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Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study
YJPDN-01547; No of Pages 7 Journal of Pediatric Nursing xxx (2017) xxx–xxx
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Journal of Pediatric Nursing
Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study Dilek Konuk Şener ⁎, Aysel Karaca Duzce University, School of Health Sciences, Department of Nursing, Duzce, Turkey
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Article history: Received 28 July 2016 Revised 3 February 2017 Accepted 3 February 2017 Available online xxxx Keywords: Family centered care Hospitalized child Mother Nurse Patient expectation Qualitative research
a b s t r a c t Purpose: This study attempted to identify the mutual expectations of mothers whose children were hospitalized in the pediatric department of a university hospital and nurses who provided care. Design and Methods: A descriptive phenomenological design has been used in this study. Data were obtained through tape-recorded semi-structured interviews. This study was conducted at a pediatric clinic, at a university hospital in a small city in Turkey. Participants comprised five nurses working in the children's clinic and 24 mothers who accompanied their children to the hospital. Results: The six major themes that emerged were mothers' feelings and thoughts about the hospital experience, mothers' expectations for attention and support during hospitalization, mothers' expectations for invasive procedures, issues regarding physical comfort and hospital infrastructure, nurses' feelings and thoughts about working in the pediatric clinic, and nurses' expectations of the mothers. Conclusions: Mothers expected nurses to provide physical support including medication administration, and installing/applying IV and nebulizer treatments; and emotional support in terms of having a friendly, rather than critical attitude, and being approachable and receptive of mothers' questions and anxieties. Nurses stated that they were aware of these expectations but needed mothers to be understanding and tolerant, considering their difficult working conditions. Practice Implications: Children's hospitalization is a stressful experience for parents. Open and therapeutic communication and relationships between parents and nurses contribute to improving the quality of care provided to children and their families. © 2017 Elsevier Inc. All rights reserved.
Children's illnesses and the consequent hospitalization involve inconvenient and unpleasant experiences for both children and their families. It leads to significant lifestyle changes for the family (Cavusoglu, 2008; Coyne, 1995, 1996; Er, 2006; Soderback & Christensson, 2008). Parents have to leave their responsibilities at home and/or work in order to stay with their hospitalized child, negatively affecting their work and family life. Adapting to unfamiliar environments, dealing with new people, and learning about procedures for diagnosis and treatment cause familial stress (Cavusoglu, 2008; Ocakcı, 2006). Previous hospital experiences, the child's health status, consistency of care, duration of hospitalization, and relationships with healthcare professionals are factors that affect parents' anxiety and fear (Coyne, 1995; Lam, Chang, & Morrissey, 2006; Ocakcı, 2006). Parents' participation and cooperation helps nurses and healthcare professionals provide quality pediatric services (Coyne, 1996; Lam et al., 2006). The family's support of the child affects his/her health status and response to nursing care (Eksi, 2011; Ocakcı, 2006). Therefore, ⁎ Corresponding author at: Duzce University, School of Health Sciences, Department of Nursing, Konuralp/Duzce, Turkey. E-mail address: [email protected] (D. Konuk Şener).
family-centered care necessitates the family's involvement at each phase of childcare, thereby instilling trust in health care providers' abilities, and ultimately lowering parents' stress levels. Nurses in pediatric services are required to attend to the family, address their concerns and issues, and meet their expectations through effective communication (Aykanat & Gozen, 2014; Eksi, 2011; Er, 2006; Ocakcı, 2006). Studies investigating parents' expectations of nurses in pediatric services have found that nurses need to have good interpersonal and communication skills (Coyne, 1995; Kiguli, Mafigiri, Nakigudde, Dalen, & Vleuten, 2011; Shields & King, 2001a; Soderback & Christensson, 2008), skillfully apply diagnostic and treatment methods (Kiguli et al., 2011; Soderback & Christensson, 2008), play an active role in the care of children (Lam et al., 2006; Latta, Dick, Parry, & Tamura, 2008), stay with children during painful procedures (Boztepe & Çavusoglu, 2009; Kiguli et al., 2011; Lam et al., 2006), and be informed about the child's health status (Coyne, 1995; Enarson et al., 2012; Er, 2006; Kiguli et al., 2011; Lam et al., 2006). Moreover, nurses' desires, needs, and expectations contribute to improving the quality of care. Changing societal needs, medical and technological developments, social awareness, and a better general understanding of children's illnesses have led to higher expectations
http://dx.doi.org/10.1016/j.pedn.2017.02.004 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
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of healthcare services. Additionally, improvements in nursing practice are also reflected in the field of child health nursing (Toruner & Buyukgonenc, 2012). Considering that work life affects the individual and vice versa, understanding nurses' expectations can help improve nurses' health and satisfaction as well as benefit the institution. Therefore, health care reforms that address nurses' difficulties and expectations are increasingly gaining importance. However, despite these positive developments, nursing is considered a stressful occupation with demanding workloads and occupational hazards, especially in Turkey (Arcak & Kasimoglu, 2006; Toruner & Buyukgonenc, 2012). In the literature, it is observed that previous studies have mostly focused on the requirements and expectations of hospitalized children, their parents and families (Boztepe & Çavusoglu, 2009; Coyne, 1995; Enarson et al., 2012; Er, 2006; Kiguli et al., 2011; Lam et al., 2006; Latta et al., 2008; Shields & King, 2001a; Soderback & Christensson, 2008). It was also found that studies which were performed with mothers were limited to newborn unit (Finlayson, Dixon, Smith, Dykes, & Flacking, 2014; Gaucher, Nadeau, Barbier, Janvier, & Payot, 2016; Povedano, Noto, Pinheiro, & Guinsburg, 2011; Punthmatharith, Buddharat, & Kamlangdee, 2007). Also, there are not sufficient studies on the experiences and expectations of the nurses who were working in children's services. Considering that working conditions, social structures, and cultural practices vary between countries, the need for a qualitative Turkish study that examines mutual expectations of mothers of hospitalized children and nurses is apparent. Therefore, this study attempts to identify mothers' feelings, thoughts, and attitudes regarding hospital experiences and investigate mothers and nurses' mutual expectations. Methods Design In this study, a descriptive phenomenological design is used in order to explain parents' and nurses' experiences, feelings and thoughts caring for the hospitalized child in a pediatric unit. In-depth qualitative interviewing not only enable the researchers to obtain rich description of parents' and nurses' feelings, thoughts and perceptions about caring their child during hospitalization but also it provides a high degree of freedom to answer questions, elaborate ideas and feelings and illustrate concepts (Yildirim & Simsek, 2008).
was no space for them to rest. A total of six people including three children and their mothers were staying within one room. Only in private rooms, were there armchairs for the mothers to sleep. Mothers of critically ill children were excluded from the study considering that their responses were likely to be affected by their high anxiety. Mothers of the children who had a good prognosis were included in the study. Each participant was only interviewed once. Instruments Data were obtained using a demographic information form and semi-structured qualitative interview form. Demographic Information Form Sociodemographic data including age, education level, number of children and nurses' work hours were obtained using the form based on a literature review (Arcak & Kasimoglu, 2006; Cavusoglu, 2008; Ocakcı, 2006). Qualitative Interview Form The semi-structured form to guide interviews included open-ended questions to identify participants' feelings, thoughts, perceptions, and attitudes. It was developed based on a thorough review of literatüre (Arcak & Kasimoglu, 2006; Cavusoglu, 2008; Ocakcı, 2006). The content of questions assessed by a panel of experts in the fields of child health, disease nursing, educational sciences, and psychiatry nursing was deemed appropriate. The order of the form was determined by the flow of the interview. Interview questions for the mothers included their emotional responses to the hospitalization of the child and their to expectations of the nurses, their expectations about their participation in care, their expectations about meeting of their information needs, their expectations during diagnosis and treatment, their thoughts about how a competent child nurse should be and their positive and negative experiences with nurses during their hospital experience. Interview questions for the nurses included their thoughts about family-centered care, their feelings and thoughts about working in pediatric service, the situations in which they have difficulty during working with the mothers, their awareness about the emotional needs of the mothers and their skills for coping with the emotional responses of the mothers.
