Caring for Children Who Are Technology-Dependent and Their

Advances in Nursing Science Vol. 42, No. 2, pp. E13–E23 Copyright c 2019 Wolters Kluwer Health, Inc. All rights reserved. Caring for Children Who Are Technology-Dependent and 1.0 Their Families The Application of Watson’s Caring Science to Guide Nursing Practice

Sydney Breneol, BScN; Lisa Goldberg, PhD; Jean Watson, PhD

Advancements in the medical ﬁeld have resulted in an increased number of children with complex chronic conditions that may depend on technology to sustain or optimize life. Given that nurses provide substantial physical and emotional care for these children and families during their frequent hospitalizations, the development of an authentic caring relationship is imperative. A critical review of the literature examining the experiences and unmet care needs of this population was carried out and analyzed using Watson’s Caring Science to explore how nurses can create an authentic caring relationship and environment for children who are technology-dependent and their families. Key words: children, critical review, nursing, nursing theory, pediatrics, technology-dependent, Watson’s Caring Science

HE aim of this article is to explore how erature examining the experiences of this T nurses can develop a caring relation- vulnerable population was carried out and ship and environment for children who are analyzed through Watson’s Caring Science. technology-dependent and their families. To Watson’s Caring Science provides a theoret- achieve this aim, a critical review of the lit- ical and pragmatic framework that engages the compassion and authentic human caring inherent to nursing practice. Leveraging criti- Author Affiliations: School of Nursing, Dalhousie cal review methodology, this article provides University, Halifax, Nova Scotia, Canada (Ms Breneol and Dr Goldberg); and Watson Caring nurses with an understanding of the unique Science Institute, Boulder, Colorado (Dr Watson). relational and caring needs of children who Authors Contributions: All authors made substantial are technology-dependent and their families. contributions to the conception of the manuscript. S.B. Implications to further develop and enhance and L.G. designed and mapped the aim and methods of this article. S.B. drafted the initial manuscript. L.G. and pediatric practice, education, and research J.W. edited the manuscript and provided substantive are provided. intellectual content. S.B. is supported by funding from the Predoctoral Kil- lam Scholarship, Doctoral Nova Scotia Health Research BACKGROUND Foundation Scotia Scholars Award, Dalhousie Univer- sity School of Nursing PhD Scholarship, Helen Watson Memorial Scholarship, and the BRIC NS Student Re- Advancements in medical technologies and search Award. treatments have resulted in improved survival There are no conflicts of interest to declare. rates and long-term management of children with acute and chronic illnesses. Children Correspondence: Sydney Breneol, BScN, Strengthen- ing Transitions in Care Lab, IWK Health Centre, 8th with special health care needs are a unique Floor Children’s Site, 5980 University Ave, Halifax, NS and resource-intensive population within the B3K 6R8, Canada ([email protected]). pediatric health care system.1 These children DOI: 10.1097/ANS.0000000000000238 and youth are often defined as those “who E13

