v i s , 1976, p. 175). P r e s c h o o l c h i l d r e n are p r e c o n c e p t u a l and e m o t i o n a l l y immature. Thoughts of p r e s c h o o l c h i l d r e n are c h a r a c t e r i z e d as i n t u i t i v e , magical and e g o c e n t r i c ( L o v e l l , 1971, pp. 20-22; P i a g e t , 1972, p. 123). To these young c h i l d r e n , medical treatment may not be a l o g i c a l course of a c t i o n to help them breathe. However, the parents can reason with t h i s age group to a s s i s t them i n understanding how to become w e l l (Nelms & M u l l i n s , 1982, p. 724). S i c k c h i l d r e n may f e e l t h a t they are r e s p o n s i b l e f o r t h e i r i l l n e s s and e i t h e r f e e l g u i l t y or t h a t they are being punished f o r c e r t a i n misdeeds (Nelms & M u l l i n s , 1982, p. 724). F r e q u e n t l y , p r e s c h o o l c h i l d r e n are unable to v e r b a l i z e t h e i r g u i l t or completely understand what i s happening to themselves. Increased a n x i e t y r e s u l t s , a l t e r i n g the c h i l d r e n ' s response to t h e i r i l l n e s s and treatments. T h i s i s f u r t h e r exaggerated i f the parents are anxious because c h i l d r e n r e c o g n i z e t h e i r p a r e n t s ' concerns (Nelms & M u l l i n s , 1982, p. 724). A normal response to i l l n e s s i n any c h i l d may r e s u l t i n r e g r e s s i o n of t h e i r behaviour (Nelms & M u l l i n s , 1982, p. 724). In a c h r o n i c i l l n e s s l i k e asthma / c h i l d r e n may exper-ience e x a c e r b a t i o n s of t h e i r i l l n e s s and r e g r e s s d u r i n g these times. A p p r o p r i a t e p a r e n t a l approaches to a s s i s t t h e i r c h i l d r e n 4 d u r i n g such times are e s s e n t i a l to prevent the c h i l d r e n from d e r i v i n g secondary gains from being i l l and becoming o v e r l y dependent (Mattss'on, 1975, p. 80; Nelms & M u l l i n s , 1982, p. 724). In summary,it i s comprehensible t h a t parents may experience the r e a r i n g of p r e s c h o o l c h i l d r e n with asthma as a complex and d i f f i -c u l t task. Statement of the Problem T h i s study was designed to i n v e s t i g a t e the ways parents help t h e i r p r e s c h o o l c h i l d r e n with asthma meet t h e i r b a s i c human needs; and how asthma and i t s treatment a f f e c t s the help the parents p r o v i d e t h e i r c h i l d r e n . The problem was approached by answering the f o l l o w i n g r e s e a r c h q u e s t i o n s : 1. What are the parents' p e r c e p t i o n s of the ways they h e l p p r e s c h o o l c h i l d r e n with asthma meet t h e i r b a s i c human needs? 2. What are the parents' p e r c e p t i o n s of the ways asthma and i t s treatment a f f e c t s t h e i r e f f o r t s t o p r o v i d e care to t h e i r c h i l d r e n with asthma? Purpose of the Study Nurses and other h e a l t h p r o f e s s i o n a l s p l a y a v a l u a b l e r o l e i n a s s i s t i n g parents to care f o r t h e i r c h r o n i c a l l y i l l c h i l d r e n (Hymovich, 1976, p. 13; S p e r l i n g , 1978, p. 6). They r e q u i r e knowledge and understanding about s p e c i f i c phenomena p r i o r to p l a n n i n g e f f e c t i v e and a p p r o p r i a t e i n t e r v e n t i o n s (Gordon & Sweeney, 1979, p. 1). A review o f the l i t e r a t u r e r e v e a l e d a p a u c i t y of i n f o r m a t i o n d e s c r i b i n g what parents do to h e l p t h e i r p r e s c h o o l c h i l d r e n w i t h asthma. T h i s i n v e s t i g a t o r i d e n t i f i e d o n l y s h o r t t e s t i m o n i a l s i n d i c a t i n g the impact of asthma and i t s treatment on the p a r e n t s ' e f f o r t s t o help the asthmatic p r e s c h o o l 5 c h i l d r e n meet t h e i r b a s i c human needs. Thus, s y s t e m a t i c ways of o b t a i n i n g r e l e v a n t data seemed to be r e q u i s i t e , and a d e s c r i p t i v e study was done as a beginning step toward the development of a knowledge base i n c l i n i c a l n u r s i n g . D e s c r i p t i v e r e s e a r c h i s con-ducted f o r the purpose o f e v o l v i n g t h e o r i e s (Notter, 1974, p. 20). In t h i s type of r e s e a r c h , o b s e r v a t i o n s are made and they are analyzed f o r the i n t e n t i o n of dev e l o p i n g hypotheses t o be t e s t e d i n f u r t h e r s t u d i e s . The purpose of t h i s study was to p r o v i d e a d e s c r i p t i o n of the parents' a c t i o n s d i r e c t e d toward h e l p i n g the p r e s c h o o l c h i l d r e n with asthma meet t h e i r b a s i c human needs with the o b j e c t i v e o f adding to i n f o r m a t i o n which i s u s e f u l to nurses. D e f i n i t i o n s of Terms The concepts f o r t h i s study were d e r i v e d from developmental, n u r s i n g , and medical t h e o r i e s . To f a c i l i t a t e an e x p l i c i t and c l e a r understanding o f the study the f o l l o w i n g terms were d e f i n e d : p a r e n t s , h e l p f u l a c t i o n s , b a s i c human needs, asthma and i t s treatment. Parents i n t h i s study were d e f i n e d as a couple, a mother and f a t h e r o f a p r e s c h o o l asthmatic c h i l d . The couple r e p r e s e n t s a u n i t i n r e l a t i o n t o the c h i l d r e n i n a f a m i l y (Anthony, 1979, p. 78; Benedek, 1970, p. 110). In t h i s study, the h e l p f u l a c t i o n s were the behaviours a couple r e p o r t e d t h a t they performed to n u rture the p r e s c h o o l c h i l d w i t h asthma t o meet t h e i r b a s i c human needs. The h e l p f u l a c t i o n s d i r e c t e d by the parents are aimed toward a c h i e v i n g developmental tasks of both the parents and c h i l d r e n (Brammer, 1979, p. 5; Hymovich & Chamberlain, 1980, pp. 22-23). The c h i l d ' s b a s i c human needs were d e f i n e d as the funda-mental requirements f o r s u r v i v a l and growth of h i s / h e r b e h a v i o u r a l 6 system (Campbell, C r u i s e , & Murakami, 1976, p. 8). A c c o r d i n g to the U n i v e r s i t y of B r i t i s h Columbia (UBC) Model f o r Nursing, man i s c o n c e p t u a l i z e d as a b e h a v i o u r a l system composed of nine sub-systems each of which represent a b a s i c human need. The assump-t i o n s about n u r s i n g are c o n t a i n e d i n Appendix A (p. 70). The nine subsystems and c o r r e s p o n d i n g needs are l i s t e d i n Table 1. Table 1 The UBC Model f o r Nursing: Subsystems and The Corresponding Needs Subsystem Need 1. Reparative For balance between p r o d u c t i o n u t i l i z a t i o n of energy. 2. E x c r e t o r y For the c o l l e c t i o n and removal of accumulated wastes. 3. A c h i e v i n g For mastery. 4. I n g e s t i v e For i n t a k e of f l o o d and f l u i d ; nourishment. 5. P r o t e c t i v e For s a f e t y and s e c u r i t y . 6. A f f e c t i v e For l o v e , belongingness and dependence. 7. S a t i a t i v e F o r s t i m u l a t i o n of the system's senses. 8. E g o - V a l u a t i v e For r e s p e c t of s e l f by s e l f . 9. R e s p i r a t o r y For i n t a k e of oxygen. For the purpose o f t h i s study the p r e s c h o o l c h i l d was con-c e p t u a l i z e d as a b e h a v i o u r a l system as d e f i n e d by the UBC Model f o r N u r s i n g . The meaning of the term asthma was i n t e r p r e t e d two d i f f e r e n t ways i n the study. For the purposes of o b t a i n i n g s u b j e c t s f o r the study the i n v e s t i g a t o r used a d e f i n i t i o n understood by med-i c a l p r a c t i t i o n e r s i n t h e i r c l i n i c a l work. Asthma i n c h i l d r e n was d e f i n e d as a " c o n d i t i o n of a l t e r e d dynamic s t a t e of r e s p i r -a t o r y passages due to the a c t i o n of d i v e r s e s t i m u l i r e s u l t i n g i n airways o b s t r u c t i o n o f v a r y i n g degree and d u r a t i o n , and r e v e r -s i b l e p a r t i a l l y or completely spontaneously or under treatment" (Kuzemko, 1976, p. 1). On the other hand, the parents seemed t o i n t e r p r e t asthma i n terms of t h e i r c h i l d ' s symptoms and behav-i o u r a l r e a c t i o n s t o the d i s e a s e . The parents' d e f i n i t i o n of asthma w i l l be d i s c u s s e d i n g r e a t e r depth i n the a n a l y s i s chapte of t h i s r e p o r t . The term treatment was d e f i n e d as the p r e s c r i b e d a c t i o n s which the p h y s i c i a n o r other h e a l t h care worker had d i r e c t e d the couple to take to prevent o r c o n t r o l the c h i l d ' s asthmatic a t t a c k s . C l i n i c a l l y , asthma can o f t e n be s u c c e s s f u l l y t r e a t e d to prevent and c o n t r o l the a t t a c k s . Parents are given the r e s -p o n s i b i l i t y to pr o v i d e the p r e s c r i b e d treatments f o r t h e i r c h i l -dren. Therapy f o r c h i l d r e n with asthma may be complex and con-s i s t o f a combination of one or more of the f o l l o w i n g : medica-t i o n s , environmental c o n t r o l , d i e t and f l u i d therapy, e x e r c i s e s , chest therapy, and psychotherapy (Green & Haggerty, 1977, pp. 333-338; Keens,1979, pp. 510-523; Knapp & We l l s , 1978, p. 115; Landau, 1979, pp. 584-586). These f i v e d e f i n i t i o n s were used to pr o v i d e a c l e a r d e s c r i p t i o n o f what was to be s t u d i e d . Approach t o the Problem D e s c r i p t i v e r e s e a r c h i n n u r s i n g i s done f o r many reasons 8 such as to expl o r e t o p i c s , develop new knowledge, or generate hypotheses f o r f u t u r e s t u d i e s (Brink & Wood, 1978, p. 79; Isaac & M i c h a e l , 1979, p. 18; N o t t e r , 1974, p. 20). Data were gathered from the s u b j e c t s u s i n g a s e m i - s t r u c t u r e d i n t e r v i e w guide. T h i s method was intended to o b t a i n guided but f r e e and abundant responses from the parents who were i n t e r v i e w e d . The UBC Model f o r Nursing was used to develop the i n t e r v i e w guide as w e l l as the c a t e g o r i e s f o r a n a l y z i n g the data o b t a i n e d from the content of the i n t e r v i e w s with the par e n t s . The r e s u l t s of the r e s e a r c h were t h e r e f o r e a d e s c r i p t i o n of the parents' a c t i o n d i r e c t e d toward h e l p i n g t h e i r p r e s c h o o l c h i l d r e n with asthma and a summary of the impact of asthma and i t s treatment on the parents' e f f o r t s to help t h e i r p r e s c h o o l asthmatic c h i l d r e n . In the subsequent chapters of t h i s r e s e a r c h r e p o r t the f o l l o w i n g w i l l be i n c l u d e d : the t h e o r e t i c a l b a s i s f o r the study, a review of the r e l a t e d l i t e r a t u r e , a d e s c r i p t i o n of the r e s e a r c h design and procedure, a summary of the analyses of the data and r e s u l t s , and f i n a l l y , a d i s c u s s i o n of the r e s u l t s , i m p l i c a t i o n s f o r n u r s i n g , and recommendations f o r f u t u r e r e s e a r c h r e l a t e d to the study. CHAPTER II T h e o r e t i c a l Framework and Review  of the R e l a t e d L i t e r a t u r e The t h e o r e t i c a l b a s i s f o r the study and a c r i t i q u e of the r e l a t e d r e s e a r c h w i l l be d i s c u s s e d i n t h i s chapter. The t h e o r -e t i c a l f oundation f o r t h i s r e s e a r c h was d e r i v e d from a review of the n u r s i n g and h e a l t h - r e l a t e d l i t e r a t u r e and the i n v e s t i g a t o r ' s o b s e r v a t i o n s of parents r e a r i n g c h r o n i c a l l y i l l c h i l d r e n . Cur-r e n t developmental theory p u r p o r t s t h a t parents perform tasks to a s s i s t t h e i r c h i l d r e n , s i c k or w e l l , to meet needs f o r o p t i m a l growth and development ( D u v a l l , 1977, p. 26; Havighurst, 1972, p. 77; P r i n g l e , 1974, p. 59). The p a r e n ts' e f f o r t s to h e l p t h e i c h i l d r e n are thought to be i n f l u e n c e d by numerous i n d i v i d u a l and environmental f a c t o r s (Hymovich & Chamberlain, 1980, pp. 29-67). The f a c t o r s of a c h r o n i c i l l n e s s and i t s treatment can a l t e r the parents' c h i l d - r e a r i n g p r a c t i c e s (Burton, 1975, p. 85; Hymovich & Chamberlain, 1980, p. 39; Mattsson, 1975, p. 82). These theo-r e t i c a l statements are supported by the i n v e s t i g a t o r ' s c l i n i c a l o b s e r v a t i o n s while working w i t h f a m i l i e s r e a r i n g c h r o n i c a l l y i l l c h i l d r e n . I t was n o t i c e d t h a t parents performed the t a s k s of .parenthood and a d d i t i o n a l tasks t h a t i n v o l v e d s p e c i a l i z e d care t h a t r e l a t e d to the c h i l d ' s d i s e a s e and i t s treatment. Some par ents found the t a s k s of h e l p i n g t h e i r c h r o n i c a l l y i l l c h i l d r e n burdensome, and o t hers i n d i c a t e d t h a t t h e i r a c t i v i t i e s r e s u l t e d i n new l e a r n i n g and a f e e l i n g of p r i d e and s a t i s f a c t i o n (Burton, 1975, pp. 65 & 69; Crummette, 1979, p. 27). These f i n d i n g s i n the l i t e r a t u r e and o b s e r v a t i o n s from the c l i n i c a l area p r o v i d e d support f o r the development of t h i s d e s c r i p t i v e study. 10 The f o l l o w i n g d i s c u s s i o n w i l l p r e s e n t a theory of parent-hood, the developmental tasks of parents r e a r i n g p r e s c h o o l c h i l -dren with a c h r o n i c i l l n e s s , and the framework u s i n g the UBC Model f o r N u r s i n g . Tasks of Parenthood Parenthood i s g e n e r a l l y acknowledged as a major phase of l i f e w ith the p r i n c i p a l g o a l of parents being to prepare t h e i r c h i l d r e n t o become wholesome, a d u l t members of s o c i e t y (Anthony & Benedek, 1970, p. 95; C a m i l l e r i & Glenn, 1978, p. 237). T h i s theory of parenthood w i l l be presented i n r e l a t i o n to develop-mental t a s k s . A developmental task i s a "task which a r i s e s at or about a c e r t a i n p e r i o d i n the l i f e o f an i n d i v i d u a l " ( D u v a l l , 1977, p. 177; Havighurst, 1972, p. 2). Parents have s e v e r a l tasks t o accomplish d u r i n g the c h i l d -r e a r i n g years of adulthood. E r i c k s o n (1963) d e s c r i b e s the stage of parenthood as " g e n e r a t i v i t y , " t h a t i s , the p a r e n t s ' task i s to guide the next g e n e r a t i o n (pp. 266-268). Benedek (1970) s t a t e s the "tasks of parents c o n s i s t s of care, t r a i n i n g and en.cul.turati.on of the s o c i e t y ' s values and norms" (p. 95). Havighurst (1972) emphasizes t h a t r e a r i n g c h i l d r e n i s the g r e a t e s t r e s p o n s i b i l i t y of an a d u l t d u r i n g the years of parenthood. To perform t h i s r e s p o n s i b i l i t y parents l e a r n t o help c h i l d r e n meet t h e i r p h y s i c a l and emotional needs (p. 77). Parents l e a r n how to d e a l w i t h t h e i r c h i l d r e n and adapt t h e i r schedules to the requirements of growing c h i l d r e n . Havighurst (1972) adds t h a t the p a r e n t s ' f e e l -i n g s about t h e i r c h i l d r e n are a r e f l e c t i o n on t h e i r peace of mind and l i f e adjustment (p. 77). T h e o r e t i c a l l y , i f parents s u c c e s s -f u l l y achieve t h e i r developmental t a s k s , they experience s a t i s f a c t i o n , a p p r o v a l , and success w i t h l a t e r t a s k s ; whereas, i f the parents f a i l to achieve t h e i r t a s k s , unhappiness, d i s -approval by s o c i e t y , and d i f f i c u l t y w i t h l a t e r developmental tasks r e s u l t s ( D u v a l l , 1977, p. 177). D u v a l l has d e s c r i b e d developmental tasks f o r a l l parents i n s o c i e t y . These tasks are not meant to be a l l - i n c l u s i v e or u n i v e r s a l l y a p p l i c a b l e . In f a c t , the p a r e n t s ' t a s k s are thought t o d i f f e r from one gen-e r a t i o n t o another and from one s u b c u l t u r e to another i n our s o c i e t y . The developmental tasks of parenthood i n c l u d e : (a) a s s i s t i n g t h e i r c h i l d r e n to become autonomous, and to have i n -i t i a t i v e and a p o s i t i v e s e l f - i m a g e , (b) e s t a b l i s h i n g a f f e c t i o n a l bonds between the parents and t h e i r c h i l d r e n , (c) h e l p i n g c h i l d -ren a d j u s t to the e x p e c t a t i o n s of o t h e r s and to conform to the demands of the c u l t u r e , and (d) e s t a b l i s h i n g h e a l t h f u l r o u t i n e s of e a t i n g , r e s t i n g , p l a y i n g , a n d working with c h i l d r e n w i t h i n the l i m i t s of the p a r e n t s ' e x p e c t a t i o n s ( D u v a l l , 1977, pp. 169-175). In summary, the t h e o r i s t s i n d i c a t e t h a t parenthood i n v o l v e s major r e s p o n s i b i l i t i e s which i n c l u d e h e l p i n g c h i l d r e n meet t h e i r p h y s i c a l , p s y c h o l o g i c a l , and s o c i a l needs. I f parents c o u l d f u l f i l l t h e i r f u n c t i o n s , c h i l d r e n would grow i n p r o d u c t i v e and h e a l t h y ways (Wandersman, Poppen, & R i c k s , 1976, p. 10). Tasks of Parents Rearing P r e s c h o o l C h i l d r e n Parents r e a r i n g p r e s c h o o l c h i l d r e n may c o n c e n t r a t e on c e r -t a i n t a s k s (Appendix B, p. 73). During the p r e s c h o o l y e a r s , c h i l d r e n are d e v e l o p i n g autonomy, and parents are faced w i t h l e a r n i n g how t o accept these changes. As a consequence, the parents may l o s e some c o n t r o l over t h e i r c h i l d ' s behaviours while m a i n t a i n i n g necessary l i m i t s (Hymovich & Chamberlain, 1980, p. 266). One of parents' major t a s k s i s to l e a r n how to separate from t h e i r p r e s c h o o l c h i l d (Hymovich, 1979, p. 86). Other tasks these parents assume may i n c l u d e : (a) s e t t i n g b e h a v i o u r a l guide-l i n e s f o r t h e i r c h i l d r e n to f o l l o w , (b) r e i n f o r c i n g the c h i l d -ren's a p p r o p r i a t e behaviours, (c) l i s t e n i n g and responding to t h e i r c h i l d r e n ' s e f f o r t s to communicate, (d) p r o v i d i n g opportun-i t i e s f o r the c h i l d r e n to d i s c o v e r , share, and to be independent, (e) p r o v i d i n g a f f e c t i o n , (f) p r o v i d i n g t h e i r c h i l d r e n with oppor-t u n i t i e s t o make d e c i s i o n s , (g) a l l o w i n g t h e i r c h i l d r e n t o express t h e i r emotions i n h e a l t h y ways, (h) p r o t e c t i n g t h e i r c h i l d r e n from p o t e n t i a l harm, (i) t e a c h i n g t h e i r c h i l d r e n about s p e c i f i c l i f e events, such as h o s p i t a l i z a t i o n ( D u v a l l , 1977, pp. 258-268; Hymovich & Chamberlain, 1980, pp. 266-269). I t i s apparent t h a t parents of p r e s c h o o l c h i l d r e n perform c e r t a i n tasks t h a t are s p e c i f i c to t h e i r c h i l d r e n ' s l e v e l of m a t u r i t y . Tasks of Parents C a r i n g f o r C h r o n i c a l l y 111 C h i l d r e n C h i l d - r e a r i n g behaviours o f parents are changed when t h e i r c h i l d r e n have c h r o n i c i l l n e s s e s (Magrab & Calcagno, 1978, p. 4). A c h r o n i c i l l n e s s r e f e r s t o a d i s o r d e r with a p r o t r a c t e d course which can be f a t a l , p r o g r e s s i v e , or a s s o c i a t e d with a r e l a t i v e l y normal l i f e span d e s p i t e impaired p h y s i c a l and/or mental func-t i o n i n g . Such d i s e a s e s f r e q u e n t l y show p e r i o d s of acute i l l n e s s e x a c e r b a t i o n s r e q u i r i n g medical a t t e n t i o n ( T r a v i s , 1976, p. 11). When a c h i l d develops a c h r o n i c i l l n e s s , such as asthma, Hymovich (1976) p u r p o r t s t h a t parents have a d d i t i o n a l tasks to perform. These tasks i n v o l v e the p a r e n t s ' being a b l e t o : (a) understand and manage t h e i r c h i l d r e n ' s i l l n e s s , (b) a s s i s t t h e i r c h i l d r e n t o understand and cope wi t h the i l l n e s s , and (c) help 13 t h e i r i l l c h i l d r e n maintain a h e a l t h y s t a t e and t h e i r i n t e g r i t y .