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A DESCRIPTIVE STUDY OF THE BELIEFS AND
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MEASUREMENT AND FEVER MANAGEMENT

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A DESCRIPTIVE STUDY OF THE BELIEFS AND ATTITUDES
OF PARENTS REGARDING TEMPERATURE MEASUREMENT
AND FEVER MANAGEMENT
by

Anne Therese Hughes

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1998

ABSTRACT
A DESCRIPTIVE STUDY or THE BELIEFS AND ATTITUDES
OF PARENTS REGARDING TEMPERATURE MEASUREMENT
AND FEVER MANAGEMENT
by

Anne Therese Hughes

In an environment replete with technological options for diagnosis and treatment,
persons who provide care to the sick have struggled for three centuries to puncture the
barriers to caring that often accompany the use of medical technology. This study
examines attitudes and behaviors surrounding the use of one piece of technology, the
thermometer, in an effort to envision a method of transforming the relationship between
tools and human users. Parents were asked by self-report questionnaire to indicate
reasons they use, or do not use, thermometers and what methods they use to manage
fevers in their own children. Factors of interest were the parent’s overall comfort with the
tool, the frequency of use in the sample population, and whether parents used the
information revealed by the tool to guide treatment. Parents overwhelmingly reported
feeling comfortable using a thermometer. While there were no cases in which parents
indicated they did not use a thermometer to evaluate a suspected fever, only one third

reported they would need to know the exact temperature before treating a fever.

ACKNOWLEDGMENTS

I was inspired and meaningfiilly directed by the members of my thesis committee--
Linda Spence PhD. -- thesis chair, Patty Peek M.S., P.N.P. and Manfred Stommel Ph.D.
Thank you all for your time, your interest and your guidance. The land of abstract ideas is
one of my favorite playgrounds. You helped me focus and finish.

I am also very gratefiil to Tom Tomlinson of MSU’s Center for Ethics and
Humanities in the Life Sciences for his willingness to supervise my independent study in
the philosophy of technology. The references he found and the ideas we discussed
contributed a great deal to the conceptual framework for this thesis.

To staff at Kid’s Creek who offered their time and assistance in the data collection
phase, thank you for your persistence. I also benefited immensely from the support of my
friends and family, they listened to my ideas and understood my desire to make sense of
them. Peggy, you can have your notebook computer back now.

Finally, I am deeply grateful to Linda Spence. As I sent drafts for her review, there
were many times I thought “This will never fly.” Linda’s responses to my ideas were
always supportive and encouraging while she patiently challenged me to write a better
paper. While she never articulated it quite this way, her approach reminded me of my

niece’s favorite words of encouragement--"You GO girl!”

iii

TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................... iv
LIST OF TABLES ......................................................................................................... vi
LIST OF FIGURES ....................................................................................................... vii
INTRODUCTION ........................................................................................................... 1
CONCEPTUAL FRAMEWORK ..................................................................................... 4
CONCEPTUAL DEFINITIONS ................................................................................... 10
LITERATURE REVIEW .............................................................................................. II
Accuracy of Temperature Measurement Tools by Site ........................................ l 1
Accuracy by Instrument ...................................................................................... 13
Effectiveness of Subjective Assessment .............................................................. 15
Efi‘ectiveness of Educational Interventions .......................................................... 17
METHODS ................................................................................................................... 19
Operational Definitions ....................................................................................... l9
Sarnple Selection ................................................................................................ 20
Procedures ......................................................................................................... 21
Protection of Human Subjects ............................................................................ 22
Instrument .......................................................................................................... 22
Data Analysis Techniques ................................................................................... 23
RESULTS ..................................................................................................................... 23
INTERPRETATION ..................................................................................................... 31

iv

IIVIPLICATIONS FOR ADVANCED PRACTICE NURSING ...................................... 36

IMPLICATIONS FOR RESEARCH ............................................................................. 4O
IMPLICATIONS FOR NURSING EDUCATION ......................................................... 41
A PROPOSAL FOR RITUAL ....................................................................................... 43
REFLECTIONS ............................................................................................................ 44
APPENDIX A ............................................................................................................... 38
UCRIHS APPROVAL ................................................................................................... 38
APPENDIX B ............................................................................................................... 39
MEMO .......................................................................................................................... 39
APPENDIX C ............................................................................................................... 40
A LETTER TO FRONT DESK STAFF AT KID'S CREEK .......................................... 40
APPENDIX D ............................................................................................................... 42
A LETTER TO PARENTS ........................................................................................... 42
APPENDIX E ............................................................................................................... 44
TREATMENT OF TEMPERATURE IN CHILDREN -- A QUESTIONNAIRE ........... 44
LIST OF REFERENCES ............................................................................................... 48

LIST OF TABLES

Table l -- Temperature At Or Above Indicated Value Constitutes Fever ........................ 10
Table 2 -- Demographics Of Study Sample .................................................................... 24
Table 3 -- Ease Of Use By Type Of Thermometer .......................................................... 25
Table 4 -- Parent’s Definition Of Fever (In Fahrenheit) .................................................. 25
Table 4a -- T-test To Compare Means ........................................................................... 26
Table 5 -- Sensory And Behavioral Clues Leading Parents To Suspect Fever ................. 27
Table 6 -- Parent Methods Of Confirming Fever ........................ _ .................................... 2 8
Table 6a -- Method Selected As Most Reliable For Confirming Fever ............................ 28
Table 7 -- Parent Reasons For Using A Thermometer .................................................... 28
Table 7a -- Reason Selected As Most Important For Using A Thermometer ................... 29
Table 8 -- Parent Methods Of Fever Treatment .............................................................. 30
Table 8a -- Fever Treatment Selected As Most Important .............................................. 31
Table 9 -- Analysis Of Educational Level And Ease Of Use ............................................ 34

Table 10 -- Analysis Of Education Level And Need To Know Exact Temperature ......... 35

Table 12 -- Percent Who Indicate Fever Cutoff At Or Higher Than Study Standard ....... 37

Table 12a -- Correct Identification Of Axillary Fever By Educational Level .................... 38
Table 12b -- Correct Identification Of Rectal Fever By Educational Level ...................... 38
Table 12c -- Correct Identification Of Oral Fever By Educational Level ......................... 38

\i

LIST OF FIGURES

Figure 1 -- Keen’s “Sheaths of a Lover’s Body” ............................................................... 7

Figure 2 -- Technodermis ................................................................................................. 9

vii

Introduction

As we close the twentieth century we are surrounded by technology. Tools and
machines permeate our lives. They-assist and encumber us. In the field of health care,
increasingly complex machines extend the reach of our hands, our eyes, our ears. These
SOphisticated sensory information and feedback mechanisms, our technoderrnis. enhance
our worldview (Keen, 1983). Unfortunately, they also have tremendous potential to
impose barriers on relationship. Hawthorne and Yurkovich state that the meaning of
caring is being eroded as a consequence of “society’s enslavement by science and
technology” (1995, p. 1088). This view of technology is prevalent in our culture, and is
particularly evident in writings about medical technology. Health professionals have been
admonished to resist the restricted view of the patient presented by medical technology
since the invention of the stethosc0pe in the early 19th century (Reiser, 1978). Modern
medical technology, however, provides invaluable assistance in achieving the goals of
disease prevention and management. The challenge is not to eliminate the use of
sophisticated technology, but rather to be clear about the best use of tools. How can we
exist in relationship with our machines so that our compassion is maximized and our
caring touch is not negated by the plastic and steel? One possibility was poetically stated
by Robert Pirsig.

The way to solve the conflict between human values and technological needs is not

to run away from technology. That's impossible. The way to resolve the conflict

is to break down the barriers of dualistic thought that prevent a real understanding

of what technology is--not an exploitation of nature, but a firsion of nature and the

human spirit into a new kind of creation that transcends both....this transcendence

should also occur at the individual level, on a personal basis, in one's own life.

(1974, pp. 284-285)

The phenomenology of human/technology relations has implications for many
areas of our lives. This paper examines the concepts as they relate to a particular piece of
medical technology, the thermometer. Many tools and machines are available to aid in the
diagnosis and treatment of illness and injury. Some are comparatively simple, such as a
mercury thermometer. Some are incredibly complex, such as a linear accelerator. In
either case, critical thinking requires that we ask the question: Why is this tool being
used?

If we are to transcend the barriers between our selves and our technology we must
begin to explore the phenomenology of human/technology relations. The use of a tool
must be based on a thorough and thoughtful decision-making process. What benefit do
we intend to see by using a particular piece of technology? This study will examine these
concepts by describing parental use of thermometers to assess fevers in children.