is present.2–5 Children who are technology- Statements of Significance dependent have a variety of complex diag- What is known, or assumed to be noses including severe neurological impair- true, about this topic? ments and acquired or congenital multisystem diseases that rely on the use of technologies • Studies emerging from the such as gastrostomies, tracheostomies, oxy- United States and Canada have gen, and/or mechanical ventilation.5,6 shown an increased prevalence The Ofﬁce of Technology Assessment pro- of children with complex poses that this population may be character- chronic conditions within ized on the basis of the presence of a “medi- pediatric hospitals. caldevicetocompensateforthelossofvital • Nurses provide substantial bodily function and require substantial and physical and emotional care for ongoing nursing care to avert death or further children who are technology- disability.”5(p3) Moreover, it is recognized that dependent and their families this type of nursing care may be provided by during their often frequent a range of individuals, including nursing pro- hospitalizations, thus requiring fessionals and/or trained parents/caretakers.5 special human caring practices Although we present this characteristic, we to attend to these children and recognize the problematic consequences that their families. may further marginalize this vulnerable pop- • Nurses have the unique ulation by imposing a restrictive and nar- opportunity to attend to the row deﬁnition. Thus, we remain inclusive and child and family’s relational and broad when describing/identifying this popu- emotional needs within the lation to encompass the wide variety of char- hospitalized setting through the acteristics and conditions present within this development of an authentic population of children. caring relationship. Children who are technology-dependent What this article adds? require substantial health care resources and experience frequent hospitalizations and • Through the application of unplanned readmissions.4,7–9 A cohort study Watson’s Caring Science, this emerging from Ontario, Canada, suggests that article explores how nurses can children with medical complexity represent create a caring relationship and less than 1% of the pediatric population environment for children who while accounting for more than one-third are technology-dependent and of their entire province’s pediatric health their families within the care spending.7 Of this pediatric population, hospitalized setting. approximately 12% required the use of technology to assist or prolong life.7 Furthermore, studies emerging from the United States have shown an increased prevalence of children have or are at increased risk of chronic phys- with complex chronic conditions within ical, developmental, behavioral, or emotional pediatric hospitals.3,10–13 This increasing conditions and require health care and related population of children has been shown to services of a type or amount beyond that re- account for an estimated 75% to 92% of quired by children generally.”1(p138) Within technology assistance–related procedures. this population, an emerging subgroup of chil- This increased use of acute care services, and dren with severe medical fragility and com- the frequent advancements in life-sustaining plex chronic conditions that often depend technologies, highlights the importance on technology to sustain or optimize life for nursing professionals to be prepared to

care for the diverse needs of this vulnerable Dr Jean Watson began the development population. of the Theory of Human Caring to refocus Children with medical fragility require the art and science of care away from the substantial and long-term nursing care both dominant biomedical, technological, and cu- within and outside the hospital setting.14 rative model surrounding nursing practice.22 Nurses must be competent in their psychomo- Watson believes and affirms that human-to- tor skills when caring for these children, human caring should remain foundational to given their risk for adverse health outcomes the nursing discipline.22 Now known as Wat- such as airway obstruction or accidental death son’s Caring Science, this theory has devel- from technology malfunction.9,15 However, oped into a “theoretical, philosophical, and despite reported financial burdens,16,17 dis- ethical framework,”23(p469) placing the art and turbed home life,18 increased stress levels,19 science of care at the core of the nurs- increased rates of depression,17,19 and de- ing discipline.22 Watson’s theory achieves a creased ability to establish trusting provider- greater level of awareness into the various parent relationships,20 there continues to physical and nonphysical dimensions of hu- be a lack of emphasis “on the emotional man care by encouraging nurses to draw and social needs of these children and their upon their artistic, aesthetic, spiritual, empir- families.”14(p38) Given that nurses provide ical, political, and ethical ways of knowing to physical and emotional care for these families achieve a higher level of human connected- during their frequent hospitalizations, the de- ness with their patients.22,24,25 Watson’s Car- velopment of an authentic caring relationship ing Science further explores the connected- is imperative.21 Despite this relationship be- ness between humans and their lives while ing fundamental to providing compassionate placing great emphasis on the relations be- and ethical nursing care, this concept remains tween the nurse and the patient.22 These as- critically understudied in the literature. sumptions allow a deeper understanding into the inner subjective phenomenon of human care experiences of nursing practice, one that Watson’s Caring Science could not be achieved by the prevailing objec- Watson’s Caring Science provides an tive biomedical-technological model.22 insightful framework to explore the act This theory challenges nurses to look be- and process of care for children who are yond the physical space and appearance of technology-dependent and their families. This a patient to attend to each unique individ- theoretical framework engages the compas- ual and his or her relational needs.22 Both sion and care inherent to nursing practice, the nurse and the patient must be present in providing a critical lens to examine this mind, body, and spirit to begin the develop- phenomenon. While theoretical, Watson’s ment of a reciprocal and mutually beneficial Caring Science can be pragmatically applied caring relationship.22 It is by acknowledging to the clinical environment, providing nurses the unique experiences of another that new with proposed strategies to incorporate into meanings of life and healing may occur.22 their own practice. The following section Within Watson’s Caring Science theoretical provides a brief overview of Watson’s Caring framework emerges the transpersonal car- Science, its core concepts, and the 10 Caritas ing relationship, the caring moment, and the Processes. Using this framework to analyze lit- Caritas Processes.22 These core concepts are erature regarding the experiences of children essential for the exploration of hospitalized who are technology-dependent and their nursing care for children who are technology- families provides the necessary critical lens dependent and their families. to reveal how nurses can begin to address the At the foundation of the caring process, caring and relational needs of this vulnerable arises the concept of transpersonal caring.22 population. This begins with the acknowledgment of each

