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Correlation between Iranian Nurses Subjective Norms (SNs) and Intentions in Family-Centered Care (FCC) after 3 Months of Intervention

Tahereh Nasrabadi

Abstract

Background: The impacts of Subjective Norms (SNs) on nurses’ intentions in Family-Centered Care (FCC) have not been uniform across the globe. The role of family in child health care in the past 4 decades has completely changed. In the 1940s and 1950s, parents did not enroll in child care centers. FCC is as one of the basic concepts of pediatric nursing remaining to be practiced in the 21^st century. Objectives: This research aimed to investigate the relationship between SNs and their effects on FCC intention among pediatric nurses in Iran. Materials and Method: A qusi-experimental study design was used for a sample of 200 pediatric nurses in 2 groups. The respondents were selected based on a simple random sampling method. Results: The results of Pearson's Correlation showed that this variable was significantly correlated with intention (Pre- test=0.497**, post-test=0.697**, and follow-up test=0.635**). Conclusion: The results were indicative of a significant relationship between SNs and nurses' intentions in FCC in Iran.

Introduction

Family-Centered Care (FCC) and Family-Centered Service (FCS) have been most prominently discussed and developed in the context of child health and childhood chronic conditions. The ways children and families should be dealt with can be facilitated through this expanded approach. FCS includes a set of values and views that provide services for children and their families with their special needs. Parents and children are taught how to treat their symptoms via integrated medical and psychiatric services in some family-centered programs like Hasbro Children's Hospital [1]. By FCS, each family is known to be unique and constant throughout the child’s life, thus acting as an expert on his/her abilities and needs. To make an informed decision after receiving services and supports, a family has to work with service providers. Therefore, all family members' strengths and needs are regarded in FCC [2].FCC has been focused on a change from the traditional aspects of a child’s biomedical condition to observing him/her in the context of his/her family and recognizing family primacy in his/her life. Through this approach, families are respected as integral and coequal parts of the health care team [2]. Thus, it is expected that the relevant principles provide an improvement of a patient's quality and safety of care via fostering a communication between health care professionals and families. In this case, families feel more comfortable to work with professionals as the family/patient inputs and concerns are considered in a care plan, while the professionals are accessible to fulfill their expectations of medical interventions and health outcomes. Sometimes, patients and families provide hospitals with consultative inputs that can generally improve care qualities [3]. Consequently, health care resources can be allocated in a much wiser way and greater patient/family satisfaction can be achieved by such health care interventions through family-centered approaches [4]. In recent years, Ajzen's psychological Theory of Planned Behavior (TPB) capable of explaining and predicting human behavior has been most widely utilized. TPB illuminates the process of human action by linking it to the 3 variables of Attitude toward performing the Behavior (ATB), Subjective Norms (SNs), and Perceived Behavioral Control (PBC) [5].

SNs refer to the Perceived Social Pressure (PSP) that leads to the probable performance of a behavior under the impacts of family, friends, and other possible role models [6]. Based on Ajzen's TPB, intentions are considered as the best predictors of a planned behavior. Entrepreneurship is exactly the type of behavior, for which intentions are necessary and useful for understanding and anticipating future developments. In the TPB, these 3 variables precede the formation of intention as a predictor of behavior.

The more supportive the SNs are, the higher the intentions will be. If the target behavior is more attractive to the individual, the intention will be higher too. Understanding the health professionals’ ATTs, SNs, and PBCs and providing the necessary supports serve as the keys for the development of an intervention that is most likely to affect behaviour [7].

Hence, this paper dealt with the impact of SNs on a FCC intention among the pediatric nurses in Iran. The aim of this study was to investigate whether SNs affect and correlate with the nurses' behavioral intentions regarding the implementation of FCC method in the pediatric wards.

Methods and Measures

The respondents were selected from 4 hospitals affiliated to Shahid Beheshti University, Tehran, Iran. A written consent was obtained from the subjects after explaining the research purpose to them. Prior to the research, an ethical approval was obtained from the Institutional Ethics Committee. Sample size: The study was conducted on 200 nurses from the pediatric wards of hospitals in Iran. Inclusion      criteria for       the                   nurses:    Full-time employment, qualification with a minimum degree in nursing, having at least a 1-year experience in the paediatric wards, and having an age of 25-55 years

Exclusion criteria for the nurses: Foreign nurses and part-time or contract workers

Type of study: This was a quasi-experimental study.