Hooker, Smith, Miles and King (1996) demonstrated that the ability of mothers to
subjectively assess even the presence of fever is not uniformly reliable. It is possible that
in some situations the choice not to measure temperature with a thermometer is a result of
insufficient experience using thermometers and/or a general lack of comfort with
technology. The potential for error in evaluating temperature by touch alone increases the
likelihood of overtreatment of fever.

Wilson (1995) discusses the concern expressed by many clinicians that fever itself

may be harmful to children. This "fever phobia" may be another cause of overtreatment.
Fever is an adaptive host defense, not a disease entity. Eliminating fever in the absence of
clear benefit to the child, such as increased comfort, is a misuse of pharmaceutical
technology. However, fever phobia provides one of the best reasons to use a
thermometer: to establish that the fever is not dangerous. Supporting the efforts of the
body to heal itself is a basic strategy of nursing and involves bio/psycho/socio/spiritual
dimensions (Nightingale, 1859). If accurate measurement can quantify the child's current
temperature, perhaps educational interventions can focus on teaching parents how to
identify a dangerous fever and how to appropriately select treatment. It is conceivable
that decreasing worry in the parent will result in increased energy spent providing support
measures such as increased fluids, reassurance and rest. Once the parent has established
that the fever is not dangerous, treatment measures--including antipyretics--can be
directed toward promoting comfort.

Educational protocols have, in fact, been developed and implemented which
instruct parents in the correct use of thermometers and antipyretic medication. Some
educational modules also include information about the nature of fever and its potential
benefits. In her thesis prepared in partial fulfillment of the requirements for a Master of
Science in Nursing (MSN) at Michigan State University, Patricia Baumgartner (1987)
developed and implemented an educational protocol on the management of fever. The
teaching module included instruction on correct use of thermometers and antipyretic
medications. Her pretest/posttest data demonstrated that caregivers learned the

information in her module. However, their behaviors when managing a child's fever did

not change. This finding raises the question: if lack of knowledge is not the reason
parents did not use a thermometer to measure fever, what is?

The behaviors and attitudes surrounding a parent's decision whether or not to use a
thermometer prior to treating a fever will be the subject of this study. An underlying
assumption will be that the parent has in mind the goal of restoration of the child's health
and that their efforts will involve bio/psycho/socio/spiritual factors. A data gathering
instrument will be developed to assess the reasons parents use or do not use a
thermometer. Of particular interest are the following hypotheses derived from the
conceptual framework underlying this study:

OParents do not use a thermometer because it does not yield any information they

do not already know.

0Parents do not believe the tool gives them any information that would change

their planned course of action.

OParents do not use a thermometer because they do not know how to properly

apply the tool.

OParents do not use thermometers because they do not believe they can

appropriately interpret the information they receive from the tool.
Conceptual Framework

It has been suggested by Keen (1983) that the division between science/technology
and art/psychology/philosophy is not a division of labor but a neurosis in need of healing.
One of the reasons machines have the effect of blocking caring is because we conceive

them as “other”. When we abandon the idea that machines are things, neutral means to

accomplish our intended ends, and begin instead to regard them as extensions of our own
bodies, the picture changes dramatically. Our tools extend the reach of our eyes, our ears
and our hands. They become our technodermis.

Martha Rogers' conceptual model of nursing defines humans as energy fields.
According to her model, energy fields are a unifying concept for both animate and
inanimate environments. The fields have no boundaries, are indivisible, dynamic, and
allow exchange with other fields. The point of interaction between the energy fields of the
tool and the user is critical to the process of transforming our relationship with
technology. We must begin to understand how the tool shapes the hand and how the hand
expresses itself through the tool. One human-tool-use phenomenon, embodiment
relations, is explored in depth by Ihde (1990). Embodying is a particular use-context
describing how a person may experience technologies in a specific way. An enhancement
and/or transformation of the senses accompanies the use of embodied technology.
Occupying a position between the self and the world, a tool that is technically capable,
well designed, and which exists in good fit with the use will "withdraw" and be scarcely
noticed. The result is a symbiosis between the artifact, which may be a simple tool or a
complex machine, and the human user. These conditions for embodiment relations, or
"withdrawal" of the tool, give direction for the perfection of technology design Design is
related not only to the tool, but also to the perceptions and actions of the human user.

Currently, there are many imperfections in our technologies. These imperfections
lead to frustration because such tools do not fulfill our expectations. Ineffective or

ineflicient technology is unable to function as technodermis. It obtrudes into the

caregiver-patient relationship and becomes an impediment to caring. We should not
expect the transformation inherent in embodiment relations to occur with the use of
inefficient technology. As we expand human/technology interactions, it is increasingly
important to perfect machine design along a bodily vector.

"The Sheaths of the Lover's Body" is Keen's conceptual model of the concentric
dimensions that define our being and doing as mature humans (Figure 1). Keen, a
graduate of Harvard Divinity School who holds a Ph.D. in the philosophy of religion, has
written extensively on the human drive for connection and fulfillment. His model
envisions a human being whose tasks are to be an agent of healing and to embody health.
One of the goals for personal growth is to develop the ability to glimpse the essential
wholeness of the human condition while remaining aware of disease, sufi‘ering and
alienation (Keen, 1983). The sheath in Keen's model that represents the technological
body symbolizes the creation, care and maintenance of the media, or technology, through
which we experience our world.

Panpsychism proposes that matter, as a physical manifestation of energy, is itself
intrinsically sentient or experiential (DeQuincey, 1997). While perhaps more easily
understood in terms of biologic matter such as the brain, this concept is intriguing in terms
of technologic matter as well. One of the most valued attributes of medical technology is
its ability to extend our physical senses. It assists us in discerning a fair amount of detail
about a patient's state of health or illness. The term con-scentia or "knowing with" (p. 33)

is the original meaning of consciousness. In connection with human users, technologies

   
   

Technological Body

Ecological Body

Mystical Body

Figure 1 -- Keen’s “Sheaths of a Lover’s Body”

can be conceptualized as having a conscious, or sentient, element. We do "know with"
our technology.

In Figure 2, Keen's technodermis is expanded to include con-scentia, defined as the
human user "knowing with" the tool. The user perceives the world through the tool, and
the tool itself recedes into the background. In order to achieve this level of symbiosis
between human user and tool, it is important to thoughtfully determine when and how our
tools will be used. Is the tool or technology truly useful in this particular instance for
evaluating illness or enhancing health? Or does critical thinking lead to the conclusion that
such use merely supports prior routine and is of no real benefit? When one operates
within the concept of con-scentia, the relationship with tools is transformed. Tools are
used to "know with, " or to communicate a treatment. They are used with conscious intent
in connection with the human energy field. Based on the twin premises that humans will
continue to exist and that technology will continue to develop, it would seem reasonable
to consider transforming our relationship with technology. The challenge is to learn to use
machines in a way that maximizes our caring.

Information gathered in this study will describe attitudes regarding the use of
technology, ranging from its obtrusiveness to its usefulness as a basis for decision-making.
Answers to particular questionnaire items may give clues as to which aspects of
technology are most problematic. The information may serve as a guide to development
of a philosophy of technology that begins to steer health professionals toward a more
constructive relationship with tools and technology. It may also give direction for aligning

patient teaching and counseling more closely with behaviors and attitudes of patients and

 

 

CON - SCENTIA
"Knowing With"
the tool

 

 

 

Ecological Body

 

Mystical Body

Figure 2 -- Technodermis

their caregivers. Unsafe practices may be identified and targeted for educational
interventions. It is possible that a professional bias toward overuse of technology will be
identified when parent practices are compared with professional expectations.
Conceptual Definitions

Attitude is defined as a persistent disposition to act in a particular manner toward a
person, object or situation. Certain attitudes toward the use of technology are of interest
to this study. The first attitude is m. Overuse is defined as the use of a
technological instrument in the absence of a clearly defined reason for doing so. The
second attitude is avoidance. Avoidance is defined as non-use of a technological
instrument for any reason other than that it is not relevant in directing treatment. The
third attitude is informed use. Informed use involves critical thinking. It is defined as
basing a decision to use technology on the fact that treatment actions will be guided by the
information obtained.

This study utilizes the commonly published definition of fever contained in Table 1
(Wilson, 1995; Uphold & Graham, 1994). Treatment of fever is defined as the specific

intervention used by the parent to respond to an identified fever.

Table l -- Temperature At Or Above Indicated Value Constitutes Fever

 

Literature Review

The literature review was conducted to explore two concepts that form the
foundation for the research hypotheses. The first concept addresses the efi‘ectiveness of
the tools and methods of temperature assessment currently available. Lack of quality may
be one explanation for a disinclination to use the technology. A search for completed
clinical trials involving thermometry yielded a number of studies that evaluate accuracy
and ease of use for various types of instruments and for several anatomic sites used in
temperature measurement. These studies illuminate some of the problems contributing to
inemciencies and/or inaccuracies in technology.

