1. No category

Parent/Caregiver Stress During Pediatric
Hospitalization for Chronic Feeding Problems
Adrienne Garro, PhD
S. Kenneth Thurman, PhD
MaryLouise E. Kerwin, PhD
Joseph P. Ducette, PhD
This study examined changes in stress in 37 mothers/caregivers of children with chronic feeding problems. Stress was measured
by the Parenting Stress Index-Short Form at three specific stages during pediatric hospitalization for treatment of chronic feeding
problems. The relationship between caregiver stress and stage of hospitalization as well as that between stress and various child
and family variables were investigated. Repeated-measures analyses of variance and t tests found that stress related to social
isolation and self-perception and total parenting stress changed significantly in relation to the stage of hospitalization.
Correlational analyses indicated that caregiver stress was positively related to the presence of mental retardation, oral – motor
dysfunction, tonal abnormalities, or a pervasive developmental disorder in the hospitalized child. Caregiver stress was
negatively related to coping strategies that involved understanding the child’s medical situation. These results provide a more
comprehensive picture of families of children with chronic feeding problems, a population that has received little attention in
the research literature. Information regarding parent/caregiver stress during a child’s hospitalization can enhance nurses’
understanding of the experiences of these families, thereby contributing to more effective treatment planning. In addition, the
results emphasize the need to examine a variety of child and family factors that may influence parenting stress as well as family
involvement in intervention services.
n 2005 Elsevier Inc. All rights reserved.
HE IMPACT OF pediatric chronic illnesses
and disabilities on families has been well
documented in the research literature. A number of
studies have found increased stress, including
greater parenting stress, in families of children with
various chronic conditions such as asthma, diabetes, and heart disease (Brazil & Krueger, 2002;
Powers et al., 2002; Sparacino, Tong, Messias,
Foote, & Chesla, 1997). Unfortunately, in the
case of pediatric feeding problems, there is relatively little information about stress and family
functioning. This is surprising given the relatively
high prevalence of these problems. Manikam and
T
From the Department of Psychology, Hutchinson Hall, Kean
University, Union, NJ, Temple University, Philadelphia, PA, and
Rowan University, Glassboro, NJ.
Address correspondence and reprint requests to Adrienne
Garro, PhD, Department of Psychology, Hutchinson Hall, Kean
University, 1000 Morris Ave, Union, NJ 07083.
E-mail: [email protected]
0882-5963/$ - see front matter
n 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2005.02.015
268
Perman (2000) reported that up to 25% of all
children present with some form of feeding
problem and that this percentage rises to 80% in
children with developmental disabilities. Pediatric
feeding problems include a number of conditions
that interfere or prevent children from obtaining
adequate food intake and/or appropriate nutrition.
Examples include food refusal, food selectivity,
excessive vomiting, volume limitations, oral–motor
dysfunction, problems advancing food textures,
gastroesophageal reflux, delayed gastric emptying,
and dysphagia (swallowing disorder). Although
many of these problems resolve with minimal
medical intervention, about 3% of cases become
serious and chronic and require hospitalization or
other intensive treatments.
Many of the studies on family functioning in
pediatric feeding problems have focused on
failure to thrive (FTT), a chronic disorder
characterized by arrested physical development
and failure to meet growth expectations for age.
This research has found more negative interactions and/or parental dysfunction in comparison to
Journal of Pediatric Nursing, Vol 20, No 4 (August), 2005
PARENT/CAREGIVER STRESS DURING HOSPITALIZATION
families of healthy children (Hagekull & Dahl,
1987; Lindberg, Bohlin, Hagekull, & Palmerus,
1996; Singer, Song, Hill, & Jaffe, 1990). However, FTT represents a relatively small part of the
picture of feeding problems, and there is a
continuing need for studies about families experiencing other pediatric feeding difficulties such as
food refusal and food selectivity. Some research
(e.g., Kerwin & Reider, 1994) has found higher
parenting stress levels in families of children with
chronic feeding problems, whereas other research
have looked into psychosocial variables in these
families. For example, research by Budd et al.
(1992) indicated that higher parenting stress was
associated with less positive disciplinary strategies,
higher socioeconomic status, older children who
showed weaker feeding skills, and feeding problems that were primarily organic. Other research by
Spender et al. (1996) found a link between oral –
motor dysfunction and problematic parent –child
interactions in families of children with feeding
problems and Down’s syndrome.