(Hymovich, 1976, p. 11). The l i t e r a t u r e seems to support t h a t parents have a d d i t i o n a l tasks to perform when t h e i r c h i l d has a c h r o n i c i l l n e s s l i k e asthma. C h i l d ' s B a s i c Human Needs: A Framework to Guide the Research As s t a t e d p r e v i o u s l y the b a s i c f u n c t i o n of parents i n s o c i e t y i s to meet the growth and developmental needs of t h e i r c h i l d r e n . The aim of t h i s r e s e a r c h was to d e s c r i b e the ways parents help p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r needs to grow and develop; t h e r e f o r e , the i n v e s t i g a t o r s e l e c t e d the UBC Model f o r Nursing, a conceptual framework which d e s c r i b e s b a s i c human needs. T h i s model was s e l e c t e d f o r t h i s study f o r two reasons. F i r s t , the UBC Model f o r Nursing was thought to be an a p p r o p r i -ate conceptual model because i t s assumptions are d e r i v e d from g e n e r a l systems and l e a r n i n g theory and i t allows f o r i n t e g r a -t i o n of developmental concepts and c o n s i d e r a t i o n s of f o r c e s which a f f e c t the c h r o n i c a l l y i l l c h i l d . Second, the UBC Model f o r Nursing p r o v i d e d the necessary d i r e c t i o n f o r the r e s e a r c h . I t s p e c i f i e d a d e f i n i t i o n of b a s i c human needs, gave guidance to the development of the I n t e r v i e w Guide and f o r the c a t e g o r i e s f o r the a n a l y s i s of the data. From the review of the l i t e r a t u r e , the UBC Model f o r Nursing appeared to be an a p p r o p r i a t e concept-u a l framework t o guide the i n q u i r y about the ways parents helped t h e i r p r e s c h o o l c h i l d r e n w i t h asthma. Review of the R e l a t e d Research In the f o l l o w i n g p r e s e n t a t i o n of r e s e a r c h about parents and t h e i r c h i l d r e n w i t h asthma, the i n v e s t i g a t o r w i l l d i s c u s s the 14 r e s u l t s of s t u d i e s which i n d i c a t e d t h a t the m a j o r i t y of parents and t h e i r asthmatic c h i l d r e n are normal i n d i v i d u a l s w i t h the added f a c t o r s of the c h i l d r e n having a c h r o n i c disease? and t h a t parents are concerned about t h e i r c h i l d r e n ' s i l l n e s s and p r o v i d e a d d i t i o n a l h e l p f o r the c h i l d r e n which i s r e l a t e d t o t h e i r d i s e a s e and i t s treatment. N o r r i s h , Tooley, and Godfrey (1977) s t u d i e d 63 school-aged c h i l d r e n with asthma who were a t t e n d i n g a h o s p i t a l c e ntered c l i n i c . The r e s e a r c h e r s used r e l i a b l e c l i n i c a l , p h y s i o l o g i c a l , and p s y c h o l o g i c a l t e s t s . The asthmatic c h i l d r e n i n t h i s study were compared to non-asthmatic c h i l d r e n i n the same r e g i o n . The goal of t h e i r study was to c l a r i f y the r e l a t i o n s h i p between emotional deviance and the s e v e r i t y of the c h i l d ' s asthma (p. 912). The r e s u l t s i n d i c a t e d t h a t emotional deviance of c h i l d r e n with asthma i s no more than i n normal c h i l d r e n ( N o r r i s h , Tooley, & Godfrey, 1977, p. 916). For the purpose of t h i s study i t was c o n s i d e r e d t h a t the m a j o r i t y of asthmatic c h i l d r e n are m e n t a l l y h e a l t h y . Parents, p a r t i c u l a r l y mothers, have been a c e n t r e of r e s e a r c h s t u d i e s i n c h i l d h o o d asthma. Chong, i n a l i t e r a t u r e review of r e s e a r c h from 1937 to 1963, d e s c r i b e d p a r e n t a l a t t i -tudes i n f a m i l i e s w i t h asthmatic c h i l d r e n . He r e p o r t e d t h a t u n s a t i s f a c t o r y p a r e n t a l a t t i t u d e s , e s p e c i a l l y the mother's, are found to be very important i n the c a u s a t i o n and p r e c i p i t a t i o n of a c h i l d ' s asthmatic a t t a c k s (Chong, 1977, p. 78). T h i s s t a t e -ment and others l i k e i t have been questioned. Byrne and M u r r e l l (1977) s t u d i e d the maternal i n f l u e n c e on c h i l d r e n w i t h asthma. They compared 65 mothers of school-aged asthmatic c h i l d r e n to 15 100 mothers of normal c h i l d r e n of the same age u s i n g a s e l f -d e s c r i p t i o n q u e s t i o n n a i r e (Semantic D i f f e r e n t i a l S c a l e ) . The instrument measured the mother's a n x i e t y and o v e r - p r o t e c t i v e maternal behaviour. T h i s study d i d not f i n d t h a t mothers of asthmatic c h i l d r e n were a n x i e t y prone but t h a t they possessed c h a r a c t e r i s t i c s of overconcern. I t was suggested t h a t a c y c l i c a l r e l a t i o n s h i p i s s e t up i n which the mother's behaviour i n response to her c h i l d ' s asthma a t t a c k f u r t h e r exacerbates r a t h e r than a m e l i o r a t e s the i l l n e s s . T h i s study was an examination of what the parents d i d to a m e l i o r a t e t h e i r c h i l d ' s asthmatic a t t a c k and whether the a c t i o n c o u l d be judged as being e f f e c t i v e or i n e f f e c t i v e . From the review of the l i t e r a t u r e , three s t u d i e s were found which p r o v i d e d i n f o r m a t i o n about the help parents r e p o r t e d they gave asthmatic c h i l d r e n and the impact of asthma and i t s t r e a t -ment on the p a r e n t s ' e f f o r t s t o care f o r t h e i r c h i l d . In one study, 41 asthmatic c h i l d r e n , ages nine to eleven years and t h e i r parents were surveyed by Reddihough, Landau, Jones and Rickards (1977). The major g o a l of t h e i r r e s e a r c h was t o study the understanding and concerns parents and t h e i r s c h o o l -aged c h i l d r e n had about asthma and i t s treatment. T h i r t y - s i x mothers, two couples, one f a t h e r , and 42 c h i l d r e n with moderate to severe asthma were i n t e r v i e w e d . They were asked open-ended and c l o s e d q u e s t i o n s about asthma, i t s treatment, and t h e i r f e e l -i n g s about how asthma a f f e c t e d t h e i r f a m i l y . Parents r e p o r t e d t h a t they f e l t g u i l t y about having c h i l d r e n w i t h asthma, and wor-r i e d about t h e i r c h i l d r e n d u r i n g an asthmatic a t t a c k . Another common concern of parents was whether the c h i l d r e n ' s medications were going to be e f f e c t i v e d u r i n g t h e i r asthmatic a t t a c k s . S e v e r a l mothers expressed a need t o be c l o s e t o t h e i r c h i l d r e n i n case they had an a t t a c k . Some parents were r e l u c t a n t t o leave t h e i r c h i l d r e n i n the care of someone e l s e . Most of the mothers b e l i e v e d t h e i r c h i l d r e n ' s asthma was under c o n t r o l but they s t i l l l i m i t e d t h e i r c h i l d r e n ' s a c t i v i t i e s to prevent f u r t h e r a t t a c k s . The mothers i n t h i s study c o n t r o l l e d the c h i l d r e n ' s medications and made d e c i s i o n s whether t h e i r c h i l d r e n w ith asthma should a t t e n d s c h o o l . In f a c t , the mothers s t a t e d t h a t they had the major r e s p o n s i b i l i t y f o r h e l p i n g t h e i r asthmatic c h i l d r e n (pp. 296-297). In the second study, Crummette (1979) s t u d i e d 30 mothers of school-aged c h i l d r e n with asthma while they attended a p e d i a t r i c a l l e r g y c l i n i c . Crummette i n t e r v i e w e d each mother once u s i n g open-ended q u e s t i o n s f o c u s i n g on the mothers' concerns r e g a r d i n g t h e i r c h i l d r e n ' s asthma and the mothers' p e r c e p t i o n s of how t h e i r c h i l d r e n ' s asthma a f f e c t e d t h e i r l i v e s . From an a n a l y s i s of the i n t e r v i e w data Crummette d e r i v e d f i v e c a t e g o r i e s of c h i l d c a r e . The mothers d e s c r i b e d t h e i r a c t i o n s as: (a) c o n t r o l l i n g t h e i r c h i l d r e n ' s environment, (b) c a r i n g f o r t h e i r c h i l d r e n ' s n u t r i t i o n a l needs, (c) ensu r i n g t h e i r c h i l d r e n got the r e q u i r e d s l e e p , (d) c o n t r o l l i n g t h e i r c h i l d r e n ' s a c t i v i t i e s , and (e) managing t h e i r c h i l d r e n ' s medical regime. In f a c t , the mothers a l t e r e d t h e i r u s u a l p a t t e r n s of mothering to care f o r the asthmatic c h i l d r e n ' s s p e c i a l needs. For example, they would prevent t h e i r c h i l d r e n ' s asthma a t t a c k s by l i m i t i n g t h e i r a c t i v i t i e s o r c o n t r o l l i n g t h e i r environment. In a d d i t i o n , the mothers found i t d i f f i c u l t t o help the c h i l d r e n become independent, but d i d teach them how to care f o r them-sel v e s . Another d i f f i c u l t y the mothers expressed was s e t t i n g l i m i t s f o r the asthmatic c h i l d r e n . They b e l i e v e d the c h i l d r e n would become f r u s t r a t e d which would p r e c i p i t a t e asthma a t t a c k s . To r e s o l v e t h i s problem, the mothers set l i m i t s f o r t h e i r c h i l d -ren f i r s t , and then t r e a t e d t h e i r c h i l d r e n ' s asthmatic attack (pp. 24-25). In the t h i r d study, T r a v i s (1976) interviewed nine couples of preschool c h i l d r e n w i t h asthma i n t h e i r homes using an unstructured format. This approach furn i s h e d a copious amount of i n f o r m a t i o n . T r a v i s noted that the parents: (a) stayed w i t h the c h i l d r e n throughout the n i g h t t o comfort them i f they were exper-i e n c i n g symptoms of asthma, (b) gave the c h i l d r e n p r e s c r i b e d med-i c a t i o n s , (c) c o n t r o l l e d the c h i l d r e n ' s environment, (d) o f f e r e d the c h i l d r e n a cup of warm tea or water when they had an asthma att a c k , (e) changed the c h i l d r e n ' s d i e t a r y h a b i t s as i t was r e q u i r e d , (f) l i m i t e d the c h i l d r e n ' s a c t i v i t i e s to prevent another asthma a t t a c k , and (g) took the c h i l d r e n to the h o s p i t a l ' s emergency s e r v i c e s when the c h i l d r e n needed f u r t h e r help to breathe (pp. 1 7 5 - 1 7 6 ) . I t was apparent t h a t these parents concentrated t h e i r e f f o r t s to help the c h i l d r e n meet t h e i r needs. There appears to be some weaknesses i n these three s t u d i e s which were considered by the w r i t e r . The samples i n the s t u d i e s were small and not r e p r e s e n t a t i v e of parents r e a r i n g asthmatic c h i l d r e n . In the Crummette (1979) and Reddihough et a l (1977) s t u d i e s , the m a j o r i t y of parents interviewed were mothers of school-aged asthmatic c h i l d r e n . In a d d i t i o n , both of these 18 s t u d i e s t e n d e d t o w a r d b i a s e d s a m p l e s . Crummette (1979) i n t e r -v i e w e d l o w e r s o c i o e c o n o m i c , b l a c k women i n Richmond, V i r g i n i a , and R e d d i h o u g h e t a l (19 77) i n t e r v i e w e d o n l y p a r e n t s and t h e i r a s t h m a t i c c h i l d r e n who were a t t e n d i n g a c l i n i c i n t h e R o y a l C h i l d r e n ' s H o s p i t a l i n M e l b o u r n e , A u s t r a l i a . S p e c i f i c c u l t u r a l and s o c i a l f a c t o r s c h a r a c t e r i s t i c o f t h e s e s a m p l e s may have b i a s e d t h e r e s u l t s o f t h e s e two s t u d i e s . The r e s e a r c h e r s u s e d c o n v e n i e n c e r a t h e r t h a n random sa m p l e s o f p a r e n t s o f a s t h m a t i c c h i l d r e n . The r e s p o n s e s o f t h e p a r e n t s i n t h e s t u d i e s o f Crummette (1979) and R e d d i h o u g h e t a l (1977) may have been i n f l u e n c e d by t h e f a m i l i e s ' p u r p o s e o f v i s i t i n g t h e c l i n i c and t h e s t r a n g e n e s s and t o n e o f t h e m e d i c a l c l i n i c e n v i r o n m e n t . T h e r e was a l a c k o f i n v o l v e m e n t o f t h e f a t h e r s i n b o t h o f t h e s e s t u d i e s . R e c e n t r e s e a r c h i n d i c a t e s t h a t f a t h e r s s e e t h e m s e l v e s as a c t i v e p a r t i c i p a n t s i n t h e d a i l y r o u t i n e o f c a r e f o r t h e i r c h i l d r e n w i t h c h r o n i c i l l n e s s e s (McKeever, 1981, p. 1 2 4 ) . The i m p o r t a n c e o f i n v o l v i n g b o t h p a r e n t s i n r e s e a r c h a b o u t t h e t a s k s o f p a r e n t h o o d i s s u p p o r t e d i n t h e o r y . A c c o r d i n g t o Benedek, t h e p a r e n t s r e p r e s e n t a s y s t e m i n r e l a t i o n t o t h e c h i l d r e n i n t h e f a m i l y . The p a r e n t s a r e v i e w e d as a g o a l d i r e c t e d u n i t made up o f two i n t e r d e p e n d e n t and i n t e r a c t i n g p a r t s (1970, p. 1 1 0 ) . O t h e r t h e o r i s t s s u p p o r t t h i s , s u c h as A n t h o n y (1979) who r e p o r t s t h a t t h e f u n c t i o n s o f m o t h e r s and f a t h e r s a r e n o t c l e a r l y d e m a r c a t e d and t o d a y p a r e n t s s h a r e t h e c h i l d - r e a r i n g r e s p o n s i b i l i t i e s (p. 7 8 ) . A c c o r d i n g t o Le M a s t e r s ( 1 9 7 7 ) , p a r e n t s c o o p e r a t e as a team t o p r o v i d e c a r e f o r t h e i r c h i l d r e n (p: 6 0 ) . B a r s c h and V o y s e y , s e p a r a t e l y , f o u n d t h a t p a r e n t s o f h a n d i c a p p e d and i l l c h i l d r e n t r i e d t o f u l f i l l t h e 19 r e s p o n s i b i l i t i e s o f c a r e and c o n t r o l o f c h i l d r e n and m a i n t a i n a f a i r d i s t r i b u t i o n o f t h e h e l p and r e s o u r c e s w i t h i n t h e f a m i l y ( B a r s c h , 1968, p. 311; Voysey, 1975, p. 139). I t s h o u l d be n o t e d t h a t t h e s e s t u d i e s d i d not use a d e v e l o p -m ental approach. However, the r e s e a r c h e r s d i d i d e n t i f y p a r e n t s of a s p e c i f i c age group of c h i l d r e n t o i n t e r v i e w ; f o r example, Crummette (1979) and Reddihough e t a l . (1977) i n t e r v i e w e d p a r e n t s o f s c h o o l - a g e d c h i l d r e n and T r a v i s (1976) i n t e r v i e w e d p a r e n t s o f p r e s c h o o l c h i l d r e n . The d e v e l o p m e n t a l s t a g e s o f c h i l d r e n a f f e c t t h e i r p a r e n t s ' r e s p o n s i b i l i t i e s and t a s k s ; t h e r e -f o r e , the ages o f t h e c h i l d r e n c o n s t i t u t e an e s s e n t i a l c o n s i d e r -a t i o n when s t u d y i n g p a r e n t a l t a s k s . From t h e l i t e r a t u r e r e v i e w and i t s a n a l y s i s , t h e i n v e s t i -g a t o r found i n s u f f i c i e n t v a l i d and r e l i a b l e d a t a f o r use i n t h e n u r s i n g c a r e o f f a m i l i e s o f a s t h m a t i c p r e s c h o o l c h i l d r e n . T h e r e f o r e , a d e s c r i p t i v e s t u d y was done w i t h an aim t o improve the q u a l i t y o f t h e r e s e a r c h a v a i l a b l e , and add t o the knowledge about c h r o n i c a l l y i l l c h i l d r e n u s i n g a d e v e l o p m e n t a l and n u r s i n g approach. The n e x t c h a p t e r d e s c r i b e s t h e r e s e a r c h method used t o s t u d y t h e p a r e n t s ' p e r c e p t i o n s o f t h e i r b e h a v i o u r s t o h e l p t h e i r p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r needs t o grow and d e v e l o p . CHAPTER I I I Research Design and Methods The evidence from the review of the l i t e r a t u r e and c l i n i c a l experience as presented i n Chapter I I i n d i c a t e d t h a t a d e s c r i p -t i v e study about the behaviours of parents i n r e l a t i o n t o t h e i r p r e s c h o o l c h i l d r e n with asthma was t i m e l y and necessary. The content of t h i s chapter w i l l focus on the r e s e a r c h p l a n i n c l u d -i n g the methods used to a c q u i r e and analyze the data secured from the i n t e r v i e w s between the i n v e s t i g a t o r and the parents of asthmatic p r e s c h o o l c h i l d r e n . I n i t i a l l y , an overview of the r e s e a r c h p l a n w i l l be presented, f o l l o w e d by a d e s c r i p t i o n of the sample, the I n t e r v i e w Guide, and the i n t e r v i e w procedure. L a s t l y , the method used to analyze the data and the e t h i c a l con-s i d e r a t i o n s i n v o l v e d i n t h i s study w i l l be summarized. Overview of the Research P l a n T h i s d e s c r i p t i v e study p r o v i d e d d e t a i l e d accounts of 10 couples * behaviours i n c l u d i n g t h e i r e f f o r t s t o help t h e i r pre-s c h o o l c h i l d r e n . D e s c r i p t i v e r e s e a r c h i s aimed at o b t a i n i n g complete and a c c u r a t e i n f o r m a t i o n about the group being s t u d i e d ( S e l l t i z , Wrightsman, & Cook, 1976, pp. 102-103). One of the ways to gather data i n a d e s c r i p t i v e study i s to i n t e r v i e w s u b j e c t s (Notter, 1974, p. 20). In t h i s study, ten couples of p r e s c h o o l asthmatic c h i l d r e n were chosen as the s u b j e c t s . Support f o r t h i s d e c i s i o n was p r o v i d e d from both theory and r e s e a r c h as d i s c u s s e d i n Chapter I I . I t was assumed t h a t the c o u p l e s ' r e p o r t s about t h e i r behaviours i n r e l a t i o n t o h e l p i n g t h e i r c h i l d r e n were honest and p r e c i s e (Hymovich, 1979, p. 284). Barnard and Douglas, i n a review of the l i t e r a t u r e , r e p o r t e d : " P a r e n t s a r e , i n many i n s t a n c e s , q u i t e a c c u r a t e i n t h e i r p e r c e p t i o n s " (1974, p. 8 ) . Coombs and Snygg (1949) s t a t e d t h a t p e o p l e do n o t behave a c c o r d i n g t o t h e f a c t s as