Article
How hospitalized children and parents perceive nurses and hospital amenities: A qualitative descriptive study in Poland
Journal of Child Health Care 1–9 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493514551313 chc.sagepub.com
Ludmiła Marcinowicz1, Paweł Abramowicz2, Danuta Zarzycka3, Magdalena Abramowicz2 and Jerzy Konstantynowicz2
Abstract A qualitative descriptive design using an interview guide approach was adopted to investigate the patient-nurse relationship and paediatric ward amenities from the perspective of parents and hospitalised children in Poland. The study included 26 parents or caregivers of hospitalised children (between 13 months and 15 years old) and 22 children (from 10 to 16 years old). Qualitative content analysis was used to analyse the recorded verbal data. Data from patients’ transcripts were coded and classified in terms of topics on the patient-nurse relationship and hospital care. We identified five main topics. 1. Nurse qualities; 2. Nurse verbal behaviour; 3. Nurse tone of voice and non-verbal behaviour; 4. Hospital amenities; 5. Parents’ expectations towards nurses. Our study contributes to increased understanding of parents’ and children’s experiences of paediatric hospital care. Keywords children’s perception, nurses, parents’ perception, Poland, qualitative study
1
Department of Family Medicine and Community Nursing, Medical University of Bialystok, Bialystok, Poland Department of Pediatrics and Developmental Disorders, Medical University of Bialystok, Bialystok, Poland 3 Chair and Department of Pediatric Nursing, Medical University of Lublin, Lublin, Poland 2
Corresponding author: Ludmiła Marcinowicz, Department of Family Medicine and Community Nursing, Medical University of Bialystok, Mieszka I 4 B, Bialystok, 15-054, Poland. Email: [email protected]
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Introduction In recent years, there has been increased international focus on assessing and improving the quality of health care for children and adolescents (Corsano et al., 2013; Moules, 2009; So¨derba¨ck et al., 2011). The use of qualitative methods and well as integrating theory and empirical findings to identify key variables which may influence the quality of care are some of the recommendations for researchers studying quality improvement (Kleinman and Dougherty, 2013). Experts also suggest documenting the experiences and opinions of adolescents who received health care as a way to improve the quality of services delivered to youths (Committee on Adolescence, 2008). The social and political transformations that occurred in Poland in the 1990s affected, among others, the health-care system and the educational system. The Polish health-care system is publicly funded and managed by the National Health Fund through a headquarters and 16 regional offices. The budget is divided among the regional offices, which contract health services for the local populations. The entrance points to the system are family doctors, whereas specialists offer their services in hospitals and ambulatory centres. Inpatient care is provided by public hospitals, which can be owned by local governments, and by university hospitals, which typically provide highly specialized services (Orlewska, 2011). Significant changes also occurred in the system of nursing education in Poland. The current model of education conforms to the European Union standards and involves the following three stages: bachelor’s degree level (3-years of education at the basic level), nursing – master’s degree level (2 years) and doctoral studies (4 years) (Zarzycka and Slusarska, 2007). The patient–provider relationship and hospital amenities are important determinants of the quality of health care and greatly influence user acceptability defined as ‘conformity to the wishes, desires and expectations of patients and responsible members of their families’ (Donabedian, 2003, p. 18). Various attributes of quality are the subject of numerous studies, both quantitative and qualitative. Although the quality of paediatric care is extensively discussed in the international literature, few studies on the topic have been carried out in Poland. The available reports describe survey-based studies of the attitudes of sick children and their parents towards hospitalization (Jakubczyk et al., 2003), mothers’ satisfaction from the stay in the paediatric ward (Puczkowska et al., 2005), expectations of parents concerning the nursing care their children receive in the hospital (Bilicka et al., 2009) and parents’ opinions about hospital care (Lukasik et al., 2010). The use of qualitative methods and a deeper understanding of health-care quality components can provide new information concerning the improvement of quality of care provided to hospitalized children. The aim of this study was to describe and assess the components of the patient–nurse relationship and paediatric ward amenities from the perspective of parents and hospitalized children.
Method A qualitative descriptive design using an interview guide approach was adopted for obtaining answers to questions about patient behaviour and experience related to the hospital stay (Sandelowski, 2000)
Setting and sample Patients admitted to one of the clinics of the Dr. Ludwik Zamenhof University Children’s Hospital in Bialystok (Poland) were recruited to the study. This hospital was selected for two reasons. 2 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Firstly, the children had chronic diseases, usually requiring several stays at the hospital. Secondly, the hospital allows parents or guardians unlimited stay during their child’s hospitalization. This, we assumed, would increase the experience of hospital care by both children and their parents. Purposeful maximum variation sampling was used. This strategy aims at capturing and describing the central themes across a broad range of varied cases (Patton, 2002). The study covered 26 parents or caregivers of hospitalized children (between 13 months and 15 years old) and 22 children. The parent/caregiver group consisted of 22 women and 4 men, ranging in age from 25 to 58 years. Twelve had higher education, 6 vocational training, 6 secondary education and 2 primary education. The interviewed children were 10 to 16 years old. Nine of them went to primary school and 13 to lower secondary school. The group included 8 boys and 14 girls. The research was carried out in 2012 and 2013.
