Parents’ experiences of care in a paediatric emergency department: A phenomenological inquiry

Australasian Emergency Care 22 (2019) 113–118

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Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec

Research paper

Parents’ experiences of care in a paediatric emergency department: A phenomenological inquiry Alison Peeler a,b,∗ , Paul Fulbrook a,b,c , Karen-Leigh Edward d,e,f , Frances B. Kinnear g,h a

School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Brisbane, Queensland, Australia Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Queensland, Australia Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa d Swinburne University of Technology, Hawthorn, Victoria, Australia e St Vincent’s Private Hospital, Melbourne, Victoria, Australia f School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom g Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia h Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia b c

a r t i c l e

i n f o

Article history: Received 9 October 2018 Accepted 5 December 2018 Keywords: Emergency care Paediatric Parental experience Phenomenology

a b s t r a c t Purpose: The purpose of this study was to provide a rich description of the lived experiences of parents whose child had received care in a new paediatric emergency department. Procedures: A descriptive phenomenological design was used. Semistructured interviews were conducted with 18 parents. Participants were asked to describe their experience of having a sick or injured child treated at the paediatric emergency department, recounting the story of their journey from when their child was first sick or injured, through to their experience within the emergency department, until discharge home. Data were analysed using Colaizzi’s phenomenological approach. Findings: Following analysis, six themes emerged: I can’t imagine my life without her; Keeping me up to date with what was happening; They treated my child in a way that was toddler friendly; They had our child’s best interest at heart; We were working as a team; and There are games and books in the waiting room. Conclusion: The findings demonstrated that parents’ experience of having an ill or injured child treated by the paediatric emergency department was a positive experience and highlighted factors that contributed to this experience. These included open communication, competent and skilled staff, being seen in a timely manner and being cared for in a thorough, family inclusive and child-friendly way. © 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.

1. Introduction The purpose of this study was to provide a descriptive analysis of the experiences of parents (or guardians) who had taken their child to a recently opened paediatric emergency department (ED). In Australia, the majority of hospital-based children’s emergency services are provided within a general hospital ED that incorporates both adult and paediatric patients (referred to as a general or mixed ED) or in a separate children’s ED within a paediatric-specific hospital. Provision of a separate paediatric ED within a hospital servicing both adult and paediatric populations is rare.

∗ Corresponding author at: Australian Catholic University, 1100 Nudgee Rd, Banyo, Qld, Australia. E-mail address: [email protected] (A. Peeler).

Paediatric emergency care in Australia has a history of evolution through an ongoing review process [1]. The most recent Australian government annual report about ED services provides information that helps to identify areas where ED services can be improved [2] and identified 287 public hospital ED across Australia. Australian hospital resource statistics identified 12 specialist children’s or women and children’s hospitals in 2017, of which five were children’s hospitals [3]. These were situated primarily in major cities and provided a broad range of paediatric-specific specialist and emergency services. Overall, 7.8 million ED presentations were reported in Australia in 2017 [2] of which 1.65 million (21.3%) were children under the age of 15 years; with another million presentations aged between 15 to 24 years. However, the report did not provide a breakdown of the specific hospital where paediatric presentations were reported. Relatively recently, a new paediatric ED was built in south-east Queensland, Australia. This part of Australia covers a geographical

https://doi.org/10.1016/j.auec.2018.12.004 2588-994X/© 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.

