Factors influencing the caregiving performance of mothers of hospitalized toddlers with acute respiratory diseases: A path analysis

Abstract

Studies on the management of respiratory diseases in children have focused on family members’ participation and caregivers’ needs. However, evidence-based data on the effectiveness of mothers’ management of acute respiratory diseases (ARDs) in toddlers are lacking. This study aimed to examine the factors influencing the caregiving performance of mothers of toddlers hospitalized for an ARD and to test a hypothetical causal model based on the Caregiving Effectiveness Model (CEM). A cross-sectional design was used, and participants included 291 mothers of toddlers aged 12–36 months who were hospitalized for an ARD. Based on the CEM, data were analyzed to identify the path of relationships between the factors influencing mothers’ care of their hospitalized children and the mothers’ caregiving performance. The modified path model had a good fit with the data, with optimal values for all fit indices. The mothers’ caregiving performance was influenced by the children’s number of hospitalizations, the mother–child relationship, and the mothers’ anxiety level. These three factors explained 51.4% of the variance in the mothers’ caregiving performance. Educational interventions targeting controllable factors such as mother–child relationships and mothers’ anxiety levels may be considered to improve mothers’ caregiving performance.

Keywords

Acute care children hospitalization mothers respiratory tract infections

Introduction

Worldwide, acute respiratory diseases (ARDs) are the most common cause of illness and death among children under the age of 5 years (Liu et al., 2012; UNICEF, 2013; WHO, 2009). In Korea, approximately 80% of toddlers’ hospital visits are attributed to respiratory or related diseases (Kim et al., 2016; Korea Ministry of Health & Welfare, 2016). This rate is much higher than that among older children because toddlers have narrower airways, more delicate chest walls, and immature respiratory systems, making it more difficult for them to overcome hypoxia, which often exacerbates symptoms, resulting in hospitalization in an intensive care unit (Ahn and Shin, 2016). In addition, current research has revealed that environmental factors such as dust, air pollution, and allergens contribute to the occurrence of ARD (Bhumi et al., 2015; Liu et al., 2012).

Family involvement and support are essential for toddlers with respiratory diseases because they cannot describe their symptoms in detail or initiate appropriate actions to alleviate them (Mattheus, 2010). When a child is hospitalized, the primary caregiver, who is most often the mother, may be in a state of anxiety (Oh and Moon, 2012). A family’s healthy adaptation to a child’s illness has a positive influence on the child’s health and recovery from a medical crisis (Montigny, 2005). However, various stressors related to adaptation to an unfamiliar environment, such as that at a hospital, can exacerbate the problems faced by the family (Jeon, 2011; Smith et al., 2002).

Therefore, when a child is admitted to a hospital, the mother is an indispensable part of the care plan. When the mother is regarded as the primary caregiver for a child who has been admitted to a hospital, health professionals, including nurses, must educate her about caregiving skills and performance to facilitate the provision of optimal care for the child.

Educational interventions should help resolve the mother’s anxiety and uncertainties regarding her child’s illness, treatment, medication, and prognosis, which should improve her effectiveness as a caregiver (Han et al., 2015; Montigny, 2005; Nam et al., 2014). Also, the mother must acquire the knowledge and skills needed to manage the illness and related health problems, to prevent symptom exacerbations and to perform health-promotion activities (Black and Lobo, 2008; Coleman and Karraker, 2003; Kim et al., 2016).

Studies on the management of respiratory diseases in children have focused on family members’ participation and caregivers’ needs (Coleman and Karraker, 2003; Kim et al., 2007; Seo, 2002), the effects of family involvement on disease progression (Yi, 2009), and the effects of nursing interventions (Jeong and Kwon, 2015; Park et al., 2011). However, evidence-based data on the effectiveness of mothers’ caregiving performance in management of ARDs in toddlers are lacking. Our literature search revealed that no study has explored the factors influencing the caregiving performance of mothers of toddlers hospitalized for an ARD using path analysis.

Purpose

The purpose of this study was twofold:

To identify the relationship between the factors associated with the caregiving performance of mothers with a child hospitalized for an ARD.

