ORIGINAL ARTICLE

New kid on the block? Community nurses’ experiences of caring for sick children at home Sarah Samuelson, Charlotta Will
en and Ewa-Lena Bratt

Aims and objectives. To investigate the experiences of Swedish community nurses in caring for sick children at home, as this is a growing population of patients in community care. Background. There is international consensus that sick children should receive care in their homes as far as possible. Home health care allows the family to stay together while the child is undergoing treatment and thus reduces strain on the family. However, it can also be demanding for parents to take on increased responsibilities for their sick child. Children as a patient group is a relatively new phenomenon in community home health care in Sweden and represents a small part of the community nurse responsibilities, making it difficult to accumulate experience. Design. A qualitative descriptive design. Methods. In-depth interviews with twelve nurses in community health care. Qualitative content analysis was used. Results. ‘Feeling confident in order to instil confidence’ was key in nurses’ experiences. Two main themes emerged: ‘Building a trusting relationship with the family’ and ‘Feeling confident in the role as caregiver’. Nurses aimed at creating a trusting nursing relationship and working closely with parents. The nurses’ feeling of confidence in their role as caregivers depended on the support they received and the knowledge they had. Conclusion. Many community nurses felt unconfident about caring for children at home but experienced it as manageable when peer support and a distinct collaboration with the paediatric clinic/hospital were present. The ongoing shift from hospital to home care urges paediatric clinics/hospitals and community health care to develop formal policies of transmural collaboration to train and support home nurses to deliver adequate care to sick children and their families at home and safeguard good outcomes. Relevance to clinical practice. The implication of the study may contribute to efforts being made to extend and improve cooperation between paediatric clinics/ hospitals and community health care.

Authors: Sarah Samuelson, RN, MScN, Department of Nursing, Health and Culture, University West, Trollh€attan; Charlotta Will
en, RN, MScN, Department of Nursing, Health and Culture, University West, Trollh€attan; Ewa-Lena Bratt, RN, PhD, Lecturer, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg.

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What does this paper contribute to the wider global clinical community?

• It provides meaningful insight

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into the importance of good collaboration between the referring paediatric clinic and the community nurse. It highlights the need to increase child-specific knowledge in community nurses who care for sick children in the home. It highlights the importance of collegial support and opportunity to receive professional guidance for nurses who care for sick children in the home. It reflects nurses0 perceptions on caring for children in community home health care without having paediatric education or training.

Correspondence: Ewa-Lena Bratt, Lecturer, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens backe, 40530 G€ oteborg, Sweden. Telephone: +46 31 7864450. E-mail: [email protected]

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2448–2457, doi: 10.1111/jocn.12823

Original article

Caring for sick children in community care

Key words: community children0 s nursing, content analysis, empirical qualitative research, home health care, nurses’ experiences, paediatric Accepted for publication: 17 February 2015

Introduction There is international consensus that children with various illnesses, including those receiving palliative treatment, should be cared for at home as far as possible. While medical and technical advances in health care over the last few decades have facilitated this (Frierdich et al. 2003, Department of Health and Department for Education and Skills 2004), home care is in a developmental stage and the way it is structured may differ both within countries and internationally (Whiting 2004, O’Leary et al. 2006, Doyle & Buckley 2012, Parker et al. 2012, Kremeike et al. 2014).

Background In Sweden, home health care is conducted under primary healthcare or municipal management. Paediatric home care services most often work from a community base in a single district, while the specialist services are hospital based, providing services to more than one district. Hospital-based paediatric home care is offered only in the bigger hospitals0 catchment areas, leaving an appreciable geographical area without these specialist home care services. In recent years, increasing numbers of severely ill children therefore have received 24-hour care at home provided by the community home health care, which essentially provide care for older (The National Board of Health and Welfare 2008, SOU 2011:55). Children who receive home health care in Sweden constitute a heterogeneous group with a wide spectrum of diagnoses, and the majority of community nurses in Sweden have no education or training in caring for sick children. Children, as a patient group, is a relatively new phenomenon within community health care, which is to a large extent dominated by a focus on elderly care making it difficult for the nurses to accumulate experience (The National Board of Health and Welfare 2008, SOU 2011:55). Many parents of children with long-term or difficult illnesses want to care for them at home with the assistance of healthcare staff for as long as possible (Hansson et al. 2012, 2013, Spiers et al. 2012). Home care allows families to be with their children while they are undergoing treat-

