Exploring the voices of children and children’s nurses in hospital: implications for nursing practice
Intended for healthcare professionals
Evidence and practice    

Exploring the voices of children and children’s nurses in hospital: implications for nursing practice

Sonya Clarke Senior lecturer (education), School of Nursing and Midwifery, Medical Biology Centre, Queen’s University Belfast, Belfast, Northern Ireland

Why you should read this article:
  • To recognise the importance of seeking the views of children about their experiences of healthcare

  • To enhance your understanding of children’s experiences of staying in hospital from the perspective of children and children’s nurses

  • To consider the improvements in nursing practice that could be made to enhance the care of children in hospital

Children should have a voice in relation to all aspects of healthcare as respected and credible service users, a belief endorsed by the United Nations Convention on the Rights of the Child. The children’s nurse is the healthcare professional who delivers care most frequently to children in hospital and their families, so is in an optimal position to offer valuable insight into children’s experiences of being in hospital. Therefore, it is important to listen to the voices of children and children’s nurses in relation to this area. This article is informed by a narrative literature review and study, undertaken by the author as part of her doctoral thesis, which explored children’s experiences of staying overnight in hospital from the perspective of children and children’s nurses. In this article, the author summarises the main findings from the study and considers the implications for children’s nursing practice based on her reflection on these findings.

Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1447

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

@sonyaclarkeCYP

Correspondence

sonya.clarke@qub.ac.uk

Conflict of interest

None declared

Clarke S (2023) Exploring the voices of children and children’s nurses in hospital: implications for nursing practice. Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1447

Published online: 06 March 2023

Seeking the views of children about their experiences of healthcare is crucial to enable service providers to meet the needs of service users (Royal College of Nursing (RCN) 2014a). The author of this article considers children to be noteworthy and unique users of healthcare services, and believes that they should have a voice in relation to all aspects of healthcare as respected and credible service users – a view that is endorsed by the United Nations Convention on the Rights of the Child (United Nations 1989).

To this end, the author conducted a narrative literature review (Clarke 2019) and a study (Clarke 2022), as part of their doctoral thesis, that explored children’s experiences of staying overnight in hospitals from the perspectives of children and children’s nurses. The aim of the study was to explore children’s experiences and viewpoints, alongside the voices of children’s nurses, rather than to generalise the findings. This article summarises some of the findings from the author’s study and considers the implications for children’s nursing practice based on her reflections on these findings.

Key points

  • Service providers should seek the views of children about their experiences of healthcare to meet the needs of service users

  • Children’s nurses may lack education on child development, find some children challenging, and experience time restraints and issues related to the ward environment, which can prevent them from providing high-quality care

  • Communication, health and well-being, environment, play specialists and the role of play, visiting access and relationships are important factors in relation to children’s experiences of staying in hospital

  • Children’s nurses should consider how they can enhance the experiences of children in hospital

Narrative literature review

The author conducted a narrative review of the literature on children’s experiences of staying overnight in hospital from the perspectives of children and children’s nurses (Clarke 2019). It found that communication, environment and ward design, play, isolation and separation, and the child’s relationship with their family members and with children’s nurses were particularly influential factors.

The review also established that many researchers have focused on the views of children in hospital and their parents, but excluded the voices of children’s nurses (Clarke 2019).

The children’s nurse is the healthcare professional who delivers care most frequently to the hospitalised child and their family (RCN 2014a), so is in an optimal position to offer valuable insight into children’s experiences of being in hospital. Clarke’s (2019) narrative literature review identified five studies that appeared to seek the views of children’s nurses who routinely provided care for children in hospital (Jolley 2003, Coyne 2006, Koller et al 2006, Jackson-Brown and Guvenir 2009, Ian et al 2016). In summary, the findings of these studies suggested that (Clarke 2019):

  • Children’s nurses often lacked education on child development.

  • Children’s nurses could sometimes find ‘knowledgeable’ children who are ‘experts’ on their own condition and those with mental health issues or learning disabilities challenging.

