. p." “,4 ‘3 . <>MV ”x ‘ ”a?! ' v «V $31??? 52331535 A ‘ t .r . . gmxfi .5 gr} _2 . ~35} 9“: w y ‘ v; , A ‘E l. .n ‘m h¢h9g$§$¥~ -' 4‘7- 95 June-r. 'r “fit: 2“ “ a . r ’gt‘ :3 w , K : 955 92k avg}: ‘ . l. X N “{%{:\r‘ géjy‘kg: r i ‘ ' u.‘ -' "’23 {3" 3“: fifigffifig MIC CHIGAN ll (Lilli! :f KIMJIIIIIHIIHIIHIIJHI 3010461717 This is to certify that the thesis entitled A COMPARISON OF PERCEIVED SELF-COMPETENCE BETWEEN FATHERS WITH CHRONICALLY ILL CHILDREN AND FATHERS WITH HEALTHY CHILDREN presented by Cynthia Marie Paige has been accepted towards fulfillment of the requirements for Master of Science degree in Nursing 1‘ : gjor professor Date—AMML 4 07639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Mlchlgan State University PLACE ll RETURN BOXtonmavombchodianflom macaw. TO AVOID FlNESMunonorbdmddodm. DATE DUE DATE DUE DATE DUE ' 'o I ”L. L, M1 A COMPARISON OF PERCEIVED SELF-COMPETENCE BETWEEN FATHERS WITH CHRONICALLY ILL CHILDREN AND FATHERS WITH HEALTHY CHILDREN BY Cynthia Marie Paige A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of ‘ MASTER OF SCIENCE College of Nursing 1994 ABSTRACT A COMPARISON OF PERCEIVED SELF-COMPETENCE BETWEEN FATHERS WITH CHRONICALLY ILL CHILDREN AND FATHERS WITH HEALTHY CHILDREN BY Cynthia Marie Paige This thesis analyzes data that compares the perceived self-competence of fathers with chronically ill children to fathers with healthy children. Data was derived from a larger primary study conducted by the College of Nursing at.Michigan State University. The primary study collected data on 20 fathers of children with asthma, cystic fibrosis, congenital heart defects and diabetes mellitus and 11 fathers with healthy children. The fathers completed Harter's Adult_§glfi: Eggcgptign Erofl 1e which is a 50-item instrument that measures twelve domains of perceived self-competence. Differences between the two groups were hypothesized as identified by the adaptation framework of Sister Callista Roy. Significant findings included increased levels of perceived competence in the nurturance and sociability' domains among fathers of chronically ill children. These results suggest that fathering a child with a chronic health condition can have positive effects on some aspects of the self-concept. TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . LIST OF FIGURES . . . . . . . . . . INTRODUCTION . . . . . . . . . . . Statement of the Problem . . . . . Research Question . . . . . . . . . Study Relevance . . . . . . . . . Definition of the Study Variables . Theoretical Framework . . . . A Description of The Roy Adaptation Model . Perceived Self Competence Within the Roy Adaptation Model . . . . Review of Literature . . . . . . . Fatherhood . . . . . . . . . Adaptation Responses to Fathering a Chronically Ill Child . . Impact on adaptation . . Influencing factors of adaptation Perceived Self-Competence . Socialization . . . . . Job Competence . . . . Nurturance . . . . . . Intimate Relationships Adequate Provider . . Household Management Intelligence . . . . Global Self-Worth . . . . Athletic, Physical Appearanc Sense of Humor . . . . . Rationale for Proposed Study . . . METHODOLOGY . . . . . . Adult Self-Perception Profile Sample . . . . . . . . . . . . Procedures . . . . . . . . . . iii e I Moralit Y D 0- 03000000000000 vi 10 10 12 15 16 18 19 21 23 24 24 24 26 27 27 27 28 28 29 3O 3O 31 32 TABLE OF CONTENTS (cont.) Instrument . . . . . . . . . . . . . . Design . . . . . . . . . . . . . . . . Data Analysis . . . . . . . . . . . Operational Definition of the Variable Study Limitations . . . . . . . . . . Protection of Human Subjects . . . . . Hypotheses . . . . . . . . . . . . . . Findings 0 O O O 0 O O O I O O O I 0 O O O Socio-Demographic Characteristics . . . . Hypotheses Results . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . Sample Characteristics . . . . . . . . . . Discussion of Hypotheses . . . . . . . . . IMPLICATIONS . . . . . . . . . . . . . . . . . Implications for RAM . . . . . . . . . . . Implications for Advanced Nursing Practice Implications for Future Research . . . . . conCIUSion O O O O O O O O O O O O O O O O O 0 REFERENCES 0 O O O O O O 0 O O O O O O O O O O APPENDICES Recruitment letter to families with healthy children . . . . . . . . . . Recruitment letter to families with chronic children . . . . . . Approval letter from UCRIHS . . . ~ . . Harter' s Adult Self- Perception 2; £1; . . (0 iv 33 38 38 39 41 42 43 45 45 47 51 51 52 60 61 61 68 71 72 76 77 78 79 LIST OF FIGURES FIGURE 1 Roy's Adaptation Model . . . . . . . . . . . . 11 FIGURE 2 Perceived Self-Competence Within RAM . . . . . 13 TABLE 1 TABLE 2 TABLE 3 LIST OF TABLES Reliability of Harter’s Adult Self-Perception PrOfile I O O O O O O O O I O O O O O O I O O 37 Socio-Demographic Characteristics of Samples . 46 Means, Standard Deviations and ANOVA Results . 48 vi INTRODUCTION Approximately 10 million children in the United States have some form of chronic illness (Clements, Copeland & Loftus, 1990). More children currently are surviving difficult births, prematurity, previously fatal congenital anomalies, accidents, and other disease processes because of advanced technology and scientific knowledge. As this trend continues, the burden of responsibility for the care of chronically ill children falls increasingly on the parents. Thus, there is a heightened need to understand the complex impacts associated with parents caring for chronically ill children. Many researchers have-studied individual family members in an attempt to understand the reality of family life with a chronically ill child. Most research has examined the mother-child dyad and a significant body of knowledge is accumulating about the complexity of mothering an ill child. Another major focus of researchers has been the psychopathology of the mother and of the chronically ill child. In contrast, there has been little research conducted on the complexity of-fathering a chronically ill child. Such an omission of knowledge is unacceptable when there is evidence today that parenting even a healthy child can have deep psychological effects on fathers (Cath, Gurwitt & Ross, 1990). 2 Frequently, knowledge obtained regarding maternal responses to parenting a chronically ill child is unjustifiably equated with overall parental responses‘ (Dolgin, 1990). Goldberg, Moss, Simmons, Fowler and Levison (1990) compared maternal and paternal reactions to chronically ill children and concluded that the mother and father rarely respond identically. Therefore, it cannot be assumed that paternal responses to a chronically ill child would be the same as maternal responses. Many attribute the lack of paternal response research to two principle factors. First, because fathers are typically more inaccessible, researchers have been unable to collect data on fathers. Mothers are more likely to interact with the health care system because they usually accompany chronically ill children to see their health care professional. Second, this society traditionally perceives fathers as having less emotional influence on their children (McKeever, 1981). As a result, researchers tend to omit fathers from mainstream family research. Some research has discredited this perception and reveals that although men generally spend less time with their children than mothers, they have very unique and important contributions to make to children's emotional, social and physical development (Parke, 1987). Despite the fact that fathers of chronically ill children have not been systematically studied, many authors postulate that a father's self-concept is profoundly 3 affected by the child's long-term illness (Schilling, Schinke & Kirkham, 1985). In addition, authors propose that fathers might have a more difficult time than mothers adjusting to the realities of their children's limitations (Sabbeth, 1984). However, because of the tremendous lack of research done on fathering a chronically ill child, these two propositions and many others remain unconfirmed. The issues regarding the effects of the chronically ill child on the psychological life of the father have many implications, especially for the Clinical Nurse Specialist (CNS) in the primary care setting. Often, the CNS is concerned with fostering adaptation of the father to the stressors of caring for a chronically ill child. Promoting the perceived self-competence of the father is an important way of maintaining the father's sense of well-being and increasing adaptation. In addition, a father with a higher perceived self-competence will be more motivated and successful in his performance of the many daily functions necessary to care for his chronically ill child. Therefore, it is crucial that the CNS understand the effects of the chronically ill child on the father's perceived self- competence. The current literature describes specific psychological effects that the chronically ill child has on the mother and the siblings (Sabbeth, 1984; McKeever, 1981). Unfortunately, there is little known regarding the effects of fathering a chronically ill child on paternal self- 4 concepts such as perceived self-competence. Therefore, it is difficult for the CNS to insure that interventions being conducted are effectively increasing paternal adaptation to parenting a chronically ill child. This research project is a secondary analysis of data collected by Professors Carla Barnes, Linda Spence and Patty Peek, in the College of Nursing at Michigan State University. The data was collected from families with and without a chronically ill child. This research study will use this data to focus on the perceived self-competence of fathers with both healthy and chronically ill children. Problem Statement It appears that fathers are equally emotionally involved with their chronically ill children as mothers, but do not respond in the same way to the demands (Cummings, 1976; Cadman, Rosenbaum & Boyle, 1991). It also appears that by understanding the nature of the parenting function as experienced by fathers, and appreciating that there may be certain impacts on the psychological self, the CNS will be able to more effectively guide fathers and facilitate family functioning. Therefore, the purpose of this study is to compare the perceived self-competencies of fathers with chronically ill children to fathers of healthy children. Research Question The following research question will be asked: Are there any differences between fathers with chronically ill children and fathers with healthy children in their 5 perception of self-competence in the dimensions of: Sociability; Job Competence; Nurturance; Athletic Abilities; Physical Appearance; Adequate Provider; Morality; Household Management; Intimate Relationships; Intelligence; Sense of Humor; and Global Self-Worth? Study Relevance The results of this investigation have the potential to contribute to the nursing profession in several ways. First, information from this study will expand theoretical knowledge on the parenting experience of fathers with chronically ill children. Second, it will assist the CNS in developing specific strategies to promote paternal and family adaptation to a chronically ill child member. These strategies will be based on what the study reveals about the perceived self-competence dimensions of the fathers of chronically ill children compared to those of healthy children. Future research on fathering a chronically ill child can be conducted to evaluate the effectiveness of these strategies. Definition of the Study Variables The independent variable under study is the health status of the child. More specifically, this study is concerned with fathers of children who have been diagnosed for at least one year with one of the following diagnoses: asthma, diabetes mellitus, cystic fibrosis or congenital heart defects. In addition, both study groups include not 6 only biological fathers, but also stepfathers and adoptive fathers. Chronically ill is defined consistently throughout many sources as any anatomic or physiologic impairment that interferes with an individual's ability to function fully in the environment (Thomas, 1984). Chronic conditions are characterized by relatively stable periods that may be interrupted by acute episodes requiring medical attention (Horner, Rawlins & Giles, 1987). The child's prognosis might vary between a normal life span and unpredictable é death. Most importantly, chronic conditions are rarely cured, and often require the child and family members to use diligent efforts to manage the conditions (Thomas, 1984). In this study, cystic fibrosis, asthma, diabetes and congenital heart defects requiring pediatric sub-specialty management are the chronic childhood illnesses. The dependent variable that is of concern in this study is the father's perception of self-competence. Harter's definition of perceived self-competence will be utilized in this study for two reasons. First, Harter clearly and specifically defines perceived self-competence conceptually. Second, this study will use Harter's own Self-Perception profile to measure the variable of perceived self- competence. Harter (1985) defines perceived self-competence as the degree of worth one attributes to oneself. Harter claims that persons do not typically view themselves equally in all 7 domains of their life. This is based on the assumption that persons make meaningful distinctions between different domains of their lives. Therefore, Harter concludes that perceived self-competence should be evaluated and defined with a multi-dimensional approach (Harter, 1985). Fitts (1965) was the first to advocate the multi-dimensional approach which included physical self, moral-ethical self, personal self, family self, and social self. However, Harter argues that Fitts' five dimensions do not tap all areas of competence about which adults presumably make self judgements. Therefore, Harter (1985) includes the following twelve domains in the definition of perceived self- competence: Sociability. Refers to one's behavior in the presence of others. The sociability domain also includes one's perception of how fun they feel they are to be with, how they feel about meeting new people and are they at ease with others? Job Competence. Perceptions of competence in one's major occupation, job, or work. More specifically, job competence refers to one's feeling of productivity and pride in their work. Nurturance. Involves the process of caring for others. Refers to one's ability to foster the growth of others (i.e. family members, friends and pets). Also includes ones caring for children as a contribution to the