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ment, which reduces the burden on both the family and the sick child. By not having to endure long and demanding hospital visits, it is easier for parents and siblings to maintain some sort of normal everyday existence during the child’s illness (Kandsberger 2007, Hansson et al. 2012). However, parents having responsibility for nursing aspects of their child’s care, such as gastrostomy feeds and complex regimens of medication, may perceive the parental responsibility as stressful and sometimes overwhelming (Carnevale et al. 2006, Spiers et al. 2011). Nurses working in the community home care sector encounter a wide range of paediatric illnesses (Parker et al. 2012). Several studies highlight the palliative care of children at home (O’Leary et al. 2006, Neilson et al. 2010, 2011, Quinn & Bailey 2011, Reid 2013b, Kremeike et al. 2014), but there is a limited amount of research on how community nurses experience home caring of children with chronic conditions that are not of palliative nature. Considering the positive effects that optimal home healthcare provision may have on families with children suffering from long-term or complex conditions, we found it important to examine nurses’ experiences in this regard. The aim of this study was therefore to explore Swedish nurses’ experiences of caring for sick children in community home health care.

Method Design The study is a qualitative descriptive study, with data from individual interviews.

Data collection Criteria for inclusion were that nurses had to have worked for at least two years in home health care and have experience of caring for one or more sick children (aged 0–18) within the community home healthcare system (Table 1). Information about the study was sent by email to 18 operational directors of home health care in the region of V€ astra G€ otaland, and 10 of 18 provided contact information for 13 nurses who fulfilled the study’s inclusion criteria

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average 46 minutes (27–72). The interviews were recorded and transcribed verbatim.

Table 1 Demographics and background of participants n = 12 Gender Age Number of years as a nurse Number of years working in home health care Number of children cared for per nurse Level of education, n Basic nurse’s training only* Specialist training as district nurse Specialist training in intensive care Specialist training in medicine/surgery Time elapsing since a child last cared for Ages of the children in care Examples of diseases in children cared for by the nurses

12 females Median: 49 (30–66) Median: 17 (4–42) Median: 7 (4–35)

Analysis

Median: 3 (1–15)

5 5 1 1 Range: current–4 years before interview Range: 9 months–15 years old Heart conditions, physical disabilities, rheumatic diseases, psychological illnesses with subsequent somatic disorders, leukaemia and brain tumours

*Some nurses had studied freestanding course modules in professional guidance, incontinence issues, diabetes, public health, geriatric care and medicine and neurosurgery.

and were willing to be interviewed. One of the selected nurses declined to participate due to a heavy workload, while the remaining 12 agreed. To obtain a detailed and multifacetted picture of the phenomenon under study, the method of data collection comprised individual interviews with open-ended questions. The questions were asked with openness and sensitivity to the nurses’ responses (DiCicco-Bloom & Crabtree 2006) and were based in four different subject areas, as shown in Table 2. The interviews were carried out in January and February 2014 by the first and second authors, the time and place being decided by the nurses. All the interviews were conducted at the nurses’ place of work and lasted on

The transcribed interview material underwent latent content analysis according to Graneheim and Lundman (2004). The analysis, which was performed in several stages, started by piecing together the twelve interviews to form a text, which was then read by the authors individually to gain a holistic picture of the content. The material was read again, and the authors reflected on it together to gain an understanding of the text’s central meaning. The next stage involved identifying meaning units, that is words, sentences and phrases that corresponded with the aim and belonged together by virtue of their meaning and context (Table 3). These meaning units were then condensed to form a shorter text, albeit with its core content preserved. The condensed meaning units were abstracted to create codes. These codes were compared and sorted according to similarities and differences – an extensive process that finally resulted in the emergence of subthemes, themes and an overarching theme. Throughout the analytical process, the authors aimed to adhere as faithfully as possible to the interview text by reading back and forth between interviews, codes, subthemes and themes and reflecting on and discussing various possibilities for interpretation and levels of abstraction until agreement was reached about the most probable interpretation of the data. Finally, the themes were further refined by discussion of the results with the third author, who was well acquainted with the material.