  • Time restraints and issues related to the ward environment often prevented children’s nurses from providing high-quality care, which affected their health and well-being.

The included studies provided limited or no demographic information on nursing participants, such as the number of nurses on a typical shift, the ratio of registered nurses to non-registered staff, and patient acuity, which are variables that can influence children’s hospital experiences.

Study summary

Aim

The main aims of the author’s study (Clarke 2022), which was conducted in 2017, were:

  • To explore the views and feelings of children who stayed overnight in a ward in a UK regional children’s hospital.

  • To explore children’s nurses’ views and experiences of providing care to children hospitalised overnight.

  • To identify differences and similarities between how children’s hospital experiences are perceived by children and children’s nurses.

Data collection

Before conducting the study, the author established a child research advisory group with five local schoolchildren aged 10-11 years to support co-production of the research questions and a data collection tool for child participants.

The data collection tool was a ten-minute semi-structured interview involving two animated characters who were voiced by two young people. The author directed the child participants (n=18, aged 6-12 years) on how to use the animated software program on a tablet on the ward. The children self-selected one of two animated characters – either ‘Sprinkle Cupcake’ or ‘Ronaldo Football’ –who asked each child the same seven questions in the same order. The questions for child participants are shown in Box 1.

Box 1.

Questions for participants

Questions for child participants

  • 1. How do you feel about being in hospital and why?

  • 2. How do you feel about having your parents around (in hospital)?

  • 3. Could you tell me about the children’s nurses who look after you?

  • 4. Do the children’s nurses listen to you? (4a) If no, why not, or if yes, give me an example?

  • 5. Do the children’s nurses ask your opinion? (5a) If no, why not, or if yes, give me an example?

  • 6. What are the worst things about hospital?

  • 7. If you had a wish in hospital, what would it be and why?

Questions for children’s nurse participants

  • 1. Tell me about your background and what attracted you to children’s nursing?

  • 2. Tell me about your experiences of caring for children in hospital?

  • 3. What are the challenges of caring for children in hospital?

  • 4. If you had a wish which may improve the child’s experience of hospital, what would it be and why?

(Clarke 2022)

This technological approach to interviewing child study participants aims to support rapport building and to enhance the child’s attention span, control and choice. It also recognises the individual capabilities and preferences of each child and supports them to communicate and express their views through an alternative medium (Cowie et al 2014).

Eight children’s nurses were interviewed in their ward setting using a semi-structured approach. The questions for children’s nurse participants are shown in Box 1.

Thematic analysis was based on Braun and Clarke’s (2006) framework, while NVivo Pro version 11 software was used to code and recode all participant interviews.

Ethical considerations

The Office for Research Ethics Committees Northern Ireland granted ethical approval. Content was obtained from the nurse participants and the parents of the child participants. Assent from the children was also obtained, and given equal value to, parental consent. Parents were given the choice to be present at their child’s interview, to offer support and help them feel safe.

Implications for children’s nursing practice

Six themes – communication, health and well-being, environment, play specialists and the role of play, visiting access, and relationships – were derived from the author’s reflections on and further consideration of the study findings (Clarke 2022). Table 1 and Table 2 summarise the themes identified from the interviews with child and nurse participants in the original study. Aspects of children’s and children’s nurses’ experiences that are similar and which relate to the themes discussed below are highlighted in bold.

Table 1.

