Resilience of Parents of Hearing-Impaired Children – Systematic Review

Aim: Th e study focuses on describing the current knowledge base related to the resilience of parents of hearingimpaired children, as described in relevant published studies. Methods: Th e basic framework of our research is evidence-based nursing and the method selected a systematic review Th e following variables were monitored: place of research, research method, sample size, sample composition, research objective, monitored variables, proposed interventions, NANDA-International nursing diagnosis. Results: Th e core sample consisted of 280 articles, of which 26 quantitative studies were selected by using exclusion criteria. It was found that none of the studies dealt with the concept of resilience, neither in their declared objectives nor in the variables. Conclusions: Th e resources of resilience can only be identifi ed on the basis of a qualitative secondary analysis of the contents of the studied texts.


INTRODUCTION
Th e study aimed at determining whether and how the resilience of the hearing parents of children with hearing impairments is investigated.Systematic review was selected as the research method within the EBN (Evidence Based Nursing) research approach.Sobotková (cf. 2003, pp. 16) defi nes family resilience as the ability of a system to maintain or restore balance and harmony in family life, or as positive behaviours, positive interactions, and functional competencies that: 1 individual members and the family demonstrate in adverse or stressful circumstances, 2 aff ect the family's ability to maintain its integrity even when exposed to stress and crises, 3 facilitate the restoration of harmony and balance within the family.
In the Czech Republic, other terms used that are similar to resilience include hardiness, sense of coherence and self-effi cacy.
According to Matějček and Dytrych (cf. 1994, p 23) the period before a child is born is one of the most beautiful times in the life of a man and woman.In their minds, the parents-to-be nurture an image of their future child, enjoying every little detail; and the more intense their expectations, the greater the shock if the child is born with a birth defect.Th is is a situation for which parents are not and cannot be prepared.Th e result is trauma stemming from the hard-to-accept jeopardy to an important value and the strong frustration of disappointed expectations.Stress aff ects all areas of life and the child's disability is perceived as a complex load (cf.Vágnerová, Strnadová, Krejčová, 2009, pp. 14-15).Compared to other types of disability, an impairment of a child's hearing is a highly specifi c type of strain.
Hearing enables human beings to receive information that is encoded acoustically.A good hearing is one of the basic prerequisites for the child's development of speech, which is one of the most important information channels.Th e inability to hear and speak completely isolates the impaired person from their environment.People with hearing disabilities are limited both on the communication and social levels.Th roughout history, society has viewed impaired individuals through the lens of prejudice and stereotypes, which are mentioned already in the works of the most prominent Athenian philosophers Plato and Aristotle (cf.Olecká, Ivanová, 2011).A hearing impairment and the related speech handicap still represent a signifi cant disadvantage for the disabled in their interactions with the surroundings.Hearing impairment continues to be seen as a stigma.Th ose unable to lip-read and speak are segregated not only from a lot of information they would normally be fl ooded with but moreover, their interactions are limited to a group of people who e. g. speak the sign language, or the impaired depend on their interpreter.Hearing people oft en tend to avoid communication with the hearing-impaired as they do not know how to communicate with the deaf.Due to the high demands on professional care for a deaf or severely hearing-impaired child, a hearing loss may be a determining factor for parents when considering relocation or a change of job.Th is type of disability thus changes the existing family lifestyle in a major way as it aff ects the lives of the parents more radically than they could have ever imagined.As Hrubý says (cf. 1999, p 41), being a parent of a disabled child is a disability in itself.To handle this diffi cult life situation, parents need to develop appropriate coping strategies and be resilient.Professionals can render signifi cant assistance, provided they know how.