Ethical considerations The study has been reviewed and approved by the University West ethics committee (Case no. 2013/1182 B 22). Confidentiality was secured, and the numbering of quotations cannot be traced to specific informants.

Table 2 Interview subject area with example questions Subject area

Example questions

The nurses’ experiences of caring for sick children in the home

How did you feel when you learned you were going to care for a sick child? Are there times when it feels particularly difficult or when it feels particularly good? Can you give examples? What do you perceive to be your main task in meeting with the family? What is your view of the parents’ participation and presence in the care scenario? Where does your current knowledge about caring for sick children come from?

Meeting with the family Nurses’ knowledge and experience of caring for sick children The nurses’ perceived need for support

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In what areas do you feel you need support when caring for sick children?

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Caring for sick children in community care

Table 3 Examples from the analytical process Meaning units

Condensed

Code

Subtheme

Theme

Overarching theme

But as far as I’m concerned, I do want to know, of course – I want to kind of be able to answer those things they’re asking me about . . .children are so very open or they. . .how should I put it. . .they don’t gloss over things – they are very straight to the point, very open

I do it for myself. I want to know and be able to answer

Wanting to be competent

The importance of knowledge

Feeling confident in their role as caregivers

Feeling confident in order to instil confidence

Children are very open and straight to the point; they don’t gloss over things

Children are straightforward in their communication

Communicating with the whole family

Building a trusting relationship with the family

Findings

The importance of knowledge

The study gives an account of nurses’ experiences of caring for sick children in community home health care. The findings are presented with the overarching theme of Feeling confident in order to instil confidence followed by two main themes, Feeling confident in the role as caregiver and Building a trusting relationship with the family, and six subthemes (Table 4). A common experience among the nurses in caring for sick children at home was the need to feel confident in their role in order to instil the family and child with confidence. The accompanying subthemes are illustrated with quotes from the nurses’ interviews. All informants were females with a median age of 49, see Table 1.

None of the nurses who participated in this study had received any paediatric training apart from that included in their basic nursing programme, and all perceived themselves as having limited knowledge of caring for children. The nurses described how parents needed to feel confident that their children were being cared for at home in a competent manner. The parents had often read up on and were knowledgeable about their children’s illness, which increased demands on the nurses. Not wanting to appear insecure in front of the parents or fuelling their anxiety by not being able to answer questions, the nurses prepared their visits, for example, by familiarising themselves with testing techniques and equipment and being well acquainted with the patient case:

Feeling confident in their role as caregiver

So I have to get. . .information at my fingertips because I can’t just

A sense of being knowledgeable was a key element of nurses feeling confident in their role. Their sense of confidence was also influenced by the emotions that arose from caring for the sick children, which was undoubtedly most difficult at end of life. Experiencing support was critically important to how the nurses felt about their caring duties, and most wished they had someone to turn to for guidance. Table 4 Overarching theme, theme and subtheme Feeling confident in order to instil confidence Feeling confident in their role as caregivers

Building a trusting relationship with the family

The importance of knowledge The nurses’ emotions Need for support and guidance

Cooperating with the family Planning their work Communicating with the whole family

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2448–2457

say ‘nah, I don’t know what that is –that doesn’t feel right, it’s unprofessional. So it, it puts demands on us.. . . (4)

The responsibility of acquiring sufficient knowledge lay with the nurses themselves, who had to both set aside time and find the relevant sources of information. Most nurses used the Internet, or read articles and books. In many cases, the hospital also assisted in providing information. While the nurses recognised there were great differences between caring for sick children and adults, they used their experience of caring for severely ill adult patients in their meetings with the children and their families: We do have young people dying and they’re in their twenties and thirties with small kids//. . .So somehow we have had training in this over the years. (5)

The nurses expressed a need for professional development, many wishing to increase their collaboration with nurses from the paediatric clinic. Many wanted more

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knowledge about the dynamics of the encounter with the family and the sick child. Others sought more disease-specific knowledge or knowledge of child physiology.