The second concept concerns the possibility that parents do not utilize the
thermometer as a tool because it is not clear how doing so will help. If one cannot think
of a reason to use a tool then it is merely a technology that yields irrelevant findings.
Literature concerning this concept is sparse. It is possible that this has not been explored
in clinical research.

Accuracy of Temmrature Measurement Tools by Site

A study by Haddock, Merrow and Swanson (1996) examined the accuracy of
axillary temperatures in screening for fever in infants and young children. The authors
state that inability to identify fever may result in delayed identification of infections such as
otitis media or meningitis and therefore, increased morbidity. The study was conducted in
North Carolina at an outpatient pediatric clinic. The researchers recruited 173 children
fiom birth to age 16 years. An electronic thermometer was used to compare axillary

temperatures with either oral or rectal temperatures. The two temperatures were taken

11

within one minute of each other with the axillary temperature always taken first. Order
was not expected to affect the reliability of findings. The mean difference between oral
and axillary temperatures in the afebrile child was 1.2°F with a mean difference of 2°F in
the febrile child. The differences between rectal and axillary temperatures were 2.2°F for
the afebrile child and 2.8°F for the febrile child. The authors point out that the common
practice of adding 1°F to axillary temperatures to approximate the oral reading and adding
2°F to approximate the rectal reading is supported by the mean afebrile temperatures but
not by the mean febrile temperatures. However, when individual difi‘erences were
considered, the use of this adjustment method was not supported. In over 77% of the
cases, febrile rectal/axillary temperatures differed by more than 2°F. In over 70% of the
cases, febrile oral/axillary temperatures difi‘ered by more than 1°F.

‘ The conclusion of these authors was that it is not acceptable to use axillary
temperatures with these corrections. Further, the low sensitivity (27%) shown by axillary
measurements in this study casts doubt on the credibility of this method in screening for
fever in children. Sensitivity is the ability to correctly identify the positive state. This
study determined that in children who actually were febrile, the axillary temperature
identified them as febrile only 27% of the time. Therefore, 63% of the fevers were missed.
There is no information, however, indicating the size of the measurement error. The
authors recommend that nurses teach parents to use the rectal site for detection of fever.
The article closes with the statement that further study needs to be done to determine
other means for accurately measuring temperatures.

A meta-analysis of 19 studies comparing tympanic temperature to oral, rectal and

core temperature in children focused on the accuracy, sensitivity and specificity of this
“rapid, emcient and noninvasive measure of temperature” (Wells, King, Hedstrom &
Youngkins, 1995, p. 95). Accuracy indicates the degree to which the test value agrees
with a standard value. In temperature measurement studies each researcher must identify
the standard by which the test instrument will be judged for accuracy.

The studies reviewed were published fiom 1989 to 1994 and were conducted in
outpatient clinics, emergency departments and inpatient settings. In these studies, oral
temperatures differed fi'om tympanic temperatures by up to .68°C. Tympanic and rectal
temperatures were found to differ by as much as 12°C. The authors state that the wide
variation in accuracy may be influenced by the subject ages. Tympanic temperatures are
not highly associated with rectal or axillary temperatures in young infants.

This meta-analysis suggested that tympanic thermometry has the greatest
sensitivity and specificity in the mid-range of fever. Specificity is the ability to correctly
identify the negative state. In this case, specificity means that a child who is actually
afebrile will have a tympanic temperature measurement that indicates they are afebrile.
This meta-analysis did find a lower association of tympanic and rectal temperatures in
afebrile children, and sensitivity declined for fevers above 39°C. In their recommendations
for practice, the authors noted that posterior retraction of the pinna resulted in increased
accuracy for tympanic thermometry. It was also suggested that for tympanic measures
over 38°C, temperatures be confirmed with oral or rectal thermometers.

Accuracy by Instrument

To examine issues related to instrument accuracy and efliciency, Pontious et al.

13

(1994) compared glass mercury thermometers, two types of tympanic thermometer and
one type of single use chemical, disposable thermometer. The TempaDOT single use
thermometer is a plastic strip with dot-like depressions filled with a chemical mixture that
melts at a given temperature. This results in a color change at the dot indicating the
current body temperature. The advantage of this instrument is safety in comparison to
glass thermometry, infection control, and cost savings.

The study was conducted in the emergency department of a large Midwestern
children's hospital and consisted of a nonrandom sample of 960 temperatures taken on 89
febrile and 83 afebrile children. Subjects ranged in age fi'om 3 months to 6 years and were
randomly assigned to sites of measurement, type of thermometer, and order of use. Oral
temperatures by glass thermometer were the standard used to define accuracy of the
experimental instruments. One-way AN OVA's detected a significant difi‘erence in
accuracy between the three instruments. Age, behavior, tympanic membrane bulge and
febrile status were not demonstrated to have an effect on instrument accuracy.
TempaDOT was found to be the most clinically useful temperature measurement
instrument.

A study by Weiss et al. (1995) was designed to determine the effectiveness of
tympanic temperature measurement in the field during or prior to emergency transport.
Tympanic temperatures and other data including patient's mental status, activity level,
paramedic's suspicion of a temperature abnormality and any treatment directed toward the
patient's temperature were recorded for all 182 patients. The thermometry instrument

used in the study was the First Temp Genius.

14

Temperature readings of the right and left car were strongly positively correlated
(.91) despite inconsistent technique. Since the patient's left ear faced the paramedic during
transport, measurement of right ear temperature required an awkward reach across the
patient. The strong correlation suggests that the technology is less subject to inaccuracies
secondary to operator error than might be supposed.
Efi‘ectivgness of Subjective fisessment

This study also investigated the paramedics’ ability to subjectively assess fever. At
the outset of the study, paramedics believed they could tell whether a patient was febrile
without measuring. However, analysis of the data revealed that less than 35% of
hypertherrnic patients and less than 20% of hypotherrnic patients were initially suspected
of having abnormal temperatures. Unfortunately, the specific question of how often a
suspected fever was actually confirmed by measurement was not answered in this article.

Mothers assessing fever in their children have a greater success rate in identifying
fever than did the paramedics. Banco & Veltri (1984) found that mothers who suspected
fever in their children were correct 52.3% of the time. Mothers were able to correctly
identify the afebrile state in their children 93.9% of the time. This study of 303 patients
between 5 days and 15 years of age was conducted in a pediatric ambulatory care center.
Mothers who brought children in for acute, non-trauma related care were asked by a study
interviewer if their children had fever at that time, how they made this determination, and
whether they used a thermometer. The interviewer then left the room while the child's
temperature was assessed by a staff nurse using either an oral or a rectal thermometer,

depending on the age of the child. Only 28 of the 303 children in this study had their

15

temperatures taken at home by thermometer. Interestingly, these children had a
significantly higher incidence of antipyretic therapy at home. Among the 28 patients who
had temperatures assessed at home by thermometer, 12 of 19 judged to be febrile and
three of nine judged to be afebrile were given antipyretics before being seen in the
ambulatory care setting. Of the 261 patients whose febrile status was determined by
subjective means at home, only 40 received antipyretics. The remainder of mothers stated
they used no method for determining febrile status. In view of this finding that the use of
a thermometer at home was associated with a three fold increase in antipyretic use
regardless of whether the child was thought to be febrile, the researchers wondered
whether antipyretic use in the presence of mild or absent fever would increase as a result
of more aggressive fever detection strategies. In other words, is it possible that increased
use of one type of technology, such as thermometers, contributed to increased use of other
types of technology, such as medications?

This study provided a critical assessment of a ritual of folk medicine, the palpation
of selected anatomical sites to determine presence or absence of fever, and concluded that
subjective evaluation is useful as a screening tool for fever in children of all ages. Further,
it was found that mothers can correctly identify high fevers (38.9 degrees C or higher) in
most young children without the use of thermometry. Finally, the authors suggest that
investigations of the criteria used by parents for clinical assessment and decision-making
would be usefiil.

More recently, a study by Hooker, Smith, Miles and King (1996) evaluated

parents’ subjective assessment of fever compared with tympanic and rectal measures. A

16

convenience sample of 180 children, aged birth to four years, was selected fiom patients
presenting for care at an emergency department. Parents were asked a brief series of
questions to determine patterns of fever assessment. Eighty-eight percent of parents
owned a thermometer but only 58% had used it before bringing the child in for care.
Parents overwhelmingly (91.1%) believed they could tell when their child had a fever by
touch.