Data collection The parents and children were asked open-ended questions to allow for free expression concerning their experience of paediatric care (see supplementary material). All interviews were conducted in a hospital classroom, which ensured confidentiality and freedom of expression. The participants were assured that the interviewer (LM) was not part of the hospital staff and was not involved in the treatment process in any way. After obtaining the participants’ written consent (in the case of interviews with children, parents granted their consent), all interviews were recorded and then transcribed in full. One child and four parents refused to participate in the study without giving reasons. The study was approved by the Ethics Committee of the Medical University of Bialystok, Poland.
Data analysis Qualitative content analysis was used to analyse the verbal data (Sandelowski, 2000). The data from transcripts were coded and classified in terms of topics, concepts and categories. The analysis was performed separately for children and parents. All transcripts were read thoroughly and the concepts which described experiences connected with paediatric care and nurses’ behaviours were noted. Both researchers (LM and PA) were involved in analysing the data.
Results We identified five main topics: (1) nurse qualities, (2) nurse verbal behaviour, (3) nurse tone of voice and non-verbal behaviour, (4) hospital amenities and (5) parent expectations of nurses.
Children’s perspectives Nurse qualities. In the statements of children concerning nurse behaviour the most frequently mentioned qualities were nice, kind and polite. They were mostly very simple statements, expressing positive experiences, for example, ‘The nurses are nice’ (girl, age 12). Another nurse quality mentioned by children was gentleness in the context of nursing procedures. When describing a nurse’s behaviour related to a procedure, participants often used the word ‘gently’ together with another quality of the nurse: ‘When they have to set up a drip, they don’t press hard, they do it gently’ (boy, age 12). 3 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Nurse verbal behaviour. Younger children liked conversations that included humour and fun. Nurses’ behaviours that the children did not like related to situations in which the nurses displayed no sense of humour. They shout, do some painful procedures and almost never laugh, and when they laugh, they laugh at things that are not funny. (Boy, age 11)
When expressing negative opinions on nurses’ behaviour, older children tried to justify their assessment. Usually it’s me who starts a conversation with a nurse. And nurses, well, I understand that they have many patients and they’re not very interested in what I have to say. But they like talking during procedures such as taking blood samples or setting up a drip. They come and say ‘‘How are you, girls?’’ They are open and kind. But I understand they are already tired with it and sometimes don’t give a damn about it. (Girl, age 14)
Nurse tone of voice and non-verbal behaviour. The tone of voice, as a paralinguistic feature, was quite often mentioned both by younger and older children: ‘The ideal behaviour of a nurse is when she is talking with a nice, calm voice’ (boy, age 12). Facial expression was mentioned quite frequently by the children. The most often perceived element was a smile or lack of a smile. ‘For example, her facial expression. Whether she is smiling or not really’ (girl, age 16). Eye contact was perceived more rarely. They look at you so grimly, so angrily, as if you were disturbing them or something like that. (Girl, age 14)
Hospital amenities. From the children’s perspective, the possibility to spend their free time in an interesting way was important. There’s a day room here. We have different games and we play. . . . And there’s a library, also great. You can use the computer and borrow games. (Boy, age 11) I especially liked the day when the hospital teachers performed a [theatrical] play and were reciting rhymes. It was very funny. It was good fun and nice. Something was going on, it wasn’t so boring. (Girl, age 14)
From the older children’s perspective, the aspect of privacy was also mentioned, it was referred to as safety. Security is the most important. To feel secure in the hospital. . . . I don’t mean that I feel insecure but for example I’m not afraid to say that I need a bedpan. I mean it’s important to ask for help and know they will actually help you. (Girl, age 14)
Parents’ perspectives Nurse qualities. In the statements of parents concerning nurse behaviour, the most frequently mentioned qualities were nice, kind, polite and gentleness. The parents’ statements indicated expectations towards a nurse, but they also included elements of evaluation. 4 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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She should do it rather gently, not hard. Because nurses are not gentle. Maybe they’re gentle but they want to do it so quickly. A little child cries, of course. They aren’t polite. Some of them are really rude. (Mother of a 2-year-old child, age 30, higher education)
Speaking about nursing care, the participants emphasized its importance, and even the therapeutic effect. At the same time, they observed that some nurses had the right touch with children, whilst others did not. They associated it with the nurse’s age as well as with their inborn predispositions. Nurses can be divided into younger and older ones. The younger ones have a very good approach to kids. And the older ones don’t have it. They do their tasks routinely: come, administer a medicine, and go. And the young ones will talk to the parent, with the child. Sometimes they even hug the child to make them calm down. They instil a sense of safety, peace and quiet. I think it’s important. It’s also part of the treatment. . . . But as for the right approach to the child, either you have it or not. (Father of a 4-month-old child, higher education)
Nurse verbal behaviour. The manner in which the nurse explained to the child the procedure she was doing, in a way the child could understand, was connected with parents’ satisfaction of nursing care. I am happy with the nursing care. The nurses are exceptionally understanding; they approach each mother and each child gently and patiently. . . . She explains that there won’t be any injection, only a drip; she doesn’t say this thing on the child’s hand is a cannula. Children can’t understand it. So she says it’s a butterfly. And the ‘butterfly’ has to be fed, watered and changed. For a child it’s very important to know what’s going on at the moment. . . . I appreciate that, the patience, this approach to children. (Mother of a 4-year-old child, age 31, higher education)
One positive element of care perceived by the participants was the possibility of the child and nurse having a conversation about topics not connected with the disease. My daughter likes talking and joking. And they [nurses] talk to her. She can find common ground with the nurses. When we were in the orthopaedic ward two years ago, she would talk to them about music bands. (Mother of a 14-year-old daughter, age 46, vocational education)