future. Athletic Abilities. Pertains to the concept of abilities related to sports. Includes one's sense of competence in sports, one's willingness to participate in and to try new physical activities. Physical Appearance. This domain refers to the way one looks and one's happiness with their looks. In addition, does one feel attractive and are they satisfied with their face and hair. 8 Adequate Provider. Is defined as supplying the means of support for oneself and one's significant others. Does the individual feel they are able to meet their own material needs and well as adequately meet the needs of important persons in their life? Morality. Morality refers to living up to one's moral standards and feeling that one's behavior is ethical. More specifically, it is one's behavior based on standards of conduct, of what is right and wrong. Household Management. The process of guiding or handling things in the household. In addition, it refers to one being organized and efficient at keeping the household running. Intimate Relationships. Implies close, meaningful interactions or relationships with one's mate, lover. and/or special friend. Refers to one's competence at seeking out and maintaining close, intimate relationships. In addition, one's ability to freely communicate openly in a close relationship. Intelligence. The ability of one to learn and know. Refers to feeling smart, understanding things, and feeling intellectually capable. Sense of Humor. Pertains to the ability to see the amusing side of things. Refers to one's ability to laugh at oneself and ironies of life, as well as finding it easy to joke or kid around with friends and colleagues. Global Self-Worth. One's global perceptions of worth, independent of any particular domain of competence/adequacy. Refers to liking the way one is leading their life, being pleased with oneself, and liking the kind of person one is. Harter's definition of perceived self-competence is also unique because of the identification of global self-worth independent of the it is important to competence and the individual because comprehensive view other domains. Harter (1985) claims that understand both the domain-specific overall perceived self-worth of an together they provide a truly of self-competence. 9 Lastly, Harter (1985) adds that perceived self- competence includes not only the degree of worth one attributes to oneself in each domain, but also the importance one attaches to the success in each domain. Harter further postulates that if one is successful in domains deemed important, the individual will possess high self-esteem. Conversely, if one is not successful in areas where one aspires to be competent, the result will be low perceived self-competence and self-worth. Therefore, Harter's full definition of perceived self-competence is the degree of worth and importance one attributes to oneself across twelve domains. Theoretical Framework In order to establish the implications of this study for advanced nursing practice, it is necessary to develop the two concepts of perceived self-competence and the child's health status within a nursing framework. This author will use the framework of Sister Callista Roy, whose theory, as set forth in the Roy Adaptation Model (RAM), focuses on the adaptive nature of the individual in response to the internal and external environment (Roy, 1991). Since Roy published RAM, many propositions have been derived and hypotheses tested, establishing its significant contribution to the body of nursing knowledge (Roy, 1991). Most importantly, her model is based on a systems theory that specifically includes the person as an adaptive system. As a result, the model is best utilized in situations related 10 to adaptation (Roy, 1991), such as the impact of a chronic illness of a child on a father. Accordingly, RAM is an appropriate nursing framework within which to develop the concepts of fathering a chronically ill child and perceived self-competence. WW1 The RAM consists of the five elements of person, goal of nursing, nursing activities, health and environment (Roy, 1991). A person is viewed as a bio-psycho-social being, an adaptive system, in constant interaction with a changing environment. Therefore, a person is continually changing and attempting to adapt to the constantly changing environment (Roy, 1991). The person as an adaptive system receives input from the external environment and internally from the self (Roy, 1991). The control processes of the person as an adaptive system are coping mechanisms. Roy identifies two subsystems of coping mechanisms unique to nursing science--the regulator and the cognator (Roy, 1991). The responses of regulator and cognator subsystems are manifested or carried out through four effector modes. Roy (1991) identifies the four effector modes as: physiological function, self-concept, role function and interdependence (Figure 1). The physiological mode is related to the need for psychic integrity. Self-Concept is defined as the composite of beliefs and feelings that one holds about oneself at a given time. The self-concept mode 11 NURSING 4r EFF ECTOR INPUT PROCESSES MODES OUTPUT Environment Piwsiological Adaptive Focal Stimuli Regulator Set Concept CortemJal I ‘; ) (or) — Slim“ Role Function . Cognator ' U L_;\_) \___J D L_/ FEEDBACK Figure 1 ' a o o e is viewed in RAM as having two sub areas: the physical self and the personal self. Both sub areas are formed from internal perceptions. Self-concept is instrumental in directing one's behaviors. The role function mode results from the individual's need to know the roles of others and what the role expectations of society holds for the individual. The goal of the role mode is social integrity (Roy, 1991). The interdependence mode involves interaction with others, especially in close relationships. The interdependence mode is the mode in which affectional needs are met. Lastly, if a person experiences a specific problem in one mode the other modes are affected (Roy, 1991). 12 The output of the person as an adaptive system are adaptive or ineffective responses (Roy, 1991). Adaptive responses maintain or promote integrity, whereas ineffective responses disrupt integrity. The responses are sent back to the person as feedback so that a level of adaptation is established. The person that manifests ineffective responses needs nursing care (Roy, 1991). Roy defines the goal of nursing as the promotion of adaptive responses in relation to the four effector modes (Roy, 1991). Roy views the person's adaptation to change as dependent on the stimuli in the environment which are input into the person. Therefore, nursing activity is defined as manipulating the stimuli impinging on the person so that adaptive responses are promoted (Roy, 1991). The stimuli Roy identifies are focal, contextual and residual. These stimuli are also what Roy defines as the environment (Roy, 1991). Eergeiyed Self-Competence within the Roy Adaptation Model Under Roy's theory, the father as an adaptive system receives input from the environment as stimuli (Figure 2). The focal stimuli is the child's health status. Roy identifies the focal stimuli as that which is immediately confronting the person (Roy, 1991). The contextual stimuli that have been identified from the literature are: the number of children in the family, family income, the amount of social support, severity of child's condition, knowledge of illness and the amount of time spent working. The 13 NURSING INPUT EFFECTOR none ’ ENVIRONMENT \ (SELF-CONCEPT MODE \ mm: Perceived Self-Competence Child's Health Status Domains: . . Sociability W111 | t [1' Number of Children. ,3:,;,?{;"°° Income, Number of ) Nurturance Hours Worked. Socrai Job Competence Support, Knowiedge. Appearance Severity 0f Illness Physical Humor . Intimate Relationships Father's Disposition gang: Management L j x 2 Figure 2 - e n ' del contextual stimuli also include all other measurable and observable stimuli affecting the father either internally or externally (Roy, 1991). The residual stimuli would be the father's disposition, whether he is easy going or rigid. The residual stimuli, according to Roy, are the make-up characteristics of the person and are unmeasurable (Roy, 1991). In addition, any nursing activity directed at manipulating the stimuli is also received by the father as input from the environment. 14 Once the stimuli are received, they are transformed into the four effector modes of: physiological, role function, interdependence and self-concept. However, this study focuses strictly on the effects of the stimuli on the self- concept effector mode. Roy (1991) claims that the psychic integrity of the self-concept mode is basic to health. Therefore, any problems within the self-concept mode may interfere with the person's ability to maintain health (Roy, 1991). Accordingly, the assessment of the father's perceived self-competence is essential to not only assist in identifying any problems within the self-concept mode, but also to ensure healthy adaptation. The assessment of the self-concept mode is carried out in this study by the administration of Harter's Adult_§§1£ :2g;ggptign_£ngfiilg. The multi-dimensional approach of this instrument will allow for a full assessment of the self- concept mode identified by Roy. The output from the father reflects his ability to adapt to the stimuli sent to the four effector modes, and is either adaptive or ineffective. The output would be assessed by looking at the individuals overall functioning as a father, but such an assessment is beyond the scope of this study. However, if the father has a problem in the self-concept mode, there is an increased risk that the output may be ineffective. In addition, the negative output is sent back to the father as input. Therefore, the negative feedback may lead to continuous ineffective fathering. 15 According to Roy, the goal of the nurse is to promote the adaptation to fathering a chronically ill child. This goal is accomplished by manipulating the focal, contextual or residual stimuli that are inputs to the person (Roy, 1991). Unfortunately, the nurse is unable to manipulate the focal stimuli which is the child's health status. However, the nurse can focus on manipulating the contextual stimuli which will increase the father's coping abilities. Not only does RAM establish the importance of assessing the self-concept mode in fathers with chronically ill children, the framework also allows for a more holistic assessment of the father. More specifically, Roy (1991) claims that the need of one mode may extract energy from or otherwise affect another mode. Therefore, the stimuli identified earlier are not the only forces affecting the father's response. For example, a father might have hypertension and is trying to meet his physiological mode problem while also trying to adapt to his child's health status. In this case, assessment of all four effector modes is necessary. However, the scope of this study strictly focuses on the self-concept mode of the father with the understanding that problems in the other three modes would be considered factors which may affect this study's outcome. Review of Literature This literature review focuses on three areas of research. First, due to the lack of extensive research specific to fathering a chronically ill child, it becomes 16 necessary to understand how fathering healthy children can affect men. Therefore, there will be a general area of research which explores the psychological well-being, self— esteem and marital relationships of fathers with healthy children. Second, there will be a focus on the relatively small amount of research that examines the experience of fathering chronically ill children. Lastly, research on fathering chronically ill children will be placed into the twelve domains of perceived self-competence. W This section describes how parenthood can affect a father. There are often two conflicting experiences that occur when one becomes a father. Fatherhood can be an experience that includes disequilibrium, stress, and crisis (Parke, 1987). However, fatherhood can also be a joyous experience that has a potential for significant individual and marital growth (Parke 1987). There has been some debate as to how these two conflicting experiences of fatherhood affect one's psychological well-being, self-esteem and marriage. According to some researchers, becoming a father can often put one "at risk" for intrapsychic stress (May, 1982; Osofsky & Osofsky, 1985), symptoms of depression, and the blues (Ventura 8 Stevenson, 1986). In addition, if men had previous psychiatric histories, fatherhood increases the risk of unipolar or bipolar affective disorders (Weiner, 1982). However, Fein (1976) found very few negative effects 17 of fathering on men's psychological well-being and concluded that being a father was a positive experience for the psyche. I When looking at the effects of fathering on men's self- esteem, most findings have been positive. The results of The Becoming a Father Project conducted by Brownstein and Cowan (1990) found that there were no differences between fathers and childless men in their overall level of self- esteem. The researchers postulate that the positive aspects of becoming a father were sufficient to balance out the difficulties. In addition, many fathers in the study reported not only surviving, but thriving in response to challenges that were unexpectantly stressful. Parke's work (1987) also supports the theory that by managing the demands and responsibilities of fathering, men may often enhance their self-esteem. However, Parke's work also reveals that the self-esteem of fathers is often influenced by many factors, but most especially the father's marital satisfaction. A strong and happy marital relationship is considered the strongest influence on whether a man will positively or negatively adjust to being a father (Griswold, 1993). Brownstein & Cowan (1990) found that there is a significant decrease in an individual's marital satisfaction after becoming a parent. This was found to be higher for men than women. Moreover, in comparison with mothers, fathers placed greater importance on spending time with their spouses. 