Susan Kools

Dimensional Analysis: Broadening the Conception of Grounded Theory

Dimensional analysis has been proposed by Schatzman as an alternate method for the generation of grounded theory. The intent of this article is to trace the evolution of dimensional analysis and describe it in relation to traditional grounded theory method. Analytic processes that characterize dimensional analysis will be reviewed, and a research exemplar is presented to illustrate the application of the dimensional analysis method.

Adolescent Identity Development in Foster Care.

Adolescent Identity Development in Foster Care* Susan M. Kools** This study examined the impact of long-term foster care on adolescents. Dimensional analysis was used to investigate adolescent perceptions of impact. Foster care was found to have a negative impact on identity development. The institutional structure of group foster care, diminished status, and stereotypical view of the foster child, contribute to devaluation of the adolescents self by others. Suggestions for clinical practice and program development are made to reduce devaluating experiences and promote normative adolescent development. Children and adolescents are growing up in a variety of family constellations today. For a growing number, longterm foster care provides a substitution for the context of their biological families. While originally conceived as a temporary respite for troubled families until reunification could be achieved, it has become increasingly used as a permanent living arrangement for many children. Foster care is defined as residence in a supervised setting outside the biological family as mandated by the social services or juvenile justice system. Foster care placements for children and adolescents include foster family care, group homes, and various forms of residential treatment. Foster care placement is most often precipitated by stressful family circumstances that endanger a child and/or deem the biological parent(s) unable or unavailable to adequately care for the child. These include child abuse and neglect, parental substance abuse, and family homelessness (Barker & Aptekar, 1990; Childrens Defense Fund, 1995; U.S. Congress, 1990a; U.S. Congress, 1990b; White & Benedict, 1985). Nearly 500,000 children are currently in foster care in the United States. If the increases continue, this number could approach 840,000 by the end of the decade (American Public Welfare Association, 1995; U.S. Congress, 1990a). Further, although length of stay in placement can vary widely from days to years, it is becoming typical for a child to spend from several years to the duration of childhood in foster care. Current estimates are that 40% of children remain in foster care for more than 2 years, with an average stay of 5 years (Pothier & Kools, 1992; U.S. Congress, 1990a). Finally, a trajectory characterized by multiple placement transitions is now commonplace for the foster care population. Up to 55% of children in foster care experience 3 or more placements (Byles, 1980; Fanshel & Shinn, 1978; Runyan & Gould, 1985a.1985b). Most theoretical and empirical literature on normative child and adolescent development places the developing child within the context of the family system. In their study of African American adolescents in foster care, Gavazzi, Alfred, and McKenry (1996) noted that there has been little emphasis on the developmental impact of living in an alternate environment like foster care. As the foster care system has rapidly grown, it has come under scrutiny and it has been suggested that growing up in foster care has multiple negative consequences for the child (Halfon, Berkowitz, & Klee, 1992; U.S. Congress, 1990a). While the impact of foster care on overall functioning, development, and wellbeing has yet to be adequately determined, investigators have begun to gather evidence that severe functional impairment is suffered by children in foster care as a group, including poor academic achievement, behavioral and emotional problems, and health-related problems (Frank, 1980; Gil & Bogart, 1982; Halfon, Mendoca, & Berkowitz, 1995; Hochstadt, Jaudes, Zimo, & Schachter, 1987; Klee & Halfon, 1987; Pardeck, 1983; Runyan & Gould, 1985a, 1985b; Simms, 1991; Simms & Halfon, 1994; U.S. Government Accounting Office, 1995). Most of these studies were based on retrospective case record review. Very few researchers have interviewed children in foster care to explore their thoughts and feelings about their status as foster children or their placement experiences. …

Methodological considerations in children's focus groups.

Focus groups are a well-known qualitative approach to gathering data in health science research. The literature on focus groups, however, primarily discusses adults as subjects. Unfortunately, the scant reports of studies using children as participants in focus groups have not described their methods in detail. This article discusses the use of children (age 6–12) in focus groups, and highlights methodological considerations in this approach, with particular attention to the integration of developmental principles. Focus groups with children can capture their perspectives, original ideas, and insights, which are often neglected in more traditional pediatric research. Focus groups can also serve as an innovative approach to understanding children’s experiences from a developmental perspective. Further, focus groups free children and investigator from the data-gathering limitations placed by literacy/reading levels that plague quantitative methods using self-report. By using relatively homogeneous groups, common cultural, emotional, and cognitive processes and responses are revealed that normally would not come to light in structured data collection. Focus groups offer a rich, interactive and developmentally effective approach to planning, content and evaluation in research with children.

Health Risk Behavior of Youth in Foster Care

PROBLEM Many adolescent health problems are predominantly caused by risk behavior. Foster adolescents have disproportionately poor health; therefore, identification of risk behavior is critical. METHOD Data from a larger study were analyzed to investigate the health risk behavior of 56 youth in foster care using the Child Health and Illness Profile-Adolescent Edition. FINDINGS Data indicated that youth in foster care had some increased risk behavior when compared with a normative adolescent population. Younger adolescents and those in relative placement had less risky behavior. Risk behavior was increased for youth in foster care when they were in group homes, had experienced a parental death, or had a history of physical or emotional abuse or attempted suicide. CONCLUSIONS These results point to areas of strength and vulnerability for youth in foster care and suggest areas for clinicians and caregivers of these adolescents to focus interventions towards harm reduction and enhancement of resiliency.