Themes identified from the interviews with child participants*

ThemesSubthemes
The needs of the child in hospital
  • Being listened to (by children’s nurses) – children appeared to be listened to, but there may be scope for improvement

  • Being able to exercise choice – nurses offered the children choice, for example about what to eat and what assistance they would like

  • Play – play was considered important by all child participants, but was not always provided

The child’s relationships in hospital
  • Parents – most children reported that parents were important to them in hospital as they made them feel safe

  • Play specialist – time with the play specialist was considered essential but was not always provided

  • Children’s nurses (and nursing students) – participants reported their relationships with the nurses positively and using simple terms, for example ‘nice’, ‘helpful’, ‘friendly’, ‘funny’ and ‘children friendly’

  • Other children (in hospital) – participants became ‘close’ to other children during their admission, for example chatting and playing games together

  • Visitors and pets – some participants spoke of their separation from family, friends and/or pets. These were essential aspects of their lives and they missed them

The child’s fears and concerns in hospital
  • Length of stay – participants’ experiences of hospital were overall more negative for extended stays than shorter stays. The effects of shorter hospital stays were varied, but more positive than for extended stays

  • Ward environment – the ward layout, noise, smells and facilities, and being cared for with their own peer group, were important to participants

  • Clinical procedures and interventions (including pain) – for all participants, an approaching children’s nurse in a blue uniform (as opposed to nursing students who wore white uniforms) signified a potential intervention, which they perceived as possibly being painful

Bold text highlights similar themes between child and children’s nurse participants

(Adapted from Clarke 2022)

Table 2.

Themes identified from the interviews with children’s nurse participants*

ThemesSubthemes
Children’s nursing
  • Love for children’s nursing – participants spoke of their love for their job and their ‘need’ for their chosen field of nursing

  • Communication – communication issues with parents, for example in relation to who provided care to the child, added pressure to the role and affected participants’ health and well-being when they did not have adequate time to provide effective care

  • The hospitalised child – all participants had observed distress associated with hospitalisation in the children, for example ‘fear’, ‘sorrow’ and ‘pain’

  • Health and well-being – participants’ level of health and well-being could affect the level of care the children received and ultimately their experiences of hospital

  • Nurse/parent – participants sometimes found parents challenging

Job pressures
  • Inadequate staffing levels – participants often felt ‘stretched’ and worried about the consequences of missing out a care intervention

  • Visiting access – one participant reported that not all children’s nurses appeared to be upset when limiting visitor access

Safe and effective care
  • Environment – all participants reported that the ward environment negatively affected children’s experiences of hospital

  • Knowledge deficit – all participants were aware of issues related to knowledge deficits in caring for children with complex needs in acute settings; for example, lack of knowledge about caring for children with mental health issues

  • Inadequate play – many participants believed that there was a need for a fully equipped playroom with age-appropriate toys and that regular time with the play specialist was important in terms of improving children’s experiences in hospital

Bold text highlights similar themes between child and children’s nurse participants

(Adapted from Clarke 2022)

Overall, a positive message for nursing practice that emerged from the study was how the children and the children’s nurses were respectful of each other, with parents and children’s nurses having central roles in children’s experiences of hospital. However, despite this, and although the children mainly spoke positively about their experience, their needs were not fully met during their time in hospital.

Communication

Across the literature, communication was cited as significantly influencing children’s experience of hospital admission (Clarke 2019). This is supported by the author’s study (Clarke 2022), which found communication by children’s nurses to patients, in terms of providing information, being listened to and being given choice, was an influential factor in children’s experiences of hospital. Although the child participants appreciated the children’s nurses and regarded them positively, they reported that inadequate communication negatively affected their experience of hospital. The child participants mostly felt listened to and respected, although many only felt ‘safe’ when their parent was present. The findings also suggested that being offered choice positively affected child participants’ experience of hospital.

The nurse participants appeared to feel frustrated by the negative effect that lack of time had on their communication and interactions with children and parents, and believed that this also negatively affected the level of care they were able to deliver.

Overall, both sets of participants agreed that children were listened to when in hospital, but that information giving could be improved.

Health and well-being

While the nurse participants talked about their passion for children’s nursing, they found the reality of nursing in the NHS challenging. Despite this, children’s nursing remained their career pathway.

The nurse participants reported that caring for children in hospital negatively affected their health and well-being because of the pressure of not having ‘time to care’. They also reported that this lack of time to spend with the children negatively affected the children’s hospital experiences.

