Academic journal article Research and Theory for Nursing Practice

Caring in Pediatric Emergency Nursing

Academic journal article Research and Theory for Nursing Practice

Caring in Pediatric Emergency Nursing

Article excerpt

An environment committed to providing family-centered care to children must be aware of the nurse caring behaviors important to parents of children. This descriptive study assessed the psychometrics of a revised version of the Caring Behaviors Assessment (CBA) and examined nurse caring behaviors identified as important to the parents of pediatric patients in a pediatric emergency department. Jean Watson's theory of human caring provided the study's theoretical underpinnings. The instrument psychometrics was determined through an index of content validity (CVI) and internal consistency reliability. The instrument was determined to be valid (CVI = 3.75) and reliable (Cronbach's alpha = .971). The revised instrument was completed by a stratified, systematic random sample of 300 parents of pediatric emergency patients. Participants rated the importance of each item for making the child feel cared for by nurses. Individual survey item means were computed. Items with the highest means represented the most important nurse caring behaviors. Leading nurse caring behaviors centered on carative factors of "human needs assistance" and "sensitivity to self and others." Nearly all nurse caring behaviors were important to the parents of pediatric patients, although some behaviors were not priority. It is important for nurses to provide family-centered care in a way that demonstrates nurse caring.

Keywords: theory of human caring; caring; pediatrics; emergency nursing; caring behaviors assessment

Emergency nurses are responsible for providing family-centered care in pediatric settings. The priorities of patient care are likely to be dependent on the findings identified during the nursing assessment and the treatment plan requested by emergency physicians and midlevel providers. The priorities of patient care may not reflect the wants and needs of the family unit, possibly leaving the family with a perception that nurses are uncaring. For example, Weman and Fagerberg (2006) reported that nurses preferred patients and families to choose patient care options from a list presented by the nurses. Nurses did not like patients or family members to identify care options that were not among those presented. This accentuates a potential disconnect between nurses and nurse caring.

The purpose of this study was to examine nurse caring behaviors identified as important to the parents of pediatric patients in a pediatric emergency department. This study will answer the following research questions: (a) What is the validity and reliability of the Caring Behaviors Assessment (CBA) instrument when adapted for use with parents of pediatric emergency patients? and (b) What nurse caring behaviors are most important to the parents of pediatric emergency patients?

An environment committed to providing family-centered care to children must be aware of the nurse caring behaviors important to the parents of children. An appropriate instrument must be identified that can be used to measure the priority nurse caring behaviors that parents desire for their children when receiving nursing care. The CBA (Cronin & Harrison, 1988) was developed to measure patient perceptions of nurse caring behaviors. The CBA was intended for use with adult patients; therefore, the CBA was adapted for use in this study. Validity and reliability testing need to be done before the revised instrument could be used to identify priority nurse caring behaviors in the pediatric emergency population.

The significance of this study in relation to human health and nursing is that identification of priority nurse caring behaviors may be used to develop and implement systems that will increase the demonstration of such nurse caring behaviors in the pediatric emergency setting. Nurses that routinely demonstrate the priority nurse caring behaviors may be perceived as more caring and, in turn, more readily foster a positive nurse-patient-family relationship. This study provided additional clarification to the priority of caring behaviors in the pediatric emergency setting by determining if a variance existed based on patient acuity level.

BACKGROUND

Perception of Caring by Nurses

McCance, McKenna, and Boore (1997) conducted a concept analysis of "caring" and identified four defining attributes of caring: serious attention to the patient, concern for the patient, providing for the patient, and getting to know the patient's wants and needs. In addition, there were two antecedents that needed to occur with nursing before caring could take place: having a respect for patients and having time to be involved with the patients.

Prior studies with nursing populations have used qualitative designs to identify the themes of nurse caring. The themes of nurse caring as reported by Cheung (1998) included the following: caring is a way of being, caring gives nurses motivation, caring gives nurses focus and direction, caring is to protect the patients, caring as an experience, and caring as a process. These findings reflect nursing's perspective of the nursing discipline to deliver nursing-centered care.