Sample and Setting Data Collection Participants in this study were selected using a purposive sampling method (Yildirim & Simsek, 2008). Potential participants comprised mothers who accompanied their children to the pediatric clinic at a university hospital in a small city in Turkey and nurses who provided care for them. Voluntary participants included five nurses working at the 18bed pediatric clinic and 24 mothers who had stayed at the hospital for at least two days. Nurses were working during two shifts (including 8 am–4 pm and 4 pm–8 am). Total working hours of a nurse per week were at least 56 h. While two nurses (one was the supervisor nurse) were working during 8 am–4 pm shift, a single nurse was working during 4 pm– 8 am. Supervisor nurse did not implement patient care except for emergency cases. Under these circumstances, there were 18 patients per one nurse. A supporting staff was present in the clinic only during 8 am– 4 pm shift. This staff performed preparation of patient beds, bringing the patient to ultrasonography, X-ray, etc. and transporting laboratory materials. There were eight rooms in the clinic. Five standard rooms had three beds and three private rooms had single beds. There were no toilets/ bathrooms in the standard rooms. Private rooms fees have to be paid by the parents. Mothers were staying with their children in the same room for 24 h. They were using the chairs next to the beds since there
Data were collected in February through June 2015 using in-depth qualitative interviews. Appointments were arranged with the nurses and mothers at an appropriate time and place, convenient and comfortable for the participants. In keeping with mothers' and nurses' preferences, interviews were conducted in the training room at the hospital. For mothers who could not leave their children alone or in the care of a relative, interviews were conducted in the child's room or in any empty room close by. The purpose of the study was first presented to potential participants. Consent was obtained after stating the approximate duration of the interview, explaining the reason for recording interviews, and providing assurance for the confidentiality of all interview data. Participants were instructed that they could turn off the recorder whenever they wanted during the interview. They were requested to share their thoughts about mutual expectations in the hospital according to interview principles. Observational notes about their behaviors and answers were recorded. Interviews with each participant lasted nearly 60 min. The researchers were women. One of them was a psychiatric nurse and the other was a pediatric nurse with PhDs. All of the interviews were performed by the psychiatric nurse who had experience conducting qualitative studies.
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
Data Analysis
Table 2 Major categories and subcategories of nurses expectations.
As indicated by Van-Manen (1990), the experiences of participants can be uncovered by a content analysis of their written statements, which was the method used for the analysis of the study data. Written observational notes and verbal responses for each question in the semi-structured questionnaire were transcribed verbatim. Opinions and notes were crosschecked for compliance with study aims; none were found to be irrelevant. Opinions were categorized according to their semantic similarities and codes to represent these opinions were generated. The frequency of opinions for each code was indicated. Codes were grouped according to the integrity of meaning, based on which themes were generated. To increase the reliability of the data analysis, researchers generated the codes and themes independently. Their data and the analyses were discussed. To ensure validity of data, a panel comprising one expert and five study participants assessed the appropriateness of the codes and themes. The final form was generated after considering the panel's views (Yildirim & Simsek, 2008).
Ethical Considerations The study was conducted in accordance with the Declaration of Helsinki for experiments involving humans. Written informed consent was obtained from the mothers and nurses who participated voluntarily. Mothers and nurses were informed that interview data and information regarding their personal identity would be kept confidential.
Demographic Characteristics All parents who were included in the study were mothers (n = 24) with a mean age of 28.0 years. More than half of them (n = 18) had graduated from elementary school; the others (n = 6) had graduated from high school. Reasons for the child's hospitalization were followups (n = 14) for pneumonia and bronchiolitis and diagnosis for chronic disease (n = 10; diabetes, cerebral palsy, asthma). Children's ages ranged between 30 days to 18 years. The mean age of the nurses (n = 5) was 30.4 years; two of them had a master's degree and three nurses had bachelor degrees. Two of the nurses were single and three of them were married. Work experience in a pediatric ward ranged between 1 and 18 years. Major categories and subcategories identified. Following the analysis, mothers (Table 1) and nurses' (Table 2) statements were grouped under six themes.
Table 1 Major categories and subcategories of mothers expectations.
Mothers' feelings and thoughts about the hospital experience
Major categories
Subcategories
Nurses' feelings and thoughts about working in a pediatric clinic
Working with the child is easy, working with the mother is difficult Difficult working conditions Expectations about care cooperation Expectations during painful invasive interventions Expectations about communication Thoughts about responding to expectations
Nurses' expectations of mothers
Mothers Expectations Feelings and Thoughts About Hospital Experience This theme included feelings and thoughts of the mothers during their experiences in the hospital. While some mothers stated that they felt desperate and experienced considerable distress, fear, and anxiety when they first learned that their child needed hospitalization, the majority stated that decision to hospitalize their child was relieving. Almost all mothers expressed concerns about their children at home. Mothers communicated these complicated emotions during interviews: I was so scared and cried a lot when the doctor told me that my child would be hospitalized. I thought that her situation was bad. It makes you feel so helpless. [(Mother 1)] I felt terrible when I heard that my child would be hospitalized, but I also wanted him to be hospitalized because he was breathing very hard and this scared me. [(Mother 2)]
Results
Major categories
3
Subcategories
Feelings about the child's sickness The hospital feels like a safe environment Concerns about other children at home Mothers expectations of attention and support Mothers' feelings and thoughts during hospitalization about nursing care Mothers' expectations of the nurses Mothers' expectations during invasive procedures Issues regarding the physical hospital environment and comfort
I felt so sad when I heard that we would need to hospitalize our child; I was distressed only because of my daughter at home. I felt sad because I would be far away from her. [(Mother 3)] The majority of mothers expressed that they felt safe and relaxed during their child's hospitalization: I felt very relieved when I heard that she would be hospitalized; I really felt much relived. I said to myself, “Oh! At least she would be under observation and would be examined by doctors and nurses.” Everything is done with perfect timing; I would not be able to do this at home. [(Mother 4)] I did not feel bad when he was hospitalized. I even felt happy. I told myself that this was the right thing to do for his recovery. If they ask me to stay for another 15 days, I will stay. I feel that he would get sicker at home. I become more anxious at home. The hospital makes me feel safe. [(Mother 5)]
Mothers' Expectations of the Nurses Another theme generated from the interviews pertained to the mothers' perceptions of the nursing care provided to the child during the hospitalization. Mothers judged two aspects of nurses' involvement, physical and emotional care. Almost all mothers stated that they were pleased with the care provided by nurses. When mothers were asked to explain their understanding of “care,” it was determined that they
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
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meant medical applications conducted in a timely fashion, such as administering medications, starting IVs and administering nebulizer applications: For example, my child's body temperature rose; the nurse came up and checked it every half an hour; I was very pleased with her efforts. It is not important for her to be good to me; it is important that she is good to my child. [(Mother 3)] Nurses give injections on time, they install the breathing apparatus correctly, and they are very careful about hygiene; I cannot provide this kind of care at home. That's why I’m happy. [(Mother 6)] When mothers were asked about their expectations of nurses, some of them stated that they did not have additional expectations; however, most expressed that they would like nurses to be friendly, rather than admonishing and critical. Some mothers expressed that they wanted interventions explained to them before administration and receive information about their child's overall condition. They also wanted nurses to be willing to answer their questions, and listen to their concerns. Nearly one third of mothers stated that nurses understood their expectations and were appreciated by nurses. However, experiences varied: One day, I asked a nurse, “Can you please insert the needle into this arm?” She scolded me very badly and said, “I will insert it wherever I can find a vein.” I got very upset. Some nurses are very rude. [(Mother 7)] My experience of this service was very bad, but the nurses did not talk to me about my problems; I wish I could talk to someone. [(Mother 8)] Thanks to God, I have met very nice nurses. I’m so pleased, they answered my questions without shouting. Some people have met nurses who were reproachful, but I did not. [(Mother 9)]
Expectations During Invasive Procedures This theme consisted of parental and nursing expectations as to whether parents chose or were allowed as determined by the nurses to be present with the child during a painful procedures. Some mothers stated that they wanted to be present during their child's medical procedures, while others did not as they could not bear to hear them in pain. While half of the mothers stated that some nurses let them stay with their children, the other half stated that nurses forbade them from being present during procedures. Moreover, they expressed the need to receive detailed information about the procedure before its application. Their expectations varied:
should also understand that they are working very hard and their job is very difficult. [(Mother 12)]