18 Lastly, fathers who experienced decreased marital satisfaction, were also more likely to experience low self- esteem, symptoms of depression and stress with their children. Overall, the literature is inconsistent on the effects of fathering on one's psychological well-being. However, the literature reveals that individuals often show no negative effects or positive effects from fathering on their self-esteem. Most especially, marital satisfaction is often decreased for an individual after becoming a parent (Brownstein & Cowan, 1990). Therefore, a strong marital relationship is important for an individual's adaptation to parenthood (Griswold, 1993). tea! a '., ;-s--. es . a ,- ',. a a on? a g',e The studies of fathers with chronically ill children are limited in number and in their focus on psychological maladaptation. However, some of the studies reveal that fathering a chronically ill child can have a negative impact. The negative effects that will be discussed are: (1) higher levels of depression and lower levels of competence; (2) decreased scores on personality tests suggestive of emotional disturbance; (3) strong feelings of hopelessness; and (4) negative psychosocial characteristics. Although most of the studies reveal that fathering a chronically ill child has negative impacts, there will be one study presented that found fathers adapting positively. 19 The rest of this section will also discuss the factors identified in the literature as influencing adaptation. Impggt_gn_gg§pt§tign. Cummings (1976) studied the effects of having a chronically ill child on emotional adaptation in one of the first studies specific to fathers of chronically ill children. The study included fathers with chronically ill children, mentally ill children and healthy children. Cummings' work revealed that when compared to fathers of healthy children, fathers with chronically ill children and with mentally ill children scored lower on expressed self-acceptance and parental competence, and showed significantly more depression. When the fathers of chronically ill children were compared to fathers of mentally ill children, the fathers with chronically ill children scored higher in the areas of expressed self-acceptance, parental competence and interpersonal satisfaction (Cummings, 1976). A study by Goldberg et a1. (1990) revealed that fathers with children who had cystic fibrosis and congenital heart defects had higher depression scores then the control group. In addition, the fathers of the congenital heart defect children scored higher on depression than both the control and cystic fibrosis groups (Goldberg et al., 1990). The negative impact of fathering a chronically ill child on personality function tests was revealed by Gayton, Friedman and Tavormina's (1977) study. The study revealed that 32 percent of the fathers who had chronically ill 20 children with cystic fibrosis were more likely to have disturbed personality functioning than the comparison group. These fathers scored significantly higher than the healthy control group on the hysteria, lie, hypochondriasis, and psychopathic deviance scales of the Minnesota Multiphasic Personality Inventory (MMPI). Simon and Smith (1992) conducted a study using a qualitative methodology approach and found that fathers are negatively impacted by persistent feelings of hopelessness and lack of control. The study explored perceptions of parents of children with chronic liver disease. The researchers reported that the fathers' adaptation seemed to be difficult due to the tremendous feeling of powerlessness. More specifically, the fathers found it especially difficult because they were unable to control their children's illness or prevent their children from being hospitalized. (In addition, a common theme verbalized by the fathers was not only a sense of hopelessness, but also guilt about not always being available or being able to do more for their children (Simon & Smith, 1992). The psychosocial characteristics of fathers with children having a chronic illness or physical disability were found to be slightly different than those of fathers with healthy children in the study done by Cadman et a1. (1991). The researchers included a sample group of 1869 randomly selected families. Analysis revealed that 8.3 percent of the fathers with chronically ill children had 21 been treated for "nerves" and 2.3 percent had been hospitalized for "nerves". The fathers with healthy children reported only 4.6 percent treated for "nerves" and .9 percent hospitalized. However, the researchers point out that the large majority of the fathers of children with a chronic illness (more than 90 percent) did not report receiving any treatment for mental health difficulties. Most of the studies above indicate that chronic illness in children can clearly have a negative impact on fathers. However, McKeever (1981) presents different results from a qualitative study that includes interviews of ten fathers of chronically ill children. This small study revealed that although the fathers experienced personal distress with their situation and often received a glaring lack of professional support, they functioned remarkably effectively. In fact, they were able to curb their negative emotions, mobilize hope, and maintain a clear sense of personal worth. Inf1ggnging_fiag§g;§_gfi_agaptgtign. Factors that have been found to influence fathers' responses are unequivocal and are also limited in number. The factors that are identified and presented are: (1) income level; (2) intellectual understanding of the child's illness; and (3) social support. McCubbin and McCubbin (1983) found that income was a strong factor in the father's ability to adapt to their children's chronic illness. The study included families 22 with children diagnosed with cystic fibrosis, and discovered that the type of coping strategies were significantly related to the family income. More specifically, in families with higher income, the fathers' coping efforts were more directed at keeping the family together and becoming involved in medical consultation. A relationship between an intellectual understanding of the chronic illness and paternal adjustment has been found in some studies. Fathers of children with chronic liver disease felt they gained some control of their situation if they were provided with a strong base of medical knowledge (Simon & Smith, 1992). Moreover, in families of children with cancer, intellectual understanding of the disease was directly related to the fathers' emotional adjustment and their relationship with their child (Murstein, 1960). However, it should also be noted that Klein and Nimorwicz (1982) studied fathers of hemophiliacs and found no relationship between knowledge of the disease and psychological distress for fathers. Finally, social support is another factor that appears to play an important role in paternal adjustment to a child's chronic condition. Sodial support has been identified as a powerful mediator of personal well-being. By maintaining social relationships outside of the family unit, the individual members are able to meet their needs of esteem, network and emotional support (Canam, 1993; McCubbin & McCubbin, 1983). However, one study on families with 23 chronically ill children revealed that the network of support for mothers was much larger than for the fathers (Tomlinson & Mitchell, 1992). Unfortunately, most studies to date have not addressed the specific relationship between social support and paternal adjustment to this experience. Literature relevant to fathers' responses and adaptation to having children with chronic illnesses has been reviewed to explain the few identified factors that may influence the fathers' responses. This literature review reveals that the studies of fathers are very limited in number and that they have never been replicated. The literature reveals that fathers' responses have been found to be mostly negative. The responses include higher levels of depression, decreased scores on personality tests and expressed feelings of hopelessness. e - etence Each domain of perceived self-competence will be discussed separately. Each domain will focus on any relevant research or information of fathers with chronically ill children. However, most domains do not have any literature specific to perceived competence. Therefore, information will instead be presented about how the fathers function within the domains. Harter (1985) claims that often one may predict how people will perceive their competence in a domain if they understand how they perform in the domain. 24 figgiglizatign. For many men, parenthood is marked by an increased number of social relationships (Schilling et al., 1985). For fathers with chronically ill children, one study revealed that they had attended approximately four social functions in the last month, which was above what is considered normal for most fathers (Timko, Stovel, & Moos, 1991). There were also no differences in the number of social activities attended between mothers and fathers. Barnes (1992) studied fathers of children with cystic fibrosis and found that they scored significantly higher than comparison fathers in sociability competence. In addition to these studies, this researcher's clinical experience indicates that sociability does not seem to be effected by fathering a chronically ill child. Qgp_ggmpgt§nge. For fathers with chronically ill children, investing time and energy into their jobs is often used as a coping strategy and used more frequently than emotive coping strategies (Canam, 1993). In addition, fatherhood often brings about a rising sense of the importance of career due to the realization that he must provide for his off-spring and be a respectable role-model (Schilling et al., 1985). Although the research is very limited regarding the job competence domain, fathers with chronically ill children appear to function well within this domain. Nurturance. The amount of time fathers of chronically ill children participate in day-to-day child rearing tasks 25 appears to be low. Barsch (1968) reported that only 38 percent of fathers of children with organic brain disease engaged in high-level care. Allan (1974) found that 17 of 50 fathers of children with cystic fibrosis left child care entirely up to the mother. There have been two studies that revealed the negative impacts of chronically ill children on the nurturance domain. Goldberg et al. (1990) did a study that included looking at parental role competence in fathers with children that had cystic fibrosis or congenital heart defects. The fathers scored a mean of 26.1, which was below the 50th percentile of 29, as established by fathers and mothers of healthy children. In addition, Timko et a1. (1991) found that fathers of children with Juvenile Rheumatic Disease had difficulties with the mastery of their nurturing role. The fathers scored only a mean of 9.6 out of a possible 20 on their perception of their ability to learn and manage their children's illness. Although the low 9.6 score was not compared to fathers of healthy children, it was much lower than the mothers of the ill children who scored 11.6 on nurturance mastery. There is also evidence that fathers with chronically ill children interact differently with their children then fathers with healthy children. Scobinger, Florin, Zimmer, Lindemann and Winter (1992) found that fathers with asthmatic children had more critical attitudes and more 26 negative verbal behaviors towards their children than fathers in the control group. Literature regarding fathers with chronically ill children within the nurturance domain reveals that fathers; (1) spend a small amount of time nurturing their children, (2) score low on parental competence scales, and (3) may interact negatively with their children. t mate a ' s s. Parenthood can have a negative impact on marital satisfaction as was already discussed previously in the section on fathers of healthy children. In addition, clinical observations and literature suggest that chronic childhood illness has a strong and often negative impact on the fathers marital satisfaction (Goldberg et al., 1989; Lansky, Cairns, Hassein, Wehr & Lowman, 1978; Silbert, Newburger, & Fyler, 1982). However, Sabbeth and Leventhal (1984) conducted an extensive literature review and analysis which revealed that chronic childhood illness had either no affect, and even some positive influence on the marriage. For example, divorce in families of chronically ill children does not appear to be more frequent than in control families. But, Sabbeth and Leventhal also found that a chronically ill child can actually bring parents closer together in their marriage. Thus, it is unclear from the literature how a chronically ill child will affect this domain of the father's perceived self-competence. 27 agegee;e_£;eyige;. This researcher has found from clinical observations of fathers of chronically ill children, that fathers often are very concerned with providing the material needs of their children. This contribution is seen by the fathers as their main role in their chronically ill children's lives. In contrast, the mother's role is focused on the day-to-day tasks. HQBEQDQIQ.M§D§Q§E§D§- As with child care tasks, fathers are less likely to participate in household tasks than mothers. Brownstein and Cowan (1990) conducted a study of a 160 fathers with healthy children which revealed that 150 fathers were not responsible for any household tasks, 8 were responsible for 1, and 2 fathers for 3 household tasks. The authors defined household tasks as cleaning inside and outside chores, buying groceries, doing laundry and organizing weekly family plans. Nagy & Ungerer (1990), who studied 37 parents of children with cystic fibrosis, found that mothers spend significantly more time carrying out domestic duties like household chores than fathers. In addition, based on this researcher's clinical observations, fathers of chronically ill children do not appear to share equally household tasks with mothers. Ingelligenee. Hymovich and Baker (1985) found that the number one identified need of fathers with chronically ill children was for more information regarding their children's chronic condition. In addition, the study revealed that 68 28 percent of the fathers wanted more information about the disease for their chronically ill children. Such an interest in information is not surprising based on the studies by McCubbin and McCubbin (1983) as well as Simon and Smith (1992) which identified "understanding things" as one of the most frequently used coping strategies of chronically ill fathers. glebe1_§elfi;fle;eh. The literature that is relevant to the father's global self-worth was already presented in the previous literature review section on the father's adaptation to a chronically ill child. Therefore, these results will not be repeated. Overall, the studies revealed that fathers with chronically ill children scored lower on overall competence, self-esteem and depression (Cummings, 1976; Gayton et al., 1977; & Goldberg et al., 1990). 