o t h e r s s e e them, b u t t h e y behave i n k e e p i n g w i t h t h e way t h e y see t h e f a c t s (1949, p. 1 7 ) . F u r t h e r m o r e , B u r t o n (1975) f o u n d i n h e r r e s e a r c h t h a t p a r e n t s were e a g e r t o d i s c u s s what t h e y d i d w i t h t h e i r c h r o n i c a l l y i l l c h i l d r e n . T h e r e f o r e , t h e i n v e s t i g a t o r p l a n n e d t o i n t e r v i e w p a r e n t s and a s k them a b o u t t h e i r b e h a v i o u r s . The I n t e r v i e w G u i d e , ( A p p e n d i x C, p. 7 7 ) , d e v e l o p e d by t h e i n v e s t i g a t o r f r o m t h e UBC M o d e l f o r N u r s i n g , was u s e d f o r t h e p u r p o s e o f c o l l e c t i n g t h e d a t a . The a n a l y s i s o f t h e c o u p l e s ' i n t e r a c t i o n s r e f l e c t e d t h e i r h e l p i n g b e h a v i o u r s i n r e l a t i o n t o t h e i r a s t h m a t i c c h i l d r e n . The d a t a were t h e n s o r t e d i n a c c o r d -ance w i t h b a s i c human need s as p r o v i d e d by t h e framework o f f e r e d by t h e UBC M o d e l f o r N u r s i n g . I n t h e f o l l o w i n g s e c t i o n s o f t h i s c h a p t e r , a d e t a i l e d a c c o u n t o f t h e r e s e a r c h p r o c e d u r e w i l l be d e s c r i b e d . D e s c r i p t i o n o f t h e Sample The f o l l o w i n g d i s c u s s i o n p r e s e n t s t h e d e s c r i p t i o n o f t h e sample o f 10 c o u p l e s , t h e c r i t e r i a f o r t h e i r s e l e c t i o n , and t h e p r o c e d u r e f o r c o n t a c t i n g them f o r t h e r e s e a r c h p r o j e c t . A c r o s s -s e c t i o n o f c o u p l e s who were c u r r e n t l y r e a r i n g p r e s c h o o l c h i l d r e n w i t h asthma was d e s i r e d f o r a r e p r e s e n t a t i v e sample ( N o t t e r , 1974, p. 7 6 ) . Two p e d i a t r i c a l l e r g i s t s i n V a n c o u v e r , B r i t i s h C o l u m b i a were a p p r o a c h e d t o p r o v i d e t h e names o f p a r e n t s who met t h e c r i t e r i a . The i n v e s t i g a t o r i n t e r v i e w e d t h e a l l e r g i s t s and d i s c u s s e d t h e f o l l o w i n g : (a) p u r p o s e o f t h e s t u d y and i t s s i g n i f i c a n c e t o n u r s i n g , (b) c r i t e r i a f o r s e l e c t i n g t h e s u b j e c t s f o r the study, (c) content of the Interview Guide, and (d) pro-cedure f o r o b t a i n i n g . t h e names, addresses, and telephone numbers f o r the p o s s i b l e s u b j e c t s . A l e t t e r was l e f t with the a l l e r g i s t s f o r f u r t h e r r e f e r e n c e which o u t l i n e d the purposes of the study and the method of data c o l l e c t i o n (Appendix D, p. 82). A f t e r the v e r b a l agreement was made w i t h the a l l e r g i s t s , they signed a consent i n d i c a t i n g t h e i r agreement t h a t the i n v e s t i g a t o r o b t a i n the p a r e n t s ' names through t h e i r o f f i c e s (Appendix E, p. 83). S i x couples were obtained by t h i s , method. The other f o u r couples were r e f e r r e d by one of the p e d i a t r i c a l l e r g i s t s from h i s medical c l i n i c . Thus, a convenience sample of couples was o b t a i n e d r a t h e r than the p r e f e r r e d method of random sampling. A convenience sample i s a n o n p r o b a b i l i t y sample t h a t happens to be a v a i l a b l e a t the time f o r p a r t i c i p a t i o n i n the study, and i s not r e p r e s e n t a t i v e of the p o p u l a t i o n (Brink & Wood, 1978, p. 97). As t h i s was a d e s c r i p t i v e study which was aimed at g a t h e r i n g more d e t a i l s about p a r e n t s ' p e r c e p t i o n s r a t h e r than p r o v i n g or d i s p r o v i n g a given h y p o t h e s i s , t h i s l i m i t a t i o n was not a major concern. In f a c t , P h i l l i p s s t a t e d : " I f the d e f i n i -t i o n of the problem emphasized the context of d i s c o v e r y , a s u p e r i o r s t r a t e g y (to random sample) f o r a given problem might be to secure d e t a i l e d data on a n o n p r o b a b i l i t y sample" ( P h i l l i p s , 1971, p. 95). A s e t of f i v e c r i t e r i a was used to s e l e c t the names of the couples from the l i s t of r e f e r r a l s s u p p l i e d by the a l l e r g i s t s . T h i s .method ensured a sample of parents which would be able to p r o v i d e the data r e q u i r e d and l i m i t e d the i n t e r v e n i n g v a r i a b l e s which may have confounded the data. The f o l l o w i n g c r i t e r i a and r a t i o n a l e were used to s e l e c t the couples: 1. The ages of the p r e s c h o o l c h i l d r e n with asthma ranged from three t o f i v e years of age. By d e f i n i t i o n , p r e s c h o o l c h i l d r e n range from two and h a l f years to f i v e years of age ( D u v a l l , 1977, p. 249). 2. The c h i l d r e n had no other i l l n e s s e s and they had been diagnosed by t h e i r p h y s i c i a n as having moderate to severe asthma f o r a t l e a s t one year. Asthmatic c h i l d r e n w i t h other c h r o n i c i l l n e s s e s such as e p i l e p s y or c y s t i c f i b r o s i s would tend to confound the data and c l e a r d i s t i n c t i o n s about how the parents helped t h e i r asthmatic c h i l d r e n would be embroiled with f a c t o r s concerning the other d i s e a s e s . I t takes time f o r parents to become accustomed to t h e i r c h i l d r e n ' s i l l n e s s e s and treatments; t h e r e f o r e , the i n v e s t i g a t o r s e t the c r i t e r i a of at l e a s t one year from the time the c h i l d r e n were diagnosed as having asthma u n t i l the date of s e l e c t i o n ( C a r l s o n , 1978, p. 88; Smith, 1981, p. 17). 3. The parents both agreed to p a r t i c i p a t e i n the study. T h i s study i n v o l v e d the couple as the sample because of the r e s e a r c h and t h e o r e t i c a l support f o r i n c l u d i n g both the mother and the f a t h e r as a u n i t (Anthony, 1979, p. 78; Benedek, 1970, p. 110; McKeever, 1981, p. 124). 4. The couple and t h e i r p r e s c h o o l c h i l d r e n w i t h asthma l i v e d i n the same house i n the area o f the Lower Mainland of B r i t i s h Columbia. The couples were i n t e r v i e w e d i n t h e i r homes, r a t h e r t h a n ' i n a c l i n i c or h o s p i t a l i n an attempt to have a r e l a x e d environment, and to f a c i l i t a t e the couples' responses 24 d u r i n g t h e i n t e r v i e w . K o r n h a u s e r and S h e a t s l e y r e p o r t t h a t t h e i d e a l s e t t i n g f o r i n t e r v i e w i n g i s a " p e r m i s s i v e s i t u a t i o n i n w h i c h t h e r e s p o n d e n t s a r e e n c o u r a g e d t o v o i c e t h e i r f r a n k o p i n i o n s " (1976, p. 5 6 4 ) . 5. The s t u d y was l i m i t e d t o c o u p l e s who u n d e r s t o o d and spoke E n g l i s h . A f t e r t e n c o u p l e s ' names were o b t a i n e d , t h e c o u p l e s were c o n t a c t e d a b o u t t h e i r p a r t i c i p a t i o n i n t h e p r o j e c t by l e t t e r ( A p p e n d i x F, p . 8 4 ) • A f t e r s e v e n d a y s i t was a n t i c i p a t e d t h a t t h e c o u p l e s had r e c e i v e d t h e l e t t e r and t h e i n v e s t i g a t o r t a l k e d w i t h them by t e l e p h o n e t o ask f o r t h e i r d e c i s i o n t o v o l u n t e e r and t o s e t a d a t e f o r t h e i n t e r v i e w . A l l t e n c o u p l e s w i l l i n g l y v o l u n t e e r e d t o p a r t i c i p a t e i n t h e s t u d y . I n t e r v i e w G u i d e The i n t e r v i e w i s an a p p r o p r i a t e way t o c o l l e c t d a t a f o r d e s c r i p t i v e s t u d i e s and t o o b t a i n d a t a a b o u t p e r c e p t i o n s o f i n d i v i d u a l s ( B r i n k & Wood, 1978, p. 1 0 6 ) . I n t h e f o l l o w i n g d i s c u s s i o n , t h e d e v e l o p m e n t o f t h e I n t e r v i e w G u i d e and i t s f e a t u r e s w i l l be d e s c r i b e d . The f e a t u r e s o f an i d e a l m e a s u r i n g i n s t r u m e n t i n c l u d e : (a) i t s r e l e v a n c e t o t h e c o n c e p t s b e i n g d e s c r i b e d , (b) i t s s e n s i t i v i t y , t h a t i s , t h a t i t makes d i s t i n c t i o n s f i n e enough f o r t h e p u r p o s e s i t i s t o s e r v e , (c) i t s v a l i d i t y o r a b i l i t y t o measure what i t was i n t e n d e d t o meas-u r e , and (d) i t s r e l i a b i l i t y o r r e p e a t a b i l i t y ( S e l l t i z , W r i g h t s -man, & Cook, 1976, pp. 160-163; W i l l i a m s o n , 1981, pp. 1 5 4 -160). The I n t e r v i e w G u i d e , a s e m i - s t r u c t u r e d q u e s t i o n n a i r e , was d e v e l o p e d p r i m a r i l y b e c a u s e t h e r e was n o t an a p p l i c a b l e a l t e r n a -t i v e a v a i l a b l e f o r t h i s p a r t i c u l a r r e s e a r c h . The UBC M o d e l f o r N u r s i n g was an a p p r o p r i a t e framework t o u s e t o d e v e l o p t h e G u i d e b e c a u s e i t p r o v i d e d an a p p r o a c h t o t h e i n d i v i d u a l ' s b a s i c human needs and i t a l l o w e d i n t e g r a t i o n o f d e v e l o p m e n t a l t h e o r y ( R i e h l & Roy, 1974, p. 2 6 ) . The d e v e l o p m e n t o f t h e I n t e r v i e w G u i d e f o l l o w e d s t a n d a r d p r o c e d u r e s ( N o t t e r , 1974, pp. 6 6 - 6 7 ) . I t s i t e m s were d e r i v e d f r o m t h e l i t e r a t u r e , t h e UBC M o d e l f o r N u r s -i n g , and t h e r e s e a r c h e r ' s e x p e r i e n c e w o r k i n g w i t h p r e s c h o o l c h i l d r e n and t h e i r f a m i l i e s w i t h asthma, and i n c o n s u l t a t i o n w i t h two n u r s i n g r e s e a r c h e r s ( A r k i n s t a l l , 1977, pp. 8-9; C a m p b e l l , C r u i s e , & Murakami, 1976, p. 8; C a m p b e l l , 1980; D u v a l l , 1977, pp. 249-258 and 264-268; Hymovich, 1976, pp. 11-13; P e r r y , 1980; S o o t h i l l , 1979, pp. 385-389). A l l i t e m s f o r t h e G u i d e were i n t e n d e d t o be c o n s i s t e n t w i t h p r e s c h o o l c h i l d r e n ' s d e v e l o p m e n t a l n eeds and a s t h m a t i c c o n d i t i o n s . F o l l o w i n g d e v e l o p m e n t , t h e G u i d e was p r e t e s t e d . Two c o u p l e s - o f p r e s c h o o l c h i l d r e n w i t h asthma v o l u n t e e r e d t o be i n t e r v i e w e d . As a r e s u l t , two q u e s t i o n s were added. One q u e s t i o n a s k e d f o r t h e c o u p l e s ' d e f i n i t i o n o f asthma and t h e s e c o n d a s k e d f o r s p e c i f i c e f f o r t s made by p a r e n t s t o p r o t e c t t h e i r c h i l d r e n f r o m i n f e c t i o n s . B o t h o f t h e s e s u g g e s t i o n s f r o m p a r e n t s were t h o u g h t t o be s i g n i f i c a n t t o t h e s t u d y b e c a u s e t h e i t e m s e l i c i t e d r e l e v a n t i n f o r m a t i o n and t h e r e -f o r e t h e y were i n c l u d e d i n t h e I n t e r v i e w G u i d e . The G u i d e r e f l e c t e d t h e p r o b l e m s t a t e m e n t s and i n c l u d e d q u e s t i o n s d e s i g n e d t o o b t a i n i n f o r m a t i o n a b o u t : (a) d e m o g r a p h i c and r e l e v a n t d a t a c o n c e r n i n g t h e p a r e n t s ' r e s p o n s i b i l i t i e s , (b) t h e c h i l d r e n ' s asthma, (c) t h e h e l p p a r e n t s p r o v i d e d t h e i r p r e s c h o o l c h i l d r e n w i t h asthma, a n d (d) t h e i m p a c t o f asthma and i t s t r e a t m e n t on t h e p a r e n t s ' e f f o r t s t o h e l p t h e i r p r e s c h o o l c h i l d r e n . 26 T h r e e t y p e s o f v a l i d i t y were c o n s i d e r e d i n r e l a t i o n t o t h i s i n s t r u m e n t ' s u s a g e . F i r s t , c o n s t r u c t v a l i d i t y was e x a m i n e d . T h i s r e f e r s t o t h e s o u n d n e s s o f c o n c e p t s and t h e o r y u n d e r l y i n g t h e I n t e r v i e w G u i d e ( W i l l i a m s o n , 1981, p. 1 6 3 ) . The i n s t r u m e n t was b a s e d on t h e o r i e s r e l a t e d t o c h i l d h o o d asthma, g r o w t h and d e v e l o p m e n t , and n u r s i n g w h i c h were d e s c r i b e d i n C h a p t e r I I . The s e c o n d f o r m o f v a l i d i t y a d d r e s s e d was f a c e v a l i d i t y w h i c h r e f e r s t o t h e p e r t i n e n c e o f t h e d a t a c o l l e c t i o n g u i d e t o t h e v a r i a b l e s b e i n g i n v e s t i g a t e d ( B r i n k & Wood, 1978, p. 120; N o t t e r , 1974, p. 7 4 ) . The I n t e r v i e w G u i d e u s e d i n t h i s s t u d y was d e v e l o p e d p a r t i c u l a r l y f o r t h i s r e s e a r c h p r o j e c t , and t h e r e -f o r e , i t was a p p l i c a b l e f o r o b t a i n i n g d a t a a b o u t t h e p a r e n t s ' p e r c e p t i o n s o f how t h e y h e l p e d t h e i r p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r n e e d s . I n a d d i t i o n , f a c e v a l i d i t y o f t h e G u i d e was e n h a n c e d by t h e p r e t e s t r e s u l t s and t h e w i l l i n g n e s s o f t h e c o u p l e s t o r e s p o n d d u r i n g t h e i n t e r v i e w s . The t h i r d t y p e o f v a l i d i t y , c o n t e n t v a l i d i t y , w h i c h a d d r e s s e s t h e d e g r e e t o w h i c h t h e c o n t e n t o f a d a t a c o l l e c t i o n d e v i c e was r e p r e s e n t a t i v e o f what i s known a b o u t t h e t o p i c ( N o t t e r , 1974, p. 1 4 0 ) . I n t h i s s t u d y , as p r e v i o u s l y r e f e r r e d t o i n t h i s c h a p t e r , t h e i t e m s c o n t a i n e d i n t h e I n t e r v i e w G u i d e were d e v e l o p e d f r o m a w i d e r a n g e o f r e l e v a n t t h e o r i e s . C o n s u l t -a t i o n a b o u t t h e v a l i d i t y o f t h e i t e m s was o b t a i n e d f r o m n u r s i n g c o n s u l t a n t s and p a r e n t s o f p r e s c h o o l c h i l d r e n w i t h asthma. I n a d d i t i o n , t h e UBC M o d e l f o r N u r s i n g p r o v i d e d a c o m p r e h e n s i v e framework f o r t h e I n t e r v i e w G u i d e . The G u i d e ' s i t e m s r e p r e s e n t e d a w i d e r a n g e o f t h e o r y e n c o m p a s s i n g p r e s c h o o l c h i l d r e n w i t h asthma. 27 R e l i a b i l i t y r e l a t e s t o the concepts of c o n s i s t e n c y and r e p e a t a b i l i t y (Notter, 1974, p. 75; Williamson, 1981, p. 164). The Interview Guide items were r e l i a b l e i n t h a t a l l couples c o n s i s t e n t l y responded to the i n t e r v i e w e r ' s q u e s t i o n s a p p r o p r i -a t e l y and d e s c r i p t i v e l y . The i n t e r v i e w procedure was made r e l i a b l e i n the f o l l o w i n g ways: the i n v e s t i g a t o r (a) i n t e r v i e w e d the parents a c c o r d i n g to a planned and c o n s i s t e n t procedure, (b) used the same Interview Guide throughout the i n t e r v i e w s , (c) conducted a l l of the i n t e r v i e w s , f a c i l i t a t i n g the c o n s i s t e n c y of the i n t e r v i e w i n g techniques (Williamson, 1981, pp. 154-160). In a d d i t i o n , to address the r e l i a b i l i t y of the i n v e s t i g a t o r ' s placement of the content of the i n t e r v i e w s , two n u r s i n g r e s e a r -chers experienced i n t h i s method of a n a l y s i s randomly s e l e c t e d segments of the audiotaped i n t e r v i e w s with the couples and com-pared t h e i r independent placement of the i n t e r v i e w content t o the t r a n s c r i b e d data prepared by the i n v e s t i g a t o r . The r e s u l t s of the n u r s i n g c o n s u l t a n t s ' c a t e g o r i z a t i o n of the data was con-s i s t e n t w i t h t h a t of the i n v e s t i g a t o r . T h i s method i s recog-n i z e d as an a c c e p t a b l e way to address r e l i a b i l i t y of the p l a c e -ment of data (Notter, 1974, p. 6). The s p e c i f i c method used t o i n t e r v i e w the couples and o b t a i n the data i s d e s c r i b e d i n the Interview Procedure (Appendix G, p. 86), and i n the f o l l o w i n g d i s c u s s i o n . Procedure f o r C o l l e c t i n g the Data The procedure which d i r e c t e d the i n t e r v i e w s was c o n s i s t e n t and i t seemed t o be e f f e c t i v e and e f f i c i e n t . A w r i t t e n consent (Appendix p. 88) was reviewed w i t h each of the couples p r i o r to b eginning data c o l l e c t i o n and was signed by both the f a t h e r 28 and the mother. During the i n t e r v i e w s both parents were prese n t and f r e e l y p a r t i c i p a t e d i n the d i s c u s s i o n . The i n v e s t i g a t o r , who was expe r i e n c e d i n the s k i l l of i n t e r v i e w i n g , d i r e c t e d a l l o f the i n t e r v i e w s . Each i n t e r v i e w took approximately s i x t y minutes t o complete. At the t e r m i n a t i o n of the i n t e r v i e w s , the i n v e s t i g a t o r thanked the parents f o r t h e i r p a r t i c i p a t i o n and pro v i d e d the names of reso u r c e s and i n f o r m a t i o n the couples requested. In summary, the i n v e s t i g a t o r i n t e r v i e w e d ten couples of p r e -school c h i l d r e n w i t h asthma i n t h e i r home u s i n g a Guide which helped t o c o l l e c t i n-depth d e s c r i p t i o n s of the parents' percep-t i o n s of how they helped t h e i r asthmatic c h i l d r e n . Procedure f o r A n a l y z i n g the Data In t h i s s e c t i o n , the c r i t e r i a and technique used to analyze the data obtained from the i n v e s t i g a t o r ' s i n t e r v i e w s w i t h the couples w i l l be d e s c r i b e d . The main technique used to analyze the i n t e r v i e w s was content a n a l y s i s . T h i s method can be a p p l i e d to any problem where the content of communication serves as a b a s i s of i n f e r e n c e ( H o l s t i , 1969, p. 2). For example, the he l p parents s t a t e d they p r o v i d e d t h e i r p r e s c h o o l c h i l d r e n was the semantic content s e l e c t e d f o r a n a l y s i s and the b a s i s f o r i n f e r -ences. The i n v e s t i g a t o r used b a s i c human needs and tasks of parenthood as a c l a s s i f i c a t i o n framework t o s o r t the statements of the couples' p e r c e p t i o n s o f t h e i r "help." T h i s i s an accept-able procedure a c c o r d i n g t o Brink and Wood: I f a study has a conc e p t u a l o r t h e o r e t i c a l framework, the r e s e a r c h e r can s e t up c l a s s i f i c a t i o n s or c a t e g o r i e s ,in advance, s i m p l i f y i n g somewhat, the process of content a n a l y s i s . (Brink & Wood, 1978, p. 146). 