Nurse tone of voice and non-verbal behaviour. The tone of voice was often mentioned by the parents. Generally, they are very nice. Only sometimes they raise their voices. I can say I don’t like it. Sometimes children make noise, because they are only children, and the nurses say ‘Please be quiet’, whilst they are themselves talking aloud. (Mother of a 12-year-old child, age 38, vocational education)
The participants interpreted a nurse’s raised tone of voice as shouting. ‘When a child starts sulking, some nurses shout instead of talking to them calmly’ (Mother of a 12-year-old child, age 37, vocational education). Facial expression was emphasized by the parents, with a particular perception of smile or lack of a smile. Looking at a nurse, I can tell that she will work well with children. . . . She is smiling so much. She enters the room and she is smiling. (Mother of a 4-year-old child, age 31 higher education) 5 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Hospital amenities. In this field, the participants’ statements referred to such properties as cleanliness, convenience and comfort. Both the parents and the children paid considerable attention to the issues of cleanliness and sterility when medical procedures were performed. Obviously whether she puts on gloves, whether everything is sterile, disposable. It’s important, because there are various diseases, germs. . . . I think I spontaneously check if the stethoscope is new, clean, if the gauze pads and the cups are disposable. Yes, I do pay attention to it. (Mother of a 5-year-old child, age 33, secondary education)
Continuous stay with the child at hospital makes the parents pay attention to the hospitality conditions and amenities connected with it. Generally, the hospital conditions. Comfort. It’s important to me. I just pay attention to that, to comfort. For example, a single room, otherwise the parent functions in the hospital as a caregiver, you know, he or she is with the baby 24 hours a day. (Father of a 2.5-month-old child, age 31, higher education)
Parents’ expectations towards nurses. Our research shows that parents of hospitalized children may consider themselves as patients, too, since they often used the word ‘we’ when relating the experiences connected with care, which indicates that the parents feel they undergo the treatment along with the child. We come here, we are treated . . . . We already know most of the doctors by sight. (Mother of a 11-yearold daughter, age 39, secondary education)
The participants’ statements reflect that the level of parental involvement in the care of a hospitalized child has evolved during the last few years. Parents see it as a positive phenomenon. I don’t visit my child but I just am with him. We have been coming here for a few years and a lot has changed over that time. I think everything has changed for the good, because now parents have better access to their children in the hospital. It used to be very limited; we couldn’t be with our children all the time. . . . And the mother or father is treated differently when they can stay by the child’s bed all the time. Now we are not treated as intruders. (Mother of a 12-year-old son, age 38, vocational education)
Because parents now stay with their children constantly, the parents expect a kind of compensation from nurses for taking care of their own children in the ward. For example, they expect nurses to tolerate their little offences. Because the parents are really here. It’s not that I’ve come here to relax, eat food and sleep well. I have a hard time here but I do it for my child. I must be here. I’d like the nurses to be grateful that we are here and help them, because without us they wouldn’t manage with all that care. We really exert ourselves. It would be nice if they at least appreciated that. And if they wanted to come and do something extra. That’s it. To give that extra help and the smile to the kid. We have our dignity here. I sit or lie in an uncomfortable position all the time, and when I sit down on the [child’s] bed, I would rather they [nurses] didn’t say ‘‘Get off the bed!’’ (Mother of a 5-year-old child, age 32, higher education)
In another situation, parents expect greater kindness on the part of nurses. 6 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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I’d expect some respect for the parents. We don’t really have to be here. We’re here because we love our children and worry about them. In addition, I try to help the nurses a bit, e.g. I administer inhalations to my child. And I sit and sit here. But it makes me angry, too. They [nurses] just should go on a course of politeness and good manners. After all, we aren’t here to play football. We are all here because something wrong’s happened. If I’m here, it must be something serious. If I’m here for a serious matter, I’d like to be treated seriously. . . . You expect more warm feelings, support. (Father of a 2-year-old child, age 39, vocational education)
Discussion To our knowledge, this is the first qualitative study in Poland concerning the provision of hospital care for children. Our study shows that a nurse on a paediatric ward is mainly perceived, by both children and parents, in the context of socio-emotional behaviours, for example, whether she is nice, kind, polite and gentle, has a friendly facial expression and smiles. A significant finding of our study is that parents and children alike are very sensitive to the nurse’s tone of voice, which can be perceived by the participants in either a positive or negative way. Our previous studies revealed that this paralinguistic feature is often noticed by primary health-care patients as well (Marcinowicz et al., 2010). The qualitative research by Chan (2013), whose aim was to explore nursing students’ perception of the role of non-verbal communication, shows, among others, that positive eye contact and facial expressions can make patients feel more comfortable. Moreover, non-verbal communication during wound cleaning and dressing procedures can reflect nurses’ warm-heartedness. Nursing students, however, did not consider tone of voice to be an important factor in communication with patients. Obviously, the results of the quoted qualitative studies must not be generalized, but nurses may be unaware of how significant their tone of voice is from the patients’ perspective, which is reinforced by the present study. In our studies, an important element of evaluation of paediatric care from the participants’ perspective concerned properties such as cleanliness, convenience, privacy and comfort. These features, as adjuncts to the desirable aspects of the patient–provider relationship, may affect users’ experience either positively or negatively (Donabedian, 2003). The issues of hygiene and cleanliness were particularly important for the parents of the hospitalized children. What mattered most for the children were the amenities which promoted play and made it possible for them to have a good time in the hospital. As the research by Coyne and Kirwan (2012) shows, inadequate play facilities