person’s experiences, perceptions, and spirit environments, preserving human dignity, and beyond that of the physical body.22 Being en- openness to miracles.22 gaged and immersed within a transpersonal Watson’s Caring Science provides the abil- caring relationship affects all those involved, ity to examine the nurse-patient relationship creating new meanings of life, illness, and in the midst of constraining hospitalized en- healing that extend beyond that single mo- vironments. In previous work, Revels et al26 ment in time.22 It is important to note that used Watson’s Caring Science as a guiding this relationship is mutually beneficial, creat- framework to explore how nurses can pro- ing room for personal growth and healing for vide authentic and dignified care to their pal- patient and nurse. What emerges is an authen- liative care patients in the often chaotic emer- tic caring moment, where both the nurse and gency department environment. However, the patient begin to enter into each other’s thisframeworkhasyettobeusedtoexplore unique phenomenal fields, achieved by go- and analyze the nurse-family relationships of ing beyond that of the physical body to see, this unique and growing pediatric popula- recognize, and appreciate each individual on tion. The theoretical and pragmatic applica- a deeper, more spiritual subjective level.22 tion of Watson’s Caring Science to this clini- Although one cannot truly know another’s cal context and setting uncovers a new and unique frame of reference, experiences, and insightful perspective on this phenomenon life histories, it is in this moment that each to support nursing care. Watson’s Caring Sci- individual strives to create the opportunity ence provides the theoretical and pragmatic for mutual growth and healing.22 This pres- framework to explore how nurses can move ence and connectedness withholds the power beyond the complex technologies and hos- to create a moment transcending space and pital institutional environments to attend to time.22 the needs of children who are technology- dependent and their families. This challenges nurses to reposition themselves within a car- Caritas Processes ing foundation, encouraging them to draw on The 10 Caritas Processes are located at their multiple ways of knowing to look be- the structural core, providing a universal yond that of the acute and technical needs of language of human caring and a founda- children and their families. The following section to this philosophical and theoretical tions describe and examine the implications framework.22 Watson’s 10 Caritas Processes of Watson’s Caring Science to the nursing care provide nurses with a guiding set of princi- of children who are technology-dependent ples and language to create and engage in car- and their families. ing relationships and environments with their patients.22 Enacting these Caritas Processes AIMS should occur in conjunction with the foundational, technological, and clinical knowledge This article aims to explore how nurses can each nurse brings to his or her personal and create and foster a theory-guided authentic professional practice.22 It is during daily inter- caring relationship and environment for chil- actions, procedures, and tasks with patients dren who are technology-dependent and their and families that the Caritas Processes guide families within the hospitalized setting. nurses’ knowledge, intentionality, and consciousness toward authentic care. Watson22 outlines each Caritas Process by describing DESIGN its focus on altruistic human values, authentic presence, sensitivity to self and others, trust- Critical reviews move beyond a simple ing relationships, negative and positive emo- summary of current literature to provide an tions, problem solving, healthy and respectful analysis and synthesis of identified articles