After completing the questionnaire, the parent was asked to subjectively assess the
child. Investigators then assessed the child’s tympanic and rectal temperature. Parental
subjective assessment of temperature agreed with the rectal glass thermometer 79% of the
time, while the tympanic and rectal measurements agreed 88.7% of the time. The overall
sensitivity of the tympanic measurement in detecting fever was 78.8% with a specificity of
963%. Parent’s subjective assessment was comparable to this technology with a
sensitivity of 8 l .8% and specificity of 76.5%. The authors conclude that while parents are
not perfect at detecting fevers subjectively, their assessment should not be ignored.
Effectiveness of Edugatignal Interventions

Patricia Baumgartner, in her MSN thesis (1987), discussed the fact that fever is an
adaptive response to illness and a normal host defense. She suggested that fever reduction
has become a ritual which may have resulted in the overtreatment and misunderstanding of
fever. Baumgartner designed an educational intervention intended to increase parental
understanding of the adaptive nature of fever. In addition, she taught practical knowledge
about assessment of fever with a thermometer and reviewed treatment of fever including

supportive and pharmacological measures. This study involved 80 parents of children

17

aged two months to four years. Parents in both the experimental and control groups
completed self report fever management logs for thirty fever episodes that occurred over
five months.

Results indicated parents used multiple factors to assess fever. Fifty percent used a
thermometer to check temperature, 83% stated their child felt hot, and 11% stated their
child looked sick. When questioned about management strategies, antipyretic therapy was
the most prevalent treatment (93%). Eighty-seven percent said they checked the
temperature as an initial management strategy. Twenty-three percent took the child to the
doctor. Twenty percent observed and did nothing else. Thirteen percent gave the child a
sponge bath and 3% called the doctor.

Baumgartner was able to support her hypothesis that the education module would
increase parental knowledge regarding fever management. However, this increase in
knowledge was not demonstrated to increase the incidence of appropriate fever
management behavior. In fact, the data demonstrated a negative relationship between
knowledge and appropriate behavior. It is possible these results occurred because
insufiicient sample size produced large random variations. Or, perhaps, lack of education
was not the problem. The author suggests that it may be helpful to go back to the basis
for her research and gather data about parents’ knowledge and behavior. A literature
search was unsuccessful in finding research concerning parents’ beliefs, attitudes and
behavior about fever management or technology in general. Therefore, exploring that

subject is the purpose of this descriptive study.

18

Methods

This is a quantitative study which describes certain behaviors and attitudes of
parents of children aged 12 months to 12 years The attitudes of interest are those related
to the use of technology. In order to elicit examples of these attitudes, a questionnaire
was developed to collect data on attitudes and behaviors concerning the use of a particular
piece of technology, the thermometer. For the purpose of this study, a thermometer is
defined as any instrument developed and utilized specifically for the purpose of measuring
the body temperature of a human being.

Since the questionnaire contains primarily closed-ended questions, the data can be
scored quantitatively. The number of subjects who choose each method of temperature
measurement and treatment, for example, can be counted. The prevalence of particular
responses in the sample may be of assistance in guiding educational efi‘orts with this
population. Analysis of the data also supplied information concerning certain attitudes
regarding technology. This information may be usefirl in refocusing the attitudes and
expectations of parents and professionals for technological interventions.

Ogratignal Definitions

The behaviors of interest for this study are those surrounding the phenomenon of
fever, including methods of assessment, measurement and treatment. W
is defined as the sensory or behavioral clues a parent uses to subjectively evaluate the
child’s physical condition and which lead to the conclusion that the child has fever. These
sensory and behavioral clues are identified in question 2 (Appendix 5).

Measurement of fever is defined as the physical action taken by the parent to

19

gather data on which to base a plan of action in response to a suspected fever in the child.
These behaviors are examined in questions 7 and 8. Treatment of fever, the specific
interventions parents used to respond to an identified fever, is examined in question 11. In
addition to questions that elicit information concerning specific behaviors in the treatment
of fever, question 12 links behavior with attitude. The element of interest here is whether
the parent used a critical thinking pathway to decide if the use of technology was relevant
to the assessment, measurement and treatment of this particular child in this particular
instance. Questions 4, 5 and 6 are indicators of how perceived ease of use and comfort
with the technology are related to the specific design of the thermometer.
Smle Selection

The target population for this study was parents and guardians of children aged 12
months to 12 years. Parents of children in this age group are diverse, even within the
Northwest Lower Michigan setting from which the sample selected for this study was
drawn. Members of the population who do not utilize the health care system at all are,
regrettably, not represented in the study. Because of time and resource constraints, an
accessible population was identified as the client base of a pediatric office in Traverse City.
The problem of selection bias in collecting data through a physician's ofice is
acknowledged. Some of the biases that may potentially be introduced by this single data
collection site involve income level, educational level and health beliefs. Although
Traverse City is a relatively small town, there is a sizable group of upper income families
who have moved into the community fiom urban areas. Factors often associated with

rural populations, such as transportation barriers to care, may not be evident in this

20

sample. Results of this study are potentially generalizable only to the population that
utilizes this particular office for health care.

Eligibility criteria were as follows: parent or guardian of a child aged 12 months to
12 years who has had previous experience with a febrile episode with a child, could read
English, and expressed willingness to participate. Parents of children with chronic
illnesses such as diabetes mellitus and cystic fibrosis were excluded since a febrile episode
in a chronically ill child may be perceived by the parent as a greater health risk than a fever
in a child whose general health is good.
Procedures

Data collection occurred over a two week period in a pediatric ofiice staffed by
five pediatricians, one pediatric nurse practitioner and one family practice nurse
practitioner. This cross sectional study design was based on a convenience sample
consisting of subjects who accessed this office for a periodic health assessment or an acute
care visit. At the time of check in for their appointments, parents accompanying children
aged 12 months to 12 years were asked by the receptionist if they would be willing to
participate in a research study involving childhood fever management. Adults who
expressed willingness received a cover letter (Appendix 4) describing the study and
requesting participation. In addition, parents were provided the questionnaire and written
directions (Appendix 5) which specified that completion of the questionnaire indicated
their consent to participate. The subjects completed the three page questionnaire on fever
and one page of demographic questions while they waited either in the waiting room or

the exam room. After completion, questionnaires were placed by the participant in a

provided envelope and returned to the office receptionist at the time of check out.
Recruitment yielded 39 cases.
Protection of Human Subjects

Procedures for the protection of human subjects were implemented according to
guidelines of the Michigan State University Committee on Research Involving Human
Subjects (U CRIHS). Approval of the UCRIHS committee was sought and obtained
subsequent to the thesis proposal defense. A letter outlining the purpose of the study and
separate directions for completing the questionnaire were given to each parent willing to
participate in the study. The letter contained assurance of confidentiality. The directions
explained that completion of the questionnaire indicated voluntary agreement to
participate. Study participants were instructed not to write their names or the name of
their child on the questionnaire. Since the completed questionnaires were collected by the
ofice staff and subjects were not known to the researcher, anonymity of the child and the
parent was preserved.
Instrument

The data collection instrument was developed by the researcher and reviewed by
two physicians and two nurse practitioners. The instrument was also reviewed by a
professional researcher and improvements were incorporated into the final form. The
questionnaire was then distributed to five adults with children in the age cohort of this
study as a pilot evaluation. The purpose of this pilot study was to determine the time
necessary for completion of the questionnaire and to assess the instrument for clarity and

readability. Participants evaluating the instrument were able to complete the questionnaire

in approximately ten minutes. Final changes were reviewed by the researcher, as well as
the aforementioned professionals.
Dgta Amiysg’ Techniques

Data were entered directly from the questionnaire into a computer data file.
Questionnaires were numbered by case and the data file printout cross-checked with the
individual questionnaires. Descriptive statistics were used to examine sample
characteristics. Frequencies were used to describe responses to attitude and behavior
questions, such as items 5, 6, 7, 8, 9,10 and 12, as well as to describe the prevalence of
selected attitudes and behaviors.

Results

Thirty-nine questionnaires were returned to the researcher. Three questionnaires
were excluded because the age of the child fell outside stated study parameters, resulting
in an n of 36. There were no instances of participants reporting that they were not the
person who usually provided care when their child had a fever. Parents in the study
sample were predominantly female (n=34) and ranged from 20 to 48 years of age with a
median age of 34. The median age of the child these parents considered when completing
the questionnaire was 5.5 years. Study subjects were generally well educated. Only one
participant was not a high school graduate, and four participants had advanced degrees.
Most participants (n=31) were insured by private health insurance carriers and only one
participant reported being uninsured (Table 2).