Overall, the research literature on families of
children with feeding problems has tended to
focus on negative parenting patterns and dysfunctional environments. The knowledge base is less
thorough when it comes to examining adjustment
and positive changes in family functioning in
response to these problems. Fortunately, research
on other pediatric chronic conditions has contributed a more balanced framework in understanding
families who deal with these conditions. Within
this framework, families experience stress, but
their responses to childhood illness or disability
are not static and instead represent fluctuating,
dynamic conditions. The work of McCubbin and
McCubbin (1993) and McCubbin, Thompson, and
McCubbin (1996) has been instrumental in establishing a theoretical foundation in these areas, and
recent research has supported this foundation. For
example, studies by Klebanov, Brooks-Gunn, and
McCormick (2001) and Rodrigue et al. (1997)
have focused on parents’ stress levels and found
that they change in connection with the treatment
of their child’s problem or specific medical
procedures, although the direction of change
seems to vary based on the type of treatment
and illness/condition. Other research has examined
intensive psychosocial interventions at the inpatient or outpatient level and found that they can
have a positive impact on child and/or family
functioning, including reduction of stress levels
(Anderson, Loughlin, Goldberg, & Laffel, 2000;
269
Burke, Harrison, Kauffmann, & Wong, 2001).
Nurses may play a central role in these interventions by helping families identify and mobilize
resources in medical and community settings
(Burke et al., 2001).
By examining relatively short-term changes in
parenting stress, the present study contributed to
the above research and built upon the conceptual
framework established by McCubbin et al. and
other theorists who emphasize family adjustment
to challenges and adversities. To date, there has
only been one study involving pediatric feeding
problems that focused on possible changes in
family functioning over time. This research by
Drotar, Pallotta, and Eckerle (1994) found that
families of children with FTT do not show
significant changes in functioning over a 3-year
period but do have lower levels of adaptation in
comparison to families of normally growing
children. Thus, there is a need for ongoing research regarding stress and adjustment in families
of children with chronic feeding problems. In
addition to addressing this need, the current study
sought to provide a more comprehensive picture
of these families by examining a wide range of
variables in relation to parenting stress. Additional
information about these variables will also increase understanding of the complexities of family
responses to chronic feeding problems, a pediatric
condition that has been underrepresented in the
research literature.
The specific hypotheses for this study were as
follows: (a) All aspects of parenting stress will
decrease from the time of admission to the child’s
first progress point, which was operationally
defined as the time when the child completed
12 of 15 therapist-facilitated feeding sessions with
at least 80% food acceptance. This change was
anticipated because the progress point was a time
when the child demonstrated clear improvement,
and parents did not have as much responsibility for
getting their child to eat because therapists were
involved in treating the feeding problems. (b) All
aspects of parenting stress will increase from the
progress point to the time of discharge. This
change was anticipated because parents assumed
greater responsibility for their child’s eating/feeding after the progress point, and it was thought that
this would raise their stress levels. There were no
specific hypotheses regarding the relationships
between parenting stress and the various child
and family variables because the correlational
analyses were exploratory.
270
GARRO ET AL
METHOD
Subjects
The subjects of this study were recruited from an
inpatient unit of a pediatric rehabilitation hospital
in a large northeastern city. The parents/caregivers
of children hospitalized with chronic feeding
problems volunteered to complete questionnaires
and provide specific child and family information.
All the children had at least one of the following
oral feeding problems: full food refusal, food
selectivity, partial food refusal, oral –motor dysfunction, problems advancing texture, excessive
vomiting, volume limitations, and/or difficulty
transitioning from tube to oral feeding. Many of
the children also experienced other feeding related
problems such as gastroesophageal reflux, FTT,
delayed gastric emptying, and/or dysphagia (swallowing disorder). All the children had serious
chronic feeding problems. The problems were
serious in that they had not improved after at least
three sessions of outpatient treatment in which a
child and his parents/caregivers were seen by an
interdisciplinary team. The problems were defined
as chronic in proportion to the child’s life.
Specifically, all the children had experienced
feeding/eating problems for at least 75% of their
life spans, and most them had never known life
without these problems.
Thirty-seven female caregivers were recruited.
Among these, 35 were biological mothers of the
hospitalized children, 1 was a grandmother, and
1 was a long-term foster mother. The sample was
81% White, 5% African American, 11% Latino,
and 3% Asian American. All the study participants
completed high school, 50% had a college education, and 83% worked outside the home. The study
participants ranged in age from 24 to 66 years with
a median age of 34 years. The hospitalized children
ranged in age from 3 to 83 months with a median
age of 30 months. Based on the Hollingshead
Index of Socioeconomic Status (Hollingshead,
1975), 68% of the families were of middle
socioeconomic status (SES), 21% were of low
SES, and 11% were of high SES.