9 -, s' a :---- anC‘ to a, ;n- -;s- . . o, The only research specific to these domains was done by Barnes (1992) who studied parents of children with cystic fibrosis. The investigation utilized Harter's Adult Self- 2e;eep§ien_£;efi11e and revealed that the fathers of children with cystic fibrosis rated themselves higher than comparison fathers on physical appearance. There is no published literature that addresses a father's perceived competence or functioning within the other three domains. However, such an omission in literature further establishes the need for this study. 29 This literature review section has discussed the literature specific to the well-being, self-esteem and marital relationships of fathers with healthy children. In addition, the discussion reviewed the literature specific to fathers with chronically ill children and the possible effects fathering these children may have on their perceived self-competence domains. The discussion revealed that fathers with chronically ill children socialize frequently, invest time and energy into their jobs and perform a small number of nurturing tasks. The fathers of chronically ill children also participate little in household tasks but are greatly interested in information regarding their childrens' illnesses. Rationale for Proposed Study Many of the studies mentioned in the literature review are not recent and were conducted with small samples. Consequently, the applicability of their results to fathers today is limited. In addition, there have been few studies that address the effects of fathering a chronically ill child on self-perceptions of competence within the twelve identified domains. Therefore, this is one area that needs investigation. There has also been no examination of the possible personal growth that may result from the experience of fathering a chronically ill child. A few of the studies, which utilized comparison groups, showed that fathers of chronically ill children have a different paternal experience than fathers of healthy 30 ,children. Therefore, it is reasonable to assume that perceptions of self-competence may also differ, which substantiates the need to conduct a study that compares the self-perceptions of fathers of chronically ill children with fathers of healthy children. Methodology As was previously mentioned, this study is a secondary analysis of data collected for a larger primary study entitled, "Family Adaptation to Chronic Childhood Illness" which was conducted by Linda Spence, Carla Barnes and Patty Peek from the College of Nursing at Michigan State University. The primary research was funded by the American Lung Association of Michigan, budget amount $12,000, and also by the American Heart Association, budget amount $3,200. The focus of the primary study was to analyze the effects of having a chronically ill child on the entire family functioning. The comparison design study included all members of the family with a chronically ill child and utilized a family theory framework. In addition, the study used numerous instruments and concepts, including Harter's In contrast to the primary study, this secondary study utilizes the Adult Self-Perception Profile and focuses strictly on the data collected from the fathers of both the chronically ill children and the healthy comparison children. This study does not analyze the functioning of 31 the entire family, but is concerned only with the differences in the perceived self-competence of fathers. The methods utilized in this study are presented in this section. Sample procedures, instrumentation, scoring, data collection and data analyses are outlined. In addition, there is a discussion on study limitations and the protection of human subjects. $3199.12 The sample consisted of 45 families with 31 fathers. There were 20 fathers with a school age child (8-12 years) who had been diagnosed with a chronic illness for at least one year prior to the data collection. There were 11 comparison fathers with healthy children in the same age group. Father was defined as either a biological, adoptive or step-parent, who was currently living in the home. The chronically ill children were diagnosed with asthma, congenital heart disease, cystic fibrosis, and insulin dependent diabetes mellitus. Families with chronically ill children were recruited through the pediatric subspeciality clinics in the Department of Pediatrics and Human Development at Michigan State University. These clinics encourage patient and family participation in management. Thus, recruitment was limited to these clinics in an effort to control the philosophical approach to the medical management of chronic childhood illness. Due to the limited number of chronically 32 ill children in the diagnostic categories, all families coming to the clinic who met the criteria were asked to participate. Interested families contacted the researchers. The comparison families were recruited by being given a letter from the investigators requesting participation from local pediatricians' offices. Chi square analysis from the original analysis revealed no significant differences between the chronic illness and comparison families on the target child characteristics (age, sex and birth order). In addition, there were no differences found between the two groups of fathers on the variables of amount of time at work or type of employment. Procedures All procedures were the same for the chronically ill families and the comparison families. Families meeting the criteria received a letter explaining the study and inviting their participation from their pediatrician or pediatric sub-specialist. The letter contained a return postcard indicating willingness to participate, most convenient times to participate, and family composition. Families who returned the postcards received a follow-up phone call from the investigator to answer any questions and schedule an appointment for a home visit with the entire family. At the home visit, done by the investigator, the study was) explained to the families and questions answered. Informed consent was obtained from the adult participants and assent was obtained from the children participants. 33 Socio-demographic information was obtained from the parents by interview at the home visit. The socio- demographic data collected included: the number of parents living in the home; number of children; income level; the age, sex and birth order of the target child; the educational level, occupation, and hours working of both parents. The family members then completed a packet of instruments and the investigator was present to answer any questions. IDELIREEDE The fathers' self-competence was assessed by administering Harter's Self Pereeptien Prefile for adults, which tests both the degree of perceived competence and worth components of self-competence. The profile contains 50 items and 12 subscales (Harter, 1986). The subscales are: Sociability (n=4); Job Competence (n=4); Nurturance (n=4); Athletic Abilities (n=4); Physical Appearance (n=4); Adequate Provider (n=4); Morality (n=4); Household Management (n=4); Intimate Relationships (n=4); Intelligence (n=4); Sense of Humor (n=4); and Global Self-Worth (n=6). The first 11 subscales are domains of perceived self- competence and each is given its own score. The 12th sub- scale measures general self-worth. The domain approach is different from most instruments in that it is a multi- dimensional approach to self-esteem. This multi-dimensional approach reflects the belief that persons do not typically view themselves as equally competent in all domains (Harter, 34 1985). Therefore, in the present study, the fathers will be compared on each sub-scale. Global Self-worth is measured independently of competence judgements in order to specifically learn about how much one likes oneself as a person, not as a total score of the domains. The 50 questions are randomly mixed. The question format is forced choice on a four-point scale. The scale uses structured alternatives, which were designed to offset the tendency to give socially desirable responses (Harter, 1985). Two statements are made per item, suggesting that people could feel either way. Subjects are asked to select which adult is most like them. This type of format legitimizes either choice (Harter, 1985). The subjects then indicate how true this statement is for them. A sample question is: Realty Son of Son at Reelly True True True True for Me for Me for Me for Me Some adults are not very SUI Other adults are sociable So, if individuals check the question as really true for them on the left side, they are answering that they are similar to those adults that are not very sociable. The wording of the items was counterbalanced so that half of the items started with a positive statement and half started with a negative statement. The general scoring procedure is to score each item on a scale of 1 to 4, where a score of 1 indicates low perceived competence/adequacy and 35 a score of 4 reflects high perceived competence/adequacy on that question. Mean scores for each sub-scale are obtained by adding the four items and dividing by four (with the exception of global self-worth, which requires adding six items and dividing by six). These mean scores, which will range from 1 to 4, will depict the individual's profile of perceived competence across the eleven domains, plus global self- worth. Harter (1985) administered the scale to many samples, one of which included 44 full-time working fathers of upper middle class families. All subjects had completed high school with the majority having finished college. The sample was drawn from Colorado. The Cronbach's alpha coefficients of reliability for the Self-Perception Profile subscales were: .91 for Global Self— Worth (n=6); .75 for Job Competence (n=4); .75 for Intelligence (n=4); .87 for Athletic Ability (n=4); .87 for Physical Appearance (n=4); .63 for Sense of Humor (n=4); .74 for Sociability (n=4); .88 for Intimate Relationships (n=4); .63 for Morality (n=4); .87 for Nurturance (n=4); .88 for Household Management (n=4); and .83 for Adequate Provider (n=4). Each sub-scale yielded a high alpha coefficient indicating a high degree of internal consistency for the subscales. The internal consistency determines the extent to which all items on a particular sub-scale consistently contribute to the overall measurement of a concept by correlating the individual items 36 on a sub-scale with each other and with the overall score (Polit & Hungler, 1991). A reliability study of the twelve sub-scales was performed for this study. The reliability was tested using Cronbach’s alpha correlational analysis of internal consistency. Table 1 reports the alpha coefficients for the twelve sub-scales from this study. As illustrated, eight out of the twelve sub-scales; sociability, nurturance, athletic ability, physical appearance, adequate provider, intimate relationships, intelligence and global self-worth had alpha coefficients of .70 or higher. This is considered acceptable correlations for this type of analysis (Polit & Hungler, 1991). The morality, household management, and humor sub-scales all had alpha coefficients lower than .70. These alphas indicate that the responses from the subjects to these questions showed considerable variation and therefore the items within these scales were not consistently measuring the same concepts. This study will still analyze and discuss the results of the morality, household management and humor sub-scales. However, their low alphas will decrease the results significance. 37 unable am Sociability .78 Job Competence .32 Nurturance .70 Athletic .85 Physical .70 Adequate Provider .85 Morality .60 Household Management .65 Intimate Relationships .77 Intelligence .75 Humor‘ .64 Global Self-Worth .88 The job competence sub-scale had an alpha of .32 and an inter-item correlation of .06. Thus, any results from this sub-scale would not reflect the fathers' levels of perceived self-competence in the domain of job competence. Therefore, this domain will not be interpreted in the discussion section. Included in Harter's AQQlL_§§1I:E§12§2§19n_212£112 is an importance rating scale, which is used to asses the importance of success in each of the eleven specific domains for the individual. However, the importance scale was not administered to the fathers in the primary study. Therefore, the importance aspect of perceived self- competence will not be assessed or examined in this study. 