To construct and test a hypothetical causal model regarding the caregiving performance of mothers with a child hospitalized for an ARD based on the Caregiving Effectiveness Model (CEM; Smith et al., 2002).

Methods

Design

This study used a cross-sectional design to examine the factors influencing mothers’ caregiving performance and to test a hypothetical causal model based on the CEM (Figure 1). This article followed the strengthening the reporting of observational studies in epidemiology checklist in reports of cross-sectional studies.

Figure 1.

Sampling flowchart.

Theoretical framework

According to the CEM developed by Smith et al. (2002), the caregiving effectiveness of family members refers to the provision of physical and emotional care to a patient to maintain the patient’s optimal health and the family’s well-being. This model is based on the context of a nursing care situation involving a patient and a caregiver and provides a linear and descriptive structure of caregiving and adaptation, with caregiving effectiveness as the outcome (Figure 1).

An understanding of the relationships among three aspects of care (caregiving, adaptation, and caregiving effectiveness) would enable nurses working in pediatric units to help caregivers and patients have positive interactions, and thus facilitate the effective caregiving performance of family caregivers (Kang, 2009; Smith et al., 2002). In this study, we retested the CEM to improve the caregiving performance of mothers of children hospitalized for an ARD.

Thus, based on the CEM (Smith et al., 2002) and previous studies (Ahn and Shin, 2016; Han, et al. 2015; Kim et al., 2016; Koo, 2002), we constructed a hypothetical causal model of the relationships among the factors influencing the caregiving performance of mothers with a child hospitalized for an ARD. This model comprised the following three aspects of care mentioned earlier, each with its own variables: (a) caregiving context (disease severity, number of hospitalizations, and mother–child relationship), (b) adaptation context (mother’s anxiety, family adaptation, and mother’s caring efficacy), and (c) caregiving effectiveness context (mother’s caregiving performance; Figure 2).

Figure 2.

Conceptual framework based on the CEM. CEM: Caregiving Effectiveness Model.

Setting and participants

The participants were mothers of toddlers who were admitted to a pediatric ward of a university hospital located in Seoul, South Korea. The criteria for inclusion in the study were as follows: (a) being a mother of a hospitalized child, (b) the child being aged 12 to 36 months, (c) the child having an ARD, and (d) mothers being able to understand and respond to all the contents of the questionnaire. Participants were excluded (a) if their children had any chronic diseases and (b) if the mothers did not possess any health literacy. Potential participants who met the selection criteria were informed of the purpose of the study by the first author when their child was admitted to the hospital with an ARD, and they were asked if they were willing to participate in the study. Signed consent forms were obtained from the mothers who agreed to participate.

Hair et al. (2006) suggest that at least 200 participants are required to perform structural equation modeling, regardless of the number of observed variables. A power analysis (Faul et al., 2009) revealed that 89 participants are required for correlation at a medium effect size (ρ H1) of .3, a significance level of .50, and 95% power. A total of 320 mothers voluntarily agreed to participate in the study; mothers who provided incomplete data (17) or refused to participate (12) were excluded. Thus, data collected from 291 mothers were analyzed. The final sample of 291 participants was considered sufficient for this study (Hair et al., 2006).

Data collection

Data were collected for 18 weeks from April 5 to August 9, 2015, at the pediatric wards of the study site. Data on the children’s characteristics, such as weight, height, severity of dyspnea, respiratory rate, and retraction level, were retrieved from nursing records.

Instruments

Disease severity

The diagnostic criteria for respiratory infection in children are fever, cough, and dyspnea (Ahn and Shin, 2016). In this study, we only used the dyspnea evaluation criteria using the Silverman-Anderson index because the children’s fever and cough symptoms could be controlled by medications, whereas their dyspnea cannot be controlled within a short time despite continuous treatment (Kim et al., 2016). Disease severity was assessed by the attending pediatric physician and the respiratory nurse practitioner on admission.

Participating mothers responded to five items consisting of symptoms indicating dyspnea (seesaw respirations, intercostal space retraction, xiphoid process retraction, flaring of the nostrils, and expiration grunting) by rating them on a three-point Likert-type scale (0–2). A higher total score indicates more severe dyspnea. A total score greater than seven points was classified as very severe, that between four and six points indicated moderate severity, and that lower than three points indicated mild severity (Han et al., 2015).