METHODS
Th e key concept of the research was evidence-based nursing (EBN), which is a methodological approach to clinical practice.It has the following four basic components (Žiaková, 2009, p 311): 1 Research fi ndings (evidence), 2 Values and preferences of the patient, 3 Clinical experience of the nurse, 4 Availability of means within a particular environment Th e concept was derived from evidence-based medicine, whose current principles and framework were developed in the 1960s and 1970s for health sciences.
Combining the best scientifi c evidence with clinical experience, values, and expectations of the patient, it facilitates clinical decision-making (cf.Žiaková, 2009, pp. 310).It involves a quantitative approach to the evaluation of clinical approaches.
Th e aim of this study is to implement the fi rst component of EBN (evidence identifi cation) in relation to the research project -see the introduction to the study.The research method used was a systematic review, which is a form of scientifi c communication that summarizes the latest developments in the theory or empirical research of the fi eld (cf.Hendl, 2005, p. 349).It has a clearly defi ned objective and purpose, and follows a clear and reproducible methodology (cf.Greenhalgh, 2003, p 123).In accordance with Hendl (2005, pp. 353, 355) we treat systematic review as any other empirical research.Its main advantage lies in the consistency and transparency of its development, the identifi cation, critical appraisal and synthesis of primary studies.
Only the primary, quantitative studies were subjected to analysis.Quantitative research is highly regarded in contemporary science (cf.Loučková, 2010, p 34). Th is approach is ideal for collecting relatively little information from a large number of monitored individuals.Its fundamental advantages include the facilitation of theory testing, generalization of results to the population, relatively fast data collection, provision of accurate numerical data, and, fi nally, a quick analysis of data where results are independent of the researcher.(Cf.Disman, 2000).Quantitative research is characterized by objectivity.In quantitative research, the researcher applies standardized methods and techniques and the outputs of his/her work are empirically guaranteed and rigorously tested, which ensures high reliability of this approach (cf.Loučková, 2010, p 34).
Th e basic dataset consisted of all studies on hearing parents of hearing-impaired children.Th e studies were searched with the help of the following keywords: deaf child, preschool children, cochlear implants, relationship with parents, parents of deaf children, deaf preschoolers, mother, father, emotion, family, problems, hearing impaired, psychological ASPECTS, relationship management, psyche, care, barriers, stress, support, challenges, demands, crisis, education, problems with deaf children, adaptability, Domain NANDA International, Nursing Diagnosis, Nurse, Nursing, NANDA classification, classification, Taxonomy II, deaf-mute, resilience.Various combinations and associations involving all the above keywords were used.Th e search method narrowed down the basic dataset to studies recorded in the following databases: Aca- Th e search generated 280 articles that formed the basic dataset of the study.Th e criteria above then eliminated most of these articles.Of the whole dataset, only 26 papers met the established criteria.Th ese articles were subsequently analyzed and the following variables monitored: the source in which the article had been published, year of publication, place of research, research methods, sample size and composition, research objective, variables, proposed interventions, use of NANDA-International nursing diagnosis.

OPERATIONALIZATION OF QUANTITATIVE VARIABLES
Th e source in which the article was published: Th is variable identifi es the type of publication to publish studies on the issue in question most frequently.
Year of publication: This variable identifies in which year the issue was most studied.Furthermore, the development of the issue was monitored.
Place of research: Th e "place of research" variable was determined from the contents of the paper, in the section where authors describe the characteristics of their research sample.Th is variable reports from which countries the collected data are.Th e information is important for the interpretation of quantitative and qualitative data, as the results may be location-specifi c.