29 From t h e a u d i o t a p e d i n t e r v i e w s , t h e i n v e s t i g a t o r t r a n s -c r i b e d e a c h c o u p l e s ' v e r b a t i m e x p r e s s i o n s o f h e l p i n t o t h e a p p r o p r i a t e c a t e g o r y . E a c h c a t e g o r y r e p r e s e n t e d one o f t h e c h i l d ' s b a s i c human n e e d s . To g u i d e t h e i n v e s t i g a t o r i n t h e p l a c e m e n t o f t h e i n t e r v i e w d a t a , t h e i n v e s t i g a t o r u s e d t h e d e f i n i t i o n s o f t h e b a s i c human needs as p r o v i d e d by t h e UBC M o d e l f o r N u r s i n g ( T a b l e 1, p. 6 ) . The a p p l i c a t i o n o f t h e UBC M o d e l f o r N u r s i n g as a framework t o o r g a n i z e t h e d a t a i m p o s e d some r e s t r a i n t s due t o t h e f a c t t h a t t h e framework was b a s e d on " s y s t e m t h e o r y . " By d e f i n i t i o n , e a c h o f t h e n i n e n e e d s a r e r e p r e s e n t e d by a s u b s y s t e m w h i c h i s i n t e r -a c t i n g and i n t e r d e p e n d e n t w i t h e v e r y o t h e r s u b s y s t e m ( C a m p b e l l , C r u i s e , & Murakami, 1976, p. 6 ) . I t was t h o u g h t , t h e r e f o r e , t h a t t h e c a t e g o r i e s o f n e e d s w o u l d n o t meet t h e c r i t e r i o n o f b e i n g m u t u a l l y e x c l u s i v e . M u t u a l e x c l u s i v e n e s s s t i p u l a t e s t h a t no c o n t e n t datum c a n be p l a c e d i n more t h a n one s i n g l e c a t e g o r y ( H o l s t i , 1969, p. 9 9 ) . To a p p r o a c h t h i s p r o b l e m , t h e i n v e s t i g a t o r g r o u p e d t h e common r e s p o n s e s as p r e s e n t e d by t h e c o u p l e s u n d e r e a c h "need" c a t e g o r y . The c o u p l e s i d e n t i f i e d what t h e y d i d t o h e l p t h e i r c h i l d r e n and t h e n gave s p e c i f i c e x a m ples o f t h e i r b e h a v i o u r s . G r o u p i n g t h i s c o n t e n t w i t h i n e a c h " a p p r o p r i a t e n e e d " c a t e g o r y a p p e a r e d t o p a r t i a l l y meet t h e c r i t e r i o n o f m u t u a l e x c l u s i v e n e s s . S o r t i n g t h e c o u p l e s ' r e s p o n s e s a c c o r d i n g t o t h e p r e s c h o o l c h i l d r e n ' s . b a s i c human n e e d s r e f l e c t e d t h e r e s e a r c h q u e s t i o n . As a r e s u l t o f t h e a n a l y s e s , a d e s c r i p t i o n e v o l v e d i n c l u d i n g t h e p a r e n t s ' p e r c e p t i o n s o f (a) t h e ways t h e y h e l p e d p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r human n e e d s , and (b) how asthma 30 and i t s treatment a f f e c t e d the help the parents p r o v i d e d t h e i r p r e s c h o o l asthmatic c h i l d r e n . To summarize, the content analyses of the i n t e r v i e w s w i t h ten couples o f p r e s c h o o l c h i l d r e n w i t h asthma from the Lower Mainland of B r i t i s h Columbia were guided by the UBC Model f o r Nursing, a b a s i c human needs framework. Both the Interview Guide and the c a t e g o r i z a t i o n of the data were developed from t h i s n u r s i n g framework. E t h i c a l C o n s i d e r a t i o n s Encountered i n the Research In t h i s study, c e r t a i n e t h i c a l i s s u e s were c o n s i d e r e d . An approval was secured from The U n i v e r s i t y of B r i t i s h Columbia Screening Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s : B e h a v i o u r a l Science (Appendix I, p. 89 ). The f o l l o w i n g d i s c u s s i o n s w i l l p r e s e n t the e t h i c a l i s s u e s and the ways the i n v e s t i g a t o r approached them. O b t a i n i n g the coupl e s ' informed consents r e g a r d i n g t h e i r p a r t i c i p a t i o n i n the r e s e a r c h was one of the i s s u e s the i n v e s t -i g a t o r c o n s i d e r e d . Each couple was informed about the study by a l e t t e r and one week was allowed f o r them to make a d e c i s i o n about p a r t i c i p a t i n g i n the study. At t h a t time, the couples were telephoned and asked i f they had decided to p a r t i c i p a t e i n the study. T h i s telephone c o n t a c t w i t h the couples p r o v i d e d an op p o r t u n i t y f o r f u r t h e r c l a r i f i c a t i o n about the study and to s e t the time and date f o r the i n t e r v i e w and a v e r b a l consent. In a d d i t i o n t o t h i s , at each i n t e r v i e w the i n v e s t i g a t o r read the contents of the w r i t t e n consent t o the couples p r i o r t o t h e i r s i g n i n g of i t (Appendix H, p. 88). The contents of the v e r b a l and w r i t t e n consents were c o n s i s t e n t , and co n t a i n e d the purpose 31 and p o s s i b l e b e n e f i t s o f t h e c o m p l e t e d r e s e a r c h . I n t h e e x p l a n a -t i o n t o t h e c o u p l e s t h e e x t e n t o f t h e i r i n v o l v e m e n t was c l e a r l y s p e c i f i e d . They were i n f o r m e d t h a t t h e y w o u l d be a u d i o t a p e d d u r i n g t h e i n t e r v i e w and t o l d a b o u t t h e e x a c t u s e d u r i n g , and d i s p o s i t i o n a f t e r , o f t h e a u d i o t a p e s f o l l o w i n g t h e c o m p l e t i o n o f t h e s t u d y . The c o u p l e s were a l s o i n f o r m e d t h a t t h e y c o u l d w i t h -draw f r o m t h e s t u d y a t any t i m e w i t h o u t j e o p a r d i z i n g t h e m e d i c a l c a r e o f t h e i r c h i l d r e n . The i n v e s t i g a t o r f e l t c o n f i d e n t t h a t t h e c o u p l e s i n t h i s s t u d y were a d e q u a t e l y i n f o r m e d a b o u t t h e i r i n v o l v e m e n t i n t h e s t u d y . A n o t h e r e t h i c a l i s s u e t h e i n v e s t i g a t o r c o n s i d e r e d was t h a t o f p r o v i d i n g t h e c o u p l e s w i t h p r i v a c y . I n t h i s s t u d y , t h e r e were t h r e e m a j o r t h r e a t s t o t h e f a m i l i e s ' p r i v a c y (The C a n a d i a n C o u n c i l , 1977, p. 1 5 ) . One o f t h e s e t h r e a t s was t h e u s e o f a t a p e r e c o r d e r . However, t h e i n v e s t i g a t o r made e x p l i c i t t h a t t h e use o f t h e i n f o r m a t i o n was f o r r e s e a r c h o n l y and t h e i r p r i v a c y was p r o t e c t e d by k e e p i n g t h e t a p e d i n t e r v i e w s c o n f i d e n t i a l and t h e c o u p l e s ' names anonymous. The c o u p l e s were a s s u r e d t h a t a t t h e c o m p l e t i o n o f t h e s t u d y a l l t h e a u d i o t a p e d and w r i t t e n d a t a w o u l d be e i t h e r e r a s e d o r d e s t r o y e d . I n t e r v i e w s i n t h e i r homes were t h e s e c o n d p o t e n t i a l t h r e a t t o t h e c o u p l e s ' p r i v a c y (The C a n a d i a n C o u n c i l , 1977, p. 1 4 ) . T h i s i n t e n t was p r e s e n t e d i n t h e i r i n i t i a l l e t t e r , b u t a l l t h e c o u p l e s w i l l i n g l y c o n s e n t e d t o be i n t e r v i e w e d i n t h e i r homes a t a t i m e c o n v e n i e n t t o t h e i r f a m i l y . The t h i r d t h r e a t t o t h e c o u p l e s ' p r i v a c y was t h e d i s c l o s u r e o f t h e ways t h e y h e l p e d t h e i r c h i l d r e n . The i n v e s t i -g a t o r p r o v i d e d s u f f i c i e n t o p p o r t u n i t y f o r t h e c o u p l e s t o c o n s i d e r t h i s t h r e a t and an o p t i o n t o w i t h d r a w f r o m t h e s t u d y 32 at any time. Furthermore, couples were asked open-ended qu e s t i o n s which allowed the parents t o answer the q u e s t i o n s as they chose. Another e t h i c a l i s s u e c o n s i d e r e d was the p r o t e c t i o n of the couples' c o n f i d e n t i a l i t y and anonymity. The i n v e s t i g a t o r ' s i n t e n t t o p r o t e c t the couples was made e x p l i c i t i n bath, the i n i t i a l l e t t e r t o the couples and i n the v e r b a l e x p l a n a t i o n p r i o r to the couples s i g n i n g of the w r i t t e n consents. I t was c l e a r l y e x p l a i n e d t h a t the audiotapes were i d e n t i f i e d o n l y by number, and t h a t names would not be a s s o c i a t e d w i t h the recorded i n f o r m a t i o n . In a d d i t i o n , the couples were assured t h a t i n a d d i t i o n to h e r s e l f o n l y the i n v e s t i g a t o r ' s T h e s i s Committee (two f a c u l t y members) would have access t o the tapes. In summary, the e t h i c a l i s s u e s were s y s t e m a t i c a l l y approached t o p r o t e c t the s u b j e c t s . The i s s u e s were t h a t of an informed consent, p r i v a c y and c o n f i d e n t i a l i t y and anonymity. T h i s r e s e a r c h p r o j e c t was accomplished by a u d i o t a p i n g i n t e r v i e w s w i t h ten couples w i t h asthmatic p r e s c h o o l c h i l d r e n . The data from the i n t e r v i e w s were c a t e g o r i z e d a c c o r d i n g to b a s i c human needs. W i t h i n each need, the content of the couples' statements of the way they helped the asthmatic p r e -s c h o o l c h i l d r e n were analyzed. The i n v e s t i g a t o r ensured t h a t the parents were e t h i c a l l y p r o t e c t e d throughout the study. In the next chapter the f i n d i n g s d e r i v e d from the i n t e r v i e w s w i t h the couples w i l l be presented. CHAPTER IV P r e s e n t a t i o n of the F i n d i n g s In t h i s chapter, the r e l e v a n t f i n d i n g s o b tained from the i n t e r v i e w s w i t h 10 couples of p r e s c h o o l c h i l d r e n with asthma w i l l be summarized. F i r s t , a d e s c r i p t i o n of the sample w i l l be presented which i n c l u d e s i n f o r m a t i o n about both the couples and t h e i r p r e s c h o o l c h i l d r e n with asthma. D e s c r i p t i v e s t a t i s t i c s were used to summarize t h i s data. Second, the content of the i n t e r v i e w s w i l l be d e s c r i b e d a c c o r d i n g to the ways the parents s t a t e d they helped p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r b a s i c human needs. The c o u p l e s ' verbatim responses were c a t e g o r i z e d a c c o r d i n g to the nine b a s i c human needs s p e c i f i e d by the UBC Model f o r Nursing. F i n a l l y , an account of the impact of the p r e s c h o o l c h i l d r e n ' s asthma and treatment on the c o u p l e s ' e f f o r t s to p r o v i d e care w i l l be summarized. D e s c r i p t i o n of the Sample Th i s s e c t i o n d e s c r i b e s the p e r t i n e n t data obtained from the i n t e r v i e w s of 10 couples of p r e s c h o o l c h i l d r e n w i t h asthma. A l l the couples i n t e r v i e w e d met the c r i t e r i a s p e c i f i e d i n Chapter I I I (pp. 23-24) and they w i l l i n g l y p a r t i c i p a t e d i n the study. The couples. Relevant data d e s c r i b i n g the couples who par-t i c i p a t e d i n the study are presented i n the f o l l o w i n g d i s c u s s i o n and summarized i n Table 2 (p. 34). The demographic data were obtained a t the beginning of each i n t e r v i e w and recorded. Each couple was s u b d i v i d e d i n t o a mother and a f a t h e r f o r purposes o f d e s c r i b i n g t h e i r ages, e d u c a t i o n a l backgrounds, and o c c u p a t i o n s . They ranged from 28 to 41 years of age w i t h a mean 34 Table 2 Demographic Data of Couples o f Pre s c h o o l C h i l d r e n w i t h Asthma Number as s i g n e d Ages E d u c a t i o n 3 Occupation* 3 to the couple Mother Father Mother Fa t h e r Mother Fa t h e r 1 30 34 2 2 4/1 3 2 37 41 1 4 4 3 3 35 37 2 2 4 2 4 30 33 2 3 2 3 5 34 40 1 3 4 1 6 34 38 1 3 4 1 7 37 31 3 3 1 1 8 32 33 2 1 4 2 9 33 36 2 4 2 2 10 28 32 1 2 2 2 Mean 33 35. 5 Number C l a s s  a E d u c a t i o n 1 Grade XII Graduate 2 Community C o l l e g e Graduate 3 U n i v e r s i t y Graduate 4 Other ( a p p r e n t i c e s h i p ) ^Occupation 1- P r o f e s s i o n a l (nurse, teacher, p r o f e s s o r ) 2 T e c h n i c a l ( h a i r d r e s s e r , secretary) 3 . Business 4 Homemaker 35 age o f 33 y e a r s f o r t h e m o t h e r s and 35.5 f o r t h e f a t h e r s . A l l o f t h e p a r e n t s i n t e r v i e w e d had c o m p l e t e d Grade X I I and 13 o u t o f t h e 20 m o t h e r s and f a t h e r s had o b t a i n e d e d u c a t i o n a l l e v e l s b e y o n d t h i s l e v e l . S i x m o t h e r s and s e v e n f a t h e r s were g r a d u a t e s f r o m a community c o l l e g e o r a u n i v e r s i t y . W i t h r e g a r d t o t h e c o u p l e s ' o c c u p a t i o n s i n f o u r c a s e s b o t h p a r e n t s were e m p l o y e d f u l l t i m e ; and, i n s i x c a s e s , o n l y t h e f a t h e r s were employed. I t was n o t -i c e d t h a t i n one o f t h e c o u p l e ' s s i t u a t i o n t h e mother was e m p l o y e d p a r t - t i m e . S i x m o t h e r s and none o f t h e f a t h e r s r e p o r t e d t h a t t h e y were homemakers. A l l o f t h e o t h e r c o u p l e s were i n v o l v e d i n p r o f e s s i o n a l , t e c h n i c a l and b u s i n e s s o c c u p a t i o n s . The p r e s c h o o l c h i l d r e n w i t h asthma. S i g n i f i c a n t d a t a p o r -t r a y i n g t h e 10 c o u p l e s ' p r e s c h o o l c h i l d r e n a r e summarized i n t h e f o l l o w i n g d e s c r i p t i o n and i n T a b l e 3 (p. 3 6 ) . The c h i l d r e n ' s a g e s r a n g e d f r o m 3 t o 5 y e a r s and t h e i r mean age was 4.2 y e a r s . T h e r e were more b o y s t h a n g i r l s (2.3 t o 1) w i t h asthma i n t h i s s t u d y . The a v e r a g e s i z e o f t h e f a m i l i e s was two c h i l d r e n p e r f a m i l y , and i n s i x f a m i l i e s t h e c h i l d r e n w i t h asthma were t h e f i r s t - b o r n . I n one f a m i l y , t h e c h i l d w i t h asthma was a d i z y g o t i c t w i n . On a v e r a g e t h e c o u p l e s had two c h i l d r e n p e r f a m i l y , w i t h t h e e l d e s t c h i l d h a v i n g asthma. \ Table 3 Demographic Data D e s c r i b i n g the P r e s c h o o l C h i l d r e n w i t h Asthma Number as s i g n e d to the couple C h i l d ' s age (years) Sex P o s i t i o n i n the f a m i l y Number of c h i l d r e n i n the f a m i l y 1 5 M 1 2 2 3 M 3 3 3 3 M 1 2 4 5 F 1 1 5 3 M 1 (Twin) 2 6 5 M 2 3 7 4 M 2 2 8 4 F 1 2 9 5 F 2 2 10 5 M 1 2 N = 10 Mean = 4.2 R a t i o 2.3:1 Mean = 2.1 The Help P r o v i d e d by the Couples In the f o l l o w i n g d e s c r i p t i o n , the couples' verbatim communi-c a t i o n s of the ways they p e r c e i v e d themselves to be h e l p f u l to the p r e s c h o o l c h i l d r e n w i t h asthma w i l l be presented. The couples r e p o r t e d ways they h e l p e d ( h e l p i n g behaviours) t h e i r asthmatic p r e s c h o o l . c h i l d r e n on a d a i l y b a s i s and d u r i n g the c h i l d r e n ' s acute asthmatic a t t a c k s . Abundant data were obtained from the c o u p l e s ' f r e e and open responses to the i n v e s t i g a t o r ' s q u e s t i o n s . The audiotapes o f the i n t e r v i e w s were t r a n s c r i b e d , c a t e g o r i z e d , and v a l i d a t e d as o u t l i n e d i n Chapter I I I . A summary of the c o u p l e s ' r e p o r t e d h e l p i n g behaviours are made e x p l i c i t i n T a b l e 4 (p. 38) and the d e t a i l e d a n a l y s i s o f the i n t e r v i e w s f o l l o w s . The c o u p l e s ' h e l p i n g behaviours are d e s c r i b e d under each o f the c h i l d ' s b a s i c human needs. Need: to breathe. The 10 couples r e p o r t e d t h a t they helped t h e i r p r e s c h o o l c h i l d r e n w i t h asthma breathe i n two major ways: they p r o v i d e d t h e i r c h i l d r e n w i t h treatments, and managed to con-t r o l the f a c t o r s t h a t t r i g g e r e d t h e i r c h i l d r e n ' s asthma. Treatment was d e f i n e d i n Chapter I as p r e s c r i b e d actions, a p h y s i c i a n or o t h e r h e a l t h care p r o f e s s i o n a l have d i r e c t e d par-e n t s to take t o prevent or c o n t r o l the c h i l d ' s asthmatic a t t a c k s . The couples r e p o r t e d t h a t they p r o v i d e d two treatments to help t h e i r c h i l d r e n breathe. F i r s t l y , they a d m i n i s t e r e d medications. That i s , a l l couples s t a t e d t h a t they gave t h e i r c h i l d r e n p r e s c r i b e d medica-t i o n s such as b r o n c h o d i l a t o r s , o r a l l y , v i a an i n h a l e r or subcu-taneous i n j e c t i o n s . Seven couples gave t h e i r c h i l d r e n medica-t i o n s on a d a i l y b a s i s . Three o t h e r couples gave t h e i r c h i l d r e n the b r o n c h o d i l a t o r s when they f e l t t h e i r c h i l d r e n r e q u i r e d the drug to help them breathe. Some sample statements made by the p a r e n t s were: "We g i v e him medications every day t o c o n t r o l the coughing and the wheezing," "As soon as she s t a r t s wheezing we g i v e her Somophyllin and Alupent," or " J . gets h i s medications b e f o r e we go to grandmother's house where there are animals." When the couples thought the medications they gave t h e i r c h i l d r e n were not e f f e c t i v e , they took t h e i r c h i l d r e n f o r f u r t h e r h e l p and c o n s u l t e d a p h y s i c i a n . Tab le 4 The C o u p l e s ' H e l p i n g Behav iou rs D u r i n g an a s t h m a t i c C h i l d ' s need C o u p l e s ' h e l p i n g b e h a v i o u r s D a i l y a t t a c k To b r e a t h e To e a t and d r i n k To e l i m i n a t e waste p r o d u c t s To have a b a l a n c e between r e s t and a c t i v i t y To be s a f e and secure To f e e l l o v e d To have sensory s a t i s f a c t i o n To have a sense o f accompl ishment To d e v e l o p s e l f - r e s p e c t P r o v i d e s t r e a t m e n t such a s : 1 .1 a d m i n i s t e r s m e d i c a t i o n s 1.2 p e r f o r m s c h e s t t h e r a p y C o n t r o l s f a c t o r s t r i g g e r i n g a s t h m a t i c a t t a c k s i n c l u d i n g : 2 . 