The nurses’ emotions The first emotion arising from the caring for children was often very different from the experience thereafter. After a few visits, the nurses felt more confident, both in their role and in the task, which generated confidence in the healthcare relationship. The prognosis, quality of contact with the parents and support from the surroundings were all critical in how the nurses continued to experience their role: . . .because each time you’re with the family, and the kids get to know you too, it. . .it gets better in terms of the relationships then. You notice how the parents and the children feel confident when I feel confident, so it’s a circle of feedback. (10)

Although most of the nurses felt that home health care for children had become more common in recent years, it was not common enough for them to be able to establish routines. Each time a child was admitted to care, the event felt like a new experience, and within the organisation, there was a general sense of apprehension among the nurses about the prospect of caring for children. This insecurity was often grounded in a lack of competence and training. Others found it to be too emotionally taxing: . . .many don’t even want to do this, because they think like. . .’It’s not our job. We haven’t received any paediatric training.. . . (5)

Most of the nurses expressed anxiety about making errors in handling medicines because the dosages and strengths were different to what they were used to: . . .She had a lot of drugs and dosages are completely different compared to adult//. . .we are not familiar with this. So that part. . .is hard to handle. (11)

Caring for children at end of life was the most difficult task for the nurses and required a huge amount of energy and focus. It felt unnatural and wrong for a child to be this sick and dying. Nurses, who had children on their own and in the same age as the sick child, became more emotionally affected. The nurses tried to concentrate on helping on a professional level to avoid becoming too emotionally involved. Compassion for the family and the desire to make things easier for them caused the nurses to reach out of their comfort zones, and when they did, they discovered they managed far more than they thought they would. Growing with their task helped increase their self-confidence:

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. . .these days I feel so confident about caring for the children that I. . .I’m more proud and happy to be able to care for them without it making me feel bad.. . . (10)

The need for support and guidance The individual nurse’s experience of caring for children was strongly influenced by the kind of support received. Adequate support made her confident in her role, even though she might initially feel insecure about the task at hand, while inadequate support generated a sense of frustration and vulnerability, which increased the psychological burden. Several nurses described how well-organised collaboration with the hospital was a source of support to them. They perceived the hospital as having chief responsibility for care, with a clear division of tasks between the hospital and home health care. The nurses also felt safe in the knowledge that they could call the hospital at any time to ask for advice if they had concerns: . . .we can reach the paediatric unit 24 hours a day if we have any questions or you find yourself in a situation where you need advice. . .//. . .then there’s some kind of security in knowing you’re not completely alone.. . . (10)

Some nurses described a lack of collaboration with the hospital, which generated a sense of being abandoned and vulnerable. They felt that duty of care rested with them and that they were left to stand alone in facing decisions and parents’ questions. The hospital rarely followed up on the care case by getting in touch with the nurses; instead, the latter had to contact the hospital if there were problems. The nurses described experiencing a lack of team spirit and a clear plan for the care initiative: . . .I would have liked it perhaps if they called me a bit more and asked me, like. . .how things were. . .so everything didn’t just depend on me, because I felt it did that a lot. (6)

In connection with their care efforts coming to an end, the nurses expressed a desire to have some kind of concluding session with the hospital, preferably involving the parents, and especially if the child had died. This gave occasion to reflect on and evaluate their work together. Alongside hospital support, collegial support was highlighted as very important to the nurses. Having two nurses share responsibility for the patient meant the burden was halved, and any questions raised by the family could be discussed between them. The nurses benefited from each other’s experiences on both a professional and personal

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levels. There was a great need to talk through difficult situations and reflect on them together – those nurses who worked alone really missed not having someone to air their thoughts with: . . .you need this kind of talk. . .//Was I thinking right now?. . .’Now I did this’,’life sucks’(laughs)//. . .so we talk a lot and if we close the door, so to speak. . .we can be there the two of us and not disturb one another. (1)

Most nurses had not received any guidance or supervision in connection with caring for sick children, but many had repeatedly flagged its necessity to their employers. Other nurses felt that collegial discussions were sufficient and that there was no need for any additional guidance.