Research method:
The "research method" variable was determined from the contents of the paper, in the section where the authors describe the methods of their research.Quantitative methods and qualitative methods were monitored separately.Based on this variable, the methods of researching the issue were identifi ed.Investigation focused on the most frequent methods and on which methods were absent from the researched sample.Th e fi ndings will be used in the design of an empirical research.
Sample size: Th e "sample size" variable was determined from the contents of the paper, in the section where authors characterize their research sample.Th e data for quantitative research and qualitative research were monitored separately.Th is variable examined the representativeness and potential for the generalization of the analyzed surveys.
Sample composition: Th e "sample composition" variable was determined from the contents of the paper, in the section where the authors characterize their research sample.Th e data for quantitative research and qualitative research were monitored separately.Along with the "sample size" variable, this variable examined the representativeness and potential for the generalization of the analyzed surveys.
Research objective: Th e "research objective" variable was determined from the contents of the paper, in the section where authors describe the objectives of their research.With this variable, the objectives of analyzed studies were monitored and compared with each other.Th e aim was to identify the focus of the research studies.
Monitored variables: Th e "monitored variables" variable was determined from the contents of the paper, either in the section where authors list the monitored variables or these variables were derived from the context of the paper.Th is variable expands the fi ndings of the "research objective" variable.
Proposed interventions: Th e "proposed interventions" variable was determined from the contents of the paper.Th is information was typically provided at the end of the paper or was continuously included in the whole text.Based on this variable, basic recommendations were generated within the quantitative analysis, involving the care for parents of hearing-impaired children.Th ese recommendations were also complemented with qualitative research outputs.
NANDA-International Nursing Diagnoses: Th e variable of "NANDA-Int diagnoses" was determined from the contents of the paper.Th e search focused on any mention of the use of NANDA-Int.nursing diagnoses and its relationship to the researched issue.1) Most of the studies, 23 in total, use the questionnaire method, while three of these studies complement the questionnaire with child skill and competence tests (cf. 13, 14, 17).Th is fi nding does not bring any new information.A questionnaire is one of the most widespread techniques because it is an inexpensive, convenient, and quick method of data collection.Th e research team of one study (cf.21) added a focus group to the questionnaire survey, while complementing it with a semi-structured interview method.Using multiple techniques ensures an improved validity of the research.Th is technique is used in three more studies (cf.12, 24 and 25), while study 25 uses an interview as a complementary technique to the questionnaire.One study (cf.16) is based on observation.A total of fi ve studies (cf. 7, 10, 11, 17, 18) validate their quantitative research fi ndings using qualitative methods.Th is is very positive as the use of one-sided research approaches tends to be viewed negatively in current science, according to Loučková (2010, p 74).Both of these approaches are extremely complementary, and may serve to minimize the disadvantages of using only one of the approaches.

RESULTS (see Table
Given the very limited number of potential respondents in the target group, studies address fewer respondents than is usual in quantitative research.A lower number of respondents, however, do not distort the results. In terms of their stated objective, more than one third of studies deal with parental stress and coping strategies (cf. 3, 5, 6, 8, 14, 15, 18, 22, 23, 25).Th ese studies, nevertheless, do not examine the stress and parental coping strategies in general terms but always in relation to a predetermined variable such as social support, level of the child's communication skills, the family's living conditions, children's behaviour, institutional support or the attitude towards the Cochlear implant surgery.Five studies aim to measure parental satisfaction with the children's post-implant results (cf. 2, 12, 20, 23, 26).Four studies evaluate the care for families of hearing-impaired children and attempt to propose recommendations for optimization (cf. 7, 18, 19, 21).Th ree studies focus on the quality of life of parents with hearing-impaired children (cf. 9, 11, 22).Th ree studies describe the decision-making factors that led the parents to have their child undergo the Cochlear implant surgery (cf. 10, 17, 20).Two studies are focused on the comparison of the educational approaches to hearing and deaf children (cf.4, 13) and one study compares the means of communication of deaf and hearing mothers with deaf children (cf.16).Only one study concentrates on identifying parental emotions (cf.1), and one study identifi es the problems that parents of deaf children are faced with (cf.24).None of the above studies aim to identify family resilience.
At the end of the text, most studies list suggestions for interventions designed to improve the care for parents of hearing-impaired children.From our perspective, the following in particular are of interest: provide parents with enough timely and high-quality information (cf. 2, 6, 7, 10, 19, 25, 26), mediate contact with families with identical impairment (cf.18), identify needs and provide support (cf. 3, 6, 11, 21, 22), coordinate the care (cf.2, 7), fi nancial counselling (cf.18), help parents manage everyday specifi c problems (cf.24), involve the father more in the treatment, decisions, rehabilitation, etc. (cf.1), be sensitive to the concerns, anxieties, and uncertainties of parents, take their problems seriously (cf.5), be aware of parental tendency to believe in a good outcome (cf.26), avoid criticism and refrain from attempts to convince parents to lower their expectations (cf. 23, 26).