Mother–child relationship

The mother–child relationship was measured using parent–child relationship (PCR), a 35-item instrument developed by Lee (2004). Each question (e.g., “I always respond to the child’s laughter, sounds, and crying without passing by”) is answered on a three-point Likert-type scale (0 = not at all, 1 = sometimes, 2 = often), with higher scores indicating a better relationship between the mother and child. The Cronbach’s α for this tool was .83 in Lee’s study (2004) and .85 in the present study.

Mothers’ anxiety

The anxiety level of the mothers was measured using the self-report State–Trait Anxiety Inventory developed by Speilberger (1972) and revised by Kim and Shin (1978). It consists of 20 items (10 positive and 10 negative) rated on a four-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating a higher level of anxiety. The Cronbach’s α for the State Anxiety Scale was .92 in Speilberger’s (1972) study and .91 in the present study.

Family adaptation

The Family Adaptation Scale developed by Epstein et al. (1993) and translated from English into Korean by Oh and Moon (2012) was used. The scale consists of 10 items that are rated on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating better family adaptation. The Cronbach’s α for this tool was .79 in the study by Oh and Moon (2012) and .88 in the present study.

Mothers’ caring efficacy

We used the Parenting Sense of Competence Scale (PSOC) developed by Gibaud-Wallston and Wandersman (1978) and revised by Lee (2009) to measure mothers’ caring efficacy. The PSOC consists of seven items that are rated on a six-point Likert-type scale ranging from 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating higher maternal-care efficacy. The Cronbach’s α for this tool was .79 in the study by Lee (2009) and .74 in the present study.

Mothers’ caregiving performance

Based on previous research (Ahn and Shin, 2016; Han et al., 2015; Kim et al., 2016; Koo, 2002), we developed a scale to measure mothers’ caregiving performance to ensure the instrument’s cultural appropriateness and consistency with the present study’s purpose (Online Appendix 1). It comprises 25 items on the areas of symptom management, infection control, and environmental management. Each question is answered using a four-point Likert-type scale ranging from 0 (not at all) to 3 (always), with higher scores indicating better performance as a caregiver. A factor analysis was performed on the instrument to examine its construct validity. The Kaiser-Meyer-Olkin (KMO) score was .834, and the results of the Bartlett’s Sphericity test were χ ² = 2605.443, df = 300, and p < .001, which indicated that it was appropriate to perform a factor analysis on the tool. Three factors (symptom management, infection control, and environmental management) explained 43.8% of the total variance in the mothers’ caregiving performance. The commonality loadings of all the items on the three factors were .18–.60. The Cronbach’s α of this scale was .87.

Content validity

The content validity of all the instruments of the study were checked to determine suitability for use with Korean mothers by five pediatric nurses who had worked in a general hospital for more than 10 years, three pediatricians and specialists, and two pediatric nursing professors. The content validity index for all the instruments’ items was greater than 80% and the content was revised according to the feedback of the panel of experts.

Further, to confirm participants’ understanding of the items and their responses to the new instrument assessing caregiving performance, a preliminary survey was conducted with 40 mothers whose children were hospitalized for an ARD. The results of the item analysis confirmed that the internal consistency of the tool was optimal, as the Cronbach’s α was greater than .90.

Ethical considerations

Ethics approval for this study was granted by Sahmyook University’s Institutional Review Board (IRB; No. 2015030HR). The IRB confirmed that the study did not violate human rights and that all processes conformed to standard ethics requirements, including issues of voluntary participation, anonymity, and confidentiality.

Data analysis

The data were analyzed using SPSS 22.0, and the path model was examined using AMOS 20.0 (IBM Corp., Armonk, New York, USA). Descriptive statistics, Pearson’s correlation coefficients, and standardized regression coefficients were used for the analyses. To evaluate the suitability of the statistical model, χ ², χ ²/df, goodness of fit index (GFI), comparative fit index (CFI), Tucker-Lewis index (TFI), adjusted goodness of fit index (AGFI), root mean squared error of approximation (RMSEA), and standardized root mean square residual (SRMR) were calculated, and the statistical model’s direct, indirect, and total effects were confirmed using path analysis. To verify the mediating effect, the bootstrap method and the Sobel test were used.