38 Design This research study is a non-experimental comparison design study because two groups are being compared on some criteria and the independent variable cannot be manipulated. The two groups are fathers with chronically ill children and fathers with healthy children. The independent variable is the child's health status (i.e., chronically ill vs. healthy) and the dependent variable is perceived self- competence. The study is not an experimental design because there is neither random group assignment nor intervention or manipulation of the independent variable. M11515 Data for this research study was analyzed using the Statistical Package for the Social Sciences (SPSS). The oneway ANOVA was performed to test the differences between the two groups on their responses to the twelve sub-scales from Ihe_Age1g_§el£;£e:eep§ien_£zefiile. The oneway ANOVA is an inferential statistical procedure that is used to compare the means of two groups on their values for one variable. The oneway ANOVA tested the differences between the groups of fathers on the following dependent variables of: perceived sociability, perceived job competence, perceived nurturance, perceived athletic abilities, perceived physical appearance, perceived provider adequacy, perceived morality, perceived household management, perceived intimate relationships, perceived intelligence, perceived sense of 39 humor and perceived global self-worth. The sub-scales were scored by obtaining the means for each sub-scale. The socio-demographic variables are presented for both groups. The fathers' ages, education level, full/part time work, family income, age of target child, number of children in the home and type of father (adoptive, biological, or step) were examined using descriptive statistics. E II J E ii i!' El] 1! . l] The independent variable of the child's health status was operationalized by the establishment of criteria which determined whether the child was either chronically ill or healthy. The criteria for the chronically ill child included: verification of a chronic illness by a physician at the pediatric sub-specialty clinics in the Department of Pediatrics and Human Development at Michigan State University; initial diagnosis of the illness was at least one year prior to the data being collected; the chronic illness being either asthma, cystic fibrosis, diabetes mellitus or a congenital heart defect; and the child must have been between the ages of 8-12 years at the time the data were collected. The healthy child was also required to be between the ages of 8-12 years, and needed verification from a parent that the child had not been diagnosed or treated for any kind of chronic illness or developmental disability. . The dependent variable of perceived self-competence was operationalized by the self-report of each father completing 40 the Aggie Self-PerceQEiog Profile. More specifically, the dependent variable domains were operationalized as follows: Perceived Sociability - (The mean of questions 2, 14, 27, 39). This variable measures one's behavior in the presence of other people. Included are items that suggest that one is fun to be with and one is at ease with people. Perceived Job Competence - (The mean of questions 3, 15, 28, 40). The items in the profile refer to feeling productive and proud of one's work. Perceived Nurturance - (The mean of questions 4, 16, 29, 42). This is tapped by items which refer to fostering the growth of others and caring for others. Athletic Competence - (The mean of questions 5, 18, 30, 43). These items tap one's sense of competence in sports, one's willingness to participate in and to try new physical activities. Physical Appearance - (The mean of questions 6, 19, 31, 44). These items refer to the way one feels about the way one looks and how satisfied one is with one's looks. Adequate Provider - (The mean of questions 7, 20, 32, 45). These items refer to meeting one’s own material needs as well as those of others important in one's life. Morality - (The mean of questions 8, 21, 34, 46). Items refer to living up to one’s moral standards and feeling that one's behavior is ethical. Household Management - (The mean of questions 10, 22, 35, 47). These items focus on being organized at household 41 tasks, being efficient, and keeping the household running smoothly. Intimate Relationships - (The mean of questions 11, 23, 36, 48). This is described by the items as seeking out close, intimate relationships and feeling free to communicate openly in one's relationships. Intelligence - (The mean of questions 12, 24, 37, 49). These items refer to feeling smart, understanding things and feeling intellectually capable. Sense of Humor - (The mean of questions 13, 26, 38, 50). The humor domain is tapped by items that show one has the ability to laugh at oneself and finds it easy to joke or kid around. Global Self-Worth - (The mean of questions 1, 9, 17, 25, 33, 41). Self-Worth is tapped by items such as liking the way one is leading one's life and being pleased with oneself. The twelve domains of perceived self-competence have been operationally defined. W There are three limitations to this study. First, although there was a comparison of families on key variables, the ability to generalize this study's results are limited. This is due to: the sampling design, a non- probability convenience sample, the difference in the two group sample sizes and because of the small size of the samples. Second, the primary study did not utilize the 42 importance rating scale when administering the Adeit Self- 2e;eep§ien_£;efii1e to the family members. Thus, a fully comprehensive assessment of the father's perceived self- competence was not performed. Finally, data collection regarding socio-demographics was self-reported by participants. No attempt was made to verify information through other sources. PW The rights of the individuals who participated in the original study were protected according to the guidelines developed by the University Committee on Research Involving Human Subjects (UCRIHS) at Michigan State University, as well as the Institutional Review Board of the hospital in which the Cystic Fibrosis clinic was located. All other clinics were on the Michigan State University campus. Approval to conduct the current study was received from UCRIHS prior to data analysis. The identity of all study participants remained confidential to this investigator. The list of participants' names and addresses was used in the primary study for the initial phone calls and home visits only, and no records identified by name were kept thereafter. The responses of all study participants remained anonymous. The participants' responses to the instruments/questionnaires were not coded in any way to identify participants. In addition, the responses were recorded in such a way that 43 they could not be linked to any participant. This investigator was only given a disk of the coded data. Hypotheses The following eight hypotheses are based on the literature specific to fathers with chronically ill children and fathers with healthy children. In addition, the hypotheses are based on this researchers clinical observations while working with fathers. The hypotheses will be tested using oneway ANOVA at the .05 significance level (1) Fathers of chronically ill children will have higher scores of perceived competence in the sociability domain than fathers of healthy children. (2) Fathers of chronically ill children will have higher scores of perceived competence in the job competence domain than fathers of healthy children. (3) Fathers of chronically ill children will have lower scores of perceived competence in the nurturance domain than fathers of healthy children. (4) Fathers of chronically ill children will have lower scores of perceived competence in the intimate relationships domain than fathers of healthy children. (5) Fathers of chronically ill children will have lower scores of perceived competence in the household management domain than fathers of healthy children. 44 (6) Fathers of chronically ill children will have lower scores of perceived competence in the global self-worth domain than fathers of healthy children. (7) Fathers of chronically ill children will have higher scores of perceived competence in the adequate provider domain than fathers of healthy children. (8) Fathers of chronically ill children will have higher scores of perceived competence in the intelligence domain than fathers of healthy children. Due to the lack of literature and clinical observations on the following four domains the null hypotheses was tested in order to establish any differences between the two groups. These hypotheses were tested with oneway ANOVA at the .05 significance level. (9) There will be no differences between fathers with chronically ill children and fathers with healthy children in the perceived competence domain of athletic ability. (10) There will be no differences between fathers with chronically ill children and fathers with healthy children on the perceived competence domain of physical appearance. (11) There will be no differences between fathers of chronically ill children and fathers of healthy children on the perceived competence domain of morality. (12) There will be no differences between fathers of chronically ill children and fathers of healthy children on the perceived competence domain of sense of humor. 45 Findings The results described in this section are compiled from the self-reports of the 31 total subjects who participated in the study. Included are tables showing the socio- demographic characteristics of the sample and the results of the data analyses. W The subjects in the sample consisted of two groups: 20 fathers in the target group and 11 fathers in the comparison group. The two groups were composed of fathers between the ages of 25 and 49. The mean age was 37.89 years for the target group and 39.4 for the comparison group. T-test analyses of the age variable revealed no significant differences between the two groups (t=.59, df 27, NS). As illustrated in Table 2, the majority of both sample groups work full-time (target=90%, comparison 100%). Over half of the target group sample (60%) reported that they had attended college for one year or more while the comparison group reported a higher percentage of college attendance (82%). T-test.analyses of the education variable revealed 0 significant difference between the two groups (t=.09, df 29, NS). Forty-five percent of the target fathers and 82 percent of the comparison fathers have a salary range of $45,000 or above. However, this difference was not found to be significant with T-test analyses (t=1.23, df 29, NS). In addition, the age of the subject child differed little 46 Table 2 1111211 mans-222 W An S l n 1 25-30 years 1 5 0 0 31-34 years 3 15 2 18 35-39 years 10 55 2 18 40-44 years 3 l5 5 55 45-50 years 2 10 l 9 (1 missing) (1 missing) atu Mean - 37.89 Mean - 39.4 Full time 18 90 11 100 Part time 1 5 0 0 Retired 1 5 0 0 el duca a High School Graduate 3 25 0 0 Business/Trade School] Junior College 3 15 2 18 Some college 6 30 2 18 College graduate 3 15 3 27 Post-graduate 3 15 4 37 fieiggz Range 12,000-19,999 3 15 0 0 20,000-29,999 3 15 4 37 30,000-44,999 5 25 0 0 45,000-64,999 6 30 3 27 65,000-74,999 1 5 3 27 > 75,000 2 10 l -9 Age_e‘_§hiig Mban 1- 9.25 Mean .— 9.69 Range - 7-12 Range . 7-12 mm "0m ' 2-8 "0m ' 2-36 W Biological 17 85 11 100 Adoptive 2 10 O 0 Step-Father 1 5 0 0 47 between the two groups with a target mean of 9.25 years and a comparison mean of 9.69 and was not significant (t=1.13, df 29, NS). The number of children in the home varied only slightly between the two groups and was also not significant (t=1.23, df 29, NS). Lastly, while the target group did have two adoptive fathers and one stepfather, the comparison group had 100 percent biological fathers. WM Oneway ANOVA was conducted to test the twelve hypotheses to determine if a child's health status affects a father’s perceived self-competence. The results of the ANOVA, including the means, standard deviations and F ratios of each domain are summarized for both groups in Table 3 and are discussed in detail below. Hypothesis 1: Fathers of chronically ill children will have higher scores of perceived self-competence in the sociability domain than fathers of healthy children. This hypothesis was accepted. The fathers of the chronically ill children scored higher (M=3.215, sd=.62) than the comparison fathers (M=2.57, sd=.51) in the sociability domain. The oneway ANOVA revealed that the difference between these scores was significant (F(1,29)=6.55, p<.013). Hypothesis 2: Fathers of chronically ill children will have higher scores of perceived job competence than fathers of healthy children. This hypothesis was not accepted. The ANOVA revealed that there was no significant difference between the target fathers' score (M=3.4, sd.38) and those 48 Table 3 Emma Igualmmus a 8 HEM iii—"29.). $93.1). 19:11). Hum EJL Hum. EJL £1 inn LLJEI Household Management 2 90 .53 2.79 .40 0.320 .675 Physical Appearance 2 98 .53 2.61 .50 3.660 .065 Athletic Competence 3 ll .69 2.72 .77 2.040 .160 Sociability 3 21 .62 2.57 .51 6.550 .013* Job Competence 3 41 .38 3.27 .51 0.752 .392 Nurturance 3 33 .56 2.84 .68 4.570 .041* Adequate Provider 3.02 .69 3.04 .67 0.006 .937 Morality 3.22 .37 3.34 .36 0.709 .406 Intimate Relationships 2.90 .57 2.52 .48 3.450 .073 Intelligence 3.25 .57 3.20 .29 0.059 .808 Humor 3 33 .70 3.31 .49 0.006 .936 Global Self-Worth 3.23 .60 3.12 62 0.240 627 * - significant difference of the comparison fathers (M=3.3, sd.50) in the job competence domain (F(1,29)=.75, p>.05). Hypothesis 3: Fathers of chronically ill children will have lower scores of perceived nurturance than fathers of healthy children. This hypothesis was not accepted. The target fathers scored significantly higher (M=3.3, sd.55) than the comparison fathers (M=2.8, sd.68) in the nurturance domain (F(1,29)=4.57, p<.05). Hypothesis 4: Fathers of chronically ill children will have lower scores of perceived intimate relationships than fathers of healthy children. This hypothesis was not accepted. While the target fathers scored higher (M=2.9, sd.57) than the comparison group (M=2.5, sd.57) in this 49 domain, the difference in scores was not significant (F(1,29)=3.4, p>.05). Hypothesis 5: Fathers of chronically ill children will have lower perceived household management competence than fathers of healthy children. .This hypotheses was not accepted. The target fathers scored higher (M=2.9, sd.53) than the comparison fathers (M=2.79, sd.40). However, the oneway ANOVA revealed that the difference was not significant (F(1,29)=.32, p>.05). Hypothesis 6: Fathers of chronically ill children will score lower on perceived global self-worth than fathers of healthy children. The target fathers did score higher (M-3.2, sd.60) than the comparison fathers (M=3.12, sd.61) in this domain. However, there was not a significant difference (F(1,29)=.24, p>.05) and, thus, the hypothesis was not accepted. Hypothesis 7: Fathers of chronically ill children will have higher adequate provider scores than fathers of healthy children. The hypothesis was not accepted. While the target fathers scored lower (M=3.02, sd.70) than the comparison fathers (M=3.04, sd.66) in the adequate provider domain, the ANOVA revealed that the differences were not significant (F(1,29)=.006, p>.05). Hypothesis 8: Fathers of chronically ill children will have higher scores in the intellectual competence domain than fathers of healthy children. The target fathers did score higher (M=3.25, sd.57) than the comparison fathers 50 (M=3.20, sd.29), as anticipated. However, the differences were not significant (F(1,29)=.05, p>.05). As a result, this hypothesis was not accepted. Hypothesis 9, 10, 11, 12. The null hypotheses that there will be no differences between fathers with chronically ill children and fathers with healthy children in the athletic ability, physical appearance, morality and humor domains, were accepted (See Table 3). The target fathers scored somewhat higher than the comparison fathers on the athletic ability, physical appearance, and humor domains, while the comparison fathers scored higher than the target fathers in the morality domain. However, the ANOVA revealed that none of these differences were significant. The results of the humor and morality domains are limited in accuracy due to their low reliability alphas (humor-.64; morality=.60). In summary, the fathers of chronically ill children scored higher than fathers with healthy children in the sociability, job competence, nurturance, intimate relationships, global self-worth, physical appearance, intelligence, athletic ability, household management and sense of humor domains. Most importantly, the differences in the sociability and nurturance domains were statistically significant. The fathers of chronically ill children scored lower than those of healthy children in the adequate provider and morality domains. These differences were not found to be statistically significant. The possible reasons 51 for these results and their implications will be discussed it the next section. Discussion This section will interpret the results of the study in several aspects. First, there is a discussion of the findings related to the characteristics of the samples. This discussion is followed by an interpretation of the results of the analyses. In addition, implications of study findings in terms of RAM and the CNS's role in the primary health care setting are presented. Finally, topics for future research are suggested. This study utilized a convenience sampling method resulting in a small, fairly homogenous sample. Both groups were highly educated, had reported incomes of $45,000 or more and were employed full-time. Because this was a comparison study such homogeneity is very important. The two groups should be comparable on the major extraneous variables, ideally differing only in the independent variable (Brink & Wood, 1988). This allows the researcher to be more confident that any effects found on the dependent variable (perceived self-competence) are truly linked to the independent variable (child's health status). Because the two groups in this study were fairly homogenous, it decreases the likelihood that the identified socio- demographic variables played much of a role in the findings. 