Building a trusting relationship with the family There were many different aspects to the nurse’s interaction with the family, but most important was building a confident and trusting relationship. By planning well and cooperating with the parents, the nurses wanted to impart a sense of confidence, their ability to communicate with all family members being an important factor in this.

Cooperating with the family Most of the nurses perceived their main task to be to carry out a healthcare initiative, according to their remit, and saw themselves as the extended arm of the hospital. At the same time, they emphasised the necessity of building a confident and trusting relationship with the parents to fulfil their task, and this was many times considered the most important aspect for them: . . .that they have trust in me. . .I think this is really important. . .// . . .it’s the most important thing, that that side of things works because if it doesn’t, you can’t take responsibility for the child. (11)

In the nurses’ experience, the parents were initially controlling and needed to keep checking that their children were receiving the right care. The nurses felt like they were being watched and monitored by the parents, but as time went on and the parents understood that the nurses were competent, they relaxed and the need for control decreased. Several nurses described how awkward it felt to be monitored, but were also sympathetic about the parents’ anxiety: . . .they [the parents] just stare at your hands. . .what you’re doing and what you’re busy with. And once you’ve done that a few

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Caring for sick children in community care times, they know that you can manage, then you see. . . then they go and do other things. (5)

The parents actively participated in the care and were generally present when a care action was performed. The nurse and the parents frequently worked together, with the parents preparing and distracting the child while the nurse performed the care procedure. This made the nurse’s job easier, and as routines became established, both child and parents felt more confident.

Planning their work Several nurses described how they tried to maintain similar routines because it instilled in the family a sense of security and confidence. Healthcare plans and clear instructions to colleagues were also important, as was thinking through all the steps in a care procedure before performing it. As far as possible, the nurses tried to create continuity in their care contact with the family. When care interventions were spread across the course of a whole day, changes to the schedule could be made to minimise the number of nurses involved. Having two nurses share responsibility for a patient created continuity, which gave confidence to both the family of the sick child and the nurses themselves: . . .therefore. . .the continuity. . .that we are a few nurses who go there, it provides security for the child and for the family.. . . (8)

The home visits were also described as being unpredictable in terms of duration. It was difficult to know in advance whether the child would be cooperative or whether someone in the family was feeling down and needed extra time and support: I always try to make sure I have plenty of time because you never know who will need encouragement or need to talk. . .you really take care of everyone in a crisis.. . . (1)

Communicating with the whole family Communicating with the family was important for the healthcare relationship. At first, the parents had a great need to ventilate their experiences of how the illness started and how they were received at the hospital. Once the relationship had become more secure, conversation could turn to more everyday things such as how the other children were getting on at nursery school or some issue in the community. In these conversations, the parents could sometimes express their anxiety and sadness about the situation.

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Many nurses felt insecure about tackling deeper discussions with the parents, for example, if the child had a bleak prognosis. Not feeling they had the requisite skills to manage more difficult conversations, the nurses referred parents to professional discussion therapists when necessary. Although they were ‘available to talk’ if parents took the initiative, the nurses did not actively seek any deeper discussions they considered beyond the scope of their profession: . . .I try not to go in as a social worker or psychologist, that’s not my job, because it’s so difficult.. . . (5)

The nurses found communicating with children to be a novel experience, describing them as very forthright and open to expressing what they felt in a completely different way to adults. Sometimes, the children would amaze the nurses with their direct communication and honest questions, and it could be a challenge to maintain composure and not buckle in an emotionally difficult situation: She can be very straight to the point and ask. . .’D’you think I’m going to die?’ And then like, being a mother. . .I’m completely horrified. And then you have to try to be professional and have the courage to stay. (1)

In this crisis situation, siblings were often marginalised, as the parents needed to invest almost all their time and energy in the sick child. As a result, the siblings tried to vie for attention, an attempt at making contact that the nurses perceived as arising from a need for affirmation. Taking notice of and affirming the siblings was therefore perceived as an important part of their home visits.