are one of the reasons for children’s dissatisfaction with the hospital and health-care professionals. Our research confirms that humour and fun are important for hospitalized children, which other researchers (Ford et al., 2011) observed as well. Another interesting result of our study is that the parents of hospitalized children expect gratitude from nurses for staying with their own children all the time and caring for them, thus helping the nurses in their tasks. As compensation, the parents would like such things as tolerance for their improper behaviours (e.g. sitting on the child’s bed) or greater respect from nurses. The situation may be specific for Poland only, as the possibility of parents staying in the hospital with children is a relatively new arrangement both for parents and for nurses (Bilicka et al., 2009; Lukasik et al., 2010). The survey-based study by Lukasik et al. (2010), conducted among parents who provided care for their children in a hospital 24 hours a day, enumerated the ways in which parents help nurses: They do nursing procedures (46.4%), take care of their children and find activities for them (44%), assist with taking blood samples and drug administration (16.6%), monitor their children’s condition (9.5%) and quiet them down (4.8%). On the other hand, parents disturb the hospital staff, because they do not observe nurses’ orders since ‘mother or father knows better’ (10.7%), interfere 7 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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in the procedures by making unhelpful remarks (7.1%), do not observe hygiene rules (3.6%) or do not observe hospital regulations (1.2%). A review of available research results shows that the attitudes and activities of nurses may be both barriers and facilitators to parent participation in the care of hospitalized children (Power and Frank, 2008). It needs to be mentioned that cultural context may have influenced our results. The historical background – the development of Poland and its transformation from communism over recent years as well as the development of the health service – may have an impact on paediatric nurses’ attitudes and their communications with children and parents. For many years, hospitalization of a child meant separation from the parents and leaving all the care of the child to nurses and doctors, which may affect nurses’ approaches towards children and their parents today. Round-the-clock presence of parents at Polish children’s hospitals is still relatively new. The relationship between a nurse and a parent is bound to evolve over time. Further qualitative studies can help develop family-centred care principles.
Limitations We did our best to ensure that the interview conditions were as convenient as possible for the participants, yet we are aware that the location of interviews in the hospital setting may have impacted the data collected.
Conclusion This study contributes to increased understanding of parents’ and children’s experiences of paediatric hospital care. To improve the quality of paediatric health care, nurses should realize how their tone of voice and non-verbal behaviours such as facial expression or eye contact can be interpreted by the recipients of care. In addition, both parents and children pay attention to the conditions in which the care is provided. Parents view the quality of accommodation facilities as being important, whereas children value the activities and amenities available to them in their free time. In the situation where a parent stays with the child in the hospital all the time, good parent–nurse communication, based on mutual respect and good manners, is very important. Acknowledgements We thank Cezary Godlewski, psychologist from Medical University of Bialystok, for contributions to the interview guide. The authors are very grateful to all the parents and children who participated in this study for sharing their time and experiences. Funding This study was supported by the research grant Nr 123-26786 from the Medical University of Bialystok (Poland). Supplemental material The online data supplements are available at http://chc.sagepub.com/supplemental References Bilicka D, Korbinska M, Popow A, et al. (2009) Expectations of the parents in relation to nursing care of the child in hospital conditions [In Polish]. Pielegniarstwo Chirurgiczne i Angiologiczne 1: 20–25. 8 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Chan ZCY (2013) A qualitative study on non-verbal sensitivity in nursing students. Journal of Clinical Nursing 22(13–14): 1941–1950. Committee on Adolescence (2008) Achieving quality health services for adolescents. Pediatrics 121(6): 1263–1270. Corsano P, Majorano M, Vignola V, et al. (2013) Hospitalised children’s representations of their relationship with nurses and doctors. Journal of Child Health Care 17(3): 294–304. Coyne I and Kirwan L (2012) Ascertaining children’s wishes and feelings about hospital life. Journal of Child Health Care 16(3): 293–304. Donabedian A (Edited by Bashshur)Rashid (2003) An Introduction to Quality Assurance in Health Care. Oxford, New York: Oxford University Press, 2003, pp. 20–21. Ford K, Tesch L and Carter B (2011) Fundamentally important: humour and fun as caring and practice. Journal of Child Health Care 15(4): 247–249. Jakubczyk M, Sakson A, Krzemkowska A, et al. (2003) The analysis of sick children’s and their parents’ attitude towards hospitalization [In Polish]. Pediatria Polska 10: 897–904. Kleinman LC and Dougherty D (2013) Assessing quality improvement in health care: theory for practice. Pediatrics 131: S110–S119. Lukasik R, Waksmanska W and Gawlik K (2010) The aspects of parents’ stay with a child in hospital [In Polish]. Nursing Topics 18(2): 169–175. Marcinowicz L, Konstantynowicz J and Godlewski C (2010) Patients’ perceptions of GP non-verbal communication: a qualitative study. British Journal of General Practice 60: 83–87. Moules T (2009) ‘They wouldn’t know how it feels . . . ’: characteristics of quality care from young people’s perspectives: a participatory research project. Journal of Child Health Care 13(4): 322–332. Orlewska E (2011) Challenges and changes in the Polish healthcare system. Society and Economy 33(3): 575–594. Patton MQ (2002) Qualitative Research & Evaluation Methods. Thousand Oaks, London, New Delhi: Sage Publications, pp. 348–354. Puczkowska E, Krajewska-Kulak E, Jankowiak B, et al. (2005) Evaluation of mother’s satisfaction with care at a pediatric department [In Polish]. Pediatria Polska 80(3): 294–298. Power N and Frank L (2008) Parent participation in the care of hospitalized children: a systematic review. Journal of Advanced Nursing 62: 622–641. Sandelowski M (2000) Whatever happened to qualitative description? Research in Nursing & Health 23: 334–340. So¨derba¨ck M, Coyne I and Harder M (2011) The importance of including both a child perspective and the child’s perspective within health care settings to provide truly child-centred care. Journal of Child Health Care 15(2): 99–106. Zarzycka D and Slusarska B (2007) The essence of nursing care: Polish nurses’ perspectives. Journal of Advanced Nursing 59(4): 370–378.