DISCUSSION
None of the analysed studies dealt with resilience of hearing parents of a hearing-impaired child in their declared objectives or monitored variables.Th e sources of resilience can only be identifi ed based on a qualitative secondary analysis of the contents of the studied texts.Following this analysis, two important steps need to be taken.First, propose an appropriate research method to carry out primary research and subsequently to implement this research.Th e performed secondary analysis of data will serve as the basis of this research; it will not only serve to identify elementary hypotheses but can also help in the specifi cation of the monitored variables.
Studying parental resilience and fi lling the knowledge gap appear more than necessary (see also Olecká, Špatenková, 2012).A disabled child may hardly enhance parental aspirations and everyday situations pose a strain on the parents.A particularly aggravating and, as Matějček puts it, also dangerous factor is an "increased burden on the parents in the form of anxiety and perpetual uncertainty, a strain or even over-strain of stress, unusual work and organizational demands, monotonous activities, and the hardly varied stimuli coming from the child."(Matějček, 2000, p. 11) According to Vágnerová, parents experience trauma that stemmed from the feeling of failure in the parental role and feelings of guilt toward the child.Th e way a disabled child is treated is very diff erent from the attitude toward a healthy child.Vágnerová draws particular attention to the fact that "parents are at a greater risk of extreme behaviour.On the one hand, the likelihood of a hyperprotective approach increases, while on the other hand, such a child can oft en be rejected.A change in the requirements and expectations, regardless of any other diff erence, may aff ect the mental development of such a child.In unfavourable circumstances, these attitudes may hinder the child's development unnecessarily.Diffi culties and peculiarities of the development of the disabled child's personality, also manifested in problems with social adaptation, tend to be more affected by the parents' inadequate attitudes, i. e. by social factors than by the defect itself " (Vágnerová, 2003, p 22). Positively infl uencing the parental attitude means positively infl uencing the child's development too; the ability of healthcare personnel to advise, assist, and sympathise with the diffi cult life situation of the parents of a disabled child is quintessential for successful treatment of the patient.One of the main tasks of a nurse is to provide support and education.Moreover, nurses oft en face role expectations of empathy, helpfulness, and understanding.Th e ability to help manage a crisis in a family, however, requires that the professional is aware of the conditions in which the family has unexpectedly found itself.In order to be able to identify and help saturate the newly emerged needs of parents, the nurse needs to be able to identify the correct nursing diagnosis and determine appropriate interventions that improve the condition, if it is possible.Th e analyzed texts were searched for nursing diagnoses based on the NANDA-International classifi cation and interventions based on the NIC classifi cation that should be relevant for the work with parents of disabled children.Implementation of these internationally recognized classifications provides comprehensive tools for identifying the unique contribution of nursing in a consistent and measurable format (cf.Brokel, Heath, 2010, p 27).According to Weir-Hughes (2010, p. 38), the use of nursing diagnoses is a key to the future of evidence-based, professionally-managed nursing care.Although the search placed a great emphasis on this classifi cation, none of the analyzed studies were found to use this classifi cation.
To increase the benefits for nursing practice we therefore propose that the subsequent qualitative secondary content analysis uses the NANDA-International terminology in the encoding and interpretation of the data.We assume that the most frequent nursing diagnoses will be in domains 7 Relationships and 9 Stress Management.Th e incidence of other nursing diagnoses, however, is not precluded.

CONCLUSION
Th e study aimed at determining whether and how the resilience of hearing parents of children with hearing impairments is investigated.Systematic review was selected as the research method within the EBN research approach.Th e basic requirement of the study was therefore to fi nd relevant sources.It is technically impossible to acquire all the topic-related resources that have been written around the world to the date.Th e primary obstacle is whether the source is entered in one of the searched databases.Th is limitation was partially saturated by the large number of databases searched, some of which have multiple sources.Th e amount of studies found also depended on the search method and the keywords entered.Th is limitation was eliminated by using synonyms and employing professionals who specialize in information retrieval and databases of three libraries, each of which uses diff erent sources and a specifi c search method.
Th is paper is dedicated to specifi c research of the Student Grant Competition of Palacký University in Olomouc, titled "Proposal of the System of Care of Parents of Hearing-Impaired Children in NANDA Domains".(FZV_2011_001).

Table 1
Summary of analysis fi ndings