of interest with a level of conceptual were identified and explored. Furthermore, innovation.27 It provides the ability to exam- using Watson’s Caring Science as a guiding ine and explore a current body of knowledge theoretical framework, strategies for nursing while acting as starting point and founda- practice were identified and examined. tion for future work.27 As such, a critical review of published literature exploring DISCUSSION nurse-child-parent relationships, unmet care needs, and patient and family experiences In alignment with critical review meth- of children who are technology-dependent ods, the following section presents an in- was conducted and analyzed using Watson’s depth analysis of identified studies resulting Caring Science as a guiding philosophical from our search of the literature.27 Using Wat- framework.22 son’s Caring Science as a guiding philosophical framework, the following sections explore the current unmet relational needs of chil- METHODS dren who are dependent on technology and their families within the hospitalized setting. This article began its development with Although all 10 Caritas Processes are relevant, a critical review of published literature in particular, the fourth, fifth, and seventh are exploring the care needs and health care explored in-depth, given their particular ap- experiences of children who are technology- plication to caring for this unique population dependent and their families. Although in relation to their emerging discourses and critical reviews do not require the reporting experiences within the literature. of search, synthesis, and analysis methods,27 the authors have chosen to do so to increase transparency. A series of search strategies Developing a helping-trusting caring were implemented in 2 electronic databases relationship (PubMed, CINAHL) using a combination of “Developing a Helping-Trusting Caring key words and MeSH headings such as child*, Relationship”22(p71) is Watson’s fourth Cari- youth, adolescent*, family*, technology tas Process. This process reminds nurses that dependent, ventilator dependent, medically the nurse-patient relationship is built on the complex, medical complexity, complex authenticity of the human presence. It is a medical needs, medically fragile, complex process of being and becoming more con- chronic conditions, car*, caring science, and scious in the world and environment that we theory of human caring, separated by the all share.22 Unfortunately, the ever-changing Boolean operators AND and OR. Databases and high-paced hospitalized environment can were searched from origin to present. Lim- create barriers and challenges to the de- iters included only English language. Relevant velopment of trusting relationships between literature in both the hospitalized and home the child, family, and provider.28 Relation- care settings was retrieved. Although this ships between nurses and the families of chil- article focuses on exploring nursing care dren who are technology-dependent are of- within the hospitalized setting, the authors ten developed over years of short- and long- believed certain concepts could be borrowed term hospital admissions.29 These parents from the home care setting and incorporated expressed the need for higher-quality care into hospital-based practice. Reference lists within the hospitalized setting, identifying of relevant articles were also hand searched factors such as being too busy or understaffed to identify any additional literature. Finally, as barriers for inpatient nurses to provide alignment of themes and concepts associated optimal care for these vulnerable children with Watson’s Caring Science as they relate to and families.30 The following section utilizes the discourses of these children and families Caring Science’s fourth Caritas Process as a