Inadequate resources, staffing levels and skill mix and high patient acuity left the nurse participants frustrated and tired when attempting to meet the needs of their patients. This resulted in them becoming anxious and stressed as they feared they might ‘miss something’. The nurse participants often felt ‘stretched’ and worried about the consequences of overlooking a care intervention – importantly, this concern was about how this would affect the child rather than how it would affect their professional registration.

Lack of resources and lack of nurses’ time also affected the children’s health and well-being; for example, many child participants suggested they were bored due to the limited time they had with the nurses and the play specialist, as well as the lack of age-appropriate toys. Some were aware and understood that their nurse was extremely busy but said that the nursing students had more time to spend with them. Several child participants’ well-being was affected by the approach of the ‘blue uniform’ worn by children’s nurses, as opposed to nursing students who wore white uniforms. They associated white uniforms with an impending clinical procedure, which caused them to feel distress.

Environment

The ward environment, including the layout of beds in bays or side rooms, can affect children’s experiences of hospital. The child and nurse participants believed the environment did not meet the children’s needs, particularly in terms of decoration, bed allocation and play resources. Although children in the study reported that they were cared for most appropriately among their own peer group, this did not always happen. The child participants also wanted a social space that was age-appropriate in which to relax, play and meet visitors. They preferred a bed space that was comfortable and met their needs and those of their parent, ideally in either a single room or in a small bay with children their own age, and with access to age-appropriate toys and technology. They also expressed a preference for bright decor with pictures, no smells and not overly noisy. Several of the child participants said that they missed their home, their bedroom and their belongings, and raised concerns about noise, smells, food, the lack of play and toys, and the lack of facilities for their parents.

While caring for children in the ward environment, all the nurse participants had observed distress invoked by hospitalisation and spoke candidly about the ‘fear’, ‘sorrow’ and ‘pain’ a child may experience in relation to clinical interventions. One nurse participant said:

‘Virtually every intervention will cause a child upset… we are all strangers to a child coming into “their space”. It must be very threatening and frightening to have things done to them that no one has done before, which most children do not understand! [The] challenge is always trying to put the child at ease. I suppose that is the big [challenge] in paediatric nursing, to put the child at ease and make the experience as good as it can in that situation.’

Meeting the environmental needs of each child may assist in putting the child ‘at ease’ and consequently reduce their distress when undertaking a clinical intervention.

A final reflection is on the knowledge deficit subtheme referred to in Table 2. The nurse participants identified educational issues which may influence nursing practice and consequently children’s experiences of hospital. For example, one senior nurse raised concerns about a lack of mental health knowledge, while others were concerned about lack of knowledge in the context of caring for children with complex healthcare needs. Many child participants reported that they felt unsafe when their parent or guardian was not present, and this may be in part due to nurses’ lack of knowledge of mental health and complex needs. The findings may suggest children need some sense of security in respect of the aspects of hospital care that cause them most concern in the ward environment. As parents are seen as offering that security, it could be suggested that they should be more involved in the care of children while in hospital.

Play specialists and the role of play

Hospital play specialists work with children in an inclusive and family-centred way by providing a secure space for meaningful play (Holland 2020). Play specialists and the role of play were reported by the child and nurse participants as important and beneficial to children’s experiences of hospital, particularly for younger children. All of the child participants wanted access to age-appropriate toys, activities and technology during the day and in the evening; however, on the wards in which the study was conducted there was either limited or no access to toys in the playroom, or to a play specialist, after 4pm. The children also reported that they missed playing outside.

Stonehouse et al (2018) reinforced the importance of play for children in all healthcare settings and suggested that nurses have an important role in facilitating this. However, in the author’s study, both groups of participants believed the nurses were too busy to engage in play, with many of the nurse participants reporting that they wanted more time to talk and play with the children. The lack of play specialists appeared to negatively affect the children and nurses. Nursing students and parents often adopted the role of playmate, while the child participants talked about being bored and often lonely.