1 e n v i r o n m e n t a l a l l e r g e n s 2 .2 e m o t i o n a l s t a t e s 2 .3 e x e r c i s e 2.4 r e s p i r a t o r y i n f e c t i o n s P r e p a r e s n u t r i t i o u s meals and snacks Urges adequate i n t a k e o f f ood and f l u i d s P r o v i d e s a s s i s t a n c e t o p r a c t i s e : 1.1 c l e a n l i n e s s • 1.2 t o i l e t h a b i t s E n f o r c e s r e s t / s l e e p r o u t i n e s Promotes a c t i v i t y 1 . P repares c h i l d f o r s e p a r a t i o n and s t r a n g e e x p e r i e n c e s 2. S u p e r v i s e s d a i l y a c t i v i t i e s 1 . Expresses r e c i p r o c a l a f f e c t i o n 1 . P r o v i d e s o p p o r t u n i t i e s f o r sensory s a t i s f a c t i o n 2 . I n t e r a c t s w i t h t h e c h i l d 1 . Teaches t h e c h i l d i n r e l a t i o n t o : 1 .1 b r e a t h i n g e a s i e r 1.2 p e r f o r m i n g a c t i v i t i e s o f d a i l y l i v i n g 1.3 p r a c t i s i n g s a f e t y r u l e s 2 . P r o v i d e s o p p o r t u n i t i e s t o make d e c i s i o n s 1 . P r a i s e s 2 . Shows c o n s i d e r a t i o n 3. Se ts l i m i t s x X X X X x x x x X X X X x x x x X x X X X X X X X X X X X X X N o t e . " x " r e f e r s t o a g e n e r a l consensus o f t h e c o u p l e s ' responses In a d d i t i o n , a l l couples performed chest t h e r a p i e s ; t h a t i s , they performed those a c t s p r e s c r i b e d by a h e a l t h p r o f e s s i o n a l which promote drainage o f b r o n c h i a l s e c r e t i o n s and e a s i e r r e s p i r -a t i o n s . These were done d u r i n g and a f t e r t h e i r c h i l d r e n ' s a s t h -matic a t t a c k s . Some s t a t e d examples o f therapy i n c l u d e d : "I put h i s body over my knee upside down and p a t h i s back over h i s lungs," or "We ask her to take deep b r e a t h s , " o r "We prop him up on p i l l o w s . " Secondly, the couples performed a c t s which c o n t r o l l e d e n v i -ronmental a l l e r g e n s , emotional s t a t e s , e x e r c i s e , and r e s p i r a t o r y i n f e c t i o n s , a l l examples o f f a c t o r s which p r e c i p i t a t e d or aggra-vated t h e i r c h i l d r e n ' s asthmatic c o n d i t i o n . The couples t r i e d to prevent t h e i r c h i l d r e n ' s exposure t o a l l e r g e n s t h a t t r i g g e r e d an asthma a t t a c k . For example, they p r a c t i s e d dust avoidance procedures such as frequent washing of t h e i r c h i l d r e n ' s bedroom w a l l s , f l o o r , and a c c e s s o r i e s . Some parents t o l d o f pur c h a s i n g e l e c t r o n i c a i r c l e a n e r s , and water beds f o r the c h i l d r e n to help c o n t r o l t h e i r exposure t o dust. One couple s t a t e d : "We put i n an e l e c t r o n i c a i r c l e a n e r , and had our furnace's a i r ducts cleaned. . . . The bedroom gets washed down once a day." In a d d i t i o n , some parents prevented t h e i r c h i l d r e n from i n h a l i n g a l l e r g e n s such as p o l l e n s and animal dander. One mother v o i c e d t h i s statement: "We a v o i d t h i n g s such as c a t s , dogs, and horses because she i s a l l e r g i c t o them." Another f a t h e r r e c a l l e d how they avoided walking through the t a l l grasses and weeds i n the summer. One couple o f a s m a l l boy spoke about c e r t a i n c r i t i -c a l i n g r e d i e n t s i n foods which r e s u l t e d i n t h e i r c h i l d e x p e r i e n c -i n g a severe asthmatic a t t a c k : "We are very s t r i c t about h i s d i e t , and i n f a c t we s e l e c t h i s food c a r e f u l l y and prepare most o f h i s food." The couples t r i e d to l i m i t the c i g a r e t t e smoking i n t h e i r homes to prevent the c h i l d from having an asthmatic a t t a c k ; o n l y two f a t h e r s s t a t e d they smoked at home but not i n the same room as t h e i r asthmatic c h i l d r e n . A l l of the couples r e p o r t e d t h a t they allowed smoking i n t h e i r homes; however, they added t h a t i t was an " i n f r e q u e n t " o c c u r r e n c e . Four couples d e s c r i b e d how they would t r y to calm t h e i r c h i l d r e n t o prevent them from having an asthma a t t a c k . One couple s a i d t h a t they gave t h e i r c h i l d a "warm bath," and another couple sang and t a l k e d q u i e t l y t o t h e i r c h i l d . Seven couples d e s c r i b e d how a c t i v e p l a y and e x e r c i s e t r i g -gered t h e i r c h i l d r e n ' s asthmatic a t t a c k s . These couples t r i e d t o prevent t h e i r c h i l d r e n from wheezing by having t h e i r c h i l d r e n do sedentary a c t i v i t i e s , and r e s t r i c t i n g them from a c t i v e p l a y with o t h e r c h i l d r e n . Some examples were: "We read to her," or "He p l a y s w i t h the r e c o r d p l a y e r , " or "We keep him indoors to p l a y q u i e t l y and without h i s f r i e n d s . " S i x couples d i s c u s s e d t h e i r methods of p r e v e n t i n g r e s p i r a -t o r y i n f e c t i o n s because they f e l t t h e i r c h i l d r e n ' s asthmatic a t t a c k s were t r i g g e r e d by a " c o l d . " These couples recounted t h a t they avoided o t h e r s who had " c o l d s , " d r essed t h e i r c h i l d r e n warmly on c o o l days, and p r a c t i s e d c l e a n l i n e s s r o u t i n e s . Need: to eat and d r i n k . The couples i n t e r v i e w e d d e s c r i b e d two ways they helped t h e i r p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r need f o r n u t r i t i o n and f l u i d b alance. The parents r e p o r t e d t h a t they prepared t h e i r c h i l d r e n ' s food and urged t h e i r c h i l d r e n t o i n g e s t adequate amounts of food and f l u i d s . A l l the parents emphasized t h a t t h e i r f a m i l i e s ate "good" foods. Some couples avoided prepared or convenience foods and made t h e i r c h i l d r e n ' s meals from b a s i c i n g r e d i e n t s . For exam-p l e , one of the mothers s t a t e d : "We make a l l h i s food and ad-j u s t h i s d i e t due t o h i s a l l e r g i e s . " Most of the couples had meals prepared a t r e g u l a r times; they r e p o r t e d : "We have three meals a day." When t h e i r c h i l d r e n were i l l w i th asthma, the parents d i d not prepare them meals as they normally would but encouraged t h e i r c h i l d r e n to d r i n k f l u i d s . S i x of the couples s t a t e d t h a t they encouraged t h e i r c h i l d r e n to eat t h e i r meals and d r i n k f l u i d s . A l l ten of the parents e n t i c e d t h e i r c h i l d r e n to d r i n k more f l u i d s d u r i n g the c h i l d r e n ' s asthmatic a t t a c k s . A common comment was: "We persuade him to d r i n k l o t s of f l u i d s when he's s i c k with asthma." In f a c t , two couples w i t h 3-year-old c h i l d r e n s t a t e d t h a t they d i d not wean t h e i r c h i l d r e n from b o t t l e s because they wanted to ensure the c h i l d r e n drank an adequate amount of f l u i d s . Two parents who were w o r r i e d t h a t t h e i r c h i l d r e n were not i n g e s t i n g s u f f i c i e n t n u t r i e n t s supplemented t h e i r d i e t s w i t h v i t a m i n and m i n e r a l p r e p a r a t i o n s . Need: to e l i m i n a t e waste products. The couples helped t h e i r c h i l d r e n e l i m i n a t e waste products from t h e i r bodies by a s s i s t i n g them to p r a c t i s e hygiene and t o i l e t h a b i t s . The parents guided t h e i r c h i l d r e n t o bathe, wash t h e i r hands, and brush t h e i r t e e t h . E i g h t of the couples r e p o r t e d t h a t t h e i r c h i l d r e n performed most of these h y g i e n i c p r a c t i c e s w i t h minimal s u p e r v i s i o n . One couple f e l t the medication t h e i r c h i l d i n g e s t -ed d a i l y t o p r o v i d e b r o n c h o d i l a t i o n contained a sweetener which 42 c o n t r i b u t e d t o t o o t h decay; t h e r e f o r e , they encouraged her to brush her t e e t h a f t e r t a k i n g the drug. A l l of the couples s t a t e d t h a t they p r o v i d e d t h e i r c h i l d r e n with more a s s i s t a n c e when they were i l l w i t h asthma. The couples a s s i s t e d t h e i r c h i l d r e n w i t h t h e i r t o i l e t h a b i t s s i n c e a l l of the c h i l d r e n had developed daytime t o i l e t h a b i t s . Only three c h i l d r e n had not developed f u l l c o n t r o l at n i g h t and the parents encouraged t h e i r c h i l d r e n t o become c o n t i n e n t by reminding the c h i l d t o go to the t o i l e t , w i t h h o l d i n g f l u i d s a f t e r d i n n e r , and e s t a b l i s h i n g a reward system f o r continence. Need; to have a balance between r e s t and a c t i v i t y . The couples r e p o r t e d they they e n f o r c e d a r o u t i n e of r e s t and s l e e p and promoted a c t i v i t i e s t o help t h e i r p r e s c h o o l c h i l d r e n w i t h asthma develop normally. S i x couples t o l d about t h e i r e f f o r t s to enforce r e s t and s l e e p p a t t e r n s w i t h t h e i r c h i l d r e n t o prevent them from becoming f a t i g u e d . One couple d e s c r i b e d the r o u t i n e w i t h t h e i r 3-year-old c h i l d : "We put him down f o r a nap d a i l y and i n t o bed r e g u l a r l y a t 7:30 or so." Whenever the p r e s c h o o l c h i l d r e n were i l l w i t h asthma the parents t r i e d to a l l e v i a t e t h e i r c h i l d r e n ' s d i s t r e s s before s e t t l i n g them f o r the n i g h t . A l l of the couples r e p o r t e d t h a t they promoted t h e i r c h i l d -ren's p a r t i c i p a t i o n i n p h y s i c a l a c t i v i t i e s . Such a c t i v i t i e s i n -cluded o r g a n i z e d r e c r e a t i o n a l programs and p l a y w i t h the f a m i l y members and the c h i l d r e n ' s f r i e n d s . Some examples were swimming, dancing, gymnastics, s o c c e r , and s k a t i n g . Nine couples spoke about having walks i n parks, b o a t i n g , and a l l o w i n g t h e i r c h i l d r e n t o p l a y f r e e l y outdoors w i t h t h e i r f r i e n d s and s i b l i n g s . However, 43 the parents r e s t r i c t e d t h e i r c h i l d r e n ' s a c t i v i t i e s when they began developing asthmatic symptoms. One couple s t a t e d : "When J . i s wheezy we l i m i t him and make him r e s t . Sometimes we s i t down with him and do a p u z z l e . " Need: to f e e l s a f e and secure. A l l of the couples helped t h e i r c h i l d r e n f e e l safe and secure by such t h i n g s as p r e p a r i n g them f o r f u t u r e events and s u p e r v i s i n g t h e i r a c t i v i t i e s . The couples t o l d t h e i r c h i l d r e n about p o t e n t i a l s e p a r a t i o n s from t h e i r f a m i l i e s and experiences they had not encountered b e f o r e . For example, the parents t o l d t h e i r c h i l d r e n when they were l e a v i n g them, and where they were going. In a d d i t i o n , the couples emphasized t h a t they would o n l y leave t h e i r c h i l d r e n with competent s u b s t i t u t e c a r e t a k e r s such as some c l o s e r e l a t i v e s or a nurse. Three couples r e p o r t e d t h a t they informed t h e i r c h i l d r e n about experiences i n v o l v i n g medical appointments, hos-p i t a l i z a t i o n s , and e d u c a t i o n a l encounters. In two cases, the parents stayed with t h e i r c h i l d r e n u n t i l they became ad j u s t e d to a new s i t u a t i o n , such as p l a y - s c h o o l or h o s p i t a l i z a t i o n . E i g h t couples r e p o r t e d f e e l i n g t h a t they had to oversee t h e i r c h i l d r e n ' s a c t i v i t i e s t o p r o t e c t them from being exposed to dangers to and t r i g g e r s f o r t h e i r c h i l d r e n ' s asthma a t t a c k s . Some of the c o u p l e s ' comments i n c l u d e d : "We do not leave him; we take him w i t h us," and, "When he wheezes we don't leave h i s s i d e . " A l l of the couples p r o t e c t e d t h e i r c h i l d r e n from other dangers such as roads and t r a f f i c and taught them s a f e t y r u l e s . The couples t o l d and demonstrated to t h e i r c h i l d r e n about s a f e t y around the home and outdoors. Ten of the couples s t a t e d they mainly taught t h e i r c h i l d r e n about t r a f f i c s a f e t y : "We t a l k to 44 P. about the dangers of the s t r e e t and how to c r o s s the road." Some couples f e l t t h a t t h e i r c h i l d r e n now only r e q u i r e d reminding about s a f e t y r u l e s . One parent expressed a concern about t e a c h i n g her c h i l d about t a k i n g medications s a f e l y . Need: to f e e l l o ved. To help t h e i r c h i l d r e n f e e l loved, the couples s a i d they expressed a f f e c t i o n f o r them and p r o v i d e d t h e i r c h i l d r e n w i t h s p e c i a l a t t e n t i o n when they were i l l w i t h asthma. A l l of the couples r e p o r t e d t h a t when they sensed t h e i r c h i l d r e n needed a t t e n t i o n and l o v i n g they responded to t h e i r c h i l d r e n w i t h a f f e c t i o n . The parents demonstrate t h e i r a f f e c t i o n i n a v a r i e t y of ways: "We g i v e her a l o t of c u d d l i n g , " or "As we walk along we h o l d h i s hand," or "We l i k e j u s t being near him," or "We speak k i n d l y to her," or "He s i t s on my knee a l o t . " A l l of the couples spoke of i n c r e a s i n g the amount of a f f e c t i o n when t h e i r c h i l d r e n became i l l w i th asthma. For example, one couple s t a t e d t h a t t h e i r c h i l d spent most of h i s time w i t h them when he was wheezing. He would be cuddled i n t h e i r bed at n i g h t or be rocked to s l e e p on a parent's knee. Need: to f e e l sensory s a t i s f a c t i o n . A l l of the couples p e r c e i v e d t h a t they helped t h e i r c h i l d r e n meet t h e i r needs f o r sensory s a t i s f a c t i o n by i n t e r a c t i n g w i t h t h e i r c h i l d r e n and pro-v i d i n g o p p o r t u n i t i e s f o r them to use t h e i r senses. A l l of the couples spent time t a l k i n g o r p l a y i n g t o enhance sensory s t i m u l a -t i o n with t h e i r c h i l d r e n . Some parents read to t h e i r c h i l d r e n and others" p l a y e d music. One couple went f o r walks w i t h t h e i r c h i l d t o p o i n t out the d i f f e r e n t c o l o u r s and sounds i n the e n v i r -onment. Nine of the couples commented t h a t they spent time t a l k i n g w i t h t h e i r c h i l d r e n and answering t h e i r q u e s t i o n s . A l l 45 of the couples promoted o p p o r t u n i t i e s f o r t h e i r c h i l d r e n to use t h e i r senses by the p r o v i s i o n of m a t e r i a l s and resources f o r them such as books, r e c o r d p l a y e r s , paper, crayons, and other appro-p r i a t e p l a y equipment. E i g h t of the couples s t a t e d they were ca u t i o u s not to expose t h e i r c h i l d r e n t o p o t e n t i a l t r i g g e r s of t h e i r c h i l d r e n ' s asthma when they s e l e c t e d p l a y m a t e r i a l s . S i x couples arranged f o r t h e i r c h i l d r e n t o a t t e n d a s p e c i a l a c t i v i t y such as " p l a y - s c h o o l " or "music l e s s o n s " to f a c i l i t a t e the c h i l -dren's development. Since c e r t a i n f a c t o r s i n the a l t e r n a t e environments c o u l d p o t e n t i a l l y t r i g g e r the c h i l d r e n ' s asthma, the parents s t a t e d t h a t they would give the c h i l d r e n t h e i r medi-c a t i o n s before such events to prevent the c h i l d r e n from having asthmatic a t t a c k s . For example, "We gi v e him h i s medications before he goes on a walk or attends p l a y - s c h o o l . " Need: to have a sense of accomplishment. The parents taught t h e i r c h i l d r e n how to perform c e r t a i n a c t i o n s to help them f e e l a sense of accomplishment. A l l of the couples taught t h e i r c h i l d r e n e i t h e r to breathe e a s i e r , perform a c t i v i t i e s of d a i l y l i v i n g , or t o p r a c t i s e s a f e t y r u l e s . Three of the parents r e p o r t e d t h a t t h e i r c h i l d r e n had developed s u f f i c i e n t s k i l l s i n some of these areas t o be independent and were allowed to make d e c i s i o n s f o r themselves. The parents t o l d o r showed t h e i r c h i l d r e n to breathe slower, to r e l a x , to a v o i d s p e c i f i c a l l e r g e n s , and to take t h e i r medica-t i o n s c o r r e c t l y as p r e s c r i b e d . A l l of the couples i n s t r u c t e d t h e i r c h i l d r e n t o perform a c t i v i t i e s such as bath i n g , washing t h e i r hands and f a c e , d r e s s i n g , e a t i n g , and performing simple household d u t i e s such as d r y i n g d i s h e s o r washing t h e i r own bedroom f u r n i t u r e . Three c h i l d r e n had l e a r n e d these tasks and r e q u i r e d only a reminder from t h e i r p a r e n t s . Need: to develop s e l f - r e s p e c t . A l l the couples p r a i s e d , c o n s i d e r e d , and s e t l i m i t s f o r t h e i r c h i l d r e n to help them develop s e l f - r e s p e c t . A l l of the couples s t a t e d t h a t they p r a i s e d t h e i r c h i l d r e n f r e q u e n t l y f o r doing tasks f o r o t h e r s . One couple t o l d how they gave approval a c c o r d i n g to the s p e c i f i c t h i n g t h e i r c h i l d d i d ; f o r example, they gave s p e c i f i c rewards t h a t the c h i l d s e l e c t e d . Four of the couples expressed how they p r o v i d e d r e s p e c t and c o n s i d e r a t i o n f o r t h e i r c h i l d r e n as an i n d i v i d u a l . For example, the parents allowed t h e i r c h i l d r e n to s e l e c t t h e i r p l a y , c l o t h i n g , and t e l l about t h e i r experiences and f e e l i n g s . Two of the couples d i s c u s s e d how they l i s t e n e d to t h e i r c h i l d r e n t e l l about t h e i r h o s p i t a l e x p e r i e n c e s . To help t h e i r c h i l d r e n understand p a r e n t a l e x p e c t a t i o n s , three couples s t a t e d t h a t they s e t and maintained l i m i t s f o r t h e i r c h i l d r e n . These l i m i t s i n c l u d e d a wide range of behaviours from avoidance of known a l l e r g e n s to t a b l e manners. Couples d e s c r i b e d how they managed t h e i r c h i l d r e n ' s behaviours such as t a l k i n g w i t h t h e i r c h i l d , or t h r e a t e n i n g the c h i l d i f they d i d not comply. I f the c h i l d r e n v i o l a t e d the l i m i t s the parents s t a t e d they would r e s o r t t o screaming, i g n o r i n g , i s o l a t i n g , or spanking t h e i r c h i l d r e n . In a d d i t i o n t o the couples' d e s c r i p t i o n of t h e i r own behaviours of h e l p i n g t h e i r p r e s c h o o l c h i l d r e n meet t h e i r b a s i c human needs, they r e p o r t e d a d d i t i o n a l t asks to care f o r t h e i r asthmatic c h i l d r e n . The Impact of Asthma and I t s Treatment The couples r e p o r t e d three ways t h a t asthma and i t s t r e a t -ment a f f e c t e d t h e i r e f f o r t s t o pro v i d e care f o r t h e i r asthmatic c h i l d r e n . The parents' e f f o r t s were a f f e c t e d by a d d i t i o n a l d e c i s i o n s t h a t had to be made r e g a r d i n g t h e i r c h i l d r e n ' s h e a l t h needs, e x t r a p h y s i c a l demands r e q u i r e d to care f o r c h i l d r e n w i t h asthma, and emotional upheavals e s p e c i a l l y d u r i n g the c h i l d r e n ' s asthmatic a t t a c k s . The c h i l d r e n ' s asthmatic a t t a c k s imposed medical t r e a t -ments, c l i n i c and h o s p i t a l v i s i t s , c o s t s f o r drugs, e n v i r o n -mental c o n t r o l a i d s , and b e h a v i o u r a l r e s t r i c t i o n s t h a t l i m i t e d the asthmatic c h i l d r e n . E i g h t couples who had been c a r i n g f o r t h e i r asthmatic c h i l d r e n d u r i n g t h e i r a t t a c k s at n i g h t r e p o r t e d e x p e r i e n c i n g f a t i g u e and worry. They cared f o r t h e i r asthmatic c h i l d r e n a t home u n t i l the c h i l d r e n d i d not respond t o the medical treatment, and then they r e s o r t e d t o h o s p i t a l i z a t i o n . In two cases, the couples continued c a r i n g f o r t h e i r asthmatic c h i l d r e n i n the h o s p i t a l . They r e p o r t e d t h a t t h i s