philosophical framework to critically analyze During Ford and Turner’s29 study explor- the relationships between the nurse, child, ing the stories of pediatric nurses caring for and family. hospitalized children with technology depen- The importance of developing a relation- dence, nurses spoke of allowing parents to ship grounded in trust has been identified by see and engage with their personal and inner- both parents and nurses as one of the essen- self beyond that of their professional identity. tial needs when caring for the hospitalized It was this open connection that nurses iden- child who is technology-dependent.31,32 Par- tified as a key component to fostering the ents have gone as far as by proposing that development of a trusting caring relationship this relationship is key to facilitating optimal with their patients and families.29 These care for their child.31 However, parents of nurses have also voiced great importance children with technology dependence have on achieving an authentic relationship with reported difficulty establishing trusting rela- children who are medically fragile and their tionships with their health care providers.20 families, as this connection becomes mutually Parents have expressed the need to be re- beneficial by facilitating their own personal spected and listened to, becoming disap- and professional growth.29 The descriptive pointed and frustrated with the quality of accounts by these pediatric nurses are in align- care provided by nurses who were lacking ment with the concepts presented within these compassionate and ethical qualities.33 this fourth Caritas Processs.22 Watson22 As Watson states, it is about “human pres- recognizes these relationships as core to ence, authentic listening, hearing, and being nursing practice. This relationship starts present for another in the moment.”22(p73) at the place of self, identifying the nurse’s Nurses who are able to apply these fundamen- presence and actions as a critical component tal nursing skills within their everyday prac- in the development of a transpersonal caring tice create the ability to generate the trust and relationship.22 Amongst the technology and care needed to establish an authentic relation- restrictive environment, Caritas pediatric ship with these vulnerable patients and their nurses must challenge themselves to remain families.22 While exploring hospital nursing authentic, reflective, and mindful while allow- care of a child with chronic illness,34 findings ing room for human connection.22 Ford and were in alignment with Watson’s Caring Sci- Turner29 concur by stating that the first prag- ence’s principles. This study acknowledged matic step in the development of an authentic that although the chaotic and often under- relationship with a child who is chronically staffed hospital environment may serve as a ill is ensuring nurses present themselves in barrier, it is essential that nurses remember to an open, honest, and personable manner. truly listen to their patients and families.30,34 Furthermore, engaging within this transper- Nurses must be mindful to re-center them- sonal caring relationship has been shown selves before and after their encounters with to increase a nurse’s love for the profession patients and families.22 Authentic listening in- and achieve a higher sense of fulfillment.24 volves being present in the moment, tem- To achieve this openness, nurses are encour- porarily disregarding thoughts about previous aged to start each shift by setting mindful or future tasks at hand, to be able to actively intentions for the day.22 In this inner place of hear and observe the meaning within their stillness, nurses may begin to set their caring stories. Developing this helping-trusting car- intentions to incorporate their full authentic ing relationship requires commitment from self in each human-to-human interaction they pediatric Caritas nurses to take the time dur- may encounter.22 By incorporating these ing their interactions with patients and fam- Caring Science principles into daily practice, ilies to enact authentic listening and pres- pediatric nurses are able to create opportu- ence despite the environmental challenges in nities to grow personally and professionally which they are surrounded. while positively impacting all those involved.

Parents of this vulnerable population have population, have been shown as a major pe- expressed their desire for nurses to pro- riod of stress and anxiety for families.38 A vari- vide genuine care to their child by attend- ety of emotions, such as fear, guilt, frustration, ing to the person beyond their physical and grief, and/or anger, may be felt by these par- technology-based needs.17,21,31,33–36 This in- ents during their child’s hospitalization. The cluded acknowledging each child as an indi- health of children and their parents has been vidual with their own unique life stories and shown to benefit from nurses acknowledging experiences.21,33 Perhaps more impactful, in these emotional burdens as normative behav- a phenomenological study exploring the lived iors while hospitalized.38 Research suggests experience of children who are ventilator- that being able to create a safe and supportive dependent, participants affirmed that nurses environment for these children and parents failed to acknowledge their status as a human to express surges of emotions is an essen- being.37 Conveying an appreciation of life, be- tial component to the caring relationship.31 yond that of the illness and technology, is an Nurses’ ability to attend to all emotions and essential competency of the pediatric Caritas feelings is a fundamental component to the nurse to sustain transpersonal caring relation- development of a caring relationship. Watson ships with their patients.22 By developing an explored this practice within her fifth Caritas increased consciousness to the needs of pa- Process as “Being Present to, and Supportive tients and their families, nurses open up the of, the Expression of Positive and Negative ability to recognize, listen, and acknowledge Feelings.”22(p101) the life of another.22 As Watson states, “When Once again, Watson highlights the impor- one is able to engage in presence and truly lis- tance of being fully present, in mind, body, ten to and hear another person’s story, that and soul, such that the patients can begin may be the greatest healing gift of all.”22(p74) to embrace and express their emotions from This challenges nurses to move beyond the deep within.22 Nurses must be open to hold biomedical paradigm of “caring” for their pa- the emotions of another without hesitation tients. Although pediatric nurses may ade- or reluctance, recognizing that no emotion quately attend to the acute and physical needs is invalid or unworthy to experience.22 It is of these vulnerable children, patients and fam- this ability to listen and accept both nega- ilies are often left feeling unsupported and un- tive and positive experiences that creates the cared for during hospitalization.6,20 Watson’s foundation for a transpersonal relationship Caring Science provides pediatric nurses with and caring moment.22 Parents have expressed the ability to attend to children’s technology- the need to talk through their various and based needs while honoring the life of these often conflicting feelings with an individual children. While completing a medical inter- outside of their family circle.38 Watson elab- vention, Caritas nurses must display compe- orates on this concept by stating that “the tence to seize this time with their patients to nurse in a given moment may be the only get to know their lives outside of the hos- person who is able to hear and receive an- pital walls. Whether it is as simple as get- other person’s story and emotions, thus help- ting to know their favorite toy or activity, ing the person find deeper meaning in his this acknowledgment of their personal life has or her situation.”22(p105) Parents and children the power to transform the moment for both may express frustrations with the health care nurses and patients into one rooted in love system such as wait times, failed treatments, and care. or having little answers to their complex conditions. Furthermore, parents may feel a deep Expression of positive and negative sense of worry and uncertainty, given their feelings child’s often fragile health status. Although Frequent and repeated hospitalizations, it may be challenging for pediatric nurses such as those experienced by this vulnerable to stand witness to these frightful emotions,