Visiting

Visiting in this context broadly relates to children in hospital being visited on their ward by a family member and/or friend. Types of visiting include ‘open’ and ‘restricted’. Open visiting involves the free movement of a parent or guardian to visit and/or stay with their child over a 24-hour period. Restricted visiting usually applies to additional family members such as siblings, as well as friends.

Visiting access was reported as an issue by the child and nurse participants. Restricted visiting affected the children’s hospital experiences as they missed their siblings, wider family members, friends and pets. Most of the nurse participants were empathic about the effects of restricted visiting on patients, although some were not. Information giving by children’s nurses to children in relation to visitor access appeared inadequate, as the children did not seem to understand the rules or rationale. The nurse participants reported that there was information about visitor access posted on the ward doors, with only one of them believing this was ineffective. It is also important to consider that not all children can read, so such written information may not always be appropriate.

Relationships

Livesley and Long (2013) noted that little is known about the relationship between children in hospital and children’s nurses from the perspective of children. The author’s study goes some way towards addressing this gap in the literature. Some of the terms used by the child participants to describe children’s nurses on their wards included ‘nice’, ‘helpful’, ‘friendly’, ‘funny’ and ‘children friendly’.

In terms of relationships with their parents, many of the children appeared to want autonomy but also wanted their parent to be present – many reported feeling unsafe, scared, unhappy and lonely when their parent left the ward. Those who did not want their parent present said they did not feel unsafe, scared or lonely, possibly due to a sense of familiarity resulting from a longer hospital stay or an admission that did not involve invasive clinical procedures. A small number of the child participants appeared to develop a parental role with the younger children, particularly when the younger child’s parent was absent, they were alone and nurses were busy.

In terms of relationships between children’s nurses and parents, some nurse participants suggested that parents had unrealistic expectations of the level of care the nurses could provide, while others wanted to provide more care to children and their parents. Nurse participants’ views on the constant presence of the parent and the effects of this on children’s experiences of being in hospital varied. For example, some participants perceived parental presence as positive in that the parents had time to sit with their child, relieve their boredom and assist with personal needs and providing fundamental care, making the child feel safe. However, a minority had a negative view of parents and perceived that they interfered with the nurses’ delivery of care. However, overall the nurse participants regarded most parents as making a valuable contribution to the care of their child while in hospital.

Discussion

The author’s reflections on some of the findings of her study detailed in this article may assist children’s nurses to consider how they could enhance the care they provide for children in hospital. However, to meet the needs of these children effectively, the needs of these nurses must also be met.

Time, resources and the ward environment appear to be central factors affecting how children experience hospital, and can affect the health and well-being of children and children’s nurses. These nurses require adequate time to provide child-centred care in an environment that meets their needs, as well as those of children and parents.

Children’s wards should include single rooms and bays of bed or cot spaces, and children should be cared for among their own peer group. There should be facilities for parents as most children want their parents with them while they are in hospital. Children’s wards also require play areas and dedicated play specialists that are accessible during the day and in the evening, while toys and equipment need to be age-appropriate to meet the needs of all children and young people.

Children’s nurses should appreciate the effects on children of separation from wider family members, such as grandparents, siblings and pets, as well as friends. The reasons for visitor restrictions should be explained in a way the child can understand. The approach to information giving should be age appropriate and include a variety of methods, for example written or pictorial leaflets and verbal explanations. The options for a child to meet visitors in a dedicated meeting room or hospital café should also be explored.

Children’s nurses need to develop their communication skills with parents. Although some of the nurse participants in the author’s study viewed parents negatively, most believed that parents made a valuable contribution to the care of their child while in hospital. Parents often provide much of the fundamental care required and can be regarded as partners in their children’s care; however, based on the findings of the study and the author’s experience, they may be sleep deprived, fearful about their child’s condition and be concerned about issues outside the hospital environment. Therefore, children’s nurses should reflect on how they value and communicate with parents and work to enhance the effectiveness of their communication. Ultimately this will improve children’s experiences of hospital.