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How hospitalized children and parents perceive nurses and hospital amenities: A qualitative descriptive study in Poland
Journal of Child Health Care 1–9 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493514551313 chc.sagepub.com
Ludmiła Marcinowicz1, Paweł Abramowicz2, Danuta Zarzycka3, Magdalena Abramowicz2 and Jerzy Konstantynowicz2
Abstract A qualitative descriptive design using an interview guide approach was adopted to investigate the patient-nurse relationship and paediatric ward amenities from the perspective of parents and hospitalised children in Poland. The study included 26 parents or caregivers of hospitalised children (between 13 months and 15 years old) and 22 children (from 10 to 16 years old). Qualitative content analysis was used to analyse the recorded verbal data. Data from patients’ transcripts were coded and classified in terms of topics on the patient-nurse relationship and hospital care. We identified five main topics. 1. Nurse qualities; 2. Nurse verbal behaviour; 3. Nurse tone of voice and non-verbal behaviour; 4. Hospital amenities; 5. Parents’ expectations towards nurses. Our study contributes to increased understanding of parents’ and children’s experiences of paediatric hospital care. Keywords children’s perception, nurses, parents’ perception, Poland, qualitative study
1
Department of Family Medicine and Community Nursing, Medical University of Bialystok, Bialystok, Poland Department of Pediatrics and Developmental Disorders, Medical University of Bialystok, Bialystok, Poland 3 Chair and Department of Pediatric Nursing, Medical University of Lublin, Lublin, Poland 2
Corresponding author: Ludmiła Marcinowicz, Department of Family Medicine and Community Nursing, Medical University of Bialystok, Mieszka I 4 B, Bialystok, 15-054, Poland. Email: [email protected]
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Introduction In recent years, there has been increased international focus on assessing and improving the quality of health care for children and adolescents (Corsano et al., 2013; Moules, 2009; So¨derba¨ck et al., 2011). The use of qualitative methods and well as integrating theory and empirical findings to identify key variables which may influence the quality of care are some of the recommendations for researchers studying quality improvement (Kleinman and Dougherty, 2013). Experts also suggest documenting the experiences and opinions of adolescents who received health care as a way to improve the quality of services delivered to youths (Committee on Adolescence, 2008). The social and political transformations that occurred in Poland in the 1990s affected, among others, the health-care system and the educational system. The Polish health-care system is publicly funded and managed by the National Health Fund through a headquarters and 16 regional offices. The budget is divided among the regional offices, which contract health services for the local populations. The entrance points to the system are family doctors, whereas specialists offer their services in hospitals and ambulatory centres. Inpatient care is provided by public hospitals, which can be owned by local governments, and by university hospitals, which typically provide highly specialized services (Orlewska, 2011). Significant changes also occurred in the system of nursing education in Poland. The current model of education conforms to the European Union standards and involves the following three stages: bachelor’s degree level (3-years of education at the basic level), nursing – master’s degree level (2 years) and doctoral studies (4 years) (Zarzycka and Slusarska, 2007). The patient–provider relationship and hospital amenities are important determinants of the quality of health care and greatly influence user acceptability defined as ‘conformity to the wishes, desires and expectations of patients and responsible members of their families’ (Donabedian, 2003, p. 18). Various attributes of quality are the subject of numerous studies, both quantitative and qualitative. Although the quality of paediatric care is extensively discussed in the international literature, few studies on the topic have been carried out in Poland. The available reports describe survey-based studies of the attitudes of sick children and their parents towards hospitalization (Jakubczyk et al., 2003), mothers’ satisfaction from the stay in the paediatric ward (Puczkowska et al., 2005), expectations of parents concerning the nursing care their children receive in the hospital (Bilicka et al., 2009) and parents’ opinions about hospital care (Lukasik et al., 2010). The use of qualitative methods and a deeper understanding of health-care quality components can provide new information concerning the improvement of quality of care provided to hospitalized children. The aim of this study was to describe and assess the components of the patient–nurse relationship and paediatric ward amenities from the perspective of parents and hospitalized children.