52 However, there are other characteristics within the RAM framework that could influence the effects of a child's health status on the father's perceived self-competence, such as the amount of social support for the father, the degree of knowledge obtained by the father regarding the child's health status and the severity of the child's health status. Because this information was not obtained in the primary study, and thus, was not available, it is possible that these factors had an unknown affect on the results of this study. Information on these variables would not only allow for a more comprehensive comparison between groups, but also within the two groups. The limited size of the sample is also problematic because it limits the researcher’s ability to infer results to the larger population. In this study, ten out of twelve domains did not have statistically significant differences between the two groups. This is perhaps due to the small sample sizes. Small sample sizes make it more difficult to find statistically significant differences between the two groups (Brink & Wood, 1988). As a result, the implications of this study are limited in their scope. W In order to answer the research question of whether a child's health status affects a father’s perceived self- competence, the twelve hypotheses posed in this investigation must be discussed separately. 53 The twelve hypotheses were based on RAM, which indicates that a child's health status may have direct effects, either positively or negatively, on a father's perceived self- competence within twelve domains. Two of the twelve domains, sociability and nurturance, showed significant differences between the target fathers and the comparison fathers. The remaining domains of household management, intimate relationships, morality, global self-worth, physical appearance, athletic ability, humor, job competence, adequate provider, and intelligence did not yield statistically significant effects on the fathers. However, the results in these domains may still provide beginning conclusions about the effects of a child's health status on the father’s perceived self-competence. Hypothesis #1. The target fathers will score higher than the comparison fathers in the sociability domain. This investigation found increased sociability in fathers with chronically ill children compared to fathers with healthy children as was predicted by this researcher and supported by other investigators (Barnes, 1992; Timko et al., 1991). The fathers of the chronically ill children felt they were more social, enjoyable to be around, and comfortable with others than the fathers of healthy children. It may be that socializing is a way for the father to cope with a difficult situation. The fathers of the chronically ill children might take on an increased role in planning social activities for the family if the mother 54 is often the primary care giver. The higher scores within the sociability domain might also be related to possible social support accessible to these fathers. Findings of increased perceived sociability of the target fathers may have been slightly influenced by the fact that one of the target fathers was retired and another worked part-time. However, closer examination of these fathers' responses indicates that their scores were consistent with the mean and so significant influence from the two subjects is unlikely. Hypothesis #2: The target fathers will have higher scores of perceived job competence than fathers in the comparison group. The reliability of the job competence sub-scale was low with an alpha of .32. Therefore, the internal consistency for this sub-scale is questionable and there was no discussion or analysis of this hypothesis. Hypothesis #3: Fathers of chronically ill children will score lower on perceived nurturance than fathers of healthy children. This investigation did not find that a child’s chronic health status decreased a father's perceived nurturance. Instead, fathers of chronically ill children scored significantly higher than the fathers with healthy children. This finding contrasts with those of other investigators (Goldberg et al., 1990; Timko et al., 1991), who found that fathers of children with cystic fibrosis and Juvenile 55 Rheumatic Disease scored lower on parental competence scales. This study found that the fathers with chronically ill children felt that they were good at and enjoyed nurturing others and gained a sense of contribution from doing so. This unexpected result may be due to several factors. First, chronically ill children require high-level care- giving skills that, according to other investigators (Barsch, 1968; Allan, 1974), are often carried out by the mothers. As a result, the target fathers in this sample may actually have taken on a greater role in taking care of their children than the comparison fathers. Secondly, the feelings of increased nurturance competency may be attributed to the fact that fathers of healthy children interact less with health care providers who encourage father participation in nurturing their children. There may also be cultural differences between the two sample groups that influence the fathers' beliefs about nurturing. Whether any of these factors affected the results of this study cannot be determined because information concerning them was not collected at the time of the survey. Hypothesis #4. The fathers with chronically ill children will score lower on the intimate relationships domain than fathers with healthy children. This study revealed that the target fathers scored higher within the intimate relationships domain than fathers with healthy children. However, the difference between 56 scores was not significant. This finding supports Sabbeth and Leventhal's (1984) work that chronic childhood illness has either no affect, or some positive influence on the marital relationship. It should be noted that both groups scored about average in this domain. However, for both groups they scored themselves lowest in this domain. This finding indicates that regardless of a child’s health status, intimate relationships could potentially be difficult for fathers. Hypothesis #5: Fathers of chronically ill children will have lower scores in the competence domain of household management than fathers of healthy children. This investigation did not support this prediction. Instead, the fathers of chronically ill children scored slightly higher on household management competence than fathers of healthy children. This finding is consistent with Harter's study instrument, which defines household management in terms of the ability to stay organized in managing activities at home. Managing the household may become an increased role for the fathers with chronically ill children, especially if the mother is the primary care giver. These findings add a new dimension to research accumulated by other investigators which found that fathers perform only a small number of household tasks (Brownstein & Cowan, 1990; Nagy & Ungerer, 1990). An issue which remains to be explored in future research is whether there is a relationship between the difference in functioning level in 57 the household and an increased level of perceived competency in this domain for fathers of chronically ill children. Hypothesis #6. The fathers with chronically ill children will have lower scores in the global self-worth domain than fathers of healthy children. This study did not support the prediction that target fathers would score lower on the global self-worth domain. Instead, these fathers scored higher in global self-worth, even though the difference was not significant. The higher target father scores contrast with those of most other investigators who found that fathers of chronically ill children scored lower on overall competence, self-esteem and depression (Cummings, 1976; Gayton et al., 1977; & Goldberg et al., 1990). It might be inferred that having a child with a chronic illness, particularly a genetic illness, would lower the fathers feeling of self-worth. However, these results indicate that the fathers of chronically ill children are happy with the way they are leading their lives, with themselves, and with the kind of person they are. Although the fathers may not be able to "make" their children well, they are able to do some things to make their children feel better. Hypothesis #7: The fathers of chronically ill children will score higher in the adequate provider domain than fathers with healthy children. This investigation did not support this hypotheses that target fathers would score lower then fathers with 58 healthy children. The target fathers scored slightly, but not significantly lower, than the comparison fathers. In addition, both scored quite high in this domain. Although there have been no known investigations specific to fathers’ perception of adequate provider, this researcher's clinical observations support such high scores. Hypotheses #8: The fathers will have higher scores of perceived competence in the intelligence domain than the fathers with healthy children. This study did not find a significant difference in the scores on the intelligence self-competency between the two groups. However, the target fathers' scores were slightly higher. The intelligence sub-scale focuses on whether one views himself as smart or as intelligent as others. These results may be explained by the work of other investigators (Hymovich & Baker, 1985; McCubbin & McCubbin, 1983; Simon & Smith, 1992), who found that understanding things and obtaining information is a frequent coping strategy utilized by fathers with chronically ill children. As a result, these fathers may have an increased understanding of their children's health status and in turn are more confident in their intellectual skills. Hypotheses #9, 10, 11, 12: There will be no differences between the two father groups in the perceived competence domains of athletic ability, physical appearance, morality, and sense of humor. 59 This investigation did not find any significant differences between the two groups within these four domains. Because of the lack of research about these domains, interpretation is difficult. In addition, the alpha for the morality sub-scale was only .60 and the humor sub-scale was .64. Therefore, the results from this study on these two domains have limited significance. Overall, the findings from this investigation indicate that both groups of fathers scored high in all of the domains of perceived self-competence. In addition, the fathers of the chronically ill children perceived themselves to be more competent in the domains of sociability and nurturance than the fathers of healthy children. These results lead this investigator to conclude that a child's health status may affect a father's perceived self- competence. These effects are mostly positive on the fathers especially in the perceived self-competence domains of nurturance and sociability. The positive effects discovered in this study contradict the major thrust of research involving fathers of chronically ill children which emphasized the negative incidence of psychopathology (Cummings, 1976; Gayton et al., 1977). This research provides evidence that indicate fathers rise to the challenge of providing for children with a chronic health condition. Data from this research also indicates a need for future work to focus on assessing 60 father and family strengths such as flexibility, cohesiveness and presence of support. There are several limitations to this investigation that may have influenced the results. The generalizability of the results of this investigation is limited because of the small sample. In addition, information about important characteristic variables was not available (e.g., knowledge of illness, social support, cultural beliefs) and the importance rating scale within the Adult Selfi-Eereeptien Ezefiile was not included in the study. Although the results of the 50 item questionnaire of The AQ2lL_§§l£:E§£E§EL12D_£IQIil§ reveal a lot of information about the level of competence a subject has in a certain domain, it does not allow an investigator to determine whether competency within that domain is important to the subject. This missing information is important in order to determine the significance of each subjects' perceived competence. More specifically, Harter (1985) claims that low competency scores affect one’s self-concept only if it is in an area which is very important to the person. Implications Taking into consideration limitations of this study, the next section will present the implications of this study for the RAM, for the CNS in the primary care setting, and for further research. 