d i s r u p t e d t h e i r f a m i l y r o u t i n e s . In f a c t , the couples d e f i n e d asthma as a b r e a t h i n g problem which a f f e c t e d t h e i r f a m i l i e s ' and c h i l d r e n ' s l i v e s . A l l of the couples emphasized t h a t they attempted to "normalize" t h e i r f a m i l y l i f e by performing a d d i t i o n a l tasks to care f o r t h e i r p r e s c h o o l c h i l d r e n w i t h asthma. F i v e of the couples expressed f e e l i n g " scared," "panicky," and "sad" whenever t h e i r c h i l d r e n had an asthma a t t a c k . They were concerned t h a t t h e i r c h i l d r e n would not be able t o breathe and e v e n t u a l l y choke to death. T h i s data supports the f i n d i n g s r e p o r t e d i n p r e v i o u s s t u d i e s c i t e d i n Chapter I I . The couples' d e s c r i p t i o n s i n d i c a t e d t h a t they performed a d d i t i o n a l p h y s i c a l 48 tasks and made d e c i s i o n s i n e f f o r t s t o normalize t h e i r f a m i l i e s ' l i v e s , and experienced emotional upheavals i n r e l a t i o n to t h e i r c h i l d r e n ' s asthma and i t s treatment. T h i s chapter has presented the data from i n t e r v i e w s w i t h 10 couples of p r e s c h o o l c h i l d r e n with asthma. The couples d e s c r i b e d 17 ways of h e l p i n g t h e i r p r e s c h o o l c h i l d r e n with asthma to meet t h e i r b a s i c human needs. The couples r e v e a l e d t h a t the help they p r o v i d e d the asthmatic c h i l d r e n were a f f e c t e d by emotional upheavals, p h y s i c a l demands, and d e c i s i o n s i n c a r i n g f o r t h e i r c h i l d r e n . In the next chapter, these f i n d i n g s w i l l be d i s c u s s e d i n r e l a t i o n t o t h e i r s i g n i f i c a n c e t o the s e l e c t e d t h e o r e t i c a l framework and n u r s i n g care. CHAPTER V D i s c u s s i o n of the F i n d i n g s The primary purpose of t h i s study was to p r o v i d e a d e s c r i p -t i o n of parents' a c t i o n s d i r e c t e d toward h e l p i n g p r e s c h o o l c h i l d -ren w i t h asthma meet t h e i r b a s i c human needs, w i t h an o b j e c t i v e of adding to knowledge which i s u s e f u l t o nurses. The f i n d i n g s of the study presented i n the l a s t chapter appears t o support the t h e o r e t i c a l p o s i t i o n t h a t parents a s s i s t t h e i r c h i l d r e n , s i c k or w e l l , t o meet needs f o r optimal growth and development (Havighurst, 1972, p. 77; Horowitz, Hughes, & Perdue, 1982, p. 79; P r i n g l e , 1974, p. 59). In t h i s chapter, the major f i n d i n g s of the study and the i m p l i c a t i o n s f o r n u r s i n g w i l l be d i s c u s s e d i n r e l a t i o n to the developmental t a s k s of parents r e a r i n g p r e s c h o o l c h i l d r e n w i t h asthma, as p r e v i o u s l y o u t l i n e d i n Chapter I I . Tasks of Parents Rearing P r e s c h o o l C h i l d r e n  with Asthma and Nursing I m p l i c a t i o n s A c c o r d i n g t o developmental and n u r s i n g t h e o r i s t s , parents r e a r i n g p r e s c h o o l c h i l d r e n have s e v e r a l tasks to assume ( D u v a l l , 1977, pp. 258-268; Hymovich & Chamberlain, 1980, pp. 266-269). These i n c l u d e t a s k s r e q u i r e d f o r the care of p r e s c h o o l c h i l d r e n p l u s a d d i t i o n a l ones e s s e n t i a l f o r the care of c h i l d r e n w i t h c h r o n i c d i s e a s e s such as asthma. The d i s c u s s i o n of the f i n d i n g s w i l l r e l a t e to the tasks as presented i n Chapter I I . One of the major t a s k s undertaken by parents r e a r i n g p r e -s c h o o l c h i l d r e n i s t o a s s i s t t h e i r c h i l d r e n i n developing auto-nomy and independence. To he l p p r e s c h o o l c h i l d r e n develop auto-nomy, the parents l e a r n t o separate from t h e i r c h i l d r e n , teach 50 them to make d e c i s i o n s and thus l o s e some c o n t r o l over them (D u v a l l , 1977, p. 255; Hymovich and Chamberlain, 1980, p. 266). L i k e most pare n t s , the couples i n t h i s study r e p o r t e d t h a t they encouraged t h e i r c h i l d r e n t o become independent and develop a sense of accomplishment, p a r t i c u l a r l y i n developing h a b i t s of t o i l e t i n g , c l e a n l i n e s s , bedtime r o u t i n e s , s a f e t y , and d r e s s i n g a p p r o p r i a t e l y . A l l of the parents encouraged t h e i r c h i l d r e n to make some d e c i s i o n s about t h e i r d a i l y care p a r t i c u l a r l y i n d r e s s -i n g , going to the bathroom, s e l e c t i n g p l a y a c t i v i t i e s , and choosing c e r t a i n foods. The couples tended to use methods of t e a c h i n g , reminding, and p r o v i d i n g o p p o r t u n i t i e s f o r the c h i l d r e n t o become autonomous. However, when the c h i l d r e n had asthmatic a t t a c k s , the couples allowed more dependency, d i d more f o r t h e i r c h i l d r e n , centered t h e i r a t t e n t i o n on the i l l c h i l d r e n , and stayed w i t h t h e i r c h i l d r e n d u r i n g the a t t a c k . Even a f t e r the asthma a t t a c k s , the couples were r e l u c t a n t to leave t h e i r c h i l d -ren w i t h others u n l e s s they had t r a i n e d s u b s t i t u t e s . Thus, the frequency and d u r a t i o n of the c h i l d r e n s ' asthmatic a t t a c k s c o u l d p o t e n t i a l l y a f f e c t the couples' a b i l i t y to promote t h e i r p r e s c h o o l c h i l d r e n s ' development of autonomy and achievement of the couples' own developmental t a s k s . Parents who assume t h i s o v e r l y p r o t e c t i v e p a t t e r n may have a d e l e t e r i o u s impact on the behaviour of t h e i r asthmatic c h i l d r e n . P s y c h o l o g i c a l s t u d i e s i n d i c a t e t h a t asthmatic c h i l d r e n may become f e a r f u l , r e g r e s s e d , r e b e l l i o u s , p h y s i c a l l y i n a c t i v e , or l a c k s e l f - c o n f i d e n c e i n r e l a t i o n to the parents' p r o t e c t i v e behaviours (Mattsson, 1975, p. 82). As a r e s u l t , i t i s necessary to i d e n t i f y the asthmatic c h i l d and par-ents a t r i s k f o r untoward developmental problems. The h e a l t h 51 care approach i n c l u d e s e a r l y d i a g n o s i s , e f f e c t i v e treatment, r e g u l a r follow-up, and e d u c a t i o n a l and s u p p o r t i v e programs t o promote growth and development of p r e s c h o o l c h i l d r e n who have asthma. T h i s approach r e q u i r e s the e x p e r t i s e of the h e a l t h team members such as nurses, n u t r i t i o n i s t s , pharmacists, p h y s i c i a n s , p h y s i o t h e r a p i s t s , and p s y c h o l o g i s t s (Dolovich and Hargreave, 1981, p. 1038; Dyer, 1977, p. 20; Mattsson, 1975, p. 8 7 ) . Nurses p a r t i c i p a t e as c o l l a b o r a t e members of the h e a l t h team p r o v i d i n g t e a c h i n g , and c o u n s e l l i n g t o the parents of p r e s c h o o l asthmatic c h i l d r e n . The outcome of the team's e f f o r t s are to reduce the r i s k of o v e r p r o t e c t i o n of p r e s c h o o l asthmatic c h i l d r e n and to f a c i l i t a t e t h e i r growth and development. The couples i n t h i s study s e t l i m i t s f o r t h e i r p r e s c h o o l c h i l d r e n c o n cerning s a f e t y , behaviours i n v o l v i n g d a i l y r o u t i n e s , and i n t e r a c t i o n s with o t h e r s . However, when the c h i l d r e n were i l l w i t h asthma the coupl e s ' e f f o r t s t o s e t l i m i t s seemed i n c o n -s i s t e n t . A c c o r d i n g t o c e r t a i n authors, l i m i t s must be c o n s i s t e n t f o r s u c c e s s f u l b e h a v i o u r a l compliances (Hersey & Blanchard, 1978, p. 70; Horowitz, Hughes, and Perdue, 1982, p. 92). In t h i s study, parents s e t a d d i t i o n a l l i m i t s to prevent the c h i l d r e n from having asthmatic a t t a c k s , by r e s t r i c t i n g a c t i v i t i e s . Yet, o v e r l y r i g o r o u s l i m i t s e t t i n g may thwart the c h i l d and c r e a t e n e g a t i v e s e l f - e s t e e m and r e s i s t a n c e t o a u t h o r i t y (Hersey & Blanchard, 1978, p. 94; Horowitz, Hughes, and Perdue, 1982, p. 93). There-f o r e , parents of p r e s c h o o l asthmatic c h i l d r e n , whether the c h i l d -ren are i l l or w e l l , may need guidance r e g a r d i n g c o n s i s t e n t and a p p r o p r i a t e ' l i m i t s e t t i n g . Nurses may encounter asthmatic c h i l d -ren i n c l i n i c a l s e t t i n g s or the community wi t h such behaviours. 52 A p p r o p r i a t e p a r e n t a l e d u c a t i o n and c o u n s e l l i n g a r e two p o s s i b l e ways t o i n t e r v e n e (Hymovich, 1976, p. 1 1 ) . The c o u p l e s s t a t e d t h e y p r a i s e d o r r e w a r d e d t h e i r c h i l d r e n d a i l y f o r p e r f o r m i n g o r b e h a v i n g a p p r o p r i a t e l y i n t h e i r d a i l y l i v e s . One c o u p l e u s e d b e h a v i o u r a l m o d i f i c a t i o n t e c h n i q u e s t o t r a i n t h e c h i l d t o c o n t r o l h i s b e d - w e t t i n g b e h a v i o u r . P r a i s i n g t h e i r c h i l d r e n was t h e most commonly u s e d t e c h n i q u e by t h e c o u p l e s i n t h i s s t u d y . T h i s a p p r o a c h i s c o n s i s t e n t w i t h t h a t a t t r i b u t e d t o e d u c a t e d , m i d d l e - c l a s s p a r e n t s ( B r o n f e n b r e n n e r , 1966, p. 3 6 2 ) . In t h i s s t u d y t h e c o u p l e s d e s c r i b e d t h e u s e o f p u n i s h m e n t s s u c h as t h r e a t s , s c r e a m i n g , i g n o r i n g , i s o l a t i n g , and s p a n k i n g t h e i r c h i l d r e n when t h e y m i s b e h a v e d . P u n i s h m e n t o r n e g a t i v e r e i n f o r c e -ment i s i n t e n d e d t o d e c r e a s e o r e r a d i c a t e b e h a v i o u r t h a t i s u n -d e s i r a b l e o r d a n g e r o u s . However, H o r o w i t z , Hughes and P e r d u e i n d i c a t e t h a t c o e r c i v e power o f p a r e n t s and t h r e a t s o f p u n i s h m e n t r a t h e r t h a n r e w a r d s may p r o d u c e a d d i t i o n a l c h i l d h o o d d e p e n d e n c y , l a c k o f i n i t i a t i v e , a n d r e s e n t m e n t o f t h e c h i l d r e n t o w a r d t h e i r p a r e n t s . E f f e c t i v e d i s c i p l i n e i s most l i k e l y a c h i e v e d when p a r -e n t s u s e r e w a r d s , p u n i s h m e n t , a n d i g n o r i n g a p p r o a c h e s i n a p p r o -p r i a t e s i t u a t i o n s . S u c c e s s f u l outcomes f r o m d i s c i p l i n a r y s i t u -a t i o n s a r e l i k e l y t o i n c r e a s e t h e c h i l d r e n s 1 s e n s e o f s e l f w o r t h and m a t u r i t y (1982, p. 131 and 1 9 6 ) . I t i s a p p a r e n t t h e c o u p l e s i n t h i s s t u d y u s e d e a c h o f t h e a p p r o a c h e s t o manage t h e b e h a v i o u r o f t h e i r p r e s c h o o l c h i l d r e n . T h i s i n f o r m a t i o n a p p e a r s t o be v a l u a b l e f o r n u r s e s c a r i n g f o r f a m i l i e s w i t h a s t h m a t i c c h i l d r e n . I t a p p e a r s t h a t i n f o r m a t i o n a b o u t t h e p a r e n t s ' e x -p e c t a t i o n s o f t h e i r c h i l d r e n s ' b e h a v i o u r and ways t h e p a r e n t s a c h i e v e t h e a c c e p t a b l e b e h a v i o u r be c o n s i d e r e d i n t h e n u r s i n g 53 h i s t o r y . A p p r o p r i a t e n u r s i n g i n t e r v e n t i o n s may i n c l u d e s p e c i f i c p a r e n t a l c o u n s e l l i n g and t e a c h i n g , depending upon the observed c h i l d r e n s ' behaviours and data o b t a i n e d i n the n u r s i n g h i s t o r y . The couples s t a t e d t h a t they p r o v i d e d a f f e c t i o n t o t h e i r c h i l d r e n i n a v a r i e t y of ways such as hugging, h o l d i n g hands, or s m i l i n g . Sharing of a f f e c t i o n i s an important aspect of the p a r e n t - c h i l d r e l a t i o n s h i p s ( D u v a l l , 1977, pp. 164-175). Sears, Macoby, and L e v i n (1957) r e p o r t e d t h a t parents who used p r a i s e o f t e n were warm and a f f e c t i o n a t e with t h e i r c h i l d r e n and t h e i r c h i l d r e n tended to become s e l f - r e l i a n t , content, and r e l a t i v e l y f r e e from problem behaviours. However, i n t h i s study when the p r e s c h o o l c h i l d r e n had an asthmatic a t t a c k the parents s t a t e d they i n c r e a s e d the amount of a f f e c t i o n and a t t e n t i o n t h e i r c h i l d -ren r e c e i v e d . In g e n e r a l , i t i s normal f o r parents to comfort t h e i r c h i l d r e n when they are i l l but c h r o n i c a l l y i l l c h i l d r e n having r e c u r r e n t asthmatic a t t a c k s become the focus i n the f a m i l y f o r a t t e n t i o n and a f f e c t i o n . The p a t t e r n r e c u r s each time a c h i l d develops asthma ( N o r r i s h , Tooley, & Godfrey, 1977, p. 917). I f t h i s p a t t e r n c o n t i n u e s , e v e n t u a l l y the c h i l d r e n w i t h asthma may develop b e h a v i o u r a l problems and d i s r u p t i o n s i n f a m i l y l i f e ensue (Minuchen, Baker, Rosman, Liebman, Milman, & Todd, 19 75, p. 1033). I d e n t i f y i n g a f f e c t i o n a l r e l a t i o n s h i p s w i t h i n f a m i l i e s with p r e s c h o o l c h i l d r e n w i t h r e c u r r i n g asthma appears to be a s i g n i f i c a n t n u r s i n g i n t e r v e n t i o n . E a r l y i d e n t i f i c a t i o n of a f f e c t i o n a l problems w i t h i n the f a m i l y w i t h a p p r o p r i a t e therapy may prevent d i s r u p t i o n s i n f a m i l y l i f e (Minuchen, Baker, Rosman, Liebman, Milman, & Todd, 1975, p. 1038). The couples l i s t e n e d and responded t o t h e i r c h i l d r e n s ' 54 e f f o r t s t o communicate. The c h i l d r e n would seek a f f e c t i o n , sensory s a t i s f a c t i o n , achievement, a c t i v i t y , r e s t , or food. Couples a l s o l i s t e n e d t o t h e i r c h i l d r e n ' s r e s p i r a t i o n s or f o r a cough which was a s i g n a l f o r the parent to p r o v i d e s p e c i a l care or t r e a t t h e i r c h i l d r e n who may be having an asthmatic a t t a c k . T h i s f i n d i n g supports the o b s e r v a t i o n noted by T r a v i s (19 76) t h a t parents l i s t e n e d c a r e f u l l y f o r t h e i r asthmatic c h i l d r e n ' s b r e a t h i n g b e f o r e p l a n n i n g t h e i r approaches to care f o r t h e i r c h i l d r e n . T h i s data r e f l e c t s the couples i n t h i s study l e a r n e d to l i s t e n t o the p r e s c h o o l c h i l d r e n ' s s i g n a l of wheezing or coughing to determine t h e i r c h i l d r e n ' s need to breathe. Since some p r e s c h o o l c h i l d r e n are p r e v e r b a l , t h i s seems to be an a p p r o p r i a t e way f o r parents to i d e n t i f y t h e i r c h i l d r e n s ' a b i l i t y to meet t h i s need. These o b s e r v a t i o n s appear to support the importance of nurses t o i n c l u d e i n the n u r s i n g h i s t o r y ways pr e -school c h i l d r e n communicate t h e i r needs, p a r t i c u l a r l y about t h e i r symptoms. Furthermore, parents f r e q u e n t l y are a v a l u a b l e resource f o r t h i s i n f o r m a t i o n . The couples i n t h i s study f a c i l i t a t e d the emotional express-ions of t h e i r c h i l d r e n by t a k i n g time to l i s t e n to t h e i r c h i l d -ren d u r i n g q u i e t or meal times d u r i n g the day or a f t e r t h e i r c h i l d r e n had a s t r e s s f u l experience such as h o s p i t a l i z a t i o n . In a d d i t i o n , the couples prepared t h e i r c h i l d r e n f o r l i f e events such as s e p a r a t i o n s and h o s p i t a l i z a t i o n s by t a l k i n g w i t h t h e i r c h i l d r e n , t e l l i n g s t o r i e s , a n d through p l a y a c t i v i t i e s . T h i s i s p a r t i c u l a r l y s i g n i f i c a n t to p r e s c h o o l c h i l d r e n s i n c e they have l i m i t e d emotional coping a b i l i t i e s and an u n p r e d i c t a b l e , a r b i t r a r y view of the world which perpetuates an atmosphere of 55 an x i e t y surrounding t h e i r i l l n e s s and medical procedures. I t i s necessary f o r the parents to be s u p p o r t i v e , understanding, and l o v i n g , y e t be able to b o l s t e r the c h i l d ' s sense of mastery and arrange f o r compensatory experiences ( S p e r l i n g , 1978, p. 58). For example, some couples would p l a n s p e c i a l experiences f o r t h e i r c h i l d r e n t o compensate from being i s o l a t e d due to i l l n e s s or environmental r e s t r i c t i o n s . Other couples taught t h e i r c h i l d -ren how to ga i n mastery by coping w i t h the symptoms of asthma by t a k i n g the c o r r e c t medications, r e l a x i n g , and r e s t i n g . T h i s i n f o r m a t i o n seems to support t h a t parents r e q u i r e knowledge and s k i l l s c oncerning c h i l d r e n s ' growth and development, c h i l d h o o d asthma and i t s treatment, and coping with c h r o n i c i l l n e s s e s . Nurses may c o n s i d e r these as content areas f o r a program f o r parents of p r e s c h o o l asthmatic c h i l d r e n . In t h i s study the couples a s s i s t e d t h e i r c h i l d r e n to under-stand and cope wi t h t h e i r i l l n e s s . They taught t h e i r c h i l d r e n about asthma and i t s treatment. They t r i e d t o help t h e i r c h i l d -ren r e l a x and stay calm by such methods as s i n g i n g to t h e i r c h i l d r e n or t e l l i n g t h e i r c h i l d r e n s t o r i e s . R e l a x a t i o n and b r e a t h i n g e x e r c i s e s a s s i s t c h i l d r e n to stay calm d u r i n g an a s t h -matic a t t a c k and use t h e i r chest muscles e f f e c t i v e l y (Keens, 1979, pp. 520-521). One couple used another chest therapy d e s c r i b e d as p o s t u r i z i n g and pummelling, which i s used i f c l e a r i n g of the a i r -ways of mucus i s r e q u i r e d ( A r k i n s t a l l , 1976, pp. 6-7; Tse, 1979, pp. 7-10). A l l of the couples i n t h i s study a d m i n i s t e r e d medica-t i o n s ( b r o n c h o d i l a t o r s ) t o t h e i r c h i l d r e n as p r e s c r i b e d . Medica-t i o n therapy i s c o n s i d e r e d the major treatment f o r c h i l d r e n w i t h asthma i n c l u d i n g drugs which are used t o prevent and c o n t r o l asthmatic a t t a c k s ( A r k i n s t a l l , 1980, pp. 8-9; Tse, 1979, pp. 7-10). I t i s thought t h a t r e c u r r i n g a t t a c k s of asthma i n c h i l d -hood may be a r e s u l t of inadequate drug therapy ( N o r r i s h , Tooley, and Godfrey, 1977, p. 917). Parents r e q u i r e understanding and s k i l l s c oncerning the i n d i v i d u a l i z e d t h e r a p e u t i c regime and ways to a s s i s t t h e i r p r e