Method A qualitative descriptive design using an interview guide approach was adopted for obtaining answers to questions about patient behaviour and experience related to the hospital stay (Sandelowski, 2000)
Setting and sample Patients admitted to one of the clinics of the Dr. Ludwik Zamenhof University Children’s Hospital in Bialystok (Poland) were recruited to the study. This hospital was selected for two reasons. 2 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
Marcinowicz et al.
3
Firstly, the children had chronic diseases, usually requiring several stays at the hospital. Secondly, the hospital allows parents or guardians unlimited stay during their child’s hospitalization. This, we assumed, would increase the experience of hospital care by both children and their parents. Purposeful maximum variation sampling was used. This strategy aims at capturing and describing the central themes across a broad range of varied cases (Patton, 2002). The study covered 26 parents or caregivers of hospitalized children (between 13 months and 15 years old) and 22 children. The parent/caregiver group consisted of 22 women and 4 men, ranging in age from 25 to 58 years. Twelve had higher education, 6 vocational training, 6 secondary education and 2 primary education. The interviewed children were 10 to 16 years old. Nine of them went to primary school and 13 to lower secondary school. The group included 8 boys and 14 girls. The research was carried out in 2012 and 2013.
Data collection The parents and children were asked open-ended questions to allow for free expression concerning their experience of paediatric care (see supplementary material). All interviews were conducted in a hospital classroom, which ensured confidentiality and freedom of expression. The participants were assured that the interviewer (LM) was not part of the hospital staff and was not involved in the treatment process in any way. After obtaining the participants’ written consent (in the case of interviews with children, parents granted their consent), all interviews were recorded and then transcribed in full. One child and four parents refused to participate in the study without giving reasons. The study was approved by the Ethics Committee of the Medical University of Bialystok, Poland.
Data analysis Qualitative content analysis was used to analyse the verbal data (Sandelowski, 2000). The data from transcripts were coded and classified in terms of topics, concepts and categories. The analysis was performed separately for children and parents. All transcripts were read thoroughly and the concepts which described experiences connected with paediatric care and nurses’ behaviours were noted. Both researchers (LM and PA) were involved in analysing the data.
Results We identified five main topics: (1) nurse qualities, (2) nurse verbal behaviour, (3) nurse tone of voice and non-verbal behaviour, (4) hospital amenities and (5) parent expectations of nurses.
Children’s perspectives Nurse qualities. In the statements of children concerning nurse behaviour the most frequently mentioned qualities were nice, kind and polite. They were mostly very simple statements, expressing positive experiences, for example, ‘The nurses are nice’ (girl, age 12). Another nurse quality mentioned by children was gentleness in the context of nursing procedures. When describing a nurse’s behaviour related to a procedure, participants often used the word ‘gently’ together with another quality of the nurse: ‘When they have to set up a drip, they don’t press hard, they do it gently’ (boy, age 12). 3 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Nurse verbal behaviour. Younger children liked conversations that included humour and fun. Nurses’ behaviours that the children did not like related to situations in which the nurses displayed no sense of humour. They shout, do some painful procedures and almost never laugh, and when they laugh, they laugh at things that are not funny. (Boy, age 11)
When expressing negative opinions on nurses’ behaviour, older children tried to justify their assessment. Usually it’s me who starts a conversation with a nurse. And nurses, well, I understand that they have many patients and they’re not very interested in what I have to say. But they like talking during procedures such as taking blood samples or setting up a drip. They come and say ‘‘How are you, girls?’’ They are open and kind. But I understand they are already tired with it and sometimes don’t give a damn about it. (Girl, age 14)
Nurse tone of voice and non-verbal behaviour. The tone of voice, as a paralinguistic feature, was quite often mentioned both by younger and older children: ‘The ideal behaviour of a nurse is when she is talking with a nice, calm voice’ (boy, age 12). Facial expression was mentioned quite frequently by the children. The most often perceived element was a smile or lack of a smile. ‘For example, her facial expression. Whether she is smiling or not really’ (girl, age 16). Eye contact was perceived more rarely. They look at you so grimly, so angrily, as if you were disturbing them or something like that. (Girl, age 14)
Hospital amenities. From the children’s perspective, the possibility to spend their free time in an interesting way was important. There’s a day room here. We have different games and we play. . . . And there’s a library, also great. You can use the computer and borrow games. (Boy, age 11) I especially liked the day when the hospital teachers performed a [theatrical] play and were reciting rhymes. It was very funny. It was good fun and nice. Something was going on, it wasn’t so boring. (Girl, age 14)
From the older children’s perspective, the aspect of privacy was also mentioned, it was referred to as safety. Security is the most important. To feel secure in the hospital. . . . I don’t mean that I feel insecure but for example I’m not afraid to say that I need a bedpan. I mean it’s important to ask for help and know they will actually help you. (Girl, age 14)
Parents’ perspectives Nurse qualities. In the statements of parents concerning nurse behaviour, the most frequently mentioned qualities were nice, kind, polite and gentleness. The parents’ statements indicated expectations towards a nurse, but they also included elements of evaluation. 4 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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She should do it rather gently, not hard. Because nurses are not gentle. Maybe they’re gentle but they want to do it so quickly. A little child cries, of course. They aren’t polite. Some of them are really rude. (Mother of a 2-year-old child, age 30, higher education)