Issues Regarding the Physical Hospital Environment and Comfort The thoughts of the mothers about the physical and comfort problems of the hospital were explained in this theme. Some mothers expressed that they were uncomfortable because of the hospital's physical environment, stating that it did not meet their expectations for resting, sleeping, and hygiene. They emphasized the need for hospital staff to respect to their sleep and rest times. Some drawbacks were related to it being a university hospital: This is a training hospital and people are constantly entering and leaving our room. It is very difficult to put my child to sleep when people enter the room; first, a student visited, then an assistant, and then a professor. When many people attend to my child all day, she does not have the chance to sleep. [(Mother 10)] We sleep in a triple room and there is one chair in the room. Every night two people have to stand. Sleeping is not possible under these conditions. Besides, my child is 14 years old; I need to change him in the presence of others as he defecates in his diaper. The room stinks. The room does not have an attached bath, I cannot shower and I’m so embarrassed. I want to stay in a single room, it would be more comfortable and we wouldn't disturb others. [(Mother 13)] Our mornings and nights are mixed up. We feel weak and giddy when we cannot sleep and rest. They wake us up. Okay, they are doing their job, but they can be more careful and respectful. They do not understand our fatigue and stress. They do not understand that we cannot care for our children if we are not well and refreshed. [(Mother 7)] My twins were admitted into the hospital. I have had many difficult days; I am so tired. I wish the nurses would be more flexible, I wish they would allow somebody to be with me, I wish they would not wake me up when I fall asleep in the morning… I think they do not understand our situation. [(Mother 13)]
Nurses Expectations Nurses' Feelings and Thoughts About Working in a Pediatric Clinic
When they attended to my child, I was there with him, they let me stay, but I could not bear to see them draw blood, so I did not want to stay. [(Mother 11)]
This theme contained the feelings and thoughts of the nurses on the difficulties about working in the pediatrics clinic. All of the nurses participating in this study expressed that they were pleased working in the pediatric clinic despite difficult working conditions and the emotional burden. Nurses stated that working with children was pleasant and reported some challenges in working with mothers. Nurses indicated that mothers tend to expect special attention and that working with newly delivered mothers, anxious/obsessive mothers, and mothers of children with acute diseases was especially difficult. Their experiences are complex:
Although the nurses answer my questions, I wish they would explain why they give these medicines and the reason for performing this procedure before I ask them questions. Generally, they are so glum; but we
I like working in the pediatric department, I become happy when I begin work, even if I’m sad. It makes me feel good to see children and spend time with them. Of course, it has its challenges; it is difficult to work with the families. Mothers cry, shout, and behave as though theirs is the only
I wanted to be close to my child when they inserted the intracatheter but they did not allow me to do so. I wanted to be there, since she would relax if she saw me there. [(Mother 10)]
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
sick child in the clinic… Mothers cannot stand seeing their children sick. I understand them. [(Nurse 1)] Playing games with the child and seeing their eyes shine when they get better motivates me. Of course, seeing a sick and suffering child affects me emotionally. I find training mothers and giving them attention more difficult. It's inevitable with our working conditions. [(Nurse 2)] All of the nurses expressed that the most challenging aspect of working in the pediatric clinic was the “unsuitability of the working conditions.” They also stated that they performed their tasks less efficiently due to overwork: For example, there are too few nurses here. We have heavier workloads, which increase our stress levels. Our biggest problem is scarcity of nurses, which is why we have long working hours. We work 56, sometimes 64 h a week. It is impossible to be efficient in the clinic when you work for such a long time. Patient care is not our only work; we have to deal with paper work. It's so difficult. [(Nurse 2)]
Nurses' Expectations of Mothers This theme covered the expectations of the nurses from the mothers for nurse/mother cooperation. Most importantly, nurses expected mothers to be “understanding” and “tolerant.” They stated that they understood the mothers' situation and were patient most of the time. They observed that sometimes communication problems resulted from the inability to meet mutual expectations. They admitted to sometimes shouting at mothers and/or having a negative attitude. One explanation for this negative attitude appeared to be work stress from difficult working conditions. Further, it may have been a response to mothers' intolerant behaviors. Of course they are scared, I can understand that, but I think their lack of patience may be a result of stress and fear regarding their child's condition; or maybe they expect everything to be perfect. Our conditions are unfortunately not perfect. They constantly expect attention from us but there is no tolerance. I work alone, so I cannot give everyone the same attention. We try to approach mothers calmly but it is not always possible. Unfortunately, I can sometimes raise my voice. [(Nurse 3)]
Although rare, I sometimes raise my voice at mothers. If I’m tired or when I have a more severe patient, I can shout at a mother who wants something. If I respond so negatively towards a mother… I apologize. [(Nurse2)] Nurses expected mothers to respect their decision to forbid their presence during invasive procedures, especially for painful procedures such as opening vascular access. They explained that mothers' emotional responses during the procedure negatively affect the child and nurse. Additionally, being watched by mothers creates performance anxiety and negatively affects the success of the procedure: We do not want mothers to present when we open a vascular route on their child because they are upset. They cry more than the child does. This is very normal, they love their children, but this makes our job more difficult. Some families get angry with us. This affects our motivation and we find it difficult to open the vascular route that we can normally do with ease. [(Nurse 1)]
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All nurses stated that they were aware of mothers' expectations but could not meet these expectations due to their workload: I cannot sufficiently respond to mothers' expectations. I’m aware of this. Due to the working conditions, I do not think that I’m able to perform my nursing roles 100%. All of them want our attention, we try to meet these expectations, but I cannot say that we meet these expectations a hundred percent because the ward is very busy. There is just one nurse on call. [(Nurse 4)]
Discussion This study attempted to obtain detailed information about the expectations, feelings, thoughts, and perceptions of mothers whose children were hospitalized in the pediatric service of a university hospital and the nurses who provided care. Mothers' Experience of the Hospital Mothers experience fear and anxiety upon learning that their child needs hospitalization. The child's health status, unfamiliarity of the hospital environment, feelings of helplessness and guilt, their recognition that their children need care at home (Caneja, Gledhill, Weaver, Nadel, & Garralda, 2005; Cavusoglu, 2008; Lam et al., 2006; Wray, Lee, Dearmun, & Franck, 2011). In the present study, some mothers stated that they experienced sadness, fear, and anxiety about children at home and the health status of the sick child when they first learn that their child needed hospitalization. This was consistent with other studies that found high anxiety levels among mothers who had learned that their child would be hospitalized (Arikan, Saban, & Gurarslan-Bas, 2014; Caneja et al., 2005; Lam et al., 2006; Wray et al., 2011). However, contrary to the literature, the majority of mothers in our study eventually felt at ease and were pleased about hospitalization. It is assumed that the reason of this might be the fact that mothers could express their feelings more comfortably during in-depth interviews, cultural differences and most of the mothers had a lower education level (elementary). Some mothers felt that they were unable to provide sufficient care to ensure the child's recovery. The immediacy of interventions available at the hospital in case of an emergency and the 24-h presence of healthcare professionals was reassuring; thus, mothers may have preferred hospitalization compared to care at home. However, families' everyday lives are typically disrupted since one parent, especially the mother, stays with the sick child at the hospital. The presence of another child who needs care at home increases mothers' stress and anxiety. Fathers need to obtain a leave of absence from work to care for the child at home and often relatives or school-age children become responsible for caring for their younger siblings. Previous studies show that stress and anxiety levels of mothers with another child at home are higher than those with a single child (Arikan et al., 2014; Lam et al., 2006). Mutual Expectations of the Mothers and Nurses Overall, mothers were pleased with the physical care provided by nurses but their expectations about emotional care were not always met. Physical statisfaction of the mothers reminds that the nurses have given priority to the physical care due to their intense working conditions. Thus, they could not have sufficient time for emotional care. The physical and emotional happiness of the child in pediatric services is important for mothers (Coyne, 1995; Er, 2006; Lam et al., 2006; Soderback & Christensson, 2008). Moreover, mothers typically want healthcare professionals to inform them about the child's health status, cause of illness, and procedures performed; and expect them to be trust worthy, foster good relationships, and communicate effectively (Arikan, Guducu-Tufekci, & Tastekin, 2007; Coyne, 1995; Enarson et al.,
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
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D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