61 MW The framework utilized for this investigation was part of Roy's Adaptation Model. The framework establishes that the focal stimuli of a child's health status in combination with the contextual stimuli, can have direct effects on a father's self-concept effector mode, which includes perceived self-competence. In addition, RAM claims that stimuli can have either positive or negative effects on both the effector modes and overall adaptation. Therefore, the results of this study indicated that the focal stimuli of a child’s health status does have effects on the effector modes of adaptation. In addition, Roy’s framework clearly identifies the proper focus of the CNS as manipulating environmental stimuli, thus, making it easier to identify the many implications for the CNS within the primary care setting. W Managing the care of a family with a chronically ill child is part of advanced clinical practice within the primary care setting. In addition, understanding each family member’s response, including the father's, is important for managing their care. This requires the expertise of the CNS as assessor, counselor, educator, advocate, planner and evaluator. In addition, all fathers regardless of the health status of their children might benefit from the expertise of the CNS. RAM provides a 62 framework to implement these roles and to plan strategies for fathers within the primary care setting. This study demonstrates that fathers of both groups had moderately high scores within all twelve domains. However, the CNS must still be aware that the fathers of chronically ill children scored significantly higher in the sociability and nurturance domains than the fathers of healthy children. The fathers of chronically ill children felt they were more social, enjoyable to be around and comfortable with others than fathers of healthy children. The fathers of healthy children also felt they were good at nurturing others. In addition, both groups had their lowest scores within the intimate relationships domains. Thus, the CNS can begin with the role of assessor. The CNS can play a vital role in assessing the effects of a child's health status on all fathers within the primary care setting. According to RAM, the assessment must be a comprehensive assessment of not only the level of self- competence within the self—concept effector mode, but must also include an assessment of the other contextual stimuli associated with a child's health status. The assessor should also be aware of any problems within the other three effector modes of; physiological, role, and interdependence. Such a comprehensive assessment is important because the focal stimuli of a child's health status affects all of the effector modes. In addition, if there is a problem within the self-concept mode (decreased self-competence), the CNS 63 must be aware that a self-concept problem will affect the other effector modes and, thus, influence adaptation. However, if there is high perceived self-competence, it may in turn assist any potential problems within the other three modes, thus, increasing adaptation. Study findings indicate that the CNS should expect to assess that fathers with chronically ill children will have high scores within the sociability and nurturance domains. Therefore, the CNS can assist the fathers in utilizing their high nurturance and socialization competencies as a resource for adaptation to other domains and stimuli. More specifically, fathers with chronically ill children would most likely respond to interventions that add to their environment, such as support groups or social functions with other fathers of chronically ill children. Such interventions would allow the fathers to use their strength within the self-concept mode to address other potential problems they might have with adaptation. Because these fathers also feel competent in their ability to nurture, they should be encouraged to participate in these roles and positively reinforced for doing so. This participation will allow for equal sharing of the burdens often associated with a chronically ill child between members and will potentially increase family functioning. This study also indicates that men who become fathers of healthy children would have decreased perceived competencies in their abilities to socialize and nurture compared to 64 fathers with chronically ill children. The CNS would need to establish strategies according to RAM to address these perceptions. The CNS should assess any informational needs that the fathers might have regarding growth and development or care of the children. In addition, an assessment of the amount of social support received by these fathers is important. If deficiencies are noted, the CNS may encourage and assist the fathers to increase their social support. However, it should also be remembered that the assessment of perceived self-competence may be quite different for fathers of different cultures or populations. For instance, fathers of lower income status, or varied ethnic origins may not have the resources. Therefore, the CNS may need to direct interventions more towards an educator and facilitator by informing and locating any services the fathers or their children would need. The CNS, regardless of the child's health status, can deal with fathers directly in the primary care setting and meet their needs. The CNS should establish relationships with the fathers and their families that are built on mutual trust and respect. Doing so will allow the CNS to develop and conduct a continual, comprehensive and coordinated plan of care, as is the function of primary care. Serving and facilitating this function will also allow the CNS to increase adaptation for all fathers. Another function of the CNS in the primary care setting is to be easily accessible. Accessibility is often 65 difficult for fathers who usually work during the week. In addition, most chronically ill children are brought into the health care setting by their mothers, not their fathers. Therefore, the CNS must implement strategies that will make it easier to access the fathers of chronically ill children. The CNS could have office hours and father support group meetings in the evenings and on the weekends. In addition, the CNS could make visits to the fathers' homes or places of employment. The study findings also indicate that both groups of fathers perceived their lowest competencies within the intimate relationships domain. As the literature review and application of the theoretical framework identified, becoming a parent was found to potentially decrease mens' marital satisfaction, which puts them at risk for symptoms of depression, stress and ineffective adaptation. Therefore, the CNS in the role of counselor should allow the fathers to express their concerns about their relationships and use problem-solving skills to increase adaptation. The CNS as a counselor is also responsible for assessing when the fathers might need more extensive emotional assistance from mental health professionals. In order to meet the needs of fathers with chronically ill children, the CNS may need to facilitate family conferences. This intervention would also assist the CNS in identifying and meeting the needs of all family members.. Family conferences would focus on establishing a trusting 66 relationship with and among all family members so that they will feel comfortable verbalizing their perceptions and needs. The expected outcome of the conferences is to maintain or increase family functioning. This study also underscores the importance of the CNS to implement the role of educator with fathers within the primary care setting. More specifically, these results can be shared with both groups of fathers to increase their awareness of perceived self-competence and the possible stimuli that affect it. Thus, the CNS would inform these fathers that both groups of fathers scored high within all twelve domains. Another educational intervention that should be provided to fathers by the CNS is anticipatory guidance. The CNS can discuss with fathers factors that may or may not put them at risk for ineffective adaptation. Most especially, the CNS would need to ensure that fathers, regardless of health status, have strong social support and all of the relevant knowledge available regarding their children's health status. The CNS must also educate other health professionals on the potential effects of a child's health status on father's perceived self-competence. Interventions might include speaking at workshops, peer groups and research presentations. In addition, the CNS should encourage programs that educate other advanced practice nurses to include this information in their curricula. Sharing the 67 positive results obtained from this study with other health professionals will alter expectations that fathers of chronically ill children adapt negatively. Therefore, the health care professionals will interact more positively with fathers of chronically ill children. The CNS needs to take an active role with all members of the health care team in establishing a comprehensive care plan specific to fathers and their children's health status. The plan should include: anticipating positive as well as potential negative effects that might be experienced by fathers, determining holistic strategies to promote or prevent the effects of fathering on adaptation, and establishing acceptable outcomes for fathers. Lastly, the CNS needs to evaluate the plan when it is utilized with fathers. The evaluation process needs to be a continual part of the CNS role with all fathers. The results of an evaluation will assist the CNS in determining if the interventions utilized with these fathers are producing the expected outcomes. This researcher's ability to further interpret these findings is somewhat limited by the fact that the fathers with chronically ill children did not experience the effects on their perceived self-competence as predicted. However, it can be seen from the discussion above that the CNS can still use the results within the primary care setting to meet the needs of fathers. 68 s the esea ch Future studies regarding the effects of a child's health status on a father's adaptation should have two focuses. First, future studies should focus on the same research question, but be replicated without the limitations of this study. Second, investigations of the future need to examine the new research questions that are the consequence of this study. The following discussion will examine both focuses. This study was limited by its small sample groups that do not represent the population of fathers as a whole. Future research warrants larger sample groups with more generalizable population representation to increase the implications of the findings. The fact that the sample groups were mostly homogenous in the variables of income, education and employment status is in accordance with the assumptions of comparison studies. However, this study compared mostly highly educated fathers who earned high incomes. Therefore, it becomes very difficult for these results to be generalized to other father groups. Future studies conducted by the CNS need to examine different groups. More specifically, the CNS needs to understand the effects of having a chronically ill child on a father who has less education, a lower income level and is unemployed. The missing characteristic variables make it difficult to make conclusions about the study results. This study was unable to clearly separate the impact of culture, the amount 69 of social support, knowledge and severity of the child's illness on the father's perceived self-competence. Therefore, future studies need to collect data on these important characteristic variables. Future studies may also evaluate the use of Harter's Age1L_§e1£;£e;eep§ien_2ze§ile. Although the profile revealed information about the father’s perceived self- competence, it also had several sub-scales with questionable reliabilities. In addition, the scale has been utilized mostly with middle to upper-middle class groups. Therefore, its reliability and validity with other groups may be questionable. Future studies could adapt the instrument to the father population by adding more items to the sub- scales. There are several new research questions that need to be examined as a result of this study. First, what is the effect of a child's health status on a father's perceived self-competence over an extended period of time or initially after the birth of a chronically ill child? This study reveals that positive effects are found after the man has been a father for only approximately 8-12 years. The CNS could conduct a longitudinal study that follows fathers from conception and beyond. An understanding of the effects of fathering a child over a longer time-period would give valuable information to the CNS that provides anticipatory guidance to fathers. 70 The second research question that is a result of this study is, are there are any correlations between the characteristic variables or contextual stimuli of: knowledge of health status, social support, income, culture, severity of illness, education level, age of child, number of children, type of occupation, and a father's perceived self- competence. The information gained from this type of inquiry would give further insight as to what variables might assist a father in coping with his chronically ill child or put him at risk for maladaptation. This study also leads one to inquire as to whether a child's health status also has positive effects on the father's other effector modes identified in RAM. More specifically, does fathering a chronically ill child have effects on the physiological, role function or interdependence modes of the father? Investigations that focus on the other three effector modes would allow for a more holistic approach to fathers. Another focus of future research questions would be to determine whether the positive effects of fathering chronically ill children on perceived self-competence are reflective of overall father adaptation and functioning. More specifically, are fathers with a high perceived self- competence functioning at high levels? Is there a true relationship between the level of perceived self-competence and individual or family functioning? The answers to these questions would verify that interventions focused at 71 increasing perceived self-competence will increase adaptation. Lastly, future research needs to utilize an experimental design study to assess what specific interventions performed by health care providers positively influence fathers' perceived self-competencies and their overall adaptation. Answers to this question will allow the CNS to evaluate the effectiveness of his/her interventions and will guide the CNS when trying to meet the needs of fathers. Conclusion This thesis study has presented the tremendous lack of current literature regarding fathers, most especially those with chronically ill children. The little literature that is available, emphasizes psychopathology instead of searching for positive adaptation. The positive significant findings found in this study within the sociability and nurturance domains indicate a need for future study and interventions to be directed towards the positive impact of a children's health status on fathers, mothers, sibling and family function. Studies of these dimensions would be useful for the CNS and other health care professionals within the primary care setting that deal with these families directly. LIST OF REFERENCES LIST OF REFERENCES Allan, J. T. (1974). Family responses to cystic fibrosis. Au_trali_n_£a_diatris_iournal 10(8). 