Results

General and disease-related characteristics of the participants

In the present sample, 50.2% (146) of the children were male and 49.8% were female (145). Further, 143 (49.1%) toddlers exhibited moderate symptoms of respiratory disease. The severity of coughing was moderate in 174 (59.8%) toddlers, severe in 94 (32.3%), and mild in 23 (7.9%). Difficulty in breathing was moderate in 143 (49.1%) toddlers, severe in 122 (41.9%), and mild in 26 (8.9%). Retraction was moderate in 139 (47.8%) toddlers, severe in 135 (46.4%), and mild in 17 (5.8%). Wheezing sounds were moderate in 140 (48.1%) toddlers, severe in 101 (34.7%), and mild in 50 (17.2%). Among the family members, 170 (58.4%) had no education related to respiratory diseases and 121 (41.6%) had received some related education.

Descriptive statistics and correlations among the variables

Table 1 shows the descriptive statistics (mean, standard deviation, and range) and skewness and kurtosis values. The skewness and kurtosis values satisfied the requirements for normality.

Table 1.

Descriptive statistics of the measured variables (N = 291).

Variables		n (%)/mean (SD)	Min	Max	Range	Skewness	Kurtosis
Severity of disease	Mild	23 (7.9)	—	—	—	—	—
	Moderate	143 (49.1)	—	—	—	—	—
	Severe	125 (43.0)	—	—	—	—	—
Number of hospitalizations	1	126 (43.3)	—	—	—	—	—
	2	74 (25.4)	—	—	—	—	—
	>3	91 (31.3)	—	—	—	—	—
Mother–child relationship		2.53 (0.22)	2.03	2.94	1–3	−.13	−.89
Mother’s anxiety		2.72 (0.49)	1.25	3.55	1–4	−.49	−.93
Family adaptation		4.08 (0.44)	2.20	5.00	1–5	−.84	1.86
Mother’s caring efficacy		3.94 (0.51)	2.43	5.14	1–6	.07	−.22
Mother’s caregiving performance		2.90 (0.33)	2.16	3.84	1–4	.30	−.38

Min: minimum; Max: maximum.

Table 2 shows the correlations among the scores for mother–child relationship, mothers’ anxiety, family adaptation, mothers’ caregiving efficacy, and mothers’ caregiving performance.

Table 2.

Correlation among the measured variables.

Variables	Mother–child relationship	Family adaptation	Mother’s caring efficacy	Mother’s anxiety	Mother’s caregiving performance
Variables	r (p)	r (p)	r (p)	r (p)	r (p)
Mother–child relationship	1
Family adaptation	.49 (<.001)	1
Mother’s caring efficacy	.48 (<.001)	.21 (<.001)	1
Mother’s anxiety	−.34 (<.001)	−.01 (.860)	−.51 (<.001)	1
Mother’s caregiving performance	.54 (<.001)	.30 (<.001)	.36 (<.001)	−.48 (<.001)	1

The mothers’ anxiety was negatively correlated with the mother–child relationship and the mothers’ caregiving efficacy. The mothers’ caregiving efficacy was positively correlated with the mother–child relationship and family adaptation. Family adaptation was positively correlated with the mother–child relationship. The outcome variable, mothers’ caregiving performance, was significantly correlated with all the other variables; the mother–child relationship, family adaptation, mothers’ caregiving efficacy, and mothers’ anxiety.

The multicollinearity test between the variables conducted before the path analysis revealed correlations ranging from .01 to .5, and all of the Variance Inflation Factors were below 10, indicating the absence of multicollinearity.

The results of the path analysis

Model fitness

The initial fit statistics for the hypothetical model showed that it was adequate (χ ²/df = 1.60, RMSEA = .05, GFI = .99, AGFI = .96, CFI = .99, NFI = .99, and TLI = .97; Figure 3). However, after evaluation of the modification indices and parameter estimates, disease severity paths in this hypothesized model were identified as being non-significant; thus, they were deleted from the measurement model. The modified final model (Figure 4) demonstrated a good fit to the data (χ ²/df = 1.52, GFI = .99, AGFI = .96, RMSEA =.04, SRMR = .01, NFI = .99, CFI = .99, and TLI = .98).