Finally, children’s nurses can access various publications to enhance their knowledge. For example, those whose pre-registration nurse education programme did not include mental health might find the Mental Health in Children and Young People: An RCN Toolkit for Nurses Who Are Not Mental Health Specialists (RCN 2014b) document useful. In the longer term, children’s nurses should seek continuing professional development and their knowledge deficits should be identified and addressed as part of the appraisal process.

Conclusion

It is vital to seek the views of children about their experiences of healthcare if their needs are to be met effectively. It is also important to listen to the voices of children’s nurses with regard to children’s experiences of hospital. The author’s study identified that communication, health and well-being, environment, play specialists and the role of play, visiting access and relationships are important factors in relation to children’s experiences of staying in hospital, from the perspective of children and children’s nurses. Children’s nurses should reflect on these themes and consider how they can address some of the issues raised to enhance the experiences of children in hospital.

References

  1. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology. 3, 2, 77-101. doi: 10.1191/1478088706qp063oa
  2. Clarke S (2019) Children’s experiences of staying in hospital from the perspectives of children and children’s nurses: a narrative review. Nursing and Health Care. 4, 1, 62-70. doi: 10.33805/2573.3877.141
  3. Clarke S (2022) An exploration of the child’s experience of staying in hospital from the perspectives of children and children’s nurses using child centered methodology. Comprehensive Child and Adolescent Nursing. 45, 1, 105-118. doi: 10.1080/24694193.2021.1876786
  4. Cowie H, Huser C, Myers CA (2014) The use of participatory methods in researching the experiences of children and young people. Croatian Journal of Education. 16, 2, 51-66.
  5. Coyne I (2006) Consultation with children in hospital: children, parents’ and nurses’ perspectives. Journal of Clinical Nursing. 15, 61-67. doi: 10.1111/j.1365-2702.2005.01247.x
  6. Holland C (2020) Play specialist practice and the value of play. Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation. 48, 1, 16-17.
  7. Ian C, Nakamura-Florez E, Lee YM (2016) Registered nurses’ experiences with caring for non-English speaking patients. Applied Nursing Research. 30, 257-260. doi: 10.1016/j.apnr.2015.11.009
  8. Jackson-Brown F, Guvenir J (2009) The experience of children with learning disabilities, their carers and staff during a hospital admission. British Journal of Learning Disabilities. 37, 2, 110-115. doi: 10.1111/j.1468-3156.2008.00522.x
  9. Jolley MJ (2003) A social history of paediatric nursing 1920-1970. Doctoral thesis, University of Hull, Hull.
  10. Koller DF, Nicholas D, Salter Goldie R et al (2006) When family-centred care is challenged by infectious disease: pediatric health care delivery during the SARS outbreaks. Qualitative Health Research. 16, 10, 47-60. doi: 10.1177/1049732305284010
  11. Livesley J, Long T (2013) Children’s experiences as hospital in-patients: voice, competence and work. Messages for nursing from a critical ethnographic study. International Journal of Nursing Studies. 50, 10, 1242-1303. doi: 10.1016/j.ijnurstu.2012.12.005
  12. Royal College of Nursing (2014a) Health Care Service Standards in Caring for Neonates, Children and Young People. RCN, London.
  13. Royal College of Nursing (2014b) Mental Health in Children and Young People: An RCN Toolkit for Nurses Who Are Not Mental Health Specialists. RCN, London.
  14. Stonehouse D, Piper C, Briggs M et al (2018) Play within the pre-registration children’s nursing curriculum within the United Kingdom: a content analysis of programme specifications. Journal of Pediatric Nursing. 41, e33-e38. doi: 10.1016/j.pedn.2018.01.013
  15. United Nations (1989) The United Nations Convention on the Rights of the Child. http://www.unicef.org.uk/wp-content/uploads/2010/05/UNCRC_united_nations_convention_on_the_rights_of_the_child.pdf (Last accessed: 3 November 2022.)

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