All participants had one child who was hospitalized in the inpatient feeding program. Because of
the serious and chronic nature of the feeding
problems and the presence of related medical
conditions (e.g., respiratory problems, need for
tube feeding, seizure disorders), these hospitalizations tended to be lengthy. The mean length
of hospitalization in the feeding program was
40.3 days. The feeding program itself was staffed
by an interdisciplinary team including physicians,
nurses, psychologists, speech language therapists,
occupational therapists, and feeding therapists who
carried out the mealtime sessions with the children.
As part of the treatment team, nurses did not feed
the children but were highly involved in other
aspects of patient care such as administering tube
feedings, administering and monitoring medications, and managing and monitoring a child’s other
medical conditions. In addition, the nurses of the
feeding program were involved in treatment planning and had frequent contact with family members
about each child’s health status and progress.
Procedures
Participants for this study were recruited over a
1-year period. All parents/caregivers of children
admitted to the inpatient feeding unit were invited
to participate. Forty-five parents were asked to
participate; among them, five declined. Three
additional participants were lost from the study
because their child was transferred or discharged
from the program before they could complete all
the questionnaires. The principal researcher made
initial contact via phone with parents/caregivers
before their child’s admission, explained the nature
of the study, and informed them that questionnaire
responses would be kept confidential. After a
child’s admission, a research assistant obtained
written informed consent from his or her parent/
caregiver. The principal researcher, who was not
involved in any aspect of patient care, gave the
questionnaires to parents/caregivers at the designated intervals, and these were completed in
privacy. They were returned to the principal
researcher in envelopes and kept in a locked office.
Each parent/caregiver received a code number that
was written on the questionnaire and, thus, no
identifying information appeared on any research
documents to help maintain confidentiality. The
parents/caregivers also gave consent for their
child’s medical records to be reviewed. All the
above procedures were approved by the hospital’s
institutional review board before the study began.
Based on each child’s medical record and
background information from the family, data were
collected for the following variables: (a) number of
other children in the family; (b) presence of
specific developmental problems such as communication delay and mental retardation (MR);
(c) presence of specific oral feeding problems;
(d) presence of other feeding complications such as
271
PARENT/CAREGIVER STRESS DURING HOSPITALIZATION
those described above; (e) presence of other
medical conditions such as respiratory difficulty
and seizure disorder; (f) number of previous
hospitalizations; (g) length of current hospitalization; (h) child age and parent age; and (i) family
SES. Data regarding parents’ coping strategies and
stressors in other life areas outside parenting were
collected approximately 1 week after the child’s
admission. Data regarding parenting stress were
collected at the three stages of the child’s hospitalization described in the hypotheses: the time of
admission, the first progress point, and the time of
discharge. These stages were chosen as key
transition points based on clinical experiences with
families of children who have chronic feeding
problems. Among the participants, there was some
variability in the length of time between the three
stages. Specifically, the interval between admission
and the progress point ranged from 11 to 45 days
with a median of 15 days, whereas the interval
between the progress point and discharge ranged
from 10 to 47 days with a median of 25 days.
Instruments
At all three data points, the Parenting Stress
Index-Short Form (PSI-SF; Abidin, 1990) was used
to measure the participants’ parenting stress levels.
The PSI-SF is a 36-item self-report questionnaire
that was directly derived from the full-length
Parenting Stress Index. The PSI-SF measures
parental stress related to three areas that compose
the instrument’s subscales: personal distress or
stress related to self-perception and social isolation
(parental distress [PD]), stress related to parent–
child dysfunctional interactions (PCDI), and stress
related to difficult child characteristics (DC). The
PSI-SF yields three subscale scores as well as a total
parental stress score. The reliability and validity of
the PSI-SF are supported by a variety of research
(Castaldi, 1988; Saft, 1990; Solis, 1990). The
normative sample for the PSI-SF consisted of 800
parents who represented a diverse population with
respect to income, marital status, education level,
and ethnicity.