s c h o o l c h i l d r e n t o f o l l o w the regime t o p r e -vent r e c u r r i n g asthmatic a t t a c k s . Nurses may i n c l u d e items i n a n u r s i n g h i s t o r y t o i d e n t i f y the ways parents s p e c i f i c a l l y h e l p t h e i r c h i l d r e n cope. Nursing i n t e r v e n t i o n s i n c l u d e parent educ-a t i o n , c o u n s e l l i n g , and a p p r o p r i a t e r e f e r r a l s to other h e a l t h team members f o r comprehensive c a r e . The couples r e p o r t e d the importance of p r o t e c t i n g t h e i r c h i l d r e n from harm by t e a c h i n g them about environmental dangers and o b s e r v i n g and s u p e r v i s i n g t h e i r c h i l d r e n ' s behaviour. They r o l e - m o d e l l e d a p p r o p r i a t e behaviours and r e p e a t e d l y d i s c u s s e d s a f e t y p r e c a u t i o n s i n the home and on the roads w i t h t h e i r c h i l d -ren. One couple v o i c e d t h e i r concerns about the s a f e t y of the medications ( b r o n c h o d i l a t o r s ) f o r t h e i r asthmatic c h i l d . T h i s concern of parents has been r e p o r t e d i n other s t u d i e s which were c i t e d i n Chapter I I . I t i s an important f i n d i n g and i t may suggest t h a t p arents r e q u i r e a d d i t i o n a l knowledge about the c h i l d r e n s ' t h e r a p i e s such as the m e d i c a t i o n s . T h e r e f o r e , i t appears t h a t nurses ought to i n c l u d e a c c i d e n t p r e v e n t i o n and medication e d u c a t i o n i n programs f o r parents of p r e s c h o o l asthmatic c h i l d r e n . The couples i n t h i s study were p a r t i c u l a r l y concerned about the h e a l t h and i n t e g r i t y of t h e i r asthmatic c h i l d r e n ; f o r example, they c a r e f u l l y prepared n u t r i t i o u s foods f o r t h e i r c h i l d r e n and 57 encouraged them to eat i t . Furthermore, they made s p e c i a l e f f o r t s t o p r o t e c t t h e i r c h i l d r e n from " c o l d s " which f r e q u e n t l y t r i g g e r e d t h e i r c h i l d r e n ' s asthmatic a t t a c k s . These f i n d i n g s support Burton's (1975) o b s e r v a t i o n s about parents r e a r i n g c h i l d r e n w i t h another c h r o n i c d i s e a s e , c y s t i c f i b r o s i s . She found some of the parents a c t i v e l y performed p r e v e n t i v e h e a l t h measures. I t was f e l t t h a t the p a r e n t s ' involvement i n the care of t h e i r c h i l d r e n m o b i l i z e d t h e i r hope, decreased f e e l i n g s of g u i l t , and i n c r e a s e d t h e i r s e l f - e s t e e m . These f i n d i n g s are r e l e v a n t t o nurses. They have the o p p o r t u n i t y to a c t i v e l y support parents through h o s p i t a l and community programs. In summary, the f i n d i n g s i n t h i s study were d e s c r i p t i v e of parents' a c t i o n s which were d i r e c t e d toward h e l p i n g t h e i r p r e -school c h i l d r e n w i t h asthma grow and develop. The couples r e p o r t e d how they helped t h e i r p r e s c h o o l c h i l d r e n become auto-nomous, have i n i t i a t i v e , and a p o s i t i v e s e l f - i m a g e . They d e s c r i b e d how they a s s i s t e d t h e i r c h i l d r e n t o f e e l l o v e d and conform to the demands of s o c i e t y . Furthermore, the couples helped t h e i r c h i l d r e n develop h e a l t h f u l r o u t i n e s such as e a t i n g , r e s t i n g , and p l a y i n g . The f i n d i n g s of t h i s study i n d i c a t e d t h a t the couples i n t h i s study not o n l y performed p a r e n t a l tasks to r e a r p r e s c h o o l c h i l d r e n as d e f i n e d by D u v a l l (1977), but assumed a d d i t i o n a l t a s k s as d e s c r i b e d by Hymovich (19 76) a s s o c i a t e d w i t h t h e i r c h i l d r e n ' s c h r o n i c d i s e a s e . These a d d i t i o n a l tasks i n c l u d e d p r e v e n t i o n of the asthmatic a t t a c k s , a d m i n i s t r a t i o n of treatments when the c h i l d r e n r e q u i r e d the therapy, and t e a c h i n g t h e i r c h i l d r e n about t h e i r d i s e a s e and i t s treatment. The p r e s c h o o l c h i l d r e n ' s asthmatic a t t a c k s appeared t o i n f l u e n c e these parents t o : (a) enhance t h e i r a f f e c t i o n a l responses with t h e i r i l l c h i l d r e n , (b) withdraw from l i m i t - s e t t i n g , (c) r e s t r i c t the a c t i v i t y f o r t h e i r c h i l d -ren, (d) encourage a f l u i d d i e t , and (e) perform t h e r a p i e s t o help t h e i r c h i l d r e n breathe. The i n f o r m a t i o n a c q u i r e d i n t h i s study appears to be s i g n i f i c a n t f o r nurses c a r i n g f o r f a m i l i e s with p r e s c h o o l asthmatic c h i l d r e n . I t was suggested t h a t the knowledge be used i n n u r s i n g assessments and i n t e r v e n t i o n s with such f a m i l i e s r e a r i n g c h r o n i c a l l y i l l c h i l d r e n . The use of the developmental approach and UBC Model f o r Nursing seemed t o be an a p p r o p r i a t e way to guide t h i s r e s e a r c h because the couples d e s c r i b e d t h e i r h e l p f u l a c t i o n s r e l a t e d to t h e i r p r e s c h o o l c h i l d r e n ' s b a s i c human needs and adundant data r e s u l t e d which appears t o have enhanced n u r s i n g knowledge. Furthermore, the f i n d i n g s support the p r e v i o u s r e s e a r c h r e s u l t s by Crummette (1979), Reddihough e t a l (1977), and T r a v i s , (1976) . In t h i s chapter, the s i g n i f i c a n t f i n d i n g s of the study were d i s c u s s e d as w e l l as the i m p l i c a t i o n s of the f i n d i n g s f o r n u r s i n g . The next chapter w i l l p r o v i d e recommendations d e r i v e d from the study and a summary of the r e s e a r c h . CHAPTER VI Recommendations and Summary T h i s chapter w i l l p resent recommendations f o r n u r s i n g and f u r t h e r r e s e a r c h . A summary of the study w i l l conclude t h i s r e s e a r c h r e p o r t . Recommendations f o r Nursing P r a c t i s e 1. One of the tasks of the parents r e a r i n g c h r o n i c a l l y i l l c h i l d r e n i s to understand and manage t h e i r c h i l d r e n ' s i l l * - , ness; t h e r e f o r e , the parents r e q u i r e the necessary knowledge, s k i l l s and a t t i t u d e s to perform the tasks adequately. Con-sequently, i t i s recommended t h a t nurses p a r t i c i p a t e w i t h a h e a l t h team i n p r o v i d i n g v a l i d and c u r r e n t e d u c a t i o n a l programs, a p p r o p r i a t e c o u n s e l l i n g , and resources f o r parents of p r e s c h o o l c h i l d r e n with asthma about growth and development, the d i s e a s e , and i t s treatment. 2. Parents r e a r i n g c h i l d r e n w i t h c h r o n i c i l l n e s s e s l i k e asthma are eager to share t h e i r concerns, and knowledge w i t h others l i k e nurses. T h i s data seems to be v a l u a b l e i n p r o v i d i n g i n s i g h t i n t o the dynamics of f a m i l i e s and t h e i r a b i l i t y t o cope wit h t h e i r c h i l d r e n s ' asthma. The parents have a d d i t i o n a l tasks to perform which i n v o l v e the knowledge and s k i l l s of h e a l t h p r o f e s s i o n a l s . Thus, i t i s recommended t h a t nurses f a c i l i t a t e the development of parent-support groups which would have the p o t e n t i a l of promoting ways t h a t they c o u l d c o o p e r a t i v e l y h e l p each other i n the care of t h e i r c h i l d r e n w i t h asthma. 3. The Inte r v i e w Guide used i n t h i s study p r o v i d e d abun-dant,and u s e f u l i n f o r m a t i o n f o r nurses and other p r o f e s s i o n a l s about the ways parents helped t h e i r p r e s c h o o l c h i l d r e n w i t h asthma grow and develop. T h e r e f o r e , i t i s recommended t h a t the Interview Guide be adapted and used as an assessment guide f o r parents of p r e s c h o o l asthmatic c h i l d r e n . Recommendations f o r Nursing Research 1. The s u b j e c t s i n t h i s study were not a r e p r e s e n t a t i v e sample of parents of p r e s c h o o l c h i l d r e n w i t h asthma. However, t h i s study and the others c i t e d i n Chapter I I have p r o v i d e d v a l u a b l e and u s e f u l i n f o r m a t i o n about f a m i l i e s of asthmatic c h i l d r e n . Thus i t i s recommended t h a t f u r t h e r r e s e a r c h be implemented which would use a l a r g e r , r e p r e s e n t a t i v e sample. 2. The Interview Guide i n a s e m i - s t r u c t u r e d form d i d pro-v i d e a way to gather abundant r e l e v a n t data which was d e s c r i p t i v e of the parent's p e r c e p t i o n s of t h e i r behaviours. A p p l i c a t i o n s of the Interview Guide i n other r e s e a r c h would enhance i t s v a l i d -a t i o n and r e l i a b i l i t y . T h e r e f o r e , i t i s recommended t h a t the Interview Guide be r e f i n e d and m o d i f i e d f o r use i n f u r t h e r des-c r i p t i v e s t u d i e s . M o d i f i c a t i o n s of the Guide are suggested f o r use w i t h parents of other age groups of c h i l d r e n such as a d o l e s -ce n t s , and h e a l t h problems such as c y s t i c f i b r o s i s . Summary Parents assume the major r e s p o n s i b i l i t y f o r p r o v i d i n g care f o r t h e i r c h i l d r e n , s i c k or w e l l , u n t i l they r e a c h m a t u r i t y . T h i s study was developed t o pr o v i d e i n f o r m a t i o n f o r nurses about pa r e n t s ' behaviours which h e l p c h i l d r e n w i t h asthma meet t h e i r needs t o grow and develop. The r e s e a r c h problem was addressed by a s k i n g two q u e s t i o n s : 1. What are the parents'" p e r c e p t i o n s of the ways they help p r e s c h o o l c h i l d r e n w i t h asthma meet t h e i r b a s i c human needs? 2. What are the parents' p e r c e p t i o n s of the ways asthma and i t s treatment a f f e c t s t h e i r e f f o r t s t o provide care t o t h e i r c h i l d r e n w i t h asthma? The approach t o the r e s e a r c h q u e s t i o n s was to i n t e r v i e w 10 couples of p r e s c h o o l c h i l d r e n with asthma u s i n g a s e m i - s t r u c t u r e d Interview Guide developed from the UBC Model f o r Nursing. The par e n t s ' names were obtained through p e d i a t r i c a l l e r g i s t c l i n i c s and f o l l o w i n g an e t h i c a l p r o t o c o l the parents were co n t a c t e d to p a r t i c i p a t e i n the r e s e a r c h . Ten w i l l i n g parents were i n t e r -viewed while being audiotaped. The content of the i n t e r v i e w s were analyzed and the parents' h e l p i n g behaviours were c a t e g o r -i z e d a c c o r d i n g to b a s i c human needs. The f i n d i n g s were d i s c u s s e d i n r e l a t i o n t o developmental tasks of parents r e a r i n g p r e s c h o o l c h i l d r e n w i t h a c h r o n i c d i s e a s e of asthma. From the f i n d i n g s , the 10 couples d e s c r i b e d 17 h e l p i n g behaviours t h a t were i n t e n d -ed t o a s s i s t p r e s c h o o l c h i l d r e n with asthma meet t h e i r needs to grow and develop. The couples r e p o r t e d t h a t the c h i l d r e n ' s asthma and i t s treatment s i g n i f i c a n t l y a f f e c t e d the help they p r o v i d e d t h e i r c h i l d r e n i n three ways: emotional, p h y s i c a l , and i n t e l l e c t u a l . Nurses, t h e r e f o r e , are encouraged t o teach, coun-s e l and support parents i n t h e i r e f f o r t s t o help t h e i r c h i l d r e n w i t h asthma to grow and develop. R e f e r e n c e s A n t h o n y , E. J . P r o g n o s i s f o r p a r e n t h o o d . I n S. D o n i a d e s ( E d . ) , The c h i l d i n t h e w o r l d o f tomorrow. T o r o n t o : Pergamon P r e s s 1979. A n t h o n y , E . J . , and Benedek, T. P a r e n t h o o d : I t s p s y c h o l o g y and  p s y c h o p a t h o l o g y . B o s t o n : L i t t l e , Brown & Co., 1970. A r k i n s t a l l , W. W. What i s i t ? Asthma. Y o u r H e a l t h , W i n t e r 1976, 3-6. A r k i n s t a l l , W. W. 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The spectrum of asthma i n c h i l d r e n . P e d i a t r i c C l i n i c s of North America, 1975, 22, 43-52. W i l l i a m s , J . Aspects of dependence-independence c o n f l i c t i n c h i l d r e n with asthma. J o u r n a l of C h i l d Psychology and  P s y c h i a t r y and A l l i e d D i s c i p l i n e s , 1975, 16_, 199-218. 70 APPENDIX A S e l e c t e d Assumptions from  The UBC Model of Nursing The UBC Model f o r Nursing i s based on theory and assumptions. The assumptions which are p a r t i c u l a r l y r e l e v a n t to t h i s study i n c l u d e those r e l a t i n g to man, man as a b e h a v i o u r a l system, and n u r s i n g . Assumptions about Man 1. Man has b a s i c human needs which he experiences as t e n s i o n s . 2. Man c o n s t a n t l y s t r i v e s to s a t i s f y each b a s i c human need by u s i n g a range of coping behaviours. 3. Man c o n s t a n t l y seeks harmony and balance as he s t r i v e s t o s a t i s f y m u l t i p l e and c o - e x i s t i n g needs. 4. Man's coping behaviours are organized i n t o r e p e t i t i v e , p r e d i c t a b l e p a t t e r n s which become h i s c h a r a c t e r i s t i c way of meeting h i s needs. 5. Development of man's coping behaviours i s dependent upon h i s growth, maturation, and l i f e e xperience. 6. When man encounters a c r i t i c a l p e r i o d i n h i s l i f e c y c l e , h i s r e p e r t o i r e of coping behaviours may not al l o w him to s a t i s f y one or more of h i s needs. 7. When coping behaviours do not permit s a t i s f a c t i o n of b a s i c human needs man experiences a t h r e a t t o h i s s u r v i v a l or growth. Assumptions about Man as a B e h a v i o u r a l System 1. Man may be viewed as a b e h a v i o u r a l system made up of nine subsystems. 71 2. Each subsystem i s r e s p o n s i b l e f o r the s a t i s f a c t i o n of one b a s i c human need. 3. Each subsystem may be viewed as a l i f e space. 4. The s t r u c t u r e of each subsystem c o n s i s t s of two p a r t s : a) an i n n e r - p e r s o n a l r e g i o n r e p r e s e n t i n g a b a s i c human need and a b i l i t i e s to meet t h a t need, b) a p s y c h o l o g i c a l environment r e p r e s e n t i n g the n e e d - s a t i s f y i n g g o a l and the f o r c e s i n f l u e n c i n g i t s attainment. 5. The f u n c t i o n of each subsystem i s to achieve i t s s p e c i f i c g o a l through the f o l l o w i n g b e h a v i o u r a l p r o c e s s : a) p e r c e p t i o n of the need t o be met by the subsystem, b) r e c o g n i t i o n of need, g o a l , a b i l i t i e s and f o r c e s , c) p l a n n i n g ( s e l e c t i n g p o s s i b l e a l t e r n a t i v e s ) t o achieve the g o a l , d) a c t i o n d i r e c t e d toward g o a l achievement. 6. Each subsystem i s i n t e r a c t i n g and interdependent w i t h every other subsystem. 7. The subsystems are i n a balanced r e l a t i o n s h i p w i t h each other and the system i s i n a balanced r e l a t i o n s h i p w i t h i t s environment. (Behavioural system b a l a n c e ) . 8. B e h a v i o u r a l system balance (steady s t a t e ) i s maintained by feedback mechanisms o p e r a t i n g w i t h i n the system and between the system and the environment. 9. Each subsystem has the p o t e n t i a l t o develop a b i l i t i e s . 10. The b e h a v i o u r a l system has the p o t e n t i a l f o r growth through the o r d e r l y p r o g r e s s i o n of maturation w i t h i n each sub-system. 72 11. The b e h a v i o u r a l system i s c o n s t a n t l y e x p e r i e n c i n g t e n s i o n s a r i s i n g from i n t e r n a l and e x t e r n a l sources. 12. The b e h a v i o u r a l system uses t e n s i o n - r e d u c i n g responses to make both i n t e r n a l adjustments and ada p t a t i o n s t o the environment. 13. M a t u r a t i o n i n f l u e n c e s the t e n s i o n - r e d u c i n g responses used at any given time. 14. When t e n s i o n - r e d u c i n g responses are inadequate t o maintain b e h a v i o u r a l system balance, imbalance r e s u l t s . B e l i e f s about Nursing and i t s P r a c t i c e 1. Nursing i s a member of the team of h e a l t h p r o f e s s i o n s whose u l t i m a t e g o a l i s the op t i m a l h e a l t h of man. 2. Nursing's unique f u n c t i o n i s to nu r t u r e man d u r i n g c r i t i c a l p e r i o d s of h i s l i f e c y c l e so t h a t he may develop and u t i l i z e a range of coping behaviours which permit him to s a t i s f y h i s b a s i c human needs and thereby move toward o p t i m a l h e a l t h . 3. The n u r t u r i n g o f man d u r i n g the c r i t i c a l p e r i o d s of h i s l i f e c y c l e makes a s i g n i f i c a n t d i f f e r e n c e to the way he copes wi t h these p e r i o d s . Reference Campbell, M., C r u i s e , M., and Murakami, R. A model f o r n u r s i n g : U n i v e r s i t y of B r i t i s h Columbia School of Nursing, Nursing  Papers, 1976, 8_, 5-6. APPENDIX B Developmental Tasks of  P r e s c h o o l C h i l d r e n 1. S e t t l i n g i n t o h e a l t h y d a i l y r o u t i n e s o f r e s t and a c t i v -i t y : Going t o bed and g e t t i n g h i s needed r e s t without a s t r u g g l e Taking h i s nap or r e s t , and l e a r n i n g to r e l a x when he i s weary E n j o y i n g a c t i v e p l a y i n a v a r i e t y of s i t u a t i o n s and p l a c e s Becoming i n c r e a s i n g l y f l e x i b l e and able to accept changes 2. M a s t e r i n g good e a t i n g h a b i t s : Becoming adequate i n the use o f the customary u t e n s i l s f o r e a t i n g A c c e p t i n g new f l a v o r s and t e x t u r e s i n foods w i t h i n t e r e s t E n j o y i n g h i s food w i t h l e s s e n i n g i n c i d e n t s of s p i l l i n g , messing, and t o y i n g Learning the s o c i a l as w e l l as the sensual p l e a s u r e s of e a t i n g 3. Mastering the b a s i c s o f t o i l e t t r a i n i n g : Growing i n h i s a b i l i t y t o i n d i c a t e h i s needs f o r e l i m i n a t i o n Cooperating comfortably i n the t o i l e t t r a i n i n g program F i n d i n g s a t i s f a c t i o n i n behaving a p p r o p r i a t e l y as t o time, p l a c e , and ways of t o i l e t i n g expected of b o y s / g i r l s of h i s age Becoming f l e x i b l e i n h i s a b i l i t y t o use the v a r i e t y of r e s o u r c e s , p l a c e s , and personnel a v a i l a b l e t o him 4. Developing the p h y s i c a l s k i l l s a p p r o p r i a t e to h i s stage o f motor development: L e a r n i n g t o climb, balance, run, s k i p , push, p u l l , throw, and c a t c h i n whole-body use of l a r g e muscle systems Developing manual s k i l l s f o r b u t t o n i n g , z i p p i n g , c u t t i n g , draw-i n g , c o l o r i n g , modeling, and m a n i p u l a t i n g s m a l l o b j e c t s d e f t l y 74 Becoming i n c r e a s i n g l y independent i n h i s a b i l i t y t o handle him-s e l f e f f e c t i v e l y i n a v a r i e t y o f p h y s i c a l s i t u a t i o n s 5. Becoming a p a r t i c i p a t i n g member of h i s f a m i l y : Assuming r e s p o n s i b i l i t i e s w i t h i n the f a m i l y h a p p i l y and e f f e c -t i v e l y L e a r n i n g to g i v e and r e c e i v e a f f e c t i o n and g i f t s f r e e l y w i t h i n the f a m i l y I d e n t i f y i n g with parent of the same sex Developing a b i l i t y t o share h i s parents with another c h i l d and w i t h o t h e r s g e n e r a l l y Recognizing h i s f a m i l y ' s ways as compared w i t h those o f h i s f r i e n d s and neighbors 6. Beginning t o master h i s impulses and to conform to o t h e r s ' e x p e c t a t i o n s : Outgrowing the i m p u l s i v e , urgent o u t b u r s t s of i n f a n c y L e a r n i n g t o share, take t u r n s , h o l d h i s own, and enjoy the com-panionship o f other c h i l d r e n — a n d a t times t o p l a y h a p p i l y alone Developing the sympathetic, c o o p e r a t i v e ways w i t h o t h e r s t h a t ensure h i s i n c l u s i o n i n groups L e a r n i n g a p p r o p r i a t e behaviour f o r s i t u a t i o n s i n which he f i n d s h i m s e l f (times and p l a c e s f o r n o i s e , q u i e t , messing, n u d i t y , e t c . ) 7. Developing h e a l t h y emotional e x p r e s s i o n s f o r a wide v a r -i e t y o f e x p e r i e n c e s : L e a r n i n g t o p l a y out h i s f e e l i n g s , f r u s t r a t i o n s , needs, and experiences L e a r n i n g t o postpone and to wait f o r s a t i s f a c t i o n s E x p r e s s i n g momentary h o s t i l i t y and making up r e a d i l y afterwards 75 R e f i n i n g g e n e r a l i z e d joy or p a i n i n t o d i s c r i m i n a t i n g e x p r e s s i o n s o f p l e a s u r e , eagerness, tenderness, a f f e c t i o n , sympathy, f e a r , a n x i e t y , remorse, sorrow, e t c . 