Speaking about nursing care, the participants emphasized its importance, and even the therapeutic effect. At the same time, they observed that some nurses had the right touch with children, whilst others did not. They associated it with the nurse’s age as well as with their inborn predispositions. Nurses can be divided into younger and older ones. The younger ones have a very good approach to kids. And the older ones don’t have it. They do their tasks routinely: come, administer a medicine, and go. And the young ones will talk to the parent, with the child. Sometimes they even hug the child to make them calm down. They instil a sense of safety, peace and quiet. I think it’s important. It’s also part of the treatment. . . . But as for the right approach to the child, either you have it or not. (Father of a 4-month-old child, higher education)
Nurse verbal behaviour. The manner in which the nurse explained to the child the procedure she was doing, in a way the child could understand, was connected with parents’ satisfaction of nursing care. I am happy with the nursing care. The nurses are exceptionally understanding; they approach each mother and each child gently and patiently. . . . She explains that there won’t be any injection, only a drip; she doesn’t say this thing on the child’s hand is a cannula. Children can’t understand it. So she says it’s a butterfly. And the ‘butterfly’ has to be fed, watered and changed. For a child it’s very important to know what’s going on at the moment. . . . I appreciate that, the patience, this approach to children. (Mother of a 4-year-old child, age 31, higher education)
One positive element of care perceived by the participants was the possibility of the child and nurse having a conversation about topics not connected with the disease. My daughter likes talking and joking. And they [nurses] talk to her. She can find common ground with the nurses. When we were in the orthopaedic ward two years ago, she would talk to them about music bands. (Mother of a 14-year-old daughter, age 46, vocational education)
Nurse tone of voice and non-verbal behaviour. The tone of voice was often mentioned by the parents. Generally, they are very nice. Only sometimes they raise their voices. I can say I don’t like it. Sometimes children make noise, because they are only children, and the nurses say ‘Please be quiet’, whilst they are themselves talking aloud. (Mother of a 12-year-old child, age 38, vocational education)
The participants interpreted a nurse’s raised tone of voice as shouting. ‘When a child starts sulking, some nurses shout instead of talking to them calmly’ (Mother of a 12-year-old child, age 37, vocational education). Facial expression was emphasized by the parents, with a particular perception of smile or lack of a smile. Looking at a nurse, I can tell that she will work well with children. . . . She is smiling so much. She enters the room and she is smiling. (Mother of a 4-year-old child, age 31 higher education) 5 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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Hospital amenities. In this field, the participants’ statements referred to such properties as cleanliness, convenience and comfort. Both the parents and the children paid considerable attention to the issues of cleanliness and sterility when medical procedures were performed. Obviously whether she puts on gloves, whether everything is sterile, disposable. It’s important, because there are various diseases, germs. . . . I think I spontaneously check if the stethoscope is new, clean, if the gauze pads and the cups are disposable. Yes, I do pay attention to it. (Mother of a 5-year-old child, age 33, secondary education)
Continuous stay with the child at hospital makes the parents pay attention to the hospitality conditions and amenities connected with it. Generally, the hospital conditions. Comfort. It’s important to me. I just pay attention to that, to comfort. For example, a single room, otherwise the parent functions in the hospital as a caregiver, you know, he or she is with the baby 24 hours a day. (Father of a 2.5-month-old child, age 31, higher education)
Parents’ expectations towards nurses. Our research shows that parents of hospitalized children may consider themselves as patients, too, since they often used the word ‘we’ when relating the experiences connected with care, which indicates that the parents feel they undergo the treatment along with the child. We come here, we are treated . . . . We already know most of the doctors by sight. (Mother of a 11-yearold daughter, age 39, secondary education)
The participants’ statements reflect that the level of parental involvement in the care of a hospitalized child has evolved during the last few years. Parents see it as a positive phenomenon. I don’t visit my child but I just am with him. We have been coming here for a few years and a lot has changed over that time. I think everything has changed for the good, because now parents have better access to their children in the hospital. It used to be very limited; we couldn’t be with our children all the time. . . . And the mother or father is treated differently when they can stay by the child’s bed all the time. Now we are not treated as intruders. (Mother of a 12-year-old son, age 38, vocational education)
Because parents now stay with their children constantly, the parents expect a kind of compensation from nurses for taking care of their own children in the ward. For example, they expect nurses to tolerate their little offences. Because the parents are really here. It’s not that I’ve come here to relax, eat food and sleep well. I have a hard time here but I do it for my child. I must be here. I’d like the nurses to be grateful that we are here and help them, because without us they wouldn’t manage with all that care. We really exert ourselves. It would be nice if they at least appreciated that. And if they wanted to come and do something extra. That’s it. To give that extra help and the smile to the kid. We have our dignity here. I sit or lie in an uncomfortable position all the time, and when I sit down on the [child’s] bed, I would rather they [nurses] didn’t say ‘‘Get off the bed!’’ (Mother of a 5-year-old child, age 32, higher education)
In another situation, parents expect greater kindness on the part of nurses. 6 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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I’d expect some respect for the parents. We don’t really have to be here. We’re here because we love our children and worry about them. In addition, I try to help the nurses a bit, e.g. I administer inhalations to my child. And I sit and sit here. But it makes me angry, too. They [nurses] just should go on a course of politeness and good manners. After all, we aren’t here to play football. We are all here because something wrong’s happened. If I’m here, it must be something serious. If I’m here for a serious matter, I’d like to be treated seriously. . . . You expect more warm feelings, support. (Father of a 2-year-old child, age 39, vocational education)