Procedure: The subjects were divided into the 2 intervention and control groups of 100 persons in each group. The data were collected from the primary source using a well-structured questionnaire. A simple random sampling technique was adapted for this study. All the participants offered their informed consents. To check the influence of SNs of the nurses' FCC intentions, they were asked to begin with the following statements: “My parents expect me …” and “ My supervisor expects me …” The first item of SNs was stated as follows: “Mother expects me to implement FCC …” Then, 6 direct question were asked to check their intentions and measure the variable of “behavioral intention”. A “generalized intention” method was applied to prepare the items of the questionnaire. Also, the items using the statements “I want to …” and “I intent to …” could demonstrate adequate internal consistency for the intention section of the questionnaire. The pre- (baseline), post- (immediately after the intervention), and follow-up (after 3 months) test measures of the TPB constructs on the SNs and intention to implement FCC were employed in the survey. A 5-point Likert-type response scale ranging from 1= strongly disagree to 5= strongly agree was utilized with single items. 24 items measured SNs by examining the social impetus from the influential others (parents, peers, and administrators). The intention was measured by 6 items asking about a pediatric nurse’s intention to implement FCC. The 2-session educational interventions lasted for 3 to 4 hours on the presentations, PowerPoint, pamphlets, questions, and answers each. Then, the evaluations were performed for both groups immediately and after 3 months.

The content validity was established based on its development from the template use recommended by Ajzen and its application by the other researchers that used the model as a basis in their studies. Pilot testing of the instrument was separately done by 30 pediatric nurses, who

claimed to have easily understood it and be able to complete it within 15-20 min. Moreover, the internal consistency, reliability (Cronbach’s alpha), and predictive validity of the research were measured. A multiple regression analysis was used to determine whether SNs could significantly explain the respondents' intentions at the baseline, immediately after the intervention, and during the follow-up tests separately. P<0.05 was considered significant.

Results A multiple regression analysis was employed to determine whether SNs could significantly explain the intention among the respondents at the pre-, post-, and follow-up tests separately. Prior to the regression analysis, Pearson's correlation coefficient was applied for the evaluation of the association between the independent variables and intention as the dependent variable. Pearson's correlation results demonstrated that this variable was significantly correlated with intention (Table The findings of Table 2 revealed that the predictor variable could significantly explain the intention at all the 3 steps. According to the pre-test results, SN was a significant predictor (β=0.166, t=2.131, p<0.01). Also, the post-test results indicated SN to be as a significant predictor (β=0.172, t=2.184, p<0.01) though at a higher level than that of the pre-test results. The last model representing SN (β=0.264, t=4.138, p<0.01) was related to the follow-up test results.

Discussion

We could observe that the pediatric nurses in the hospitals in Iran gave more values on the perceptions of their closest peers, families, and administers. In general, the influence of SNs existed among the respondents. Family perception, to which the respondents gave a more value was also supported by Ajzen’s study [8]. Such a perception would reinforce the respondents' possible awareness of the role of family in children's care. The fact that family plays a significant role in the care for children has been also discovered in some other studies.

Parental norms influence on eating habits as the evidence indicating that SN is the strongest predictor of behavioural intentions among all the TPB components [9, 10]. It is expected that SNs have an additive effect on intention and a significant impact on an individual’s behaviour [2]. The impact of the professional group membership highlights the importance of designing some tools to measure group-specific influences and then tailoring the interventions to the reference norms of that specific group. Following a similar research conducted by Casper, [11] the data collected from the 98 participants by mental health professionals through the TPB applied to their continuing education in that panel analysis were indicative of a 30% change of the variance in the combined ATT, SN, and PBC, whereas knowledge gains accounted for just 1% of the post-intervention classes. The participants in the TPB class obtained significantly higher SN scores. Therefore, the influences of important people on nurses, such as families, colleagues, and supervisors were pivotal as their SNs put more effects on their intentions. As a result, educational intervention had a significant effect on the promotion of SN-INT relationship. Although we achieved similar results via the same theory, our sample size and job positions were different. This finding was important since it showed that an intervention can still improve nurses’ intentions to implement FCC in the pediatric wards. It is worth noting that the majority of the respondents seemed to be very satisfied with the interventions. This result was consistent with a recent research that revealed an eager intention to a shared decision- making behavior is effectively changed by the implementation of the target SNs [12]. Also, is was in line with a previous study on the 124 nurses working at the selected hospitals of Isfahan and another investigation conducted in Australia, in which SN as the strongest behavioral variable was

Conclusion

Analysis of the correlation between Iranian nurses’ SNs, intentions, and behaviors based on FCC in this study revealed that family backgrounds and SNs play a major role in FCC intention among the pediatric nurses in Iran. It is noteworthy to say that the intervention focused on the reinforcement of the SNs of health professionals may help tailoring care to the patients. This has strong implications  for FCC designing and educational interventions that may provide an effective way to change professionals' behavioral intentions by using social norms, such as co-workers, families, and managers' views that improve nurses' intentions to eagerly engage in FCC behaviors.

Conflicts of interest

No conflicts of interest are declared by the authors.

Acknowledgements:

This publication is the result of 4 years of work, during which we have been accompanied and supported by many people. We express our gratitude to the Dean and Deputy Dean of the Research Department of Graduate Studies and sincere thanks to Syed Tajuddin Syed Hassan, Professor, Doctor (PhD), Universiti Putra Malaysia (UPM), Faculty of Medicine and Health Sciences for all their supports for this study. We would be also very thankful to Dr. Farideh Yaghma'ie and those responsible in the International Branch of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Finally, we would like to thank those in charge of Islamic Azad University, Chalous Branch.

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This work will be presented in 27th Global Nursing and Health Care Conference