Figure 3.

Hypothetical path diagram.

Figure 4.

A final path diagram of the study.

Direct, indirect, and total effects found in the path model

The results of the path analysis are presented in Table 3 and Figure 2.

Table 3.

Standardized effect of the model.

Direct, indirect, and total effects in the model
Endogenous variables	Exogenous variables	Direct effect		Indirect effect		Total effect		Squared multiple correlations
Endogenous variables	Exogenous variables	β	p	β	p	β	p	%
Mother’s anxiety								.115
	Number of hospitalizations	.04	.535	—	—	−.04	.535
	Mother–child relationship	−.33	.005	—	—	−.33	.005
Family adaptation								.289
	Number of hospitalizations	−.17	.012	.01	.411	−.16	.012
	Mother–child relationship	.52	.004	−.06	.010	.46	.003
	Mother’s anxiety	.18	.016	—	—	.18	.016
Mother’s caring efficacy								.372
	Number of hospitalizations	.05	.312	−.02	.509	.03	.570
	Number of hospitalizations	.05	.312	−.02	.509	.03	.570
	Mother–child relationship	.35	.004	.13	.003	.48	.005
	Mother–child relationship	.35	.004	.13	.003	.48	.005
	Mother’s anxiety	−.40	.004	—	—	−.40	.004
Mother’s caregiving performance								.514
	Number of hospitalizations	−.35	.003	−.02	.349	−.37	.003
	Mother–child relationship	.35	.004	.13	.002	.48	.004
	Mother’s anxiety	−.33	.004	.01	.709	−.32	.002
	Family adaptation	.05	.373	—	—	.05	.373
	Mother’s caring efficacy	−.01	.924	—	—	−.01	.924
Mediation effects in the model
					Estimate (standardized estimates)		SE	Sobel test
					Estimate (standardized estimates)		SE	Z	p
Mother–child relationship → Mother’s anxiety → Mother’s caregiving performance					.16 (.11)		.04	4.43	<.001
Mother–child relationship → Mother’s anxiety → Family adaptation → Mother’s caregiving performance					−.01 (−.00)		.01	−0.97	.320
Mother–child relationship → Mother’s anxiety → Mother’s caring efficacy → Mother’s caregiving performance					−.00 (−.00)		.01	−.15	.856
Mother–child relationship → Family adaptation → Mother’s caregiving performance					.04 (.03)		.04	1.02	.294
Mother–child relationship → Mother’s caring efficacy → Mother’s caregiving performance					−.00 (−.00)		.03	−.15	.856

Mothers’ anxiety was positively affected by the mother–child relationship. The direct and total effect (β = −.33) was significant, and the mother–child relationship explained 11.5% of the variance in the mothers’ anxiety. Family adaptation was influenced by the mother–child relationship, mothers’ anxiety, and the child’s number of hospitalizations. The mother–child relationship had a significant direct effect (β = .52) and indirect effect (β = −.06) on family adaptation and had the largest total effect (β = .46). Mothers’ anxiety had a direct and total effect (β = .18) on family adaptation. The number of hospitalizations had a direct effect (β = −.17), no indirect effect (β = .01), and a significant total effect (β = −.16) on family adaptation. The number of hospitalizations, mother–child relationship, and mothers’ anxiety explained 29.8% of the variance in family adaptation.

The mothers’ caring efficacy was influenced by the mother–child relationship and the mothers’ anxiety. Specifically, the mother–child relationship had a direct (β = .35), indirect (β = .13), and total effect (β = .48) on the mothers’ caring efficacy. The mothers’ anxiety had a significant direct and total effect (β = −.40) on their caring efficacy. The mother–child relationship and the mothers’ anxiety explained 37.2% of the variance in their caring efficacy.