2012; Shields & King, 2001a). Kiguli et al. (2011) found that mothers' expectations included the implementation of accurate and complete diagnostic and treatment methods, having access to information about the child's illness, and receiving attention and support. Similarly, Soderback and Christensson (2008) found that mothers expected treatments to be implemented accurately through accurate diagnosis and that the focus would be on the care of children. They also expected that nurses would establish good relationships with both mothers and children, that they would spend time with children, and provide guidance to mothers. In Lam et al.'s (2006) qualitative study, mothers expected nurses to demonstrate positive attitudes when offering help, provide information about the child's improvement and ensure that their and their children's needs were met. In the present study, mothers indicated that hospital personnel were friendly and approached them with compassion and kindness; however, they sometimes felt neglected and experienced communication problems. In the present study, mothers expected that nurses would provide detailed information about medical procedures. Although the child and family have the right to information about impending procedures, it was often forgotten or ignored. In our study, all of the nurses stated that they were aware of these expectations of the mothers but they could not meet these expectations adequately due to their intense workload. Parental fears and anxieties increased when information about treatment and procedures are not provided to the child and family (Boztepe & Çavusoglu, 2009). Nurses should consider the child's cognitive capacity, concerns, and expectations while preparing the child and family for procedures (Cavusoglu, 2008; Ocakcı, 2006). The present findings are similar to those of other studies. Kiguli et al. (2011) found that mothers expected procedures to be explained using language that was understandable, avoiding medical jargon. Moreover, they expected that nurses would provide support to the child and mothers during the procedure. Boztepe and Çavusoglu (2009) found that 50.6% of mothers reported that nurses informed them about treatments, of which 41.5% did not understand this information. Regarding the presence of mothers during procedures in the current study, some mothers expressed a willingness to be present, while others preferred to stay away as they could not bear witnessing their child crying. Soderback and Christensson (2008) found that only half of the mothers in their study preferred to stay with their child and help during painful and traumatizing procedures. They partly attributed this to mothers' perception of the health personnel's role as well as the protocol to disallow mothers' presence during procedures. However, Lam et al. (2006) found that mothers wanted to be close to their children during invasive interventions. Although some mothers were anxious about these procedures, they did not watch the actual procedure but focused on their child in order to cope with their fears. Notably, nurses recommended that mothers not be present during the child's pain procedures as the nurses felt it could have not only an adverse impact on the child emotionally but also on the individual performing the procedure. This finding is consistent with previous research. For example, Boztepe (2012) found that 62.8% of nurses expressed that mothers should not be present during painful procedures; 77.1% of nurses stated that it increased the child's anxiety and 60.0% stated that it increased anxiety levels of healthcare professionals, ultimately affecting the success of the procedure. Further, in the present study, mothers expected healthcare professionals to be more careful and understanding about satisfying their personal needs such as sleeping, eating, and bathing. Staying in the hospital with children is challenging. Since mothers generally express the needs of their children during this difficult period, they may neglect their own needs (Lam et al., 2006; Shields, Kristensson-Hallstrom, & O'Callagha, 2003). The inadequacy of infrastructure in hospitals is an additional stressor. Crowded wards, poor sleep arrangements, and lack of personnel affect mothers'satisfaction, particularly because their own needs are unmet. Meeting mother’ needs is necessary to help them cope with their child's illness (Shields et al., 2003; Soderback & Christensson,
2008). In the study, mothers shared that the environment did not meet their expectations for resting, sleeping and hygiene. It was considered that the mothers who could not meet their own physical needs adequately also could not meet care requirements of their children. In Lam et al.'s (2006) study, mothers reported feeling very tired in the hospital and noted the lack of resting areas. Mothers also felt numbness in their joints and experienced gluteal pain from sitting on plastic chairs through the night. Further, their rest was disturbed during medical applications. In the present study, mothers expressed concerns regarding hospital hygiene, which is consistent with previous studies; mothers reported having to sleep on their child's bed or on the chair next to the bed and were unable to eat well or bathe due to a lack of facilities (Soderback & Christensson, 2008). Mothers experienced discomfort pertaining their sleeping needs on the bed of their children or on the chair. As in most of the hospitals in Turkey, inadequacy of the physical conditions was evident in the hospital in which this study was carried out. In the study by Kidak and Aksarayli (2008) which was performed to evaluate patient satisfaction in Turkey, the ratios of individuals who have found patient rooms and toilets and bathrooms clean were determined as 5.3% and 4.8%, respectively. In the same study, it was also observed that the ratio of satisfaction about hospital meals was low (30%). Further, in the other studies performed in Turkey, it was found that mothers who could not meet these physical needs in the hospital had low emotional satisfaction (Arikan et al., 2007; Arikan et al., 2014). In the present study, nurses were aware of the family's expectations, but could not meet these because of the lack of nurses, challenging working conditions, and extra work hours. Nurses stated that they were less efficient as only one nurse was on shift; however, they attempted to meet mothers' expectations as best they could. Nurses are healthcare professionals on call 24 h to address various problems faced by the sick child and family. Nursing is deemed a stressful occupation due to the challenging working environment and demanding workload. These issues negatively affect nurses' physical and mental health, as well as their social and family life (Arcak & Kasimoglu, 2006; Tan, Polat, & Akgun-Sahin, 2011). Lam et al. (2006) and Soderback and Christensson (2008), found that mothers first sought nurses' help regarding problems faced by their child and therefore; they have declared that nurses are “very intense”. Boztepe and Çavusoglu (2009) found that nurses did not sufficiently inform mothers about the care of their children and mothers did not participate in treatment-related decision-making. Moreover, mothers were unable to ask nurses questions or share their concerns because of nurses' demanding workload and their unwillingness to answer questions. In the other studies performed in Turkey, it was determined that working hours were irregular for 65% of the nurses, workload was intense for 94.1% and the number of vigils was high for 84.6% (Ozkan, Kocyigit, & Sen, 2013); and 64.7% found the number of nurses insufficient, 54.7% were reluctant to work due to heavy working conditions (Yazici & Kalayci, 2015); 70.9% had a poor sleeping quality and 52.9% had depression and anxiety problems (Gunaydin, 2014). Nurses should be expected to have working conditions that are supportive of their professional well-being to ensure the provision of quality nursing care and that adhere to established labor principles/laws. The International Labor Organization (ILO) has stipulated standards of working and resting hours for nurses. In 1977, “C149 Nursing Personnel Agreement” was accepted by the signatures of 38 countries (ILO, 2005). Turkey is still not among these countries that signed this agreement and intense working conditions of the nurses continue (Gunaydin, 2014). In this study, nurses believed that mothers needed to be more understanding and tolerant to avoid communication problems. In Shields and King's (2001b) qualitative study, healthcare professionals reported that communication with mothers was the most important aspect of care. Tel, Karadağ, Tel, and Aydin (2003) demonstrated that communication problems with patients and relatives contributed to healthcare professionals' work-related stress. Further, nurses frequently cited communication problems with patients and their relatives as work challenges (Arcak & Kasimoglu, 2006).
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
Limitations Since only limited generalizations can be performed in qualitative studies, this study was limited to mutual expectations of 24 mothers in the pediatric service and five nurses who were providing care to them. Mothers of critically ill children were excluded from the study considering that their responses were likely to be affected by their high anxiety. Care was taken to include mothers whose children showed progress. It was limited only to the mothers. The small sample size of mothers and nurses enrolled in this study is a limitation. Additionally, the cultural beliefs and norms, organizational delivery system of care and professional practice standards are factors that impact the provision of care that reflect the level of pediatric care provided in this hospital in Turkey. The scope and standards of professional nursing practice are challenged by the work conditions in Turkey as referred to previously in the discussion. Conclusions This study examined the mutual desires and expectations of mothers of hospitalized children and nurses at a university hospital in Turkey. Six main themes were generated in accordance with the mutual expectations of the mothers and the nurses. Mothers were pleased with the physical care provided by nurses, but aspects of emotional care were lacking, such as a friendly rather than admonishing approach and openness to mothers' questions and concerns. Further, they found that the hospital infrastructure was inadequate, and their basic needs for food, sleep, and hygiene were not met. Nurses stated that they were aware of these expectations but also believed that mothers needed to be understanding and tolerant, considering their difficult working conditions. Nurses in Turkey work under very stressful work conditions: long working hours, low nurse–patient ratio, and high volume of patients. Human resource management is required to create more productive work environments. Studies that attempt to improve nurses' working conditions are necessary. Legislation to protect nurses' rights is essential and factors that negatively affect their jobs should be minimized. Cooperation between managers and policy-makers is necessary to improve hospital infrastructure. Further, nurses must adopt the philosophy of their institution and work towards specific goals, particularly developing their communication skills and fostering good relationships with mothers of hospitalized children to ensure that quality care is provided. Ethics Approval Number Clinical Research Ethics Committee of the Duzce University of Turkey 2014/87. Funding This study received no external funding. Conflicts of Interest none. Acknowledgments The authors would like to thank all mothers and nurses who participated in the study. References Arcak, R., & Kasimoglu, E. (2006). Roles on the health care and the placement at work of the nurses working at the hospitals and the health centers in Diyarbakir city. Dicle Medical Journal, 33(1), 23–30. Arikan, D., Guducu-Tufekci, F., & Tastekin, A. (2007). Problems and expectations of hospital attendants and relationship with their problem solving levels of in pediatric clinics. Journal of Atatürk University School of Nursing, 10(2), 49–57.