In addition to the PSI-SF, the parents/caregivers
in this study completed the Family Inventory of Life
Events and Changes (FILE; McCubbin, Patterson,
& Wilson, 1983) and the Coping Health Inventory
for Parents (CHIP; McCubbin, McCubbin, Nevin,
& Cauble, 1981). The FILE is a 71- item self-report
questionnaire designed to look at the cumulation of
stressors and life changes that occur in the natural
life cycle of families over the course of 1 year. The
FILE was included as part of the current study
because it provides comprehensive information
about stressors and changes that an entire family
experiences and not only those that are specific to
parenting activities. A number of reliability and
validity studies have been conducted with the FILE,
and results indicate satisfactory internal consistency
and construct validity (Barton & Baglio, 1993;
Lavee, McCubbin, & Olson 1987; McCubbin &
Patterson, 1983). The CHIP is a 45-item self-report
questionnaire designed to assess the types of coping
behaviors used by parents when their child has a
serious and/or chronic illness. The items are
grouped into three factors that describe three main
types of coping patterns: Maintaining Family
Integration and Cooperation; Maintaining Social
Support, Self-esteem, and Psychological Stability;
and Understanding the Medical Situation. The three
factors of the CHIP have generally good internal
consistency, and a number of studies have provided
evidence of the instrument’s construct and criterion
validity (e.g., Berenbaum, 1988; McCubbin, 1989;
McCubbin & Patterson, 1983).
Analysis of Data
The present study used three main forms of data
analysis. First, the relationship between parent/
caregiver stress and stages of the child’s hospitalization was studied through four repeated-measures
analyses of variance (ANOVAs). The independent
variable in the ANOVAs was stage of hospitalization; admission, progress point, and discharge were
the three stages. The dependent variables were the
four stress areas/scores measured by the PSI-SF.
Second, following the ANOVAs, t tests were used
to specifically address the hypotheses and determine if there were significant changes in each area
of parenting stress between each stage of hospitalization. Lastly, Pearson’s product and point
biserial correlations were used to examine the relationships between parent/caregiver stress and a
number of child and family variables including
demographic variables and child medical and
developmental problems.
RESULTS
The results show significant changes in parent/
caregiver stress across the stages of hospitalization
for feeding problems. The four repeated-measures
ANOVAs found that these changes occurred for
two aspects of parenting stress: stress related to
parents’ self-perception and social isolation as
272
GARRO ET AL
Table 1. Changes in Parent/Caregiver Stress During
Child’s Hospitalization
Subscale 1 of PSI-SF (PD)
Subscale 2 of PSI-SF (PCDI)
Subscale 3 of PSI-SF (DC)
Total PSI-SF score
Score at
Admission
Score at
Progress Point
Score at
Discharge
33.16
23.32
33.32
89.81
31.78
23.68
32.14
87.62
30.59
23.19
32.11
85.89
indicated by the PD subscale score of the PSI-SF,
F(2, 72) = 3.68, p b .05, and total parenting stress
as indicated by the total score of the PSI-SF,
F(2, 72) = 3.39, p b .05. The mean scores for the
four aspects of parenting stress at each stage of the
hospitalization are shown in Table 1. An examination of these means indicated that both the PD
subscale score and the total score decreased
between admission and the progress point and
then again between the progress point and discharge. However, to determine if each of these
decreases was significant, as proposed by the
hypotheses, additional data analysis was necessary.
Results from the follow-up t tests did not
support the hypotheses. Specifically, stress related
to parents’ self-perception and social isolation did
not decrease significantly between admission and
the progress point, t(36) = 0.812, or between the
progress point and discharge, t(36) = 0.721, but did
decrease significantly between admission and
discharge, t(36) = 1.74, p b .05. Similarly, the
t tests also found that total parenting stress did not
decrease significantly between admission and the
progress point, t(36) = 0.592, or between the
progress point and discharge, t(36) = 0.481, but
did decrease significantly between admission and
discharge, t(36) = 1.72, p b .05.
The significant results from the correlational
analyses are shown in Table 2. These results
indicate that there were four types of child
developmental problems that showed significant
positive associations with parent/caregiver stress.
Specifically, the presence of MR, tonal abnormalities, or pervasive developmental disorder in the
hospitalized child was associated with greater total
parent/caregiver stress at all three stages of treatment. A fourth factor associated with higher
caregiver stress, specifically stress related to child
characteristics, was the presence of oral – motor
dysfunction in the hospitalized child. Among the
parent/family variables, only two — total life
change as measured by the FILE and the coping
pattern of Understanding the Medical Situation as
measured by the CHIP — showed a significant
relationship to parenting stress. Specifically, greater
life change was associated with higher stress related
to self-perception and social isolation (PD subscale
of the PSI-SF) at admission and the progress point.