Discussion In Sweden, home health care for children may be delivered by nurses without any paediatric education or training and the findings of this study reflect the profession’s perceptions on this. The overarching theme indicates that nurses who care for children in the home need to feel confident in their role in order to instil the family and sick child with confidence. A trusting care relationship is the foundation on which health care at home is carried out and allows the nurse to identify needs and tailor an individual approach to fulfilling them. When trust is lacking, the work situation is often perceived as difficult to master. The nurses described a widespread feeling of insecurity when it came to caring for children, which often generated reluctance to take on the task. Many times, this insecurity arose from a sense of inadequate experience and knowledge within the area, as well as fear of becoming too emotional

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in the encounter with the sick child and the family. Nevertheless, several informants stated that their insecurity and fears largely dissipated with time and that they became increasingly confident in their professional role. It was also satisfying to be able to accommodate the family’s wish to be at home, and the nurses were motivated by being able to facilitate this – a feeling confirmed by other studies (Stevens et al. 2004, Spiers et al. 2012). There was a clear distinction between the general apprehension about caring for children and the intense, emotional demands that were experienced in connection with caring for children in a palliative stage. Having to witness the child’s suffering and death felt unacceptable and emotionally difficult to handle. Other factors that provoked strong emotional reactions included bleak prognoses, lack of contact with the family and psychological suffering in the family. The emotional stress associated with paediatric palliative care is well known from earlier research (Costello & Tinder-Brook 2000, Clarke & Quin 2007, McCloskey & Taggart 2010, Reid 2013b), but to our knowledge, there are no studies highlighting the emotional experiences of community nurses in caring for children with medical conditions that are not of palliative nature, which makes parts of our results difficult to compare with other research. Health care in the home is focused on the older, and children are a comparatively small and recently emerging group of patients for its activities (Law et al. 2011, SOU 2011:55). Research shows there are great differences between the palliative care of children and that of adults (Sourkes et al. 2005), and the composite picture highlights a complexity that poses stringent demands on the capabilities of nurses to care for children, especially in the palliative stage. In the present study, the nurses felt personally responsible for acquiring adequate knowledge, but nevertheless felt their competence was limited in this field. Previous experience from caring for adults was an important source of knowledge in caring for the children. O’Leary et al. (2006) assert that experience from adult palliative care and providing support to children when adults die forms a useful foundation of knowledge for paediatric palliative care. However, Law et al. (2011) highlight the problems associated with the fact that district nurses, who are more likely to have cared for older patients and not necessarily have the requisite paediatric nursing knowledge and competence, must take responsibility for caring for children in the home. This can lead to the children and their families not being offered the care and support that should be tailored to their specific needs (O’Brien & Duffy 2010). Several studies call for theoretical and clinical training as a necessary support to increase nurses’ child-specific © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2448–2457