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Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
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Journal of Pediatric Nursing
Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study Dilek Konuk Şener ⁎, Aysel Karaca Duzce University, School of Health Sciences, Department of Nursing, Duzce, Turkey
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Article history: Received 28 July 2016 Revised 3 February 2017 Accepted 3 February 2017 Available online xxxx Keywords: Family centered care Hospitalized child Mother Nurse Patient expectation Qualitative research
a b s t r a c t Purpose: This study attempted to identify the mutual expectations of mothers whose children were hospitalized in the pediatric department of a university hospital and nurses who provided care. Design and Methods: A descriptive phenomenological design has been used in this study. Data were obtained through tape-recorded semi-structured interviews. This study was conducted at a pediatric clinic, at a university hospital in a small city in Turkey. Participants comprised five nurses working in the children's clinic and 24 mothers who accompanied their children to the hospital. Results: The six major themes that emerged were mothers' feelings and thoughts about the hospital experience, mothers' expectations for attention and support during hospitalization, mothers' expectations for invasive procedures, issues regarding physical comfort and hospital infrastructure, nurses' feelings and thoughts about working in the pediatric clinic, and nurses' expectations of the mothers. Conclusions: Mothers expected nurses to provide physical support including medication administration, and installing/applying IV and nebulizer treatments; and emotional support in terms of having a friendly, rather than critical attitude, and being approachable and receptive of mothers' questions and anxieties. Nurses stated that they were aware of these expectations but needed mothers to be understanding and tolerant, considering their difficult working conditions. Practice Implications: Children's hospitalization is a stressful experience for parents. Open and therapeutic communication and relationships between parents and nurses contribute to improving the quality of care provided to children and their families. © 2017 Elsevier Inc. All rights reserved.
Children's illnesses and the consequent hospitalization involve inconvenient and unpleasant experiences for both children and their families. It leads to significant lifestyle changes for the family (Cavusoglu, 2008; Coyne, 1995, 1996; Er, 2006; Soderback & Christensson, 2008). Parents have to leave their responsibilities at home and/or work in order to stay with their hospitalized child, negatively affecting their work and family life. Adapting to unfamiliar environments, dealing with new people, and learning about procedures for diagnosis and treatment cause familial stress (Cavusoglu, 2008; Ocakcı, 2006). Previous hospital experiences, the child's health status, consistency of care, duration of hospitalization, and relationships with healthcare professionals are factors that affect parents' anxiety and fear (Coyne, 1995; Lam, Chang, & Morrissey, 2006; Ocakcı, 2006). Parents' participation and cooperation helps nurses and healthcare professionals provide quality pediatric services (Coyne, 1996; Lam et al., 2006). The family's support of the child affects his/her health status and response to nursing care (Eksi, 2011; Ocakcı, 2006). Therefore, ⁎ Corresponding author at: Duzce University, School of Health Sciences, Department of Nursing, Konuralp/Duzce, Turkey. E-mail address: [email protected] (D. Konuk Şener).
family-centered care necessitates the family's involvement at each phase of childcare, thereby instilling trust in health care providers' abilities, and ultimately lowering parents' stress levels. Nurses in pediatric services are required to attend to the family, address their concerns and issues, and meet their expectations through effective communication (Aykanat & Gozen, 2014; Eksi, 2011; Er, 2006; Ocakcı, 2006). Studies investigating parents' expectations of nurses in pediatric services have found that nurses need to have good interpersonal and communication skills (Coyne, 1995; Kiguli, Mafigiri, Nakigudde, Dalen, & Vleuten, 2011; Shields & King, 2001a; Soderback & Christensson, 2008), skillfully apply diagnostic and treatment methods (Kiguli et al., 2011; Soderback & Christensson, 2008), play an active role in the care of children (Lam et al., 2006; Latta, Dick, Parry, & Tamura, 2008), stay with children during painful procedures (Boztepe & Çavusoglu, 2009; Kiguli et al., 2011; Lam et al., 2006), and be informed about the child's health status (Coyne, 1995; Enarson et al., 2012; Er, 2006; Kiguli et al., 2011; Lam et al., 2006). Moreover, nurses' desires, needs, and expectations contribute to improving the quality of care. Changing societal needs, medical and technological developments, social awareness, and a better general understanding of children's illnesses have led to higher expectations
http://dx.doi.org/10.1016/j.pedn.2017.02.004 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
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of healthcare services. Additionally, improvements in nursing practice are also reflected in the field of child health nursing (Toruner & Buyukgonenc, 2012). Considering that work life affects the individual and vice versa, understanding nurses' expectations can help improve nurses' health and satisfaction as well as benefit the institution. Therefore, health care reforms that address nurses' difficulties and expectations are increasingly gaining importance. However, despite these positive developments, nursing is considered a stressful occupation with demanding workloads and occupational hazards, especially in Turkey (Arcak & Kasimoglu, 2006; Toruner & Buyukgonenc, 2012). In the literature, it is observed that previous studies have mostly focused on the requirements and expectations of hospitalized children, their parents and families (Boztepe & Çavusoglu, 2009; Coyne, 1995; Enarson et al., 2012; Er, 2006; Kiguli et al., 2011; Lam et al., 2006; Latta et al., 2008; Shields & King, 2001a; Soderback & Christensson, 2008). It was also found that studies which were performed with mothers were limited to newborn unit (Finlayson, Dixon, Smith, Dykes, & Flacking, 2014; Gaucher, Nadeau, Barbier, Janvier, & Payot, 2016; Povedano, Noto, Pinheiro, & Guinsburg, 2011; Punthmatharith, Buddharat, & Kamlangdee, 2007). Also, there are not sufficient studies on the experiences and expectations of the nurses who were working in children's services. Considering that working conditions, social structures, and cultural practices vary between countries, the need for a qualitative Turkish study that examines mutual expectations of mothers of hospitalized children and nurses is apparent. Therefore, this study attempts to identify mothers' feelings, thoughts, and attitudes regarding hospital experiences and investigate mothers and nurses' mutual expectations. Methods Design In this study, a descriptive phenomenological design is used in order to explain parents' and nurses' experiences, feelings and thoughts caring for the hospitalized child in a pediatric unit. In-depth qualitative interviewing not only enable the researchers to obtain rich description of parents' and nurses' feelings, thoughts and perceptions about caring their child during hospitalization but also it provides a high degree of freedom to answer questions, elaborate ideas and feelings and illustrate concepts (Yildirim & Simsek, 2008).
was no space for them to rest. A total of six people including three children and their mothers were staying within one room. Only in private rooms, were there armchairs for the mothers to sleep. Mothers of critically ill children were excluded from the study considering that their responses were likely to be affected by their high anxiety. Mothers of the children who had a good prognosis were included in the study. Each participant was only interviewed once. Instruments Data were obtained using a demographic information form and semi-structured qualitative interview form. Demographic Information Form Sociodemographic data including age, education level, number of children and nurses' work hours were obtained using the form based on a literature review (Arcak & Kasimoglu, 2006; Cavusoglu, 2008; Ocakcı, 2006). Qualitative Interview Form The semi-structured form to guide interviews included open-ended questions to identify participants' feelings, thoughts, perceptions, and attitudes. It was developed based on a thorough review of literatüre (Arcak & Kasimoglu, 2006; Cavusoglu, 2008; Ocakcı, 2006). The content of questions assessed by a panel of experts in the fields of child health, disease nursing, educational sciences, and psychiatry nursing was deemed appropriate. The order of the form was determined by the flow of the interview. Interview questions for the mothers included their emotional responses to the hospitalization of the child and their to expectations of the nurses, their expectations about their participation in care, their expectations about meeting of their information needs, their expectations during diagnosis and treatment, their thoughts about how a competent child nurse should be and their positive and negative experiences with nurses during their hospital experience. Interview questions for the nurses included their thoughts about family-centered care, their feelings and thoughts about working in pediatric service, the situations in which they have difficulty during working with the mothers, their awareness about the emotional needs of the mothers and their skills for coping with the emotional responses of the mothers.