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area of over 7500 square kilometres and has a population of 3.4 million [4]. The paediatric ED, was designed for functionality, is colocated with an adult ED but has a separate entrance and triage area. Specific nursing, medical and administrative staff are allocated to the department but with respect to the medical staff the majority work in both areas on a shift or term basis. The paediatric ED has twelve separate consultation rooms, two fast track bays and two treatment rooms, and is supported by up to a further twelve beds in the form of a short stay ward (coordinated by ED physicians) and a general paediatric ward (overseen by paediatricians); the ratio varies according to need. There is also an on-site outpatient clinic. With respect to shared services, major resuscitations involve a combined resuscitation team (drawn from both areas), and are performed in either the adult or the paediatric ED, depending on time of day. Allied health support and ED-specific imaging facilities are also shared between the adult and paediatric ED. Given the relative rarity of a co-located adult-paediatric emergency service, as well as a paucity of literature in this area, a comprehensive evaluation of the new paediatric ED was warranted. A multi-phase evaluation study was designed to investigate the service from the perspectives of the service, staff and consumers. This paper presents the findings of the second phase of a four phased evaluation, which examined parents’ experience of having an ill or injured child treated in the paediatric ED. The findings of this research will help inform health service delivery decisions regarding the provision of paediatric emergency services. 2. Aim The aim of this study was to describe the lived experience of parents (or guardians; hereafter collectively referred to as parents) whose child had attended the paediatric ED. 3. Method 3.1. Design This qualitative study used a phenomenological approach [5] to enable description of paediatric care within an ED, from the perspectives of parents of ill or injured children. Phenomenology as a methodological framework has evolved into a process that seeks reality in individuals’ narratives. Its aim is to reach the essence of the lived experience of a phenomenon while ascertaining and defining it [5–8]. In this way, phenomenology generates insights that are meaningful and significant [6–8]. The study adhered to the National Statement on the Conduct of Human research in Australia [9] and was approved by the relevant hospital and university human research ethics committees (ref: HREC/16/QPCH/10; 2016-72R). 3.2. Setting and sample The setting for this study was a paediatric ED in a tertiary general hospital in south east Queensland, Australia; as described above. Participants were recruited using purposive sampling. All parents that had experienced having their child treated in the paediatric ED, and were able to speak English, were eligible to participate. Parents of children that had experienced a major traumatic event, such as resuscitation or death, were excluded.

information about the research study, including contact details of the research team. Parents who provided written consent at that time were later contacted at home by telephone for the purpose of interviewing. When contacted, the researcher re-confirmed that they were still willing to participate and gave them the option of withdrawing. Semi-structured interviews were used in this study since they allow for in-depth discussion of the phenomenon of interest [10,11,13]. An interview guide, using several open-ended questions, was used to focus the interviews in the research area of interest. A copy of the interview guide is available from the authors on request. To facilitate in-depth exploration of the phenomenon open-ended questions were used, such as: “Can you tell me about yours and your child’s experience in the paediatric emergency department?” These were supplemented with prompt questions such as, “Can you expand on that previous point about. . .?” Interviews were conducted by telephone by an academic with 25 years’ experience as a paediatric clinical nurse and researcher (AP), and were recorded using a digital recorder. Telephone interviews were conducted because they were more convenient for parents with young children, who were able to select a time to talk when they were less likely to be interrupted. In addition, the interview was conducted in the security of the participant’s own home, which helped them to feel relaxed, and offered them more control. Findings in a study by Stang support the use of telephone interviews for parents of children in ED [14]. Interviews were coded to de-identify participants and were transcribed verbatim by an independent professional transcriber. Both recordings and transcripts were stored in a password-protected computer. In order to ensure confidentiality, participants’ names were replaced with pseudonyms. 3.4. Data analysis Colaizzi’s [8] method of phenomenological analysis, which is frequently used in descriptive research [5,8], was used to analyse the interview transcripts. Using NVIVO© software to organise the data, Colaizzi’s seven-step approach was employed (Table 1) [10–12]. Initial analysis was undertaken by the first author (AP) and reviewed and authenticated by two authors (PF, KE). 4. Findings 4.1. Participants Twenty parents were invited to participate in the study. Two declined and eighteen participants consented to be interviewed: 15 mothers, two fathers, and one grandmother. The majority of participants were married, and the children they accompanied were aged between two months to 13 years of age. For 13 participants, it was their first visit to an ED with a child. Two participants (mothers) were Asian and the remainder was Caucasian. All spoke fluent English (see Table 2). 4.2. Themes Following data analysis, six themes emerged: I can’t imagine my life without her; Keeping me up to date with what was happening; They treated my child in a way that was toddler friendly; They had our child’s best interest at heart; We were working as a team; and There are games and books in the waiting room. These themes are described below, using verbatim examples from participants.