136- 146- Barnes. C-L- (1992. February)- The_innact_2f_cxstic fibr2sis_2n_parentsi_self__snnetense -c . Paper presented at 11th annual research conference for Sigma Theta Tau International, Tampa, Florida. Barsch. R- (1968). The_narent_of_the_handissnned_cnildi_a siudx_2f_child_rearins_nractices. Chicago= Charles E- Thomas. Brink. P-J-. & Wood. M-J- (1988). Adzanced_desisns_in nursing_research. Newbury Park. 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Schilling, R., Schinke, P., 6 Kirkham, M. (1985). Coping with a handicapped child: Differences between mothers and fathers. §ooidl_§oienoe_and_nedioine 21(8). 857- 863. Schobinger, R., Florin, I., Zimmer, C., Lindeman, H., 6 Winter, H. (1992). Childhood asthma: Paternal critical attitude and father-child interaction. l2§£fldl.9£ BorehosomariooBessaroh. 15(8). 743-750. Silbert, A.R., Newburger, J.W. 6 Fyler, D.C. (1982). Marital stability and congenital heart defects. Pediatrics. 62(3). 747-750. Simon, N., 6 Smith, D. (1992). Living with chronic pediatric liver disease: The parents' experience. 22913§Ii£.fl22§1n9: 15(5): 453‘458- Thomas, R.D. (1984). Nursing assessment of childhood chronic conditions. Eedieenie Nunsing, 1(5), 165-176. 75 Timko, C., Stovel, R., 6 Moos, R. (1991). Functioning among mothers and fathers of children with juvenile rheumatic disease: A longitudinal study. EQBIDdl_Q£_£§Qid&I1£ Milo—L931: 11(5): 705-724° Tomlinson, P.S. 6 Mitchell, K.E. (1992). On the nature of social support for families of critically ill children. 1ourna1_of_2od1arrio_uuroins. 1(6). 386-394- Ventura, J.N. 6 Stevenson, M.B. (1986). Relations of mother' s and father’ 8 reports of infant temperament, psychological functioning and family characteristics. Morrill:£alnor.9uarterlL 12(3). 275- 289- Weiner, A. (1982). Childbirth-related psychiatric illness. Comprehensixo_£§xohiarrx. 21(7). 143-154- APPENDICES MICHIGAN STATE UNIVERSITY COLLEGE Of NUISING EAST LANSING 0 MICHIGAN 0 488244517 Dear Family, We are currently conducting a research project on situations that may influence family functioning. Our purpose is to develop ways for health care providers to work more effectively with families who have chronically ill members. We are therefore studying both families with and without chronically ill children. For families who agree to participate, we will request that parent(s) and all children age 8 and older living at home complete a packet of questionnaires. ' Families will complete the entire packet of questionnaires, once at the beginning of the study and again six months later. One of the researchers will make four home visits, twice at the beginning of the study and twice at the end to assist your family in completing the packets. The researchers will also be available by phone. Each completed packet will take about two hours of your time. In addition to the information that your family will provide, the researchers will obtain data from your asthmatic child’s medical record regarding the extent of the disease. Your participation in the study is voluntary and you are free to withdraw from the study at any time without penalty. Your decision whether to participate will not affect the health care that you or your family members will receive. Confidentiality will be maintained and your family will remain anonymous. At no time will your names appear in any publication with results from-this study. Your are free to ask questions at any time during the study by calling one of the researchers at (517) 355-6526. Participation in the study does not guarantee any beneficial results to you. At the completion of the study we would like to give you an 8 x 10 color family portrait as an expression of our appreciation. If your family is willing to participate, please return the attached self-addressed stamped postcard. After receiving the postcard, one of the researchers will be contacting you to answer any questions you may have and to schedule a home visit. Thank you for considering participating in this study. Sincerely, Carla L. Barnes, Ph.D., ACSH Assistant Professor Linda J. Spence, H.S., R.N. Assistant Professor Patricia L. Peek, M.S., R.N. Assistant Professor mus-WWW“ 77 OFFICE or RESEARCH AND GRADUATE STUDIES “00119341 SUE UfllvefSrfy 225 Administmon Bmldmg East Lansing. Michigan “824-1046 517/35521w FAX 5173361171 160 c an Wm. MW Wm MICHIGAN STATE UNIVE March 3|. I994 RSITY T0: Ms. Cynthia Paige 727 Colonial Court Birmingham. MI 48009 RE: IRB I: 94424 TITLE: THE EFFECTS OF CHILD'S HEALTH STATUS ON FATHER‘S PERCEIVED SELF-COMPETENCE REVISION REQUESTED: NIA CATEGORY: l-E APPROVAL DATE: 03/3l/I994 The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complete. I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore. the UCRIHS approved this project including the revision listed above. Renewal: Revisiom: Cinnci; UCRIl-lSapprovalisvalidforonecalendaryear, beginning withtheapproval date shown above. Investigators planning to continue at project beyond one year must use the green renewal form (enclosed with the original approval letter or when a project is renewed) to seek updater! certification. - There is a maximum of four such apedited renewals possible. Investigators wishing to continue a- project beyond that time need to submit it again for complete review. UCRIHS must review any changes in procedures involving human subjects. prior toinitiationofthechange. lfthis isdoneatthetimeofrenewal. please use the green renewal form. To revise an approved protocol at any other time during the year. send your written request to the UCRIHS Chair. requesting revised approval and referencing the project's [RB # and title. Include in your request a description ofthechangeandany revised instruments. consent fonnsoradvertisementsthatare applicable. Shouid either of the following arise during the course of the work. investigators must notify UCRIHS promptly: (I) problems (unexpected side effects. complaints. etc.) involving human subjects or (2) changes in the research environment or new information indicating greater risk to the human subjects than existed when the protocol was previously reviewed and approved. lfwe can he of any future help. please do not hesitate to contact us at (5l7) 355-2180 or FAX (.517) 336-117]. Sincerely. David E. Wright. Ph. UCRIHS Chair DEW:pjm cc: Dr. Linda Spence 78 .WHAT I AM uxr These are statements which allow people to describe themselves. There are no right or wrong answers since people differ markedly. Please read the entire sentence across. First decide which one of the two parts of each statement best describe; you; then go to that side of the statement and check whether that is just sort of true for you or really true for you. You will just check ONE of the four boxes for each statement. 10. 11. C] Really Sort of True for Me for Me True C] D Some adults like the way they are leading their lives Some adults feel that they are enjoyable to be with Some adults are not satisfied with the way they do their work Some adults see caring or nurturing others as a contri- bution to the future In games ,and sports some adults usually watch instead of play Some adults are happy with the way they look Some adults feel they are not adequately supporting them- selves and those who are important to them Some adults live up to their own moral standards Some adults are very happy being the way they are Some adults are not very organized in completing household tasks Some adults have the ability to develop intimate relationships 79 OUT BUT BUT IUT OUT OUT BUT BUT IUT IUT IUT Other adults don't like the way they are leading their lives. Other adults often question whether they are enjoyable to be with. Other adults are satisfied the way they do their work. Other adults do not gain a sense of contribution to the future through nurturing others. Other adults usually play rather than just watch. Other adults are not happy with the way they look. Other adults feel they are providing adequate support for themselves and others. Other adults have trouble living up to their moral standards. Other adults would like to be different. Other adults are organized in completing household tasks. Other adults do not find it easy to develop intimate relationships. Sort of True Really True for Me for Me [3 C] 12. 13. 14. 15. 16. 17. 1B. 19. 20. 21. 22. 23. 24. Really Sort of True for Me for Me U U True U U When some adults don't understand something, it makes them feel stupid Some adults can really laugh at themselves Some adults feel uncomfortable when they have to meet new people Some adults feel they are very good at their work Some adults do not enjoy fostering the growth of others Some adults sometimes question whether they are a worthwhile person Some adults think they could do well at just about any - new physical activity they haven't tried before Some adults think that they are not very attractive or good looking Some adults are satisfied with how they provide for the important people in their lives Some adults would like to be a better person morally some adults can keep their household running smoothly Some adults find it hard to establish intimate relationships Some adults feel that they are intelligent 8O BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT Other adults don't necessarily feel stupid when they don't understand. Other adults have a hard time laughing at themselves. Other adults like to meet new people. Other adults worry about whether they can do their work. Other adults enjoy fostering the growth of others. Other adults feel that they are a worthwhile person. Other adults are afraid they might not do well at physical activities they haven't ever tried. Other adults think that they are attractive or good looking. Other adults are dissatisfied with how they provide for these people Other adults think that they are quite moral. Other adults have trouble keeping their household running smoothly. Other adults do not have difficulty establishing intimate relationships. Other adults question whether they are very intelligent. Sort of True Really True for Me for Me C] [fl [3 ['l ll. I 1 H U l J [J l l [] 25. 26. 27. 2B. 29. 31. 32. 33. 34. 35. 36. 37. Really Sort of True for Me C] [ll Cl C] True for Me C! C] D U [3 I] Some adults are disappointed with themselves . Some adults find it hard to act in a joking or kidding manner with friends or colleagues Some adults feel at ease with other people Some adults are not very productive in their work Some adults feel they are good at nurturing others Some adults do not feel that they are very good when it comes to sports I Some adults like their physical appearance the way it is Some adults feel they cannot provide for the material necessities of life Some adults are dissatisfied wrth themselves Some adults usually do what they know is morally right Some adults are not very efficient in managing activities at home Some people seek out close relationships Some adults do not feel that they are very intellectually capable 81 BUT BUT BUT BUT BUT BUT BUT BUT - BUT BUT BUT BUT BUT Other adults are quite pleased with themselves. Other adults find it very easy to joke or kid around with friends and colleagues. Other adults are quite shy. Other adults are very productive in their work. Other adults are not very nurturant. Other adults feel they do very well at all kinds of sports. Other adults do nOt like their physical appearance. Other adults feel they do adequately provide for the material necessities of life. Other adults are satisfied with themselves. Other adults often don't do what they know is morally right. Other adults are.efficient in managing activities at home. Other persons shy away from close relationships. Other adults feel that they are intellectually capable. Sort of True for Me U fl I? [1 Really True for Me ll 1] F] 39. 41. 42. 43. 44. 45. 46. 47. 49. Really Sort of True for Me for Me U True D Some adults feel they have a good sense of humor 0 Some adults are not very sociable Some adults are proud of their work Some adults like the kind of person they are Some adults do not enjoy nurturing others Some adults feel they are better than others their age at sports Some adults are unsatisfied with something about their face or hair Some adults feel that they provide adequately for the needs of those who are important to them Some adults often question the morality of their behavior Some adults use their time efficiently at household activities Some adults in close relationships have a hard time communicating openly Some adults feel like they are just as smart as other adults Some adults feel that they are often too serious about their life BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT BUT Messer and Harter. Adult SelfMeption Profile. University of Denver. 1964. "ll 82 Other adults wish their sense of humor was better. Other adults are sociable. Other adults are not very proud of what they do. Other adults would like to be someone else Other adults enjoy being nurturant. Other adults don't feel they can play as well. Other adults like their face and hair the way they are. Other adults feel they do not provide adequately for these needs. Other adults feel that their behavior is usually moral. Other adults do not use their time efficiently. Other adults in close relationships feel that it is easy to commirnicate openly. Other adults wonder if they are as smart. Other adults are able to find humor in their life. Sort of True Really True for Me for Me C] H H ['J D D ['l l] l‘] I] I] ll U [3 MICHIGAN STRTE UNIV. LIBRRRIES ||11|”WWlllllimllllWWMINI”WNW 31293010461717