Sample and Setting Data Collection Participants in this study were selected using a purposive sampling method (Yildirim & Simsek, 2008). Potential participants comprised mothers who accompanied their children to the pediatric clinic at a university hospital in a small city in Turkey and nurses who provided care for them. Voluntary participants included five nurses working at the 18bed pediatric clinic and 24 mothers who had stayed at the hospital for at least two days. Nurses were working during two shifts (including 8 am–4 pm and 4 pm–8 am). Total working hours of a nurse per week were at least 56 h. While two nurses (one was the supervisor nurse) were working during 8 am–4 pm shift, a single nurse was working during 4 pm– 8 am. Supervisor nurse did not implement patient care except for emergency cases. Under these circumstances, there were 18 patients per one nurse. A supporting staff was present in the clinic only during 8 am– 4 pm shift. This staff performed preparation of patient beds, bringing the patient to ultrasonography, X-ray, etc. and transporting laboratory materials. There were eight rooms in the clinic. Five standard rooms had three beds and three private rooms had single beds. There were no toilets/ bathrooms in the standard rooms. Private rooms fees have to be paid by the parents. Mothers were staying with their children in the same room for 24 h. They were using the chairs next to the beds since there
Data were collected in February through June 2015 using in-depth qualitative interviews. Appointments were arranged with the nurses and mothers at an appropriate time and place, convenient and comfortable for the participants. In keeping with mothers' and nurses' preferences, interviews were conducted in the training room at the hospital. For mothers who could not leave their children alone or in the care of a relative, interviews were conducted in the child's room or in any empty room close by. The purpose of the study was first presented to potential participants. Consent was obtained after stating the approximate duration of the interview, explaining the reason for recording interviews, and providing assurance for the confidentiality of all interview data. Participants were instructed that they could turn off the recorder whenever they wanted during the interview. They were requested to share their thoughts about mutual expectations in the hospital according to interview principles. Observational notes about their behaviors and answers were recorded. Interviews with each participant lasted nearly 60 min. The researchers were women. One of them was a psychiatric nurse and the other was a pediatric nurse with PhDs. All of the interviews were performed by the psychiatric nurse who had experience conducting qualitative studies.
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
Data Analysis
Table 2 Major categories and subcategories of nurses expectations.
As indicated by Van-Manen (1990), the experiences of participants can be uncovered by a content analysis of their written statements, which was the method used for the analysis of the study data. Written observational notes and verbal responses for each question in the semi-structured questionnaire were transcribed verbatim. Opinions and notes were crosschecked for compliance with study aims; none were found to be irrelevant. Opinions were categorized according to their semantic similarities and codes to represent these opinions were generated. The frequency of opinions for each code was indicated. Codes were grouped according to the integrity of meaning, based on which themes were generated. To increase the reliability of the data analysis, researchers generated the codes and themes independently. Their data and the analyses were discussed. To ensure validity of data, a panel comprising one expert and five study participants assessed the appropriateness of the codes and themes. The final form was generated after considering the panel's views (Yildirim & Simsek, 2008).
Ethical Considerations The study was conducted in accordance with the Declaration of Helsinki for experiments involving humans. Written informed consent was obtained from the mothers and nurses who participated voluntarily. Mothers and nurses were informed that interview data and information regarding their personal identity would be kept confidential.
Demographic Characteristics All parents who were included in the study were mothers (n = 24) with a mean age of 28.0 years. More than half of them (n = 18) had graduated from elementary school; the others (n = 6) had graduated from high school. Reasons for the child's hospitalization were followups (n = 14) for pneumonia and bronchiolitis and diagnosis for chronic disease (n = 10; diabetes, cerebral palsy, asthma). Children's ages ranged between 30 days to 18 years. The mean age of the nurses (n = 5) was 30.4 years; two of them had a master's degree and three nurses had bachelor degrees. Two of the nurses were single and three of them were married. Work experience in a pediatric ward ranged between 1 and 18 years. Major categories and subcategories identified. Following the analysis, mothers (Table 1) and nurses' (Table 2) statements were grouped under six themes.
Table 1 Major categories and subcategories of mothers expectations.
Mothers' feelings and thoughts about the hospital experience
Major categories
Subcategories
Nurses' feelings and thoughts about working in a pediatric clinic
Working with the child is easy, working with the mother is difficult Difficult working conditions Expectations about care cooperation Expectations during painful invasive interventions Expectations about communication Thoughts about responding to expectations
Nurses' expectations of mothers
Mothers Expectations Feelings and Thoughts About Hospital Experience This theme included feelings and thoughts of the mothers during their experiences in the hospital. While some mothers stated that they felt desperate and experienced considerable distress, fear, and anxiety when they first learned that their child needed hospitalization, the majority stated that decision to hospitalize their child was relieving. Almost all mothers expressed concerns about their children at home. Mothers communicated these complicated emotions during interviews: I was so scared and cried a lot when the doctor told me that my child would be hospitalized. I thought that her situation was bad. It makes you feel so helpless. [(Mother 1)] I felt terrible when I heard that my child would be hospitalized, but I also wanted him to be hospitalized because he was breathing very hard and this scared me. [(Mother 2)]
Results
Major categories
3
Subcategories
Feelings about the child's sickness The hospital feels like a safe environment Concerns about other children at home Mothers expectations of attention and support Mothers' feelings and thoughts during hospitalization about nursing care Mothers' expectations of the nurses Mothers' expectations during invasive procedures Issues regarding the physical hospital environment and comfort
I felt so sad when I heard that we would need to hospitalize our child; I was distressed only because of my daughter at home. I felt sad because I would be far away from her. [(Mother 3)] The majority of mothers expressed that they felt safe and relaxed during their child's hospitalization: I felt very relieved when I heard that she would be hospitalized; I really felt much relived. I said to myself, “Oh! At least she would be under observation and would be examined by doctors and nurses.” Everything is done with perfect timing; I would not be able to do this at home. [(Mother 4)] I did not feel bad when he was hospitalized. I even felt happy. I told myself that this was the right thing to do for his recovery. If they ask me to stay for another 15 days, I will stay. I feel that he would get sicker at home. I become more anxious at home. The hospital makes me feel safe. [(Mother 5)]
Mothers' Expectations of the Nurses Another theme generated from the interviews pertained to the mothers' perceptions of the nursing care provided to the child during the hospitalization. Mothers judged two aspects of nurses' involvement, physical and emotional care. Almost all mothers stated that they were pleased with the care provided by nurses. When mothers were asked to explain their understanding of “care,” it was determined that they
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
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meant medical applications conducted in a timely fashion, such as administering medications, starting IVs and administering nebulizer applications: For example, my child's body temperature rose; the nurse came up and checked it every half an hour; I was very pleased with her efforts. It is not important for her to be good to me; it is important that she is good to my child. [(Mother 3)] Nurses give injections on time, they install the breathing apparatus correctly, and they are very careful about hygiene; I cannot provide this kind of care at home. That's why I’m happy. [(Mother 6)] When mothers were asked about their expectations of nurses, some of them stated that they did not have additional expectations; however, most expressed that they would like nurses to be friendly, rather than admonishing and critical. Some mothers expressed that they wanted interventions explained to them before administration and receive information about their child's overall condition. They also wanted nurses to be willing to answer their questions, and listen to their concerns. Nearly one third of mothers stated that nurses understood their expectations and were appreciated by nurses. However, experiences varied: One day, I asked a nurse, “Can you please insert the needle into this arm?” She scolded me very badly and said, “I will insert it wherever I can find a vein.” I got very upset. Some nurses are very rude. [(Mother 7)] My experience of this service was very bad, but the nurses did not talk to me about my problems; I wish I could talk to someone. [(Mother 8)] Thanks to God, I have met very nice nurses. I’m so pleased, they answered my questions without shouting. Some people have met nurses who were reproachful, but I did not. [(Mother 9)]
Expectations During Invasive Procedures This theme consisted of parental and nursing expectations as to whether parents chose or were allowed as determined by the nurses to be present with the child during a painful procedures. Some mothers stated that they wanted to be present during their child's medical procedures, while others did not as they could not bear to hear them in pain. While half of the mothers stated that some nurses let them stay with their children, the other half stated that nurses forbade them from being present during procedures. Moreover, they expressed the need to receive detailed information about the procedure before its application. Their expectations varied:
should also understand that they are working very hard and their job is very difficult. [(Mother 12)]