Dancing Around Death Hospitalist–Patient Communication About Serious Illness

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient’s understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

Cultural Competencies for Graduate Nursing Education

Nursing is challenged to meet the health needs of ethnic and socioculturally diverse populations. To this end, American Association of Colleges of Nursing (AACN) charged an expert nursing faculty advisory group to formulate competencies for graduate nursing education, expanding them to integrate leadership and scholarship. The Cultural Competency in Baccalaureate Nursing Education served as the springboard for the initiative. In formulating the graduate cultural competencies and the toolkit, the advisory group reviewed all AACN Essentials documents and the cultural competency literature, drew upon their collective experiences with cultural diversity, and used cultural humility as the supporting framework. Six core competencies were formulated and endorsed by the AACN board of directors and key professional nursing organizations. A companion toolkit was compiled to provide resources for the implementation of the competencies. A 1-day conference was held in California to launch the cultural competencies and toolkit. Dissemination to graduate nursing programs is in process, with emphasis on faculty readiness to undertake this graduate educational transformation. The AACN Cultural Competencies for Graduate Nursing Education set national standards to prepare culturally competent nurses at the graduate level who will contribute to the elimination of health disparities through education, clinical practice, research, scholarship, and policy.

Family Transitions in Congenital Heart Disease Management: The Impact of Hospitalization in Early Adulthood

With advances in medical and surgical management of congenital heart disease (CHD), it is becoming more common for patients to survive into adulthood. This article reviews family management of CHD over the life course of the disease and presents the findings of a study of the psychosocial needs of hospitalized adults with CHD and their families. Thirty-four patients, family members, and nurses were interviewed for their perceptions of the hospital experience. Hospitalization was characterized by differing expectations of care between participant groups, resulting in conflict, tension, and dissatisfaction. This dissonance in care had a negative impact on individual and family transitions in illness management. The data suggest that family-centered standards of nursing practice based on an understanding of both the physical and psychosocial effects of CHD on adults are needed.

Culturally appropriate family assessment: analysis of the Family Assessment Device in a pediatric Chinese population.

As part of a larger study, we investigated the adaptation of the Family Assessment Device (FAD) to a Chinese population of hospitalized children (N = 313) compared to a sample of families with healthy children (N = 29) in Hong Kong and Chinese Mainland. Confirmatory factor analysis and exploratory factor analysis (EFA) were performed to examine the FAD structure. The results supported the notion of cultural variations in measuring family functioning. Eight factors were found to explain 30.34% of the variance in family functioning. The Cronbach’s alphas of families with hospitalized children ranged from 0.29 to 0.74. Similar reliability scores were found in nonhospitalized families. This study indicates that the Chinese FAD has a different factor structure, reliabilities, and mean scores in several subscales compared to U.S. studies. The psychometric properties of the Chinese FAD may be influenced by the fact that the sample was focused on children rather than adults.

Parents’ Refusal of Medical Treatment for Cultural or Religious Beliefs: An Ethnographic Study of Health Care Professionals’ Experiences

Pediatric nurses working in acute care settings serving religious and culturally diverse families may encounter parents whose beliefs influence treatment decisions. Previous literature describes how these complex situations lead to emotional distress and strained relationships between health care provider and family members. An ethnographic study was conducted to investigate the impact of parental treatment refusal on the bedside interactions between pediatric nurses and parents. Twenty in-depth interviews with nurses were conducted, and extensive field notes were taken during data collection. Emotional feelings associated with possible loss of guardianship and subsequent mandated treatment, the impact of the situation on the nurses’ health and stress levels, and functional status were all explored. Three themes were identified following interpretive narrative analysis of transcriptions and field notes: weathering the storm of moral conflict, closeness and involvement versus distance and retreat, and battles between the supportive and oppositional groups. The findings of the study lead to a deeper understanding of the complexities of the ethical dilemma surrounding treatment refusal in pediatrics.

Separation and reunification: The experiences of adolescents living in transnational families

There are increasing numbers of mothers as well as fathers who engage in long-term migration to support their children and other family members in their home countries. In this article, the current state of the literature about children and adolescents left at home in these transnational families is surveyed and reviewed. The article reviews the effects on children of the process of separation from parents, the impact of gifts and remittances home, communication with distant parents and the quality of life with their substitute caregivers. The effects of immigration in late childhood or adolescence on these separated children are examined, as well as what is known about the processes of adaptation and family reunification, including migration traumas, impact of gender, and educational outcomes. Suggestions are given for pediatric clinicians working with reunifying families. Gaps in the literature are highlighted and the need for research into factors that promote successful family re-engagement and overall adaptation upon reunification.