8. L e a r n i n g to communicate e f f e c t i v e l y w i t h an i n c r e a s i n g number of o t h e r s : Developing the vocabulary and a b i l i t y t o t a l k about a r a p i d l y growing number of t h i n g s , f e e l i n g s , experiences, impressions, and c u r i o s i t i e s L e a r n i n g to l i s t e n , take i n , f o l l o w d i r e c t i o n s , i n c r e a s e h i s a t t e n t i o n span, and respond i n t e l l e c t u a l l y to s i t u a t i o n s and to others A c q u i r i n g the s o c i a l s k i l l s needed to get over f e e l i n g s of shy-ness, s e l f - c o n s c i o u s n e s s , and awkwardness, and to p a r t i c i p a t e w i t h o t h e r people comfortably 9. Developing the a b i l i t y to handle p o t e n t i a l l y dangerous s i t u a t i o n s : L e a r n i n g t o r e s p e c t the dangers i n f i r e , t r a f f i c , h i g h p l a c e s , b a t h i n g areas, poisons, animals, and many o t h e r p o t e n t i a l hazards L e a r n i n g to handle h i m s e l f e f f e c t i v e l y without undue f e a r i n s i t -u a t i o n s c a l l i n g f o r c a u t i o n and s a f e t y p r e c a u t i o n s ( c r o s s i n g s t r e e t s , g r e e t i n g strange dogs, responding to a s t r a n g e r ' s o f f e r o f a r i d e , etc.) Becoming w i l l i n g t o accept h e l p i n s i t u a t i o n s t h a t are beyond him without undue dependence or too i m p u l s i v e independence 10. L e a r n i n g to be an autonomous person w i t h i n i t i a t i v e and a conscience of h i s own: Becoming i n c r e a s i n g l y r e s p o n s i b l e f o r making d e c i s i o n s i n ways a p p r o p r i a t e to h i s r e a d i n e s s 76 T a k i n g i n i t i a t i v e f o r p r o j e c t i n g h i m s e l f i n t o s i t u a t i o n s w i t h i n n o v a t i o n s , e x p e r i m e n t s , t r i a l s , and o r i g i n a l a c h i e v e m e n t s I n t e r n a l i z i n g t h e e x p e c t a t i o n s and demands o f h i s f a m i l y and c u l t u r e g r o u p s i n h i s d e v e l o p i n g c o n s c i e n c e B ecoming r e a s o n a b l y s e l f - s u f f i c i e n t i n a v a r i e t y o f s i t u a t i o n s — i n a c c o r d a n c e w i t h h i s own makeup and s t a g e o f d e v e l o p m e n t 11. L a y i n g f o u n d a t i o n s f o r u n d e r s t a n d i n g t h e meanings o f l i f e : B e g i n n i n g t o u n d e r s t a n d t h e o r i g i n s o f l i f e and how t h e two s e x e s d i f f e r ; and t o be aware o f h i s o r h e r g e n d e r T r y i n g t o u n d e r s t a n d t h e n a t u r e o f t h e p h y s i c a l w o r l d — w h a t t h i n g s a r e , how t h e y work and why, and what t h e y mean t o him A c c e p t i n g t h e r e l i g i o u s f a i t h o f h i s p a r e n t s and l e a r n i n g a b o u t t h e n a t u r e o f God and a b o u t t h e s p i r i t u a l n a t u r e o f l i f e . R e f e r e n c e D u v a l l , E. M a r r i a g e and f a m i l y d e v e l o p m e n t ( 5 t h E d . ) . P h i l a d e l p h i a : J . B. L i p p i n c o t t Co., 1977, 244-246. 77 APPENDIX C Interview Guide; How Parents Help The Pr e s c h o o l C h i l d r e n w i t h Asthma Meet T h e i r Needs Date: Code Number: A. Demographic Data. Ask the parents f o r the f o l l o w i n g i n f o r m a t i o n : 1. What i s the p r e s c h o o l c h i l d ' s age? and sex? 2. How many c h i l d r e n are there i n the f a m i l y ? 3. Where does the asthmatic c h i l d come among the c h i l d r e n i n the f a m i l y ? 1st, 2nd, 3rd, 4th, e t c . 4. How many other c h i l d r e n i n the f a m i l y have asthma? 5. What are the pa r e n t s ' ages? a) Mother's age b) F a t h e r ' s age 6. How much formal e d u c a t i o n have the parents had? (Mark "M" f o r mother, and "F" f o r f a t h e r ) a ) . l e s s than 8th grade b ) 8-10th grade c ) l l - 1 2 t h grade d ) - community c o l l e g e o r t e c h n i c a l s c h o o l education e ) u n i v e r s i t y degree f) o t h e r 7. What i s the f a t h e r ' s occupation? 8. What i s the mother's occupation? \ ' 9. How many hours are spent by the parents w i t h the asthma-t i c p r e s c h o o l c h i l d per day? -Father _ ; Mother 78 10. How much time does the asthmatic c h i l d spend i n o t h e r s i t u a t i o n s ? hours per day. 11. Where does the asthmatic p r e s c h o o l c h i l d spend most of h i s / h e r time? 12. Who takes the r e s p o n s i b i l i t y f o r h e l p i n g the asthmatic p r e s c h o o l c h i l d ? a) the mother takes the predominant r o l e b) the f a t h e r takes the predominant r o l e c) the r o l e i s shared by both the f a t h e r and the mother d) o t h e r c a r e t a k e r s 13. Do the parents smoke? a) F a t h e r : Yes , No '. I f yes, how much? , and do you smoke at home? ' Yes, No. b) Mother: Yes , No . I f yes, how much? , and do you smoke at home? Yes, No. c) Do you permit o t h e r s t o smoke i n your home? Yes , No . I f yes, how much? and when? . 14. What does the word asthma mean to the parents? 15. What was the l a s t time the c h i l d had an asthmatic a t t a c k ? ' ' ' 16. What medical treatment i s p r e s c r i b e d f o r the c h i l d ? ' 17. How o f t e n do t h e p a r e n t s t a k e t h e a s t h m a t i c c h i l d t h e d o c t o r f o r m e d i c a l h e l p r e g a r d i n g h i s / h e r asthma? t i m e s p e r month I n t e r v i e w Q u e s t i o n s What do p a r e n t s do t o a s s i s t t h e i r c h i l d t o b r e a t h e ? a) What h e l p do y o u p r o v i d e y o u r c h i l d t o p r e v e n t h i m / h e r f r o m w h e e z i n g ? b) When y o u r c h i l d wheezes, what h e l p do you p r o v i d e t o h e l p y o u r c h i l d b r e a t h e e a s i e r ? What do p a r e n t s do t o h e l p t h e i r c h i l d e a t and d r i n k n o u r i s h i n g and a d e q u a t e f o o d and f l u i d s ? a) What do you do t o h e l p y o u r c h i l d t o e a t and d r i n k n o u r i s h i n g f o o d and f l u i d s ? b) What i m p a c t does asthma and i t s t r e a t m e n t have on y o u r e f f o r t s t o h e l p meet y o u r c h i l d ' s n e e d t o e a t and d r i n k n o u r i s h i n g f o o d and f l u i d s ? What do p a r e n t s do t o h e l p t h e i r c h i l d e l i m i n a t e t h e wa s t e p r o d u c t s f r o m h i s / h e r body? a) What do y o u do t o h e l p y o u r c h i l d d e v e l o p t o i l e t h a b i t s ? b) What do y o u do t o h e l p y o u r c h i l d wash and b a t h e ? c) What do y o u do t o h e l p y o u r c h i l d c a r e f o r h i s / h e r t e e t h ? d) What i m p a c t d o e s asthma and i t s t r e a t m e n t have on y o u r e f f o r t s t o h e l p y o u r c h i l d e l i m i n a t e t h e w a s t e p r o d u c t s f r o m h i s / h e r body? What do p a r e n t s do t o h e l p t h e i r c h i l d t o have a b a l a n c e between r e s t and a c t i v i t y ? a) What do you do to help your c h i l d r e s t and sleep? b) What do you do to help your c h i l d get the e x e r c i s e he/she needs or wants? c) " What impact does asthma and i t s treatment have on your e f f o r t s t o help your c h i l d meet h i s / h e r needs f o r r e s t and a c t i v i t y ? What do parents do to help t h e i r c h i l d p r o t e c t h i m s e l f / h e r s e l f ? a) What do you do to help your c h i l d a v o i d being h u r t o r i n j u r e d ? b) What do you do to help your c h i l d understand he/she has done something wrong? c) What do you do to help your c h i l d f e e l secure? d) What do you do to help your c h i l d a v o i d i n f e c t i o n s ? e) What do you do to pl a n f o r your absence from home? f) What do you do to p l a n f o r your c h i l d ' s absence from home? g) What impact does asthma and i t s treatment have on your e f f o r t s to help p r o t e c t your c h i l d from: i ) emotional s t r e s s and/or i i ) p h y s i c a l s t r e s s ? What do parents do t o h e l p t h e i r c h i l d f e e l loved? a) What do you do to h e l p your c h i l d f e e l loved? b) What impact does asthma and i t s treatment have on your e f f o r t s to help your c h i l d f e e l loved? What do parents do to h e l p t h e i r c h i l d have sensory s a t i s f a c t i o n ? a) What do you do to encourage your c h i l d to use h i s / h e r senses? b) What do you do to h e l p your c h i l d experience s u f f i c i e n t s t i m u l a t i o n ? c) What impact does asthma and i t s treatment have on your e f f o r t s to h e l p your c h i l d f e e l sensory s a t i s f a c t i o n ? What do parents do to help t h e i r c h i l d have a sense of accomplishment? a) What do you do to encourage your c h i l d to do tasks a c c o r d i n g t o the l e v e l of h i s / h e r a b i l i t y ? b) What do you do to encourage your c h i l d to do a c t i v i t i e s independently? c) What do you do to h e l p your c h i l d make d e c i s i o n s a c c o r d i n g to h i s her l e v e l of a b i l i t y ? d) What impact does asthma and i t s treatment have on e f f -o r t s t o help your c h i l d f e e l a sense of accomplishment? What do parents to do to help t h e i r c h i l d develop r e s p e c t f o r h i m s e l f / h e r s e l f ? a) What do you do to help your c h i l d f e e l "good" about h i m s e l f / h e r s e l f ? b) What do you do to help your c h i l d r e c e i v e r e s p e c t from o t h e r s ? c) What do you do to help your c h i l d l e a r n about being a b o y / g i r l ? d) What do you respond to your c h i l d when he/she completes a task? e) What impact does asthma and i t s treatment have on your e f f o r t s t o h e l p your c h i l d f e e l s e l f r e s p e c t ? 82 APPENDIX D L e t t e r to the P h y s i c i a n s Dear As a Master's Student i n Nursing at the U n i v e r s i t y of B r i t i s h Columbia, I need to complete a r e s e a r c h p r o j e c t , to f u l f i l l the requirements of the degree. The r e s e a r c h p r o j e c t I am i n t e r e s t e d i n pursuing i s designed to answer the f o l l o w i n g q u e s t i o n s : 1. What a c t i o n s dp parents take to help t h e i r c h i l d w i t h asthma meet h i s / h e r b a s i c human needs? 2. In what way do parents p e r c e i v e asthma and i t s t r e a t -ment a f f e c t i n g t h e i r e f f o r t s t o help t h e i r c h i l d meet h i s / h e r b a s i c human needs? To o b t a i n data to answer these q u e s t i o n s , I p l a n t o i n t e r -view the parents o f p r e s c h o o l c h i l d r e n . Since many asthmatic c h i l d r e n have a l l e r g i e s , I thought you might be a b l e to help me f i n d p o s s i b l e v o l u n t e e r s f o r the study. Would i t be p o s s i b l e f o r you to p r o v i d e me with names of parents of p r e s c h o o l c h i l d r e n w i t h asthma? You may be assured t h e i r names w i l l be kept con-f i d e n t i a l . The l i s t w i l l be used only by me, and w i l l be des-t r o y e d a f t e r the study i s completed. I b e l i e v e t h a t a b e t t e r understanding of the p a r e n t s ' h e l p i n g behaviours should r e s u l t i n improved n u r s i n g c a r e . I t r u s t you w i l l be a b l e to help me i n g e t t i n g s u b j e c t s f o r my r e s e a r c h . S i n c e r e l y yours, C a r o l M i t c h e l l , B.N. W r i t t e n APPENDIX E Consent from the P h y s i c i a n s 83 TITLE OF THE RESEARCH PROJECT: What Parents Do to Help t h e i r P r e s c h o o l C h i l d with Asthma Meet h i s / h e r B a s i c Human Needs. I grant C a r o l M i t c h e l l p e r m i s s i o n to o b t a i n the f o l l o w i n g i n f o r m a t i o n from my o f f i c e : 1. the names of parents w i t h p r e s c h o o l c h i l d r e n with asthma. 2. the addresses o f the p a r e n t s . 3. the telephone numbers of the p a r e n t s . FROM: DATE: APPENDIX F L e t t e r to the Parents 84 Dear I am a graduate student i n the School of Nursing o f the U n i v e r s i t y o f B r i t i s h Columbia, s t u d y i n g the ways i n which par-ents h e l p t h e i r c h i l d r e n with asthma grow and develop. Dr. has suggested t h a t you may be i n t e r e s t e d i n p a r t i c i p a t i n g i n t h i s study. The purpose of t h i s study i s to l e a r n the ways i n which parents help t h e i r c h i l d with asthma meet h i s / h e r b a s i c human needs; and how asthma and i t s treatment a f f e c t the help parents g i v e t h e i r c h i l d . The r e s u l t s o f the study w i l l b e n e f i t h e a l t h care p r o f e s s i o n a l s by p r o v i d i n g i n f o r m a t i o n f o r use i n c o u n s e l -l i n g and e d u c a t i o n a l programs. Your p a r t i c i p a t i o n would i n v o l v e an i n t e r v i e w w i t h both o f you p r e s e n t . I t w i l l take me approx-i m a t e l y s i x t y minutes t o conduct the i n t e r v i e w . I f i t i s con-v e n i e n t f o r you, we c o u l d meet i n your home. The i n t e r v i e w w i l l be recorded on an audiotape. The tape w i l l be i d e n t i f i e d by a number, and your names w i l l not be asso-c i a t e d with the recorded i n f o r m a t i o n . Only I and my T h e s i s Committee (two f a c u l t y members) w i l l have access to the tapes. At the end o f the study, the tapes w i l l be erased. 85 You would be f r e e t o withdraw from the study a t any time without j e o p a r d i z i n g the medical care of your c h i l d . In one week, a f t e r you have had time to t a l k t h i s over, I w i l l c a l l you f o r your d e c i s i o n about p a r t i c i p a t i n g i n the study. I f you are w i l l i n g t o be i n t e r v i e w e d we can arrange f o r a time t o meet. Thank you f o r c o n s i d e r i n g t h i s r e q u e s t . S i n c e r e l y , C a r o l M i t c h e l l , B.N. 86 APPENDIX G Interview Procedure Read the f o l l o w i n g i n s t r u c t i o n s b e f o r e conducting the i n t e r v i e w : 1. A s s i g n the Demographic Data sheet and audiotapes a code number and f i l l i n the date. 2. E s t a b l i s h a ra p p o r t w i t h the parents and e x p l a i n your r o l e as an i n t e r v i e w e r . 3. Review the contents o f the consent form w i t h the parents and o b t a i n the pa r e n t s ' p e r m i s s i o n to be i n t e r v i e w e d . 4. Ask the parents t o respond t o the q u e s t i o n s as h o n e s t l y and completely as p o s s i b l e . 5. T e l l the parents t h e r e are two p a r t s t o the i n t e r v i e w : a) The f i r s t p a r t of the i n t e r v i e w i s t o o b t a i n f a c t s about the c h i l d and the pa r e n t s . b) The second p a r t of the i n t e r v i e w i s t o o b t a i n the pa r e n t s ' d e s c r i p t i o n s o f what they do t o help t h e i r c h i l d w ith asthma and to o b t a i n t h e i r o p i n i o n s o f how asthma and i t s treatment a f f e c t the way they help t h e i r c h i l d . 6. Ask the parents the qu e s t i o n s on the Demographic Data form. 7. Begin the d i s c u s s i o n by a s k i n g the parents t o t h i n k about what they do t o help t h e i r c h i l d on a d a i l y b a s i s . S t a t e : "During the day you do many t h i n g s t o help your c h i l d . I would l i k e you to t e l l me i n as much d e t a i l as p o s s i b l e what you do to hel p your c h i l d meet h i s / h e r needs to grow and develop. E x p l a i n how your c h i l d ' s asthma and i t s treatment a f f e c t your e f f o r t s t o h e l p your c h i l d meet h i s / h e r needs. For example, how do you help your c h i l d i n the morning?" 8. Use the Interview Guide q u e s t i o n s whenever necessary d i r e c t the i n t e r v i e w . 9. S t a r t the audiotape. 10. Terminate the i n t e r v i e w w i t h the p a r e n t s . 88 APPENDIX H Consent from the Parents Consent f o r P a r t i c i p a t i o n o f Parents i n the Study:  "What Parents Do to Help t h e i r P r e s c h o o l C h i l d  with Asthma Meet His/Her B a s i c Human Needs." We understand t h a t the purpose of t h i s study i s to d e s c r i b e what parents do to h e l p t h e i r p r e s c h o o l c h i l d w i t h asthma grow and develop. We agree to p a r t i c i p a t e i n the study by b e i n g i n t e r v i e w e d by the r e s e a r c h e r about the t o p i c f o r approximately s i x t y minutes. We agree to having the i n t e r v i e w recorded on an audiotape. We agree to permit C a r o l M i t c h e l l t o use the i n f o r m a t i o n we p r o v i d e , whether i t be w r i t t e n or on the tape i n a study f o r a graduate t h e s i s i n Nursing a t the U n i v e r s i t y of B r i t i s h Columbia. I t i s our understanding t h a t the i n f o r m a t i o n w i l l be u s e f u l to the work of h e a l t h p r o f e s s i o n a l s . We understand t h a t we can withdraw from the study at any time o r r e f u s e to answer q u e s t i o n s , without j e o p a r d i z i n g the treatment of our c h i l d . Date: S i g n a t u r e of the P a r e n t s : and 

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