Discussion To our knowledge, this is the first qualitative study in Poland concerning the provision of hospital care for children. Our study shows that a nurse on a paediatric ward is mainly perceived, by both children and parents, in the context of socio-emotional behaviours, for example, whether she is nice, kind, polite and gentle, has a friendly facial expression and smiles. A significant finding of our study is that parents and children alike are very sensitive to the nurse’s tone of voice, which can be perceived by the participants in either a positive or negative way. Our previous studies revealed that this paralinguistic feature is often noticed by primary health-care patients as well (Marcinowicz et al., 2010). The qualitative research by Chan (2013), whose aim was to explore nursing students’ perception of the role of non-verbal communication, shows, among others, that positive eye contact and facial expressions can make patients feel more comfortable. Moreover, non-verbal communication during wound cleaning and dressing procedures can reflect nurses’ warm-heartedness. Nursing students, however, did not consider tone of voice to be an important factor in communication with patients. Obviously, the results of the quoted qualitative studies must not be generalized, but nurses may be unaware of how significant their tone of voice is from the patients’ perspective, which is reinforced by the present study. In our studies, an important element of evaluation of paediatric care from the participants’ perspective concerned properties such as cleanliness, convenience, privacy and comfort. These features, as adjuncts to the desirable aspects of the patient–provider relationship, may affect users’ experience either positively or negatively (Donabedian, 2003). The issues of hygiene and cleanliness were particularly important for the parents of the hospitalized children. What mattered most for the children were the amenities which promoted play and made it possible for them to have a good time in the hospital. As the research by Coyne and Kirwan (2012) shows, inadequate play facilities are one of the reasons for children’s dissatisfaction with the hospital and health-care professionals. Our research confirms that humour and fun are important for hospitalized children, which other researchers (Ford et al., 2011) observed as well. Another interesting result of our study is that the parents of hospitalized children expect gratitude from nurses for staying with their own children all the time and caring for them, thus helping the nurses in their tasks. As compensation, the parents would like such things as tolerance for their improper behaviours (e.g. sitting on the child’s bed) or greater respect from nurses. The situation may be specific for Poland only, as the possibility of parents staying in the hospital with children is a relatively new arrangement both for parents and for nurses (Bilicka et al., 2009; Lukasik et al., 2010). The survey-based study by Lukasik et al. (2010), conducted among parents who provided care for their children in a hospital 24 hours a day, enumerated the ways in which parents help nurses: They do nursing procedures (46.4%), take care of their children and find activities for them (44%), assist with taking blood samples and drug administration (16.6%), monitor their children’s condition (9.5%) and quiet them down (4.8%). On the other hand, parents disturb the hospital staff, because they do not observe nurses’ orders since ‘mother or father knows better’ (10.7%), interfere 7 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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in the procedures by making unhelpful remarks (7.1%), do not observe hygiene rules (3.6%) or do not observe hospital regulations (1.2%). A review of available research results shows that the attitudes and activities of nurses may be both barriers and facilitators to parent participation in the care of hospitalized children (Power and Frank, 2008). It needs to be mentioned that cultural context may have influenced our results. The historical background – the development of Poland and its transformation from communism over recent years as well as the development of the health service – may have an impact on paediatric nurses’ attitudes and their communications with children and parents. For many years, hospitalization of a child meant separation from the parents and leaving all the care of the child to nurses and doctors, which may affect nurses’ approaches towards children and their parents today. Round-the-clock presence of parents at Polish children’s hospitals is still relatively new. The relationship between a nurse and a parent is bound to evolve over time. Further qualitative studies can help develop family-centred care principles.
Limitations We did our best to ensure that the interview conditions were as convenient as possible for the participants, yet we are aware that the location of interviews in the hospital setting may have impacted the data collected.
Conclusion This study contributes to increased understanding of parents’ and children’s experiences of paediatric hospital care. To improve the quality of paediatric health care, nurses should realize how their tone of voice and non-verbal behaviours such as facial expression or eye contact can be interpreted by the recipients of care. In addition, both parents and children pay attention to the conditions in which the care is provided. Parents view the quality of accommodation facilities as being important, whereas children value the activities and amenities available to them in their free time. In the situation where a parent stays with the child in the hospital all the time, good parent–nurse communication, based on mutual respect and good manners, is very important. Acknowledgements We thank Cezary Godlewski, psychologist from Medical University of Bialystok, for contributions to the interview guide. The authors are very grateful to all the parents and children who participated in this study for sharing their time and experiences. Funding This study was supported by the research grant Nr 123-26786 from the Medical University of Bialystok (Poland). Supplemental material The online data supplements are available at http://chc.sagepub.com/supplemental References Bilicka D, Korbinska M, Popow A, et al. (2009) Expectations of the parents in relation to nursing care of the child in hospital conditions [In Polish]. Pielegniarstwo Chirurgiczne i Angiologiczne 1: 20–25. 8 Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on August 21, 2015
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