All respondents reported having a thermometer at home. Ninety-seven percent

(n=35) reported feeling comfortable using the thermometer. Sixty-four percent (n=23)

Table 2 -- Demographics Of Study Sample

 

 

 

 

 

 

 
 

 

20 -- 29 years 9 25

30 —- 39 years 21 58.3
40 -- 49 ears 6 16.7
1--4years 15 41.7

 

 

 

 

 

 

 

 

 

some high school 1 2.8
high school graduate 7 19.4
some crflegei 10 27.8
Associate’s degree 8 22.2
Bachelor’s degree 6 16.7

 

advanced degree

 

5H thinsuranee

 

 

 

 

 

 

 

 

private 3 1 86. 1
public 4 1 1 .1
none 1 2.8

 

 

 

 

 

described their thermometer as “very easy” to use. Although there was a suggestive
indication that car thermometers were easier to use than glass or rectal, the type of

thermometer had no significant relationship to the perceived ease of use (Table 3).

Table 3 -- Ease Of Use By Type Of Thermometer

60.0%

40.0%

1 5
100% 100%

 

Note. xi= .676 and p = .713

Parents were asked to mark on a thermometer scale the temperature they interpret
as fever. The range and mean for these values are reported in Table 4. For rectal and oral
sites of temperature measurement, the mean value for parent definition of fever was lower
than the values used to define fever in this study. The Fahrenheit value defining fever

(Table 1) is included in Table 4 for clarity.

Table 4 -- Parent’s Definition Of Fever (In Fahrenheit)

 

25

A t-test to compare means of parent definition of fever with the value used to
define fever for this study showed the difference was significant in all three sites. This

information is presented in Table 4a.

Table 4a -- T-test To Compare Means

 

Parents were asked to write the specific indicators that cause them to suspect their
child has fever. Responses to this open-ended question were coded into eleven categories.
Hot to touch and flushed skin were the most commonly reported subjective indicators of
fever (Table 5).

Ninety-seven percent (n=3 5) of respondents in this sample verified their subjective
findings by taking the child’s temperature using a thermometer. When given the
opportunity to include more than one subjective indicator, parents selected observation of
the child’s behavior and appearance in 28 cases. The use of touch to confirm the presence
of fever was selected in 27 cases. These results are shown in Table 6. When asked to
indicate which method provided them the best information, 77.8% chose the use of a

thermometer (Table 6a).

Table 5 -- Sensory And Behavioral Clues Leading Parents To Suspect Fever

 

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The most commonly identified reasons for using a thermometer were to determine
how high the temperature was before giving medicine and to make sure the fever was not
dangerously high (Table 7). Although few parents chose other reasons as most important,
many indicated that anticipating being asked the child’s temperature by the doctor or nurse
(n=20), uncertainty about presence of fever (n=21) and coming fi'om a family that always
used a thermometer (n=23) were reasons they considered in making the choice to use a
thermometer. When asked to indicate the reason they considered most important in
making the decision to use a thermometer, over one third of parents did not indicate a
reason. However, for those who did, findings were fairly consistent with those in Table 7.
The desire to know the exact temperature before giving medication was selected most

fi'equently, followed by to make sure the fever was not dangerously high (Table 7a).

27

Table 6 -- Parent Methods Of Confirming Fever

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 7a -— Reason Selected As Most Important For Using A Thermometer

 

 

 

 

 

 

 

: "e AA" a 7 at «in 1‘ “VIE-t a' f. 23:
_, , _ ‘ 7 ff» :1 f;:':_ a. _‘ a: if F‘F‘lue-‘W ' Perm"
Check exact temperature before medication .. . 10 27.8
Make sure fever was not dangerously high 8 22.2
Wasn t sure the child had fever 4 1 1.1
Thought doctorfnurse would ask temperature F 1 2.8
Did notrank :qiii‘.;~f-Tf 13 36.1

 

 

 

 

 

Only one parent completed the “did not use a thermometer” question to the
exclusion of “did use a thermometer.” In this case the reason for not using the
thermometer was described as “didn’t have ear refills so I used my hand, otherwise I
would have used it.” In this case, the need for items in addition to the tool itself limited
the usefulness of the technology. Eleven respondents completed both the “did use” and
“did not use” sections. Responses to these questions were mainly in the negative.
However, certain items received a few ‘yes” answers. Reasons given for not using a
thermometer included my child feels better just to be touched (n=3), my mother always
checked my fevers with her hand (n=3), the fever was nothing to worry about (n=2), the
child was sleeping (n=1), the child was crying and hot (n=1) and I would have given the
medicine no matter what the thermometer said (n=1). No parents reported being afraid to
know how high the fever was, that the thermometer was a bother to use, or that they were
concerned the thermometer would upset or injure the child.

The fever treatment most commonly selected as most important was administration

of acetaminophen, with administration of ibuprofen the next most common response.
Although parents did indicate they utilized such measures as increasing fluids, removing
clothes and blankets and cuddling the child, the use of “edible technologies” (Ihde, 1990,
p. 113) such as Tylenol and Motrin were indicated as the most important treatment (Table
8a). This question represents the third time parents were asked to answer yes or no to
several options and then indicate the most important option by placing a star beside that
option. Nearly two thirds of parents did not indicate which treatment they felt was most
important. However, when individual items were examined and parents were free to
indicate any action they took to treat fever, increasing fluids (n=34) was included in
treatment more often than any other action. Cuddling (n=31) and administering

acetaminophen (n=3 0) were the next most fi'equently selected treatments (Table 8).

Table 8 -- Parent Methods Of Fever Treatment

 

K. .........

 

 

 

Administer acetarnmophen F F £1er .-;I4i”-fl‘;’§ 30 90.9

 

Administer ibuprofen FF 7'55, 22 68.8

,5 AA T3,? . . _.,: \

Cuddle child 5‘: 31 91.2

 

 

Increase oral fluids ‘ If? 34 94.4

 

Remove blankets and clothes F F}??? 19 61.3

I Increase blankets and clothes i 7 25.9

 

 

Place child in cool bath 7;; 23 65.7

 

 

 

 

 

 

3O

Only one questionnaire item showed evidence of a difference of opinion within this
sample. In response to the question whether a parent would treat a suspected fever
without knowing the exact temperature, 58% of parents indicated they would treat, 36%

indicated they would not, and the remainder did not respond to the question.

Table 8a -- Fever Treatment Selected As Most Important

 

 

 

 

 

 

 

 

 

 

 

 

Administer acetaminophen 6 f 16.7

Administer ‘buprofen F 5 13.9

Cuddle child 2 5.6

Increaseoralflurds 1 2.8

Did notrank 22 61.1
Interpretation

The questionnaire for this study was structured to collect yes and no answers. In
approximately one third of the cases(n=11) participants indicated “yes” answers but failed
to indicate any “no” answers. The missing data may represent refusal to answer a
particular question, but it is likely that for the cases in which only ‘yes” responses were
checked, the missing responses were intended to indicate a “no” response. The data was
analyzed in that numner.

Three of the study hypotheses were formulated based on the premise that some
parents would report they did not take objective measurement of temperature. There

were no cases in which a parent checked no to the item “I take the temperature with a

31

thermometer.” In one case this item was unanswered and therefore a “no” answer was
entered in the data file. All other subjects checked yes to indicate they take the
temperature with a thermometer. The responses of the study sample, therefore, do not
support the basic assumption that parents do not routinely assess suspected fevers in their
children by using a thermometer. Because the null hypothesis for three out of the four
hypotheses assumes that parents do use a thermometer, it is not possible to reject the null
or support these three study hypotheses.

Although parents listed many subjective indicators that led them to suspect fever in
their child, most (n=23) included “hot to touch.” This finding difl’ers from all others listed
by parents in that it can be objectively quantified by a tool. A number can be assigned to
indicate exactly how hot. We do not have tools to quantify lethargy, pallor, flushing or
irritability. Is hot to touch really any more reliable an indicator of fever than other signs,
or is attention focused on this finding because temperature can be measured?

Three of the study questions were intended to explore general reasons parents
might not use a thermometer. These reasons were: parents feel the tool does not yield
any information they do not already know, parents do not know how to properly apply the
tool and parents do not believe they can appropriately interpret the information they
receive {Tom the tool. It was hoped that chi square analysis could be used to explore
patterns of behavior and attitudes related to these hypotheses by contrasting answers of
thermometer users with those of nonusers. This statistical analysis was not possible given
the available data.

The perception that parents do not regularly assess their child’s fever with a

thermometer is expressed in literature and by health care providers in Traverse City,
including those practicing at the physician office from which the study sample was drawn.
The fact that the data did not confirm this perception was an unexpected finding. It is
possible that this sample, by chance or bias, included only parents who typically do use
thermometers to assess fever. Level of education for this sample was quite high, a
potential influence for the use of technology. Another possible explanation is that parents
felt it would be inappropriate to admit they did not use thermometers. Also, despite
written directions to choose one incident of fever management as a reference when
completing the questionnaire, it may be that parents merged several incidents and in some
but not all of the instances they used a thermometer.