Also, use of coping strategies related to understanding the child’s medical problem was associated with lower total parenting stress and lower
parenting stress related to difficult child characteristics (DC subscale of the PSI-SF) at admission and
the progress point. Specific examples of coping
strategies that fit this category include reading
about the child’s medical problem(s), talking to
healthcare professionals about concerns regarding
the child, talking to other parents of children with
the same problem(s), and asking questions or
otherwise seeking information from healthcare
professionals about the child’s problems.
DISCUSSION AND IMPLICATIONS FOR
PRACTICE
This study examined stress in mothers/caregivers of children with serious chronic feeding
problems. Because there is little previous research
regarding stress and adjustment in this population, these results contribute to a growing
foundation for understanding their experiences
Table 2. Correlations Between Parent/Caregiver Stress and Child/Family Variables
PSI-SF Score at Admission
MR
Pervasive developmental disorder
Tonal abnormalities
Oral–motor dysfunction
Total FILE score
CHIP Subscale Score III
(Understanding the
Medical Situation)
Tp b .05.
yp b .01.
.4066T (total parenting stress)
.4319y
.3572T (total parenting stress)
.4754y (DC)
.4744y (PD)
.3492T (DC)
.3569T (total parenting stress)
PSI-SF Score at Progress Point
.3822T
.3584T
.3425T
.4114T
.3872T
.4560y
.4115T
(total
(total
(total
(DC)
(PD)
(DC)
(total
parenting stress)
parenting stress)
parenting stress)
parenting stress)
PSI-SF Score at Discharge
.3898T
.4232y
.3476T
.3475T
.2757
.3448T
.3282T
(total
(total
(total
(DC)
(PD)
(DC)
(total
parenting stress)
parenting stress)
parenting stress)
parenting stress)
PARENT/CAREGIVER STRESS DURING HOSPITALIZATION
and have significant implications for nurses and
other members of hospital-based teams who work
with these families. Improved understanding of
parenting stress will help in the formulation of
successful treatment plans for children with
chronic feeding problems and their families.
Specifically, because high stress levels contribute
to negative parent –child interactions, including
feeding interactions, it is extremely important for
nurses and other healthcare professionals to help
parents identify specific stressors and develop
coping strategies to deal with them as effectively
as possible. This process is beneficial not only for
treatment and hospitalization but also for postdischarge when parents must resume full caretaking for the child with feeding problems. Although
the mean stress levels in the current study were
not above average based on PSI-SF norms,
significant changes in these levels warrant consistent monitoring by healthcare professionals.
The present study provides valuable information
regarding changes in stress. The results related to
parent/caregiver stress and stage of hospitalization
were significant in two areas, although these did
not support the original hypotheses. Specifically,
stress related to self-perception and social isolation,
as measured by the PD subscale of the PSI-SF, and
total parenting stress significantly decreased from
the time of the child’s admission to the time of
discharge. These results lend support to previous
research regarding changes in stress among pediatric illness populations. This research, although
minimal, suggests that hospital-based and other
intensive intervention services provided by nurses
and other team members can have positive impacts
on family functioning including reduced stress
levels (Burke et al., 2001; Klebanov et al., 2001).
In addition, there are other factors that may have
contributed to the decreases in stress levels such as
fulfillment of parent/caregiver goals and expectations for the hospitalization, confirmation of their
perceptions regarding the feeding/eating problems,
clarification of specific problems or medical conditions, and the provision of interventions and
supports that were not previously in place. Thus,
even if their children did not make large gains in
their eating, parents/caregivers may have experienced less stress owing to other positive aspects of
the hospitalization. Clearly, nurses can contribute to
these positive aspects through the direct and indirect
patient care services that they provide. For example,
in the current study, although the nurses in the
inpatient feeding program were not involved in
273
mealtimes, they did carry out other interventions,
such as tube feedings and management and monitoring of related medical problems, which helped
children to improve and enabled them to be
successfully discharged.
For the present research, there were no specific
hypotheses about the relationships between parenting stress and various child and family variables.
The correlational analyses in this study were
exploratory and, thus, need to be interpreted with
caution. Previous research (e.g., Budd et al., 1992;
Singer et al., 1990; Spender et al., 1996) has
found that parenting stress in families of children
with serious feeding problems is related to a
number of variables including older child age,
child fussiness and irritability, higher SES, and the
presence of organic/medical factors such as oral –
motor dysfunction. The current study found a
number of factors to be significantly associated
with parenting stress, and some of these results
correspond with previous research. For example,
the presence of oral – motor dysfunction or tonal
abnormalities, both of which are organic factors,
was found to be positively related to higher
parenting stress levels. Also, the presence of
pervasive developmental disorder or MR in the
hospitalized child was related to greater parenting
stress. Some previous studies have found that these
disabilities were positively related to family stress
levels, although these studies did not specifically
focus on feeding issues (Heaman, 1995; Lam &
Mackenzie, 2002; Minnes, 1988).