The mothers’ caregiving performance was influenced by the mother–child relationship, number of hospitalizations, and the mothers’ anxiety. Specifically, the mother–child relationship had a direct effect (β = .35), indirect effect (β = .13), and the largest total effect (β = .48). The number of hospitalizations had a significant direct effect (β = −.35) and total effect (β = −.37) on the mothers’ caring efficacy. Furthermore, the mother’s anxiety was significantly related to their caregiving performance, showing a direct (β = −.33) and total effect (β = −.32). The mother–child relationship, number of hospitalizations, and mothers’ anxiety accounted for 51.4% of the variance in the mothers’ caregiving performance.

Indirect effects of the intervening variables

The results of the Sobel test revealed that mothers’ anxiety had a significant mediating effect (Z = 4.43) on the relationship between the mother–child relationship and the caregiving performance. This finding confirmed that the mothers’ anxiety acted as a partial mediator in the relationship between the mother–child relationship and the mothers’ caregiving performance (Table 3).

Discussion

In this study, we presented a revised path model through the verification of fitness indices associated with actual data. Antecedents and intervening factors influencing the mothers’ caregiving performance were identified, and the specific paths of these influences were verified.

The path analysis revealed that the number of hospitalizations of the child, the mother–child relationship, and the mothers’ anxiety directly affected the mothers’ caregiving performance. Furthermore, the number of hospitalizations had a direct negative effect on the caregiving performance of the mothers. However, the participants’ children in this study had two or fewer hospitalizations. Further studies need to be conducted with a broader range of number of hospitalizations to identify their effects more clearly and to improve the generalizability of these findings.

The mother–child relationship had a direct and positive influence on the mothers’ caregiving performance, consistent with a study conducted by Davis and Cooper (2011), who found that a better mother–child relationship was associated with a higher level of caregiving performance by mothers. In studies conducted so far regarding the mothers’ caregiving performance for their children, the mother–child relationship has not been considered as an important influencing factor and has been overlooked. Therefore, the main principles of caregiving can be mastered and implemented through communication and interactions that enhance the mother–child relationship and quality of care.

The present study revealed that the anxiety of the mothers had a direct negative influence on their caregiving performance. Mothers might experience psychological instability and feel burdened when a child is admitted to the hospital (Park et al., 2014); thus, it is necessary for pediatric nurses to reduce their burden and anxiety. Studies have not examined the influence of mothers’ anxiety on their caregiving performance in the context of respiratory illnesses, which occur frequently during childhood. Therefore, it is imperative to conduct such research on this population.

Among the other variables, we found that the mother–child relationship had a direct influence on the mothers’ anxiety and that the mother–child relationship was a significant antecedent to mothers’ anxiety. Therefore, the CEM is a suitable model to explain the path of mother’s caregiving performance, and we suggest that future studies explore the nature and extent of the influence of the mother–child relationship on mothers’ anxiety.

The mother–child relationship showed direct and indirect effect on family adaptation. This relationship is one of the most basic family ties, as it affects most individuals’ entire life. Bang (2009) found that a better parent–child relationship was associated with better outcomes related to the child’s psychological functioning and family adaptation, which is consistent with the findings of the present study.

Mothers’ anxiety had a direct negative effect on family adaptation. Thus, better adaptation of the mothers and children was associated with lower levels of anxiety among the mothers. Poor family adaptation has been found to increase mothers’ anxiety, which in turn increases their emotional response suppression, thereby exacerbating maladaptive emotional regulation in the child (Jeon, 2011; Oh and Moon, 2012). Family support and positive emotional exchanges affect not only the mother’s emotions, but also those of the child, necessitating the development of varied programs to support positive family adaptation. Regarding family adaptation as an intervening variable that did not affect the caring performance significantly, we explain this nonsignificant result into two ways. One of the possible explanations is that the hospitalized children in this study had an acute disease, which had not occurred for a long enough period to affect family adaptation. Another explanation is that the characteristics of ARD may have a good prognosis with effective treatment and care during hospitalization. These two factors may have avoided the negative influence on family adaptation. Therefore, further research is needed to confirm our findings.

In the current study, the mother–child relationship was found to have a direct and indirect effect on mothers’ caring efficacy. A mother with high caring efficacy interacts with the child intimately, which has a positive influence on the healthy development of the child (Nam et al., 2014).