3.3. Data collection 4.3. I can’t imagine my life without her Data were collected in 2016 during May to September. A purposive sample of parents of children that presented to the ED were invited to participate on discharge. They were provided with

A common recurrent theme described by parents was that they were fearful for their child’s health and wanted the initial

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Table 1 Seven-step approach to analysis. 1. Checking the transcript

The researcher reads the participants’ transcripts to acquire a feeling for their ideas in order to understand them. Significant statements and phrases were extracted from each transcript and coded. In total 315 significant statements were identified. The researcher intuited, described and analysed the data. The underlying meaning of each statement was then written.

2. Extracting significant statements 3. Formulating meanings Examples of formulated meanings Significant statements I can’t imagine my life without her. Every 5 or 10 minutes there would be someone talking to me and giving me an idea of what was going on, what was happening next and what they were going to do now. They treated my child in a way that was toddler friendly. They really knew their stuff. They won over Harry (child) which was impressive. 4. Grouping formulated meanings 5. Developing and clustering themes 6. Exhaustive description

7. Returning to participants for final validation

Formulated meanings This spoke of the child’s preciousness and how unimaginable it would be for the mother to lose her child The mother was reassured by the constant communication about her child’s status and treatment. The mother was pleased that the staff appeared to be knowledgeable and were able to interact with their child in a child friendly way that increased their child’s state of happiness Formulated meanings were then grouped together from which emerging themes could be identified The first three steps for each transcription were repeated and arranged to formulate meanings into clusters of themes, and then returned to the original descriptions to validate the themes. An exhaustive description should communicate the “voices, feelings, actions and meanings” of the interacting individuals. This step in the analysis produced an exhaustive description of the lived experiences of parents who had taken a sick or injured child to the PED. Of the participants who were contactable following data analysis, all responded favourably.

Table 2 Participant characteristics. Participant (pseudonym)

Marital status

Relationship to child

Child’s age

Child’s presenting problem

Number of siblings

Jacqui Melissa Amanda Billy Jill Hannah Nicole Sylvia Glenda Marion Bradley Peter Geraldine Mary Sasha Beryl Ashleigh Vivian

Married Married Single Married Single Married Married Married Married Single Married Married Married Married Married Married Single Married

Mother Mother Mother Mother Grandmother Mother Mother Mother Mother Mother Father Father Mother Mother Mother Mother Mother Mother

5 years 6 years 12 years 4 years 1 year 8 months 7 months 1 year 7 years 8 years 2 months 8 months 2 years 2 years 2 years 2 years 13 years 2 years

Abdominal pain Fractured arm Abdominal pain Swollen and painful neck Croup Urinary tract infection Tick Diarrhoea and vomiting Fractured nose Fractured arm Fever Breathing difficulties Seizures Fever Head injury Diarrhoea and vomiting Abdominal pain Asthma

0 2 0 1 0 0 1 0 2 2 1 2 2 1 1 3 2 0

assessment of their child by a medical practitioner to occur quickly. The idea of waiting and fearing that the child would deteriorate increased their anxiety about their child’s outcome which for some included the possibility that their child might die. This was demonstrated by Vivian who stated; I arrived in the ED with my daughter who had asthma. I was so worried that we would have to wait and that she would get worse. I can’t imagine my life without her. Sylvia echoed the sentiment by saying; There is nothing worse than sitting with a sick child in ED and not getting seen to quickly. My baby is precious to me and I needed reassurance that she was going to be OK as soon as I got there. I only waited a short time ‘til they saw us. That was fantastic. This theme highlighted the fear parent’s faced when dealing with a sick or injured child. Some feared the worst possible outcome for their child (death) whether reality based or not. By taking their child to emergency department, they expected that they would be seen quickly and that their child would be given priority of care. Only after their child had been seen by a medical practitioner, and they were reassured that their child was out of danger was parents’ anxiety reduced.