Issues Regarding the Physical Hospital Environment and Comfort The thoughts of the mothers about the physical and comfort problems of the hospital were explained in this theme. Some mothers expressed that they were uncomfortable because of the hospital's physical environment, stating that it did not meet their expectations for resting, sleeping, and hygiene. They emphasized the need for hospital staff to respect to their sleep and rest times. Some drawbacks were related to it being a university hospital: This is a training hospital and people are constantly entering and leaving our room. It is very difficult to put my child to sleep when people enter the room; first, a student visited, then an assistant, and then a professor. When many people attend to my child all day, she does not have the chance to sleep. [(Mother 10)] We sleep in a triple room and there is one chair in the room. Every night two people have to stand. Sleeping is not possible under these conditions. Besides, my child is 14 years old; I need to change him in the presence of others as he defecates in his diaper. The room stinks. The room does not have an attached bath, I cannot shower and I’m so embarrassed. I want to stay in a single room, it would be more comfortable and we wouldn't disturb others. [(Mother 13)] Our mornings and nights are mixed up. We feel weak and giddy when we cannot sleep and rest. They wake us up. Okay, they are doing their job, but they can be more careful and respectful. They do not understand our fatigue and stress. They do not understand that we cannot care for our children if we are not well and refreshed. [(Mother 7)] My twins were admitted into the hospital. I have had many difficult days; I am so tired. I wish the nurses would be more flexible, I wish they would allow somebody to be with me, I wish they would not wake me up when I fall asleep in the morning… I think they do not understand our situation. [(Mother 13)]
Nurses Expectations Nurses' Feelings and Thoughts About Working in a Pediatric Clinic
When they attended to my child, I was there with him, they let me stay, but I could not bear to see them draw blood, so I did not want to stay. [(Mother 11)]
This theme contained the feelings and thoughts of the nurses on the difficulties about working in the pediatrics clinic. All of the nurses participating in this study expressed that they were pleased working in the pediatric clinic despite difficult working conditions and the emotional burden. Nurses stated that working with children was pleasant and reported some challenges in working with mothers. Nurses indicated that mothers tend to expect special attention and that working with newly delivered mothers, anxious/obsessive mothers, and mothers of children with acute diseases was especially difficult. Their experiences are complex:
Although the nurses answer my questions, I wish they would explain why they give these medicines and the reason for performing this procedure before I ask them questions. Generally, they are so glum; but we
I like working in the pediatric department, I become happy when I begin work, even if I’m sad. It makes me feel good to see children and spend time with them. Of course, it has its challenges; it is difficult to work with the families. Mothers cry, shout, and behave as though theirs is the only
I wanted to be close to my child when they inserted the intracatheter but they did not allow me to do so. I wanted to be there, since she would relax if she saw me there. [(Mother 10)]
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
D. Konuk Şener, A. Karaca Journal of Pediatric Nursing xxx (2017) xxx–xxx
sick child in the clinic… Mothers cannot stand seeing their children sick. I understand them. [(Nurse 1)] Playing games with the child and seeing their eyes shine when they get better motivates me. Of course, seeing a sick and suffering child affects me emotionally. I find training mothers and giving them attention more difficult. It's inevitable with our working conditions. [(Nurse 2)] All of the nurses expressed that the most challenging aspect of working in the pediatric clinic was the “unsuitability of the working conditions.” They also stated that they performed their tasks less efficiently due to overwork: For example, there are too few nurses here. We have heavier workloads, which increase our stress levels. Our biggest problem is scarcity of nurses, which is why we have long working hours. We work 56, sometimes 64 h a week. It is impossible to be efficient in the clinic when you work for such a long time. Patient care is not our only work; we have to deal with paper work. It's so difficult. [(Nurse 2)]
Nurses' Expectations of Mothers This theme covered the expectations of the nurses from the mothers for nurse/mother cooperation. Most importantly, nurses expected mothers to be “understanding” and “tolerant.” They stated that they understood the mothers' situation and were patient most of the time. They observed that sometimes communication problems resulted from the inability to meet mutual expectations. They admitted to sometimes shouting at mothers and/or having a negative attitude. One explanation for this negative attitude appeared to be work stress from difficult working conditions. Further, it may have been a response to mothers' intolerant behaviors. Of course they are scared, I can understand that, but I think their lack of patience may be a result of stress and fear regarding their child's condition; or maybe they expect everything to be perfect. Our conditions are unfortunately not perfect. They constantly expect attention from us but there is no tolerance. I work alone, so I cannot give everyone the same attention. We try to approach mothers calmly but it is not always possible. Unfortunately, I can sometimes raise my voice. [(Nurse 3)]
Although rare, I sometimes raise my voice at mothers. If I’m tired or when I have a more severe patient, I can shout at a mother who wants something. If I respond so negatively towards a mother… I apologize. [(Nurse2)] Nurses expected mothers to respect their decision to forbid their presence during invasive procedures, especially for painful procedures such as opening vascular access. They explained that mothers' emotional responses during the procedure negatively affect the child and nurse. Additionally, being watched by mothers creates performance anxiety and negatively affects the success of the procedure: We do not want mothers to present when we open a vascular route on their child because they are upset. They cry more than the child does. This is very normal, they love their children, but this makes our job more difficult. Some families get angry with us. This affects our motivation and we find it difficult to open the vascular route that we can normally do with ease. [(Nurse 1)]
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All nurses stated that they were aware of mothers' expectations but could not meet these expectations due to their workload: I cannot sufficiently respond to mothers' expectations. I’m aware of this. Due to the working conditions, I do not think that I’m able to perform my nursing roles 100%. All of them want our attention, we try to meet these expectations, but I cannot say that we meet these expectations a hundred percent because the ward is very busy. There is just one nurse on call. [(Nurse 4)]
Discussion This study attempted to obtain detailed information about the expectations, feelings, thoughts, and perceptions of mothers whose children were hospitalized in the pediatric service of a university hospital and the nurses who provided care. Mothers' Experience of the Hospital Mothers experience fear and anxiety upon learning that their child needs hospitalization. The child's health status, unfamiliarity of the hospital environment, feelings of helplessness and guilt, their recognition that their children need care at home (Caneja, Gledhill, Weaver, Nadel, & Garralda, 2005; Cavusoglu, 2008; Lam et al., 2006; Wray, Lee, Dearmun, & Franck, 2011). In the present study, some mothers stated that they experienced sadness, fear, and anxiety about children at home and the health status of the sick child when they first learn that their child needed hospitalization. This was consistent with other studies that found high anxiety levels among mothers who had learned that their child would be hospitalized (Arikan, Saban, & Gurarslan-Bas, 2014; Caneja et al., 2005; Lam et al., 2006; Wray et al., 2011). However, contrary to the literature, the majority of mothers in our study eventually felt at ease and were pleased about hospitalization. It is assumed that the reason of this might be the fact that mothers could express their feelings more comfortably during in-depth interviews, cultural differences and most of the mothers had a lower education level (elementary). Some mothers felt that they were unable to provide sufficient care to ensure the child's recovery. The immediacy of interventions available at the hospital in case of an emergency and the 24-h presence of healthcare professionals was reassuring; thus, mothers may have preferred hospitalization compared to care at home. However, families' everyday lives are typically disrupted since one parent, especially the mother, stays with the sick child at the hospital. The presence of another child who needs care at home increases mothers' stress and anxiety. Fathers need to obtain a leave of absence from work to care for the child at home and often relatives or school-age children become responsible for caring for their younger siblings. Previous studies show that stress and anxiety levels of mothers with another child at home are higher than those with a single child (Arikan et al., 2014; Lam et al., 2006). Mutual Expectations of the Mothers and Nurses Overall, mothers were pleased with the physical care provided by nurses but their expectations about emotional care were not always met. Physical statisfaction of the mothers reminds that the nurses have given priority to the physical care due to their intense working conditions. Thus, they could not have sufficient time for emotional care. The physical and emotional happiness of the child in pediatric services is important for mothers (Coyne, 1995; Er, 2006; Lam et al., 2006; Soderback & Christensson, 2008). Moreover, mothers typically want healthcare professionals to inform them about the child's health status, cause of illness, and procedures performed; and expect them to be trust worthy, foster good relationships, and communicate effectively (Arikan, Guducu-Tufekci, & Tastekin, 2007; Coyne, 1995; Enarson et al.,
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