Parents indicated they were comfortable using thermometers and described them
as easy or very easy to use. This perception may have been influenced by their high level
of education, despite the fact that this speculation was not supported by the data fi'om this
particular sample (Table 9). Intuitively, one suspects that parents of this age and
educational level have a general comfort with technology. A working knowledge of
technology may allow the user more flexibility in making adjustments to compensate for
minor inconveniences of thermometers.

The fact that the user can adapt is not sufficient indication that the technology is a
good fit with the use. Also, the technology may be useable but excessively precise. In a
child of this age group, is it necessary for a parent to discriminate between a fever of
100.6F° and 101 .8°F? Or is it merely necessary to know whether a fever is dangerously

high? A paper strip thermometer that changed from green to yellow at 99°F and fiom

33

yellow to red at 104° F may provide an acceptable level of precision. The thermometer
reading itself then diminishes in significance and can be integrated with other subjective

findings for a holistic view of the sick child.

Table 9 -- Analysis Of Educational Level And Ease Of Use

 

 

 

 

 

' ‘1 3783”" F5 Very easy to use “Bahama Total
5 3 8
I Less than college degree 95:3 62.5 37.5 100
A .. :37 17 7 24
College degree “I 70.8 29.2 100
.. 22 10 32
T0131 68.8 31-3 100

 

 

 

 

 

 

Note. fi=.194 and p_ = .660

Parental educational level seems to be associated with the use of thermometers to
confirm a suspected fever. In the 1987 thesis by Baumgartner, 87% of parents in the
experimental group used the thermometer to confirm the presence of fever. In her study,
the highest level of education for 62% of parents was a high school diploma and only 8%
had earned a Bachelor’s or advanced degree. While a significant relationship was not
found, data in the present study suggest a positive relationship between educational level
and the perceived need to know the exact temperature before administering treatment
(Table 10). Parents with a college degree or higher were more likely to depend on the
thermometer to direct treatment. In addition, a similar relationship is suggested by a cross
tabulation of education level and the use of acetaminophen to treat fever (Table l 1). It

has been noted previously that medications are another type of technology, an edible

34

technology. However, the tendency to rely on technology does not necessarily imply right
use. Baumgartner found a negative relationship between education and fever management
behavior. It is interesting to note that in the current study the administration of aspirin, a
potentially harmfill action, was selected as a fever treatment by a parent with a college

degree.

Table 10 -- Analysis Of Education Level And Need To Know Exact Temperature

7
42.9 . 100
23
1
30
00

 

Note. 13 = 2.329 and p = .127

Table 11 -- Analysis Of Education Level And Acetaminophen Use

 

Note. 3': = 2.462 and p = .117

There is no evidence from the data gathered in this sample that parents perceived

the thermometer as an impediment to caring. It is conceivable that some parents consider

35

the use of a thermometer in confirming the presence of fever to be an expression of caring.
Within the theoretical framework that serves as the basis for this paper, this is a potential
function of the use of a tool. Physicians began to use thermometry to guide therapy in the
early eighteenth-century (Reiser, 1978). Today it is a familiar technology. The parents in
this study sample had a mean age of 33.8 years, were well educated and had regular access
to medical care. The combined factors of a well-known tool in the hands of an
experienced user are conditions that promote embodiment relations. The data suggest that
parents use the thermometer to “know with” Use of a thermometer was the most
prevalent action taken to confirm the presence of a suspected fever.

The reason cited most often (n=32) for using a thermometer was to determine the
temperature before administering antipyretics. This finding suggests that some parents use
thermometers to guide their treatment actions. It is also possible that the decision to
medicate was made for other reasons and the parent was seeking an objective finding on
which to justify the plan.

Implications For Advanced Practice Nursing

The question regarding administration of aspirin was included to screen for unsafe
practices. Most parents answered no to the option of aspirin as treatment for fever.
However, one parent responded yes and nine parents gave no response. Since aspirin
administration has been associated with Reye’s syndrome, this finding indicates
professionals must continue to be vigilant in educating parents on the dangers of aspirin

use in children (Fox, 1997).

36

With the exception of the axillary measure, parents in this study defined fever
significantly lower than does the medical literature (Table 12). Despite their relatively
high level of education, many parents in this sample did not know what constitutes fever.
Cross tabulations of educational level and identification of fever as a value at or above that
used as the standard for this study are reported in Tables 12a, 12b and 12c. These
findings, while not statistically significant, suggest an opportunity for client education. In
the absence of accurate knowledge, appropriate treatment is difficult. Teaching parents to
identify and manage fever can begin in prenatal classes with instructions in the use of an
axillary thermometer. Any temperature over 99°F in a baby under three months of age
should be reported to the health care provider. As the child grows, fever management
education specific to the age and health status of the child can be included during health

assessments and acute care visits.

Table 12 -- Percent Who Indicate Fever Cutoff At Or Higher Than Study Standard

 

Periodic review of fever management strategies may be more efl‘ective than a

single educational intervention. Baumgartner’s (1987) nursing intervention to increase

parental knowledge about fever had limited efl‘ectiveness. The study demonstrated that

37

Table 12a -- Correct Identification Of Axillary Fever By Educational Level

 

Note. 13 = .758 and p = .384

Table 12b -- Correct Identification Of Rectal Fever By Educational Level

 

 

 

 

 

 

 

 

Note. x3 = .938 and p = .333

Table 12c -- Correct Identification Of Oral Fever By Educational Level

 

 

 

 

 

 

 

 

 

 

ote. x: = .672 and p = .412

38

parents’ knowledge about fever and fever management could increase without resulting in
more appropriate fever management behaviors. It is certainly important for Advanced
Practice Nurses (APNs) and other primary care providers to assess parent knowledge
regarding fever management and provide correction and afirmation as appropriate.
Critical thinking in the management of fever is not possible in the absence of accurate and
current scientific evidence. Many parents rely on health care providers for this
information.

Knowledge is necessary but not sumcient for implementation of a critical thinking
pathway. Behaviors will also be affected by attitudes. Nearly all the parents in this sample
(n=34) used a thermometer to evaluate a suspected fever. Fifiy-eight percent expressed
the attitude that they would treat the child even if they did not know the exact
temperature. This combination suggests overuse of technology, defined as use of a tool
without a clear reason for doing so. What is the source of this attitude? Over halfthe
parents in this sample indicated that one of the reasons they used a thermometer was
because they thought the doctor or nurse would ask them the exact temperature. Is it
possible that parents who regularly access the health care system are afl‘ected by the
attitudes of providers? Do we as professionals overuse technology by using tools and
tests even when the results will not change our plan of care? Do we, by our expectations
and questions of parents, encourage their overuse of thermometers? The concept of
informed use of technology, basing decisions to use a tool on the expectation that
treatment actions will be guided by the results, is worthy of our exploration and thought.

If we are to “know with” and care through tools, we must cultivate an attitude of

39

informed use.
Implications For Research

As an initial trial of a self report instrument to examine behaviors and attitudes
related to thermometer use and fever treatment, this study utilized a small and relatively
homogenous sample. Replication of the study using a revised instrument with a larger
sample may reveal significant findings in cases where there was a suggested correlation in
the present study. For example, the chi square for type of thermometer and ease of use
suggested a relationship (13 = .676) but did not show significance (p = .713).

This particular questionnaire could be revised to be more effective in revealing
parental attitudes and behaviors regarding temperature assessment. Questions such as “In
the last year, when your child has been sick, how often have you used a thermometer to
confirm your impression that your child had a fever? Always, Sometimes, Rarely, Never”
may be more acceptable to parents and document more variability in thermometer use than
the yes/no approach of the current questionnaire. The concept of ease of use may be more
clearly defined by the question “Does your thermometer need technological improvement?
Much, Some, Little, None.”

This data was collected by self report questionnaire, a method that allows the
subject a fair degree of latitude in interpreting questions and directions. In this case, the
possibility that subjects drew on several instances of fever rather than just one, may have
resulted in an overstatement of thermometer use. A verbal survey, which allows feedback
from the researcher, may avoid this problem. This method might also minimize the

number of omissions when parents are asked to indicate a “most important” response.

40

Regular access to health care has been demonstrated to correlate with increased
use of thermometers (Schwartz, Guendelman & English, 1997). Since data was collected
exclusively at a pediatrician’s oflice, this bias is acknowledged. Using a different site for
data collection, such as an urgent care center or a shopping mall, may result in a more
diverse data set.

While 89% of parents indicated that when they did use the thermometer it was for
the purpose of determining the child’s exact temperature before administering medication,
58% indicated they would treat a suspected fever without knowing the exact temperature.
This seems to support the hypothesis that many parents do not believe the tool would give
them any information that would change their planned course of action. It would be
useful to know whether parents would be deterred fi-om administering medication if the
temperature reading was low. If not, perhaps their decision to medicate was based on the
child’s discomfort and the temperature reading perceived as an objective finding that could
justify an existing plan.