4.4. Keeping me up to date with what was happening This theme describes how parents felt once they were seen by ED staff. They told of being in a distressed state on arrival to the ED and detailed that clear and thorough communication from the staff on a regular basis helped alleviate their stress and concern for their child’s wellbeing. This was demonstrated by Geraldine who stated: At one point I was standing there in the doorway and I was starting to lose it and get upset and the nurse looked over and saw me and said, “Are you okay, Mum?” The staff, doctors and nurses, were constantly asking me questions but also keeping me up to date with what was happening. It made a huge difference in calming me down. In a similar vein, Hannah stated; It’s a very uncomfortable time, worrying about your child. As things changed and moved forward, they were giving me updates. We were there for a couple of hours and I had people talking to me all the time. Every 5 or 10 minutes there would be someone talking to me and giving me an idea of what was going on, what was happening next and what they were going to do now.

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This theme describes parents’ desire for constant and frequent updates about what is happening to their child, why their child is having specific investigations and when their child is likely to get better. It highlights the importance of effective communication when caring for both parents and children in the ED.

One doctor asked, “Is it all right with you as his parents?” It was like there was an agreement. He didn’t just say this is what we’re going to do. There seemed to be some choice, which was good. I felt that he took us into consideration and we were working as a team. Jane (another mother) felt that she was included too by stating:

4.5. They treated my child in a way that was toddler friendly

As well as looking after Merrin, they also looked after me. They made sure I had a say in what was going to happen.

Participants described being pleased that staff were ‘child friendly’ in their approach. They felt that when the staff appeared to be knowledgeable about children and treated their child in an age appropriate way, that this had an impact on their child’s wellbeing. It also helped to give them confidence that their child was in the right place and that their needs were being met. This was demonstrated by Peter saying;

However, a disgruntled mother (Mary) stated:

The staff were amazing. They treated my child in a way that was toddler friendly. They really knew their stuff. They won over Harry (child) which was impressive. Melissa also agreed by saying; My child was really frightened but the doctor and nurses were fantastic. One in particular even managed to make him laugh! When staff were able to alleviate the child’s fears, it increased the parent’s confidence, this then led to an increased sense of reassurance that their child was being helped in the most appropriate and child-friendly way. 4.6. They had our child’s best interest at heart This theme describes how parents felt about the care shown towards their child during their treatment. They came to the ED fearful and upset about their child’s illness or injury. Parents described how ‘thoroughness of care’ enhanced their sense of wellbeing as they felt that their child was being investigated and treated diligently. Ashleigh stated: They were very thorough and friendly and they didn’t waste any time in helping Willow. They were looking into all sorts of possible things it could be. I was really impressed with [doctor named]. He was very thorough. He did every test and ruled things out and didn’t want us to leave until he knew it was safe to go. He definitely had our child’s best interest at heart. We weren’t just a number to him. Jill, a grandmother, supported this by saying: I think the staff are very well trained and very professional however they were also really thorough. It [the ED] is where we always go if we need anything. Parents also felt reassured when staff appeared to them not only to be child-friendly but investigating their child’s illness thoroughly and exploring all avenues of treatment. This perceived thoroughness of care directly influenced how parents felt about the ED and their satisfaction in the care they received. 4.7. We were working as a team This theme describes how parents felt about the way they were regarded along with their child. They appreciated the concern the staff showed for their wellbeing alongside that of their child. It was important for parents to feel respected and cared for as well as being included in the decision-making process relating to their child’s health. Although the majority of comments from participants were positive, there are some mixed views within this theme. For example, one mother (Beryl) was very satisfied with the care given to her and her child. She stated;

They [ED staff] just took control and I was not included in how or why she should have something done. I couldn’t leave her at all either. I didn’t eat all day! When medical and nursing staff included parents in how they were treating or investigating their child, it made the parents feel more in control of the situation, as well as making them feel respected. They felt that their experience in the paediatric ED was a collaborative effort; not just one-sided from the emergency team. Parents also appreciated it when staff asked them how they were coping and if they could help in any way.