Watson22 reminds us that this release of emo- this often overwhelming and emotional time. tion from patients and families can be trans- Watson22 reminds nurses of the importance formed into a moment of healing and growth. of recognizing each patient as an individual, Being accepting and open to all positive and as families will differ in their readiness to learn negative expressions is essential to the prac- and in their perceptions toward the teaching tice of pediatric Caritas nurses caring for chil- content. It is this acknowledgment of indi- dren who are technology-dependent and their vidualized teaching needs that the teaching- families. learning process can become transpersonal, thus affecting all those involved.22 With ev- ery transpersonal teaching relationship, the Transpersonal teaching-learning nurse will themselves experience a lesson in Health policies and programs have sup- tending to the unique needs of future patients ported the shift from hospital to home- and families. If nurses sense that their teach- based care for children with complex med- ing style or content is not connecting with ical needs who are technology-dependent.39 the child and/or parents, they must not be Given this change in care provision, par- afraid to step back from the moment, take an- ents are often taught to perform skilled other approach, ask for guidance, or inquire medical and nursing interventions for their into their readiness for knowledge.40 By in- child. Unfortunately, there is a paucity of corporating these principles into each teach- literature exploring the experiences of par- ing encounter, nurses are able to facilitate a ents and children when adapting to a new teaching environment for children and fami- life with technology-assistive devices. Rather, lies grounded in care and trust. the literature focuses primarily on the role This Caritas Process was chosen to ex- of the parent during the frequent hospital- amine the concept of the expert parent, as izations after their initial discharge home. it challenges nurses to be open to the reci- Given their active involvement in the ev- procity of the teaching-learning process.22 eryday care for their child’s technological, Parents who have been caring for a child medical, and emotional needs, parents want who is technology-dependent at home hold a to be recognized as experts in the child’s significant amount of knowledge about their care during hospitalization.6,14,20,30,33 These child’s individualized care needs. This creates concepts will be further investigated using a unique and dynamic relationship between Watson’s seventh Caritas Process, “Engage in the nurse, patient, and family. Caring Science Genuine Teaching-Learning Experience that provides nurses with the strategies to create Attends to Unity of Being and Subjective a self-reflexive practice by being aware of not Meaning.”22(p125) only one’s knowledge and beliefs but also In this Caritas Process, Watson22 explores those of others.22,25 Parents feel an increased the role of teaching within nursing practice. sense of trust with nurses who ask for their Teaching is viewed as much more than the expertise and incorporate it into the care they transfer of knowledge from the nurse to the provided for their child.33 It is imperative that patient; rather, it is a momentous process in- Caritas pediatric nurses must themselves be fluenced by the trusting relationship.22 The ready and open to learn from both parents and nurse must be open to the sharing of power children in order to provide optimal and com- and control within the teaching-learning pro- passionate care during their hospitalization. cess, moving away from previous authoritar- In fact, Watson22 stipulates that the first step ian practices.22 For the child and the fam- in the teaching-learning process is seeking to ily that are newly adapting to life with a learn what is already known by the individual. technology-assistive device, the Caritas pedi- This step should be completed upon admis- atric nurse must be able to identify the pa- sion and continued throughout their hospital- tient and family’s readiness to learn during ization. By remaining in the frame of reference