Perception of Caring by Patients

Chinese patients with cancer have identified caring attitudes, professional responsibility by the nurse, emotional support, and being knowledgeable and skilled as key behaviors that define nurse caring (Liu, Mok, & Wong, 2006). When assessed in the perioperative setting, nurse caring behaviors of most importance were a reassuring presence by the nurse, verbal reassurance, and an attention to comfort control (Parsons, Kee, & Gray, 1993). This reflects that the priority nurse caring behaviors may vary by the clinical setting. Baldursdottir and Jonsdottir (2002) found that priority behaviors using the CBA with Icelandic emergency care patients were nurses needing to be competent, knowledgeable, and show respect, honesty, and compassion. These studies all targeted adult populations.

Perception of Caring by Families

Nurses need to connect with patients and include the patient's family while providing care (Weman & Fagerberg, 2006; Wilkin & Slevin, 2004). An environment where family-centered care occurs is an ideal environment for a study focused on nurse caring behaviors. Care delivery should reflect nurse caring deemed most important to patients and patient families (Frazee, 2011). In a pediatric setting, family members may be the historian and the person providing consent for nursing care. In this environment, it is important for nurses to understand what is most important to the families of the pediatric patient in order for care to be family centered and not just patient centered.

Harbaugh, Tomlinson, and Kirschbaum (2004) found in their qualitative study that what parents desired most from nurses providing care to their children were affection, caring, watching, and protecting. Parents wanted the nurses to demonstrate qualities similar to that of parenting. Desired nurse caring behaviors were providing information, including the parent, family presence, appreciating the uniqueness of the child, and providing competent patient care. Negative attributes that did not reflect nurse caring behaviors reported by the parents were poor communication, separating the parent from the pediatric patient, and a lack of affection and protection for the pediatric patient. Scott (1998) reported that for an environment to be family centered, an organization needs to be aware of parental needs in addition to that of providing patient-centered care.

Summary

There is a difference in nurse caring behaviors deemed most important among nurses, patients, and patients' families. Although patients are more concerned with the knowledge and technical skills of nurses, nurses themselves believe that experience, spending time with patients, and patients' safety were more important (Baldursdottir & Jonsdottir, 2002; Liu et al., 2006; McCance et al., 1997; Parsons et al., 1993). Scott (1998) found that parents believed they were important to a child's illness recovery significantly more often than nurses. This reflects a critical mismatch between nurses and patients/parents. Therefore, it is important to determine the parental perception for the nurse caring behaviors most important for nurses to demonstrate when providing care to pediatric patients.

THEORETICAL PERSPECTIVE

Jean Watson's theory of human caring provides the theoretical underpinnings for this study. The theory of human caring is a holistic theory that guides the practice of nursing. A key concept in the theory of human caring is that caring is an essential component of a healing environment and represents the essence of nursing (Watson, 1985). Watson identified 10 carative factors for nurse caring: (a) humanistic-altruistic system of values; (b) faith and hope; (c) sensitivity to self and others; (d) helpingtrusting, human care relationship; (e) expressing positive and negative feelings; (f) creative problem-solving caring process; (g) transpersonal teaching and learning; (h) supportive, protective, or corrective mental, physical, societal, and spiritual environment; (i) human needs assistance; and (j) existential, phenomenological, and spiritual forces.

Any interactions between nurses and patients occur in the presence of human caring (Watson, 1985). Nursing has always held a human care and caring stance regarding people with health-illness concerns. Caring has become such a key part of nursing that caring and "nursing" are now synonymous and a unifying focus for nursing practice in some settings (McCance et al., 1997; Watson, 1985). Human care can be effectively demonstrated and practiced only interpersonally, and the intersubjective human process keeps alive a common sense of humanity teaching us how to be human as we identify ourselves with others.