4.8. There are games and books in the waiting room This theme emphasised how important it was to the parents that the environment in which children were treated was child-friendly. It illustrates parents’ perception that the environment played a significant role in their ED experience. Four participants had had previous experiences of taking a child to a general mixed ED but felt more comfortable in this ED. For example, Billy stated: This paeds ED is so much nicer to come to as everything is set up for children. There are games and books in the waiting room and definitely no drunk and disorderly people hanging around. It’s so much better! Participants who had not had any previous experience of either type of ED were still appreciative of how comfortable the environment made them feel. Amanda demonstrated this by saying; It was just so much more calming to be in a room where my child could look at pictures on the wall and play with toys or read a book. This theme described how the environment in which a child is exposed to can influence parents’ experience of the ED. Parents who had had previous experience recognised how much more appropriate a child-friendly environment was for a scared child or parent to be presented with. This child-friendly environment decreased further concerns about unsightly adult scenes as well as contributing to a sense of wellbeing.

5. Discussion The findings of this study have revealed some important factors that increase the overall positive experience of parent/guardians who have had a child with an illness or injury present to the paediatric ED. The quality of the parent and child experience seems to depend on factors that incorporate child specific care, child friendly attitudes and environments as well as thoroughness of that care.[15] This included the following: being seen by ED staff in a timely manner, open frequent communication about their child’s health status, being treated by staff they perceived to be child friendly, thorough and competent and who look after the child in a child friendly environment whilst also addressing the needs of the parent. All these factors help to reassure and relax the parent and child when needing to access health care in a paediatric ED and this in turn not only enriches the experience but helps

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facilitate communication and ultimately enhances the likelihood of delivery of quality care. Parents identified that they were happier when their child was seen by the ED staff as soon as possible. They spoke of how their anxiety for their child was such that it was desirable for them to have their child treated in a timely manner. When this did occur their anxiety about their child’s health was often alleviated. Parents often believe that the child may be seriously compromised and seek reassurance about their child’s mortality [16]. This psychological response has not been widely explored and there is a dearth of literature around this issue hence the need for further research in this area. Having been seen in a timely manner by staff in the paediatric ED, the parents described a desire to be frequently informed about their child’s health and possible treatment. Clearly delivered communication, given frequently, was key to alleviating anxiety and reducing their concern for their child. This aligned with a study by Wanzer et al. [17] that was conducted in large children’s hospital, surveying 195 parents in their paediatric ED. The results found patients also judge quality of the care that they receive based on the communication skills of the health care provider. They continued saying that patients did not necessarily understand diagnosis or treatment however instead evaluated their health care experience based on the quantity and quality of the communication with healthcare professionals [17]. Staff that parents judged to be confident and competent were able to instil in the parents a sense of reassurance that their child was in good hands. Staff who were child-orientated seemed to display empathy and reassurance to parents allowing them to feel confident that the health care that their child was receiving was optimal. Parents’ perception of the staff’s apparent thoroughness of care was also highlighted as an issue for parents when evaluating their ED experience. They were impressed by the staff’s diligence and concern for their child. Their meticulous attention to detail and exploration of all health issues led to a sense of reassurance in the participants who perceived their child as having been thoroughly investigated. However, the quality of care that children and their parents receive is inevitably shaped by the experience and attitudes of the healthcare providers, which in turn will influence parents’ perception of the quality of that care. These findings align with a French study by Wong et al. [18], who surveyed parents attending a paediatric ED in a children’s hospital about what motivated them to take their children to an emergency department. They found evidence for six separable motives (in order of importance): seeking quick diagnosis, treatment, and reassurance; paediatric ED as the best place to go; empathic concern for child’s suffering; being considered by others as responsible parents; external factors; and dissatisfaction with previous consultation. These motives appear to align with that of the participants in this study. Parents’ motives in bringing their children to the paediatric ED are primarily serious and goal-oriented; they are, however, also often emotion based [18]. Family-centred care has long been established as the gold standard for care for children and families in hospital [19–22]. Family-centred care has been utilised in paediatric settings and the theme; We were working as a team, highlighted the need to involve parents in decision making as well as the need to take the parents’ feelings and wellbeing into consideration [20,22]. Participants described the collaboration between themselves and the paediatric ED staff as positive, allowing them some control. Although the staff managed to combine the needs of the child and the families, on some occasions some participants felt that their needs were not considered when they were in the ED with their child. This lack of family-centred care led to a decrease in satisfaction of the overall experience of using the service.