Unlike previous research, the present study did
not find a connection between SES and parenting
stress. In fact, among the family variables, only total
life change and the coping pattern of Understanding
the Medical Situation (Subscale III of CHIP)
showed a significant relationship to parenting stress.
Mothers/caregivers with higher levels of change in
other life areas (e.g., finances, job/career roles, etc.)
as measured by the FILE showed greater stress
related to self-perception and social isolation. This
may indicate that caregivers with higher levels of
life stress were more likely to feel distressed and
isolated in their parenting role. There is some
research support for this explanation in the chronic
illness population (Auslander, Bubb, Rogge, &
Santiago, 1993). In addition, mothers/caregivers
who made greater use of coping strategies that
involved learning about and understanding their
child’s medical problems had lower parenting stress
related to difficult child characteristics. They also
had lower total parenting stress. Although the link
274
GARRO ET AL
between this pattern of coping and parenting stress
may not be causal, previous research suggests that
this type of coping can be helpful to families dealing
with a variety of pediatric chronic conditions
(Anderson et al., 2000; Horn, Feldman, & Ploof,
1995; Rodrigue et al., 1997). In addition, according
to the theoretical framework of McCubbin et al.,
healthy coping is a key mechanism that mediates the
effects of stress on families and enables them to
successfully adapt to a wide range of transitions and
challenges including pediatric chronic illness.
From a practical standpoint, the above results
indicate that it is important for nurses who work
with children who have chronic feeding problems
to closely attend to specific factors in the child’s
and his or her family’s history and current profile
because these may increase parenting stress.
Healthcare professionals, including nurses, often
play an integral role in the assessment of family
stressors and can use this information as part of
treatment planning (Burke, Kauffmann, Harrison,
& Wiskin, 1999). The link between coping,
specifically strategies related to understanding the
child’s medical situation, and lower parenting
stress found in the current study also has important
implications for nurses. More specifically, because
communication with healthcare providers is a key
component of this coping pattern and one that is
valued by families (Balling & McCubbin, 2001;
Hallstrfm, Runesson, & Elander, 2002), nurses
have the opportunity to channel this communication in a number of positive directions. For
example, consultations with families enable nurses
and other members of treatment teams to assist
them in identifying, securing, and mobilizing other
coping resources such as early intervention and
support groups. In some cases, nurses serve as
contact points within the hospital who coordinate
communication with other service providers who
are involved in the child’s treatment (e.g., occupational therapists, behavioral therapists, etc.).
Thus, by carrying out these roles, nurses may be
able to help reduce parent/caregiver stress (Burke
et al., 2001). In the case of pediatric feeding
problems, nurses’ contacts with families may serve
a number of beneficial functions such as simplifying and clarifying complex medical information,
answering questions about medications and feeding-related medical problems, providing feedback
about the child’s progress, and training members
in the use of specific procedures or treatments
(e.g., tube feedings).
Although the current study provided more comprehensive information about stress in families of
children with chronic feeding problems, it presented
some limitations and issues that need to be
addressed in future research and practice. First, the
sample was relatively small (N = 37) and focused
exclusively on female caregivers. These factors
limit the ability to generalize from the results. In
addition, the small sample size may have diminished
the power of some of the statistical tests that were
used. Second, the design of the study, which
involved exploratory correlations and the use of
the aforementioned stages to measure stress change,
was based on the authors’ clinical experiences and
has not been substantiated in prior research.
Therefore, this design may have generated spurious
results. Future research using other research designs
may provide further evidence of changes in parenting stress among families of children with chronic
conditions. From a practice standpoint, the current
study suggests that nurses can make valuable
contributions to families of children with chronic
feeding problems by monitoring their stress levels,
identifying specific stressors, and directing them to
appropriate resources. However, some nurses may
need training to develop skills in family stress
assessment and intervention. In addition, nurses’
contributions in these areas are less viable if they are
already being understaffed and overextended in
their responsibilities. Continued advocacy and
policy overhaul are needed so that nurses will have
the time, education, and opportunities to effectively
treat children with chronic conditions and form
collaborative relationships with their families.
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