of the parent or child, the nurse is able to nurses from attending to their underlying facilitate the cocreation of a trusting and emotional needs.42 Nurses must develop the supportive teaching-learning environment. proficiency to care for both the lifesaving technologies and the emotional human caring needs of children and their families. Possess- CONCLUSION ing the ability to care for one or the other is not sufficient to providing compassionate, Children who are technology-dependent ethical, and moral nursing practice.42 are a unique and resource-intensive pop- The integration of Caring Science into ev- ulation within the pediatric health care eryday clinical practice challenges nurses to setting.2,4 Their medical fragility and com- look beyond that of the physical-objective fo- plex technologies place them at a greater risk cus in order to develop deep human-to-human for adverse health outcomes, resulting in fre- connections and caring relationships.22 While quent hospital readmissions.9 With continu- practicing in a deeply biomedical and ous advancements in medical technologies, it technology-focused environment, it is crucial is essential that we address the care needs that nurses recognize and refocus the im- of this vulnerable population of children and portance of caring theory within the nursing their families. Nurses have the unique oppor- discipline.43 Despite little recognition in this tunity to advance practice through theory- area of practice, Caring Science can be un- guided approaches to meet their relational covered within nurses’ everyday interactions and emotional caring needs within the hos- with patients and families. Proposed nursing pitalized setting. As outlined in this criti- strategies, and their implications to clinical cal review, Watson’s Caring Science and the practice, have been highlighted throughout 10 Caritas Processes provide nurses with a the discussion of this article with the aim philosophical, theoretical, and practical dis- to enhance pediatric nursing practice while ciplinary framework to attend to the unmet caring for these medically complex children. care needs of this population while overcom- These strategies may be presented to nurses ing the institutionalized barriers surrounding new to the profession or new to those caring the nursing practice. for others with this complex population. This exploration and review of the liter- RELEVANCE TO NURSING PRACTICE, ature revealed a clear lack of research ex- RESEARCH, AND EDUCATION ploring nursing practice and care of children who are technology-dependent within As discussed earlier, advancements in med- the hospitalized setting. Future nursing re- ical technologies will likely result in the search, using Watson’s Caring Science as growth of children who depend on tech- a philosophical underpinning, is warranted nology to sustain or optimize life. Given to explore discipline-specific nursing inter- that nurses work more closely with pa- ventions that can promote optimal care for tients and families than other health care these children and their families. Further- professionals,41 it is imperative that nurses more, given the lack of research in this gain a greater understanding of how a the- area, educational initiatives or interventions oretical disciplinary foundation to their prac- should be explored and evaluated to guide tice can help advance the relational, human nurses in helping children and families ad- caring needs for this population of children just to new life with a technology-assistive de- with medical fragility. However, nurses are vice. These research initiatives will guide the not only challenged by the fast-paced biomed- development of philosophical, theoretically ical environment that is a characteristic of oriented health policies and practices, the acute care setting but also children’s supporting children who are technology- technology-based interventions may distract dependent, and their families.

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