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Having a child-friendly environment also contributed to participants’ overall experience in the paediatric ED. Participants who had previously experienced a general ED were able to compare that experience to the paediatric ED experience. They appreciated the fact that the ED only catered for children and that there were not any distressing adult scenes or behaviour to contend with. Those with no previous experience also found the child friendly environment conducive to decreasing their child’s fears. This aligns with the charter for children and young people’s rights in healthcare in Australia [23]. The findings of this study support the findings of a patient satisfaction study undertaken by Margaret et al. [24], where children and their families were surveyed in a paediatric ED in a university hospital. They found that parents were more satisfied when waiting times were shorter, they received adequate information and had good quality provider-patient interactions [24]. These factors along with a child-friendly staff and environment combine to produce a service that is both suitable and age appropriate. Participants described how the new paediatric ED facilitated better service delivery to children patients than a general mixed ED and that children were less likely to be exposed to harmful or unsightly behaviour from adult patients. From the earliest research into children’s experience of hospitalisation, there have been persistent themes around the desirability of an appropriate environment, privacy and access to age appropriate activities [23,25]. However, there has been little research into the provision of child-focused services in ED, especially mixed ED, which may have been designed with little consideration of the particular needs of children and their parents. Some professional consensus guidelines are available that offer suggestions about the most effective design of paediatric ED [26–28]. In summary, these guidelines suggest: child friendly clinical cubicles should be available, waiting areas should be large and audio-visually appropriate for children, all paediatric areas should be separate from adult areas to limit potential stress caused by adult patients, bereaved parents or carers should be accommodated within private areas, and all children’s areas should be well monitored and secure to protect children from potential harm. However, in a 2010 study that aimed to develop recommendations for improving emergency services for children and youth, a survey of 197 Australian hospitals with identified EDs revealed that only 11 had paediatric waiting rooms within their general ED [27]. Hence the results of this study reflect congruence with these guidelines and how important they are for families who utilise these services. In addition, a recent study also looked at parent and child experiences in the waiting room and concluded similar areas of concern.[15] Importantly, participants agreed that the new model of service was better for the community; a sentiment that closely aligns with the standards for the care of children and adolescents in Australian health services [25,27,28]. 5.1. Implications for practice The findings may be of use for practice or implementation of similar services. Parents’ concerns for their child’s wellbeing, believing in the staff’s ability to care for their child in a child friendly, thorough and competent way, in an environment suitable to the physical and psychological state of the paediatric patient, are prominent themes which need to be explored and utilised in all paediatric settings. 5.2. Limitations Due to the qualitative nature of this study, the findings are not generalisable as such, although in terms of transferability they may have relevance to other similar settings and implications for further research direction. In qualitative research, multiple interpretations

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are possible, therefore different researchers may have had different interpretations. Furthermore, data collection will have been shaped by the interviewer’s personal knowledge and experience.

[10] [11]

6. Conclusions In conclusion, the findings indicate that the co-located adult and paediatric model of ED that was investigated in this study was generally well received with respect to the delivery of a child-focused service. Emergency services that wish to employ a similar model of care may benefit from the knowledge gained from this study to help inform the service when delivering age appropriate care in a paediatric setting. The findings emphasise the importance of alleviating parental concerns or anxiety by timely, child-friendly treatment and frequently informing them of their child’s health status, whilst also highlighting the need for staff to be caring, competent and focused on the needs of the whole family.

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Conflict of interests [18]

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