METHODS

Study Design and Setting

A nonexperimental descriptive design was used for this study. The study itself was conducted at a large Midwestern U.S. pediatric health center. The emergency department for this health center where data were collected delivers family-centered care to more than 80,000 patients per year.

Study Population

Participants were at least 18 years old and the parent or legal guardian of a patient from birth up to the patient's 18th birthday. Because of the absence of the survey tool being available in Spanish or other languages, only parents who could read English were included. Parents of patients being treated in the express care/ short-stay emergency department for nonurgent illnesses or in the shock-trauma suite for life-threatening conditions were also excluded.

Stratified random sampling was conducted to obtain 100 parents of children in each of the three nurse-assigned acuity levels: emergent, urgent, and nonurgent. Recruitment for participants continued with the parent of every second emergent patient and every fourth urgent or nonurgent patient until the sample quota was achieved. The data were reviewed for quality after 100 total participants had completed the survey; no changes to the randomization process were needed.

Sample size was determined based on DeVellis (2003) criteria for instrument development: 10 participants per question up to 300 participants. Because there were more than 30 questions on the study survey, a sample size of 300 was chosen.

Instrumentation

The instrument used for this study was the CBA developed by Cronin and Harrison (1988) to determine the behaviors of caring that were most important to patients following a myocardial infarction. The researchers reported that face and content validity were established by a panel of four content specialists familiar with Jean Watson's theory of human caring (Cronin & Harrison, 1988). The panel of experts rated each survey item to a subscale. Any item not designated to a single subscale by at least three of the four experts was recategorized into a more appropriate subscale (Cronin & Harrison, 1988). The CBA demonstrated strong validity and reliability in the literature with internal consistency reliabilities of .93-.96 for adult study samples (Cronin & Harrison, 1988; Schultz, Bridgham, Smith, & Higgins, 1998; Stanfield, 1991).

Stanfield (1991) tested the CBA with adult medical-surgical inpatients. Internal consistency reliabilities were reported for the subscales ranging from .78 to .89 and an overall reliability of the data at .96. Construct validity was established with factor analysis. Schultz et al. (1998) tested the instrument with antepartum and postpartum patients. Reliability was reported for the subscales ranging from .71 to .88. The overall scale reliability was .93. Marini (1999) tested the instrument with long-term care residents in an assisted living facility. Correlations between instrument subscales and gender were reported: up to .89 for women and .85 for men. Manogin, Bechtel, and Rami (2000) tested the instrument with women hospitalized for uncomplicated labor and delivery. The researchers determined that the instrument had content validity based on an expert panel. Reliability for the subscales ranged from .66 to .90.

The original instrument was a 63-item self-report survey with participants indicating the importance of each item on a 5-point Likert scale with 1 being "of little importance" and 5 being "of much importance." Items from the CBA were reworded to focus the items on the parent and child because the instrument was originally created to measure the perception of the adult patient. For example, the original item "Ask me how I like things done" was reworded as "Ask me how my child and I like things done."

Procedures

Patients were assessed in the triage area by a registered nurse in the pediatric emergency department and assigned an acuity level: shock/trauma (highest acuity), emergent, urgent, and nonurgent (lowest acuity). Triage nurses were previously trained to assign an acuity level based on triage guidelines. Examples of patients assigned to the shock/trauma acuity level were patients actively seizing, in supraventricular tachycardia, and/or with a penetrating injury to the head or torso. Examples of patients assigned to the emergent acuity level were patients in sickle cell crisis, significant respiratory distress, newborns with high fevers, and patients with obvious extremity deformities. Examples of patients assigned to the urgent acuity level were patients with moderate respiratory distress, toddlers with high fevers, and patients with signs of dehydration. Examples of patients assigned to the nonurgent acuity level were patients with rashes, dental pain, and patients whose symptoms resolved prior to emergency department arrival

A trained clinical research coordinator approached family units to discuss the purpose of the study after placement into a treatment room. Parents were informed that participation was strictly voluntary, and the patient's care would not be altered based on study participation. Following informed consent, the clinical research coordinator connected the parent to an Internet-based version of the study survey on a study laptop. SurveyMonkey is an Internet-based survey system that administers survey questionnaires and stores data confidentially. Connection to the instrument required a unique Web address and limited access password known only to the study team and clinical research coordinators. The survey was self-guided and closed upon study completion.

Human Subjects Protections

The study protocol was approved by the local institutional review board prior to any study procedures. Study participation was completely anonymous. No record was generated that tracked parents who participated or opted to not participate. No names of study participants (parents) or patients were included in the database associated with this study. Data confidentiality was protected at all times. The limited access password provided to the clinical research coordinators granted access to the instrument only, not to the raw data.

Data Analysis

Research Question 1. Content validity of the revised instrument was determined through a CVI (Beck & Gable, 2001). Five content experts evaluated the content of the revised study instrument to measure nurse caring behaviors with parents of pediatric emergency patients. Each expert rated the revised individual survey items as they pertained to nurse caring behaviors on a scale from 1 (not relevant) to 4 (very relevant). A Cronbach's alpha was computed to determine the adequacy of reliability for the revised CBA with the population of parents of pediatric patients. Cronbach's alpha of .70 or greater reflects good internal consistency reliability (DeVellis, 2003).

Research Question 2. Individual survey item means were computed for the total sample. Items were ranked from highest mean to lowest mean. Items with the highest means represent items that were the most important nurse caring behaviors to parents of pediatric patients. Subscale means for level of importance (ranging from 1 [little importance] to 5 [much importance]) were computed for each of the seven instrument subscales. A multiple analysis of variance (MANOVA) was computed to determine if there was a significant difference between nurse-assigned patient acuity level (emergent, urgent, nonurgent) and parent-perceived acuity level (emergent, urgent, nonurgent) for subscales. Alpha was set at .05.

RESULTS

The Study Sample

Five hundred seven family units were approached to participate in this study. There was 41% attrition to achieve the sample size of 300 participants. The leading reason stated for nonparticipation was the parent was holding the patient and did not want to lay down the child to participate. Participant demographic data are provided in Table 1. The mean age of participants was 35 years ranging from 18 to 73 years. Most were women (83%) and the patient's mother (80%). Sixty-nine percent of participants were White, non-Hispanic; and 25% were Black, non-Hispanic. The pediatric patients' mean age was 8 years ranging from 7 days to 18 years. There was an even split for the patients' sex.

Research Question 1. The first research question aimed to determine the validity and reliability of the revised CBA. The instrument CVI showed that two items had an average rating less than 3 and were therefore omitted from the study instrument. The two deleted items were the following: "talk to my child and me about my child's life outside the hospital" and "visit my child if my child moves to another hospital unit." The CVI of the instrument subscales following the removal of the two items ranged from 3.27 to 3.89 (see Table 2). The overall CVI of the revised instrument was 3.75. The internal consistency reliability of the instrument subscales reflected Cronbach's alphas ranging from .807 to .925. The overall reliability of the revised instrument was strong at .971. The instrument was thus deemed valid and reliable for use in this study.

Research Question 2. The most important nurse caring behaviors had a mean item score ranging from 4.83 to 4.93 (see Table 3). The five leading items were the following: (a) know what they're doing; (b) know how to give shots, intravenous lines (IVs), and so forth; (c) be kind and considerate; (d) really listen to my child and me when we talk; and (e) give my child treatments and medications on time. The least important nurse caring behaviors had a mean item score ranging from 3.95 to 4.30. The five least important nurse caring behaviors were the following: (a) encourage my child and me to talk about how we feel, (b) leave my child's room neat after working with my child, (c) touch my child when my child needs it for comfort, (d) ask my child and me what my child likes to be called, and (e) consider my child and my spiritual needs.

Leading nurse caring behaviors are presented in Table 4 and compared