Verbal comments of local health care providers concerning parental use of
thermometers suggest that professionals believe that all fevers should be assessed
objectively. Determining if such a perspective exists would be an interesting focus of
study. As would the degree to which attitudes and expectations of professionals drive the
behavior of parents in their fever management strategies.

Implications For Nursing Education
As we educate nursing professionals at all levels, it is imperative that we

reforrnulate the relationship between health care providers and their technology.

41

Literature reviewed for this paper provides support for the premise that technology is
often viewed as an impediment to caring (Reiser, 1978; Sandelowski, 1997). Rather than
to simply exhort novice nurses to remember that there is a patient on the other side of
their instruments, a tactic that has been insufficient for three hundred years to change the
distancing effects of medical technology, nursing educators must reconceptualize the
approach to technology. A starting point for this transformation could be to teach nurses
to critically examine each use of technology as clinicians, health educators and patient
advocates.

Concerning the implications of this study relative to fever identification and
management, it is important that all nurses caring for expectant mothers and children be
educated about the meaning of fever and appropriate management strategies. Health care
providers must be aware of what fever is and is not, how the risks associated with fever
change with the age and general health of the child, and what place thermometers have in
fever management. It may not be necessary for all fevers to be assessed objectively.
Subjective findings give useful information, clues to the child’s response to the illness and
direction for treatment that will promote comfort and healing. Thermometers are
necessary for identifying any fever in an infant less than 90 days old and screening for
dangerously high fever in a child of any age. It is important that nurses and nurse aides
working in primary care know when a fever is dangerous. It is also important to have the
ability to discriminate a fever that is most likely benign. When health professionals

overcome “fever phobia,” parents and children will be better served.

A Proposal For Ritual

Baumgartner (1987) suggests that fever management strategies, including the use
of thermometers and antipyretics, have become a ritual that may not be rooted in scientific
principles. The transformation of our relationship with technology will involve the
development of new rituals that synthesize technology and caring. As an illustration of
information gathered in this study, the following vignette is submitted as a proposal for an
integrated ritual for fever management. It is presented with the caveat that an underlying
cause for the fever has been identified and treatment measures instituted as needed.

A mother observes that her 5 year old daughter is warm to touch and has flushed
cheeks. Because the child’s body fluid reserves are reduced during periods of high
metabolic activity, the mother begins oral fluid replacement. The child is dressed in a tee
shirt and underwear to allow body heat to radiate fieely, because fevers above 103 °F
result in increased physical discomfort for the child (Fox, 1997). Skin to skin contact is
comforting for mother and child and also provides the mother with subjective data on the
fever. The child may fall asleep. On the other hand, the child may become increasingly
irritable as the fever rises. The child’s discomfort interferes with her own emotional
reserves for healing and is unsettling to the mother as well. The decision is made to
administer acetaminophen to the child to promote comfort. The child falls asleep in the
mother’s arms. An hour later the sleeping child feels quite hot to touch. The mother
becomes concerned that the child’s Sleep may be evidence of lethargy and a dangerous
fever. Rather than wake the child, the mother uses a thermometer to assess the

temperature. The reading is 102°F. The mother is reassured that this fever is not a threat

43

but an adaptive host response.
Reflections

We must remind ourselves that while medical tools do enhance our senses, they
give only a partial and somewhat mythical representation of the world we seek to
understand. There are significant differences between machines and organisms. A tool or
machine will perform only within the parameters of its design With care and maintenance,
a machine can be expected to perform predictably and consistently. Organisms, on the
other hand, can be expected to perform unpredictably. Some organisms possess the ability
to function in the absence of adequate care and maintenance; they adapt to challenge.
However, in order to maximize their potential, most organisms benefit fiom observation,
feedback and awareness of their multidimensionality.

Transformation of the relationship between humans and their tools requires an
understanding of the strengths and limitation of the tool, as well and those of the
organisms on both sides of the tool, the observer and the observed. What do we hope will
be revealed to us by the tool? What human performance do we hope can be enhanced by
the use of a tool? As we make tools part of ourselves, part of our technodermis, our
expectations will become increasingly focused. If we demand it, and only if we demand it,

those expectations will be fulfilled.

44

APPENDICES

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research Involving
HumanSuMems
(UCRIHS)

Michigan State University
246 Administration Building
East Lansing, Michigan
48824-1046

517/355-2180
FAX: 517/432-1171

The Michigan State University
mensmmmmwomww;
Excellence in Action.

MS U is an atfimutimach‘on,

   
  
   

MICHIGAN STATE
u N 1 v E R s I T Y

 

February 25, 1998

TO: Linda S ence_
A230 Li e SCiences

98-104

A DESCRIPTIVE STUDY OF THE BELIEFS AND ATTITUDES
OF PARENTS REGARDING TEMPERATURE MEASUREMENT AND
FEVER MANAGEMENT

RE: IRB#:
TITLE:

REVISION REQUESTED: N/A
CATEGORY: 1 --C
APPROVAL DATE: 02/19/98

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.

herefore, the UCRIHS approved this project and any reVisions listed
above.
RENEWAL: UCRIHS approval is valid for one calendar year, beginning with

the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original approval letter or when a
progect is renewed) to seek u date certification. There is a
maXimum of four such expedite renewals possible. Investigators
wishing to continue a progect beyond that time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
reVise an approved protocol at ang other time during the year,
send your written request to the CRIHS Chair, requesting revised
approval and referenCing the project's IRB # and title. Include
in your request a description of the change and any revised
instruments, consent forms or advertisements that are applicable.

PROBLEMS /
CHANGES: Should_either of the following arise during the course of the
work, investigators must noti y UCRIHS promptly: (1) roblems
(unexpected Side effects, comp aints, etc.) involving uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub'ects than

existed when the protocol was previously reviewed an approved.

If we can be of any future help, p se do not hesitate to contact us
2-1

at (517)355-2180 or FAX (517)4

cerely,

 
  

vid E. Wright,
CRIHS Chair

DEW : bed

cc: Anne Therese Hughes

45

APPENDIX B

Memo
To: Anne Hughes, RN MSU graduate student
From: Michael J. Eldredge, MD Kid's Creek Children's Clinic

Subject: Thesis proposal "A Descriptive Study of the Beliefs and Attitudes of

Parents Regarding Temperature Measurement and Fever Management"

It is acceptable for you to recruit subjects for your study at Kid's Creek with the
understanding that patient confidentiality will be preserved by the following procedures:
1) patient and caregiver names will not be written on the data collection questionnaire and
2) the questionnaire will be distributed and collected by front oflice stafl‘ rather than the

researcher.

As discussed, findings of the study will be shared with us at the conclusion of the

study.

46

APPENDIX C

A LETTER TO FRONT DESK STAFF AT KID'S CREEK

First, let me tell you how grateful I am for your help in this data gathering process.
This thesis describing behaviors and attitudes of parents/guardians regarding the use of
thermometers to assess fever in children is part of my graduate studies in the MSU
College of Nursing. 1 will be exploring how the use of the thermometer relates to
underlying attitudes about technology in general and the treatment of fever in particular. I
am very interested in this tOpic and excited to be at this phase of the project.

The process for recruiting subjects for the study is as follows: Please ask parents
who bring a child in for any reason if they would consider participating in the study. They
are eligible to participate if they have a child who is aged 12 months to 12 years and they
have taken care of that child when he or she had a fever. The age of the child they
brought in today and the reason for their visit doesn't really matter, as long as the parent,
at some time, has managed a fever in a child 12 months to 12 years old. Please do not ask
parents of children with chronic illness (such as diabetes and cystic fibrosis) to participate
in the study.

The cover letter attached to the questionnaire explains the study to the parent and

directs them to return the completed questionnaire (in a provided envelope) to fi'ont desk

47

stafi‘ after completion. The directions explain that they are not to write their name or their
child's name on any materials and that their completed questionnaire indicates their
consent to participate. If you see that names have been written on the envelope, please

blot them out. Then place the questionnaires in this box and I will pick them up.

Thank you again for your help!

Anne Hughes, RN

48

APPENDIX D

A LETTER TO PARENTS
Dear Parents,

Thank you for taking the time to read this letter explaining a research study. This
study is being conducted by Anne Hughes, RN, a graduate student at Michigan State
University, College of Nursing. Information fiom the study questionnaire will be used to
describe how and why parents and guardians use (or decide not to use) thermometers to
evaluate fevers in children. In addition, it gives some idea of the methods
parents/guardians use to manage fever.

