Aim

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

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.

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.

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.