Original article

competence (O’Brien & Duffy 2010, Law et al. 2011). One avenue may be to design a course on paediatric care in the home that is included in specialist education programmes focused on home health care, and could also be studied as an individual module. However, it may be difficult to maintain such knowledge when children are so rarely cared for at home (Frierdich et al. 2003, Law et al. 2009, 2011, Neilson et al. 2010, 2011). An increased, more well-defined collaboration between paediatric clinics and home healthcare teams would prove a significant complement, as confirmed by previous research (Kremeike et al. 2014). The results of this study revealed that the paediatric clinic was seen as an important source of knowledge. When a child was admitted to home health care, some nurses described how receiving patient-specific information from the clinic about the disease, prognosis and planning refreshed their previous knowledge. The nurses expressed a desire to increase knowledge exchange with the paediatric clinic through lectures, particularly concerning how to approach the meeting with the family and the children. A number of nurses also admitted to feeling unsure about entering deeper discussions, which revealed the parents’ concerns and anxieties. Feeling they did not have adequate training or experience, there was a fear of initiating emotionally loaded conversations, the course of which they might not be able to manage. Studies show that healthcare providers who have the opportunity to practise through practical training or education feel more comfortable in conversations about death and dying (Bagatell et al. 2002, Harrison et al. 2014). Most nurses expressed anxiety about making errors in handling medicines because the dosages and strengths were different from what they were used to. Educational initiatives may thus make a difference to how confident nurses feel in these situations. The nurses’ perception of the support they received was critical in determining how they felt about caring for sick children at home. As perceptions of what was most difficult about the experience varied widely, it is very important to adapt this support to the individual nurse’s perceived needs. In our study, collegial support was highlighted as important, with the nurses helping and unburdening each other in their day-to-day care duties. Having the opportunity to ventilate and discuss things with colleagues was essential for the nurses to be able to manage emotionally demanding situations, as also confirmed by previous research (Beringer et al. 2007, Reid 2013a,b). The structure of the care organisation is very important in this regard. When nurses are organised into teams, working alone is avoided and a foundation for collegial support is created. In contrast, working alone puts the nurse in an exposed and vulnerable position. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2448–2457

Caring for sick children in community care

A number of nurses desired time for reflection and professional guidance. Reflective discussions elicit new knowledge and insights, which may be helpful in the nurses’ care work (Neilson et al. 2010). Moreover, for times of great emotional stress, professional guidance and reflective discussions are an important aspect of staff care and can prevent burnout in the long term (Gerow et al. 2010). In our study, when collaboration with the hospital was good, the nurses found it to be an incredibly important source of support. Clear areas of responsibility and established channels of communication facilitated their work, and having constant access to the paediatric clinic’s expertise imparted a sense of security. By extension, good quality cooperation and a consistent approach by the caregiver also create a sense of security for the child and their family. The reliability of the study has been strengthened by a detailed description of the analytical process and by quoting various informants. A thorough description of the study context also allows the reader to form an impression as to whether the results can be translated and implemented into the activities of similar contexts (Guba & Lincoln 1982, Houghton et al. 2013, Moon et al. 2013). A strategic selection process was employed, with a view to promoting heterogeneity as far as possible. It may therefore be seen as a weakness that four of twelve informants came from the same municipality, as there was an increased risk of their individual experiences being influenced by the conditions and circumstances prevailing in that particular care organisation. The four informants did, however, belong to three different work teams, and one was from a staff pool and only brought in occasionally. Otherwise, there was a large geographic spread and informants represented a wide range of ages, professional experience, number of children cared for and level of education. The fact that all the informants were women may have influenced the results of the study, but nevertheless reflects the predominance of female nurses in municipal home health care.

Conclusion Many nurses in community home health care feel uncertain when faced with the task of caring for sick children. Collegial support and well-defined collaboration with the hospital were crucial to determine whether or not the nurse feels able to cope with caring for a child in its home. Nurses also sought after professional guidance and training to feel more secure in their role. Moreover, they see the creation of a trusting relationship as an important task in helping reassure the child and their family feel about receiving health care at home.

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Relevance to clinical practice This study provides significant insight into the importance of establishing close collaboration between the referring paediatric clinics and the municipality, which would assist in implementing initiatives to develop and improve liaison between caregivers. The study also highlights the need for community nurses to increase their child-specific knowledge by means of improved liaison with paediatric clinics, combined with studying short, university-level course modules that focus on paediatric care in the home. By organising home health care to avoid nurses having to work alone, opportunities for collegial support would increase and the employer could also support nurses working with

children in community home health care by making space for reflective discussion and professional guidance in their schedules.

Contributions SS, CW, ELB were responsible for the Study design; Data analysis and Manuscript preparation of this paper.

Funding None.

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