There are no known risks or direct benefits to you if you participate in this study.
Your decision to participate or not will have no efi‘ect on the health care your child is
receiving at Kid’s Creek. You are flee to refuse to participate in this study or withdraw
from it at any time. Also you have the right to refuse to answer any of the study
questions. Participation in this study will not cost you anything nor will you be paid for
your participation. If you have any questions, you may contact the nurse researcher, Anne
Hughes at (616) 223-4681. Linda Spence PhD., RN, Assistant Professor and Thesis
Chairperson, College of Nursing, Michigan State University can also be reached for
questions at (517) 353-8684.

If after reading this letter you decide to participate, please fill out the attached

49

questionnaire. So that your information stays confidential, do not write your name or
your child's name on the questionnaire. The questionnaire takes about 10 minutes to
complete. You may take it into the exam room with you if you need more time to finish.
Then place it in the envelope provided and return it to fiont desk stafl‘ as you leave. This
way, you and your family remain anonymous to the researcher. By filling out the
questionnaire it is understood that you have consented freely to participate in this study
and I am very grateful for your help. If you are interested in the results of the study, they

will be available at this office next May.

Thank you,

Anne Hughes, RN

Family Nurse Practitioner Candidate, Michigan State University

50

APPENDIX E

Treatment of Temperature in Children -- A Questionnaire

, Think about the last time your child had a fever and what you did for him or her.
For most of the questions you will check yes or no to indicate the answers that best
describe what you did for that fever. Remember not to write your name or your child's
name on the questionnaire. When you are done, place the completed questionnaire in the
envelope and give it to the receptionist when you leave. That way your privacy and your
child's privacy are preserved. You indicate your voluntary agreement to participate by
completing and returning this questionnaire.

1. Who usually takes care of your child when he or she has a fever?
[3 I do D another person does

2. What makes you suspect that your child has a fever?
describe how you know

3. Do you have a working thermometer at home?
[:1 yes (go to question 4) D no (go to question 8)
4. What kind is it?

I] glass CI digital [:1 car [:I paper strips
El other (describe)

5, Do you feel comfortable using the thermometer?
D yes [:I no

6. How easy is it for you to use?
D very easy I] easy I: hard [I very hard

51

7- If you use a thermometer, what temperature tells you your child has fever?

Mark an X on the thermometer scales to show this temperature.

 

 

98 99 100 101 102 103 104 105 106
I I I I I | I I I
98 99 100 101 102 103 104 105 106
I I I I I I I I |
98 99 100 101 102 103 104 105 106

I l I I I l I I I
8. When you suspect your child has a fever, how do you make sure?

in the mouth

under the arm

rectal

CHECK yes or no for each of the following, and place a STAR (*) beside the ONE

answer you feel gives you the BEST information.
a) I take the temperature with my hand.
b) I observe how my child looks.
c) I take the temperature with a thermometer.
d) I observe how my child acts.

e) I take other action.
please describe

Dyes
Elves
Dyes
Dyes
Eyes

9. If you DID USE A THERMOMETER the last time your child had a fever,
CHECK yes or no for each of the following, and place a STAR (*) beside the

MOST IMPORTANT reason.

a) I wasn't sure whether my child had a fever.

b) I thought the doctor/nurse would ask me what the exact
temperature was.

c) I wanted to make sure the fever wasn't dangerously high.

d) In my family we have always used a thermometer.

e) I wanted to know how high the temperature was before I
gave any medicine.

1) I had other reasons.
please describe

52

Dyes
Elm

CI yes
I] yes
E] yes

Dyes

Duo
Duo
Duo
Duo
Duo

Duo
Duo

Duo
Duo
Duo

Duo

10. If you DID NOT USE A THERMOMETER the last time your child had a fever

CHECK yes or no for each of the following, and place a STAR (*) next to the

MOST IMPORTANT reason.
a) I don't have a thermometer. D yes D no
b) I thought using the thermometer would upset my child. D yes D no
c) My child was sleeping and I didn't want to wake him/her. D yes D no
d) My mom/dad always checked my fevers with their hand. D yes D no
e) I think it makes my child feel better just to be touched. D yes D no
t) My child was crying and hot. D yes D no
g) I would have given the medicine no matter what the CI yes I_—_I no
thermometer said.
h) My thermometer is a bother to use. D yes D no
i) The thermometer doesn't tell me more than I already know. D yes D no
j) I'm afi'aid the thermometer might injure my child. D yes D no
k) I was afiaid to know how high the fever was. D yes D no
1) The fever was nothing to worry about. D yes D no
m) I had other reasons. I:I 3'93 , CI 110

Please describe

11- What do you do to treat a fever?
CHECK yes or no for each of the following, and place a STAR (*) beside the
treatment you feel is the MOST IMPORTANT.

 

a) give Tylenol D yes D no
b) give Motrin/Advil CI yes CI no
c) give Aspirin D yes D no
d) give other medicine. please describe El YES D I10
e) cover my child with blankets and clothes CI 3'93 D no
e) take blankets and clothes ofl‘ my child [I yes CI no

53

i) give my child more to drink
g) cuddle my child
h) place my child in a cool bath

i) I take other action.
please describe

12. Would you treat fever if you didn't know the exact temperature?

Would you please indicate a few pieces of information about yourself.

13. How old are you? years

I3 yes
[I yes
CI yes
CI yes

CI yes

14. How old is the child you thought about when you answered these questions?

years
15. What is your gender? Dmale Dfemale

16. What is your highest grade completed in school or college?
D completed grade school
D some high school
D completed high school
D some college
D Associate's degree
D Bachelor's degree
D advanced degree
17. What type of medical insurance does your child have?
D private (Blue Cross, North Med, CHAMPUS, etc.)
D public (Medicaid)

D no insurance

54

[Inc
[In
One
Duo

Duo

LIST OF REFERENCES

LIST OF REFERENCES

Banco, L. & Veltri, C. (1984). Ability of mothers to subjectively assess the
presence of fever in their children. American Journal of Diseases in Children, 138(10),
976-978.

Baumgartner, P. A. (1987). The 1_r_np' act of a nursing intervention on mntal
knowledge and behavior in relation to childhood fever. Unpublished master’s thesis,

Michigan State University, East Lansing.

DeQuincey, C. (1997). Consciousness: The final fi'ontier? Noetic Sciemes
Review, 42(2), 30-33.

Fox, J. A. (Ed.). (1997). P' Health are of hil 11. St. Louis: Mosby.

Haddock, B. J., Merrow, D. L. & Swanson, M. S. (1996). The falling grace of
axillary temperatures. Pedta' tric Nmmg’ , 22(2), 121-125.

Hawthorne, D. L. & Yurkovich N. J. (1995). Science, technology, caring and the
professions: Are they compatible? low of Advanced Nuging, 21, 1087-1091 .

Hooker, E. A., Smith, S. W., Miles, T. & King, L. (1996). Subjective assessment
of fever by parents: Comparison with measurement by noncontact tympanic thermometer

and calibrated rectal glass mercury thermometer. Annals of Emergency Medicine, 28(3),
313-317.

Ihde, D. (1990). Technology and the lifeworld. Indianapolis: Indiana University
Press.

Keen, S. M. (1983). The passionate life. San Francisco: HarperCoIlins.
Nightingale, F. (1859). Notes on nursing; _W_hat it 31' , ggd what it 18' not. London:

Harrison.

Pirsig, R. M. (1974). Zen and the art of motorcycle maintenance. New York:
William Morrow.

55

Pontious, S. L., Kennedy, A., Chung, K. L., Burroughs, T. E., Libby, L. J. &
Vogel, D. W. (1994). Accuracy and reliability of temperature measurement in the
emergency department by instrument and site in children. Pediatric Nursing, 20(1), 58-63.

Reiser, S. J. (1978). Medicine and the reign of technology. Cambridge:
Cambridge University Press.

Sandelowski, M. (1997). (Ir)Reconcilable difl‘erences?: The debate concerning
nursing and technology. Im_age: Journal of Nursing Scholarohip, 29(2), 169-174.

Schwartz, N., Guendelman, S. & English, P. (1997). Thermometer use among
Mexican immigrant mothers in California. Social Science and Medicine 45(9), 1315-
1323.

 

Uphold, C. R. & Graham, M. V. (1994). Clinical guidelines in family practice.
Gainesville, FL: Barmarrae Books.

Weiss, S. J., Hanhart, E. J., McBride, R., Johnson, H., Denninghof, K. & Johnson,
W. D. (1995). Tympanic membrane thermometry in the care of out-of-hospital patients.
Annals of Eme_rgency Medicine 25(1), 41-47.

 

Wells, N., King, J., Hedstrom, C. & Youngkins, J. (1995). Does tympanic
temperature measure up? American Journal of Matemal thlo thing, 20(2), 95-100.

Wilson, D. (1995). Assessing and managing the febrile child. Nurse Praotitionor,
2_0_(11), 59-74.

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