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2012; Shields & King, 2001a). Kiguli et al. (2011) found that mothers' expectations included the implementation of accurate and complete diagnostic and treatment methods, having access to information about the child's illness, and receiving attention and support. Similarly, Soderback and Christensson (2008) found that mothers expected treatments to be implemented accurately through accurate diagnosis and that the focus would be on the care of children. They also expected that nurses would establish good relationships with both mothers and children, that they would spend time with children, and provide guidance to mothers. In Lam et al.'s (2006) qualitative study, mothers expected nurses to demonstrate positive attitudes when offering help, provide information about the child's improvement and ensure that their and their children's needs were met. In the present study, mothers indicated that hospital personnel were friendly and approached them with compassion and kindness; however, they sometimes felt neglected and experienced communication problems. In the present study, mothers expected that nurses would provide detailed information about medical procedures. Although the child and family have the right to information about impending procedures, it was often forgotten or ignored. In our study, all of the nurses stated that they were aware of these expectations of the mothers but they could not meet these expectations adequately due to their intense workload. Parental fears and anxieties increased when information about treatment and procedures are not provided to the child and family (Boztepe & Çavusoglu, 2009). Nurses should consider the child's cognitive capacity, concerns, and expectations while preparing the child and family for procedures (Cavusoglu, 2008; Ocakcı, 2006). The present findings are similar to those of other studies. Kiguli et al. (2011) found that mothers expected procedures to be explained using language that was understandable, avoiding medical jargon. Moreover, they expected that nurses would provide support to the child and mothers during the procedure. Boztepe and Çavusoglu (2009) found that 50.6% of mothers reported that nurses informed them about treatments, of which 41.5% did not understand this information. Regarding the presence of mothers during procedures in the current study, some mothers expressed a willingness to be present, while others preferred to stay away as they could not bear witnessing their child crying. Soderback and Christensson (2008) found that only half of the mothers in their study preferred to stay with their child and help during painful and traumatizing procedures. They partly attributed this to mothers' perception of the health personnel's role as well as the protocol to disallow mothers' presence during procedures. However, Lam et al. (2006) found that mothers wanted to be close to their children during invasive interventions. Although some mothers were anxious about these procedures, they did not watch the actual procedure but focused on their child in order to cope with their fears. Notably, nurses recommended that mothers not be present during the child's pain procedures as the nurses felt it could have not only an adverse impact on the child emotionally but also on the individual performing the procedure. This finding is consistent with previous research. For example, Boztepe (2012) found that 62.8% of nurses expressed that mothers should not be present during painful procedures; 77.1% of nurses stated that it increased the child's anxiety and 60.0% stated that it increased anxiety levels of healthcare professionals, ultimately affecting the success of the procedure. Further, in the present study, mothers expected healthcare professionals to be more careful and understanding about satisfying their personal needs such as sleeping, eating, and bathing. Staying in the hospital with children is challenging. Since mothers generally express the needs of their children during this difficult period, they may neglect their own needs (Lam et al., 2006; Shields, Kristensson-Hallstrom, & O'Callagha, 2003). The inadequacy of infrastructure in hospitals is an additional stressor. Crowded wards, poor sleep arrangements, and lack of personnel affect mothers'satisfaction, particularly because their own needs are unmet. Meeting mother’ needs is necessary to help them cope with their child's illness (Shields et al., 2003; Soderback & Christensson,
2008). In the study, mothers shared that the environment did not meet their expectations for resting, sleeping and hygiene. It was considered that the mothers who could not meet their own physical needs adequately also could not meet care requirements of their children. In Lam et al.'s (2006) study, mothers reported feeling very tired in the hospital and noted the lack of resting areas. Mothers also felt numbness in their joints and experienced gluteal pain from sitting on plastic chairs through the night. Further, their rest was disturbed during medical applications. In the present study, mothers expressed concerns regarding hospital hygiene, which is consistent with previous studies; mothers reported having to sleep on their child's bed or on the chair next to the bed and were unable to eat well or bathe due to a lack of facilities (Soderback & Christensson, 2008). Mothers experienced discomfort pertaining their sleeping needs on the bed of their children or on the chair. As in most of the hospitals in Turkey, inadequacy of the physical conditions was evident in the hospital in which this study was carried out. In the study by Kidak and Aksarayli (2008) which was performed to evaluate patient satisfaction in Turkey, the ratios of individuals who have found patient rooms and toilets and bathrooms clean were determined as 5.3% and 4.8%, respectively. In the same study, it was also observed that the ratio of satisfaction about hospital meals was low (30%). Further, in the other studies performed in Turkey, it was found that mothers who could not meet these physical needs in the hospital had low emotional satisfaction (Arikan et al., 2007; Arikan et al., 2014). In the present study, nurses were aware of the family's expectations, but could not meet these because of the lack of nurses, challenging working conditions, and extra work hours. Nurses stated that they were less efficient as only one nurse was on shift; however, they attempted to meet mothers' expectations as best they could. Nurses are healthcare professionals on call 24 h to address various problems faced by the sick child and family. Nursing is deemed a stressful occupation due to the challenging working environment and demanding workload. These issues negatively affect nurses' physical and mental health, as well as their social and family life (Arcak & Kasimoglu, 2006; Tan, Polat, & Akgun-Sahin, 2011). Lam et al. (2006) and Soderback and Christensson (2008), found that mothers first sought nurses' help regarding problems faced by their child and therefore; they have declared that nurses are “very intense”. Boztepe and Çavusoglu (2009) found that nurses did not sufficiently inform mothers about the care of their children and mothers did not participate in treatment-related decision-making. Moreover, mothers were unable to ask nurses questions or share their concerns because of nurses' demanding workload and their unwillingness to answer questions. In the other studies performed in Turkey, it was determined that working hours were irregular for 65% of the nurses, workload was intense for 94.1% and the number of vigils was high for 84.6% (Ozkan, Kocyigit, & Sen, 2013); and 64.7% found the number of nurses insufficient, 54.7% were reluctant to work due to heavy working conditions (Yazici & Kalayci, 2015); 70.9% had a poor sleeping quality and 52.9% had depression and anxiety problems (Gunaydin, 2014). Nurses should be expected to have working conditions that are supportive of their professional well-being to ensure the provision of quality nursing care and that adhere to established labor principles/laws. The International Labor Organization (ILO) has stipulated standards of working and resting hours for nurses. In 1977, “C149 Nursing Personnel Agreement” was accepted by the signatures of 38 countries (ILO, 2005). Turkey is still not among these countries that signed this agreement and intense working conditions of the nurses continue (Gunaydin, 2014). In this study, nurses believed that mothers needed to be more understanding and tolerant to avoid communication problems. In Shields and King's (2001b) qualitative study, healthcare professionals reported that communication with mothers was the most important aspect of care. Tel, Karadağ, Tel, and Aydin (2003) demonstrated that communication problems with patients and relatives contributed to healthcare professionals' work-related stress. Further, nurses frequently cited communication problems with patients and their relatives as work challenges (Arcak & Kasimoglu, 2006).
Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004
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Limitations Since only limited generalizations can be performed in qualitative studies, this study was limited to mutual expectations of 24 mothers in the pediatric service and five nurses who were providing care to them. Mothers of critically ill children were excluded from the study considering that their responses were likely to be affected by their high anxiety. Care was taken to include mothers whose children showed progress. It was limited only to the mothers. The small sample size of mothers and nurses enrolled in this study is a limitation. Additionally, the cultural beliefs and norms, organizational delivery system of care and professional practice standards are factors that impact the provision of care that reflect the level of pediatric care provided in this hospital in Turkey. The scope and standards of professional nursing practice are challenged by the work conditions in Turkey as referred to previously in the discussion. Conclusions This study examined the mutual desires and expectations of mothers of hospitalized children and nurses at a university hospital in Turkey. Six main themes were generated in accordance with the mutual expectations of the mothers and the nurses. Mothers were pleased with the physical care provided by nurses, but aspects of emotional care were lacking, such as a friendly rather than admonishing approach and openness to mothers' questions and concerns. Further, they found that the hospital infrastructure was inadequate, and their basic needs for food, sleep, and hygiene were not met. Nurses stated that they were aware of these expectations but also believed that mothers needed to be understanding and tolerant, considering their difficult working conditions. Nurses in Turkey work under very stressful work conditions: long working hours, low nurse–patient ratio, and high volume of patients. Human resource management is required to create more productive work environments. Studies that attempt to improve nurses' working conditions are necessary. Legislation to protect nurses' rights is essential and factors that negatively affect their jobs should be minimized. Cooperation between managers and policy-makers is necessary to improve hospital infrastructure. Further, nurses must adopt the philosophy of their institution and work towards specific goals, particularly developing their communication skills and fostering good relationships with mothers of hospitalized children to ensure that quality care is provided. Ethics Approval Number Clinical Research Ethics Committee of the Duzce University of Turkey 2014/87. Funding This study received no external funding. Conflicts of Interest none. Acknowledgments The authors would like to thank all mothers and nurses who participated in the study. References Arcak, R., & Kasimoglu, E. (2006). Roles on the health care and the placement at work of the nurses working at the hospitals and the health centers in Diyarbakir city. Dicle Medical Journal, 33(1), 23–30. Arikan, D., Guducu-Tufekci, F., & Tastekin, A. (2007). Problems and expectations of hospital attendants and relationship with their problem solving levels of in pediatric clinics. Journal of Atatürk University School of Nursing, 10(2), 49–57.
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Please cite this article as: Konuk Şener, D., & Karaca, A., Mutual Expectations of Mothers of Hospitalized Children and Pediatric Nurses Who Provided Care: Qualitative Study, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.02.004