Mothers’ anxiety had a direct negative effect on caring efficacy, indicating that those with higher anxiety levels were more likely to be emotionally distant and interact negatively with their child. Furthermore, high anxiety has been found not only to reduce a mother’s efficacy in caring for her child, but also to affect her problem-solving abilities (Montigny, 2005; Oh and Moon, 2012).

This study confirmed that the disease severity did not affect mothers’ caregiving performance; therefore, it was deleted from the final model. Han et al. (2015) reported that, among children with severe respiratory symptoms, the mother’s care was worse than that observed among those with moderate symptoms. This finding is not consistent with the results of the present study. However, most of the toddlers in this study had moderate to severe symptoms that required hospitalization; therefore, we suggest that future studies explore the effect of disease severity on mothers’ caregiving performance using a sample that represents all severity levels.

Based on the CEM (Kang, 2009; Smith et al., 2002), this study examined causality in relation to the influences of various factors on mothers’ caregiving performance, including the role of intervening variables (mother’s anxiety, family adaptation, and mother’s caring efficacy). The strength of this study is that the results could help nurses recognize the factors influencing mothers’ caregiving performance during their children’s hospitalization. It is noteworthy that the mother–child relationship was identified as an important factor in mothers’ caregiving performance. Therefore, nurses should consider the mother–child relationship more carefully to improve mothers’ caregiving performance. In the clinical setting, our results can be used as evidence-based data for mothers of toddlers with an ARD.

The present findings can be used to develop and implement appropriate educational programs for mothers of young children hospitalized for an ARD. Such programs should involve mothers when their child is undergoing the healing process to improve the child’s overall health. To date, no studies have been conducted to determine the pathways of the variables that influence mothers’ caregiving performance in the context of childhood respiratory diseases and the relationships among the relevant variables. Therefore, the present study makes a substantial contribution to the body of nursing knowledge on the clinical practice of pediatric nurses who collaborate with families, in particular, mothers, to care for their young children who have been hospitalized for an ARD.

Limitations

This study has several limitations. First, the participants were recruited from only one university hospital. To increase the generalizability of the findings, further research should include participants from different geographical locations. Second, the study focused on mothers of toddlers with an ARD. Therefore, there is a need to expand the research to include mothers of children with chronic respiratory diseases. Studies involving mothers of children in other developmental stages should also be conducted. Third, in the current study, the disease severity of children with ARD was mostly at or above the moderate level. Therefore, further research including all levels of disease severity is needed. Further, to assess disease severity, we only considered the degree of dyspnea using the Silverman-Anderson index because the other two indexes, fever and cough symptoms, were controlled by medications. Therefore, it may be necessary to assess disease severity using other methods in future studies. Thus, if future studies examine various factors affecting mothers’ caregiving performance considering these limitations, we should be able to draw more reliable conclusions regarding the caregiving performance of mothers of hospitalized toddlers.

Conclusion

The present study revealed that mothers’ anxiety had a partial mediating effect on the association between the mother–child relationship and the mothers’ caregiving performance. This finding suggests the need for pediatric nurses to help mothers build positive mother–child relationships with their hospitalized children. Additionally, it revealed the need for mothers to manage their anxiety in order to enhance their caregiving performance. Based on these results, we propose the development of interventions tailored to the management of children’s respiratory diseases and the implementation of effective educational programs to help mothers optimize their knowledge and skills.

Supplemental Material

Supplemental Material, jchc-2017-0215-File001_supplement - Factors influencing the caregiving performance of mothers of hospitalized toddlers with acute respiratory diseases: A path analysis

Supplemental Material, jchc-2017-0215-File001_supplement for Factors influencing the caregiving performance of mothers of hospitalized toddlers with acute respiratory diseases: A path analysis by Han Hye-Yul, Kim Shin-Jeong, Ellis Kevin Wayne, and Kang Kyung-Ah in Journal of Child Health Care

Footnotes

Authors’ note

This article is based on a part of the first author’s doctoral thesis from Sahmyook University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kang Kyung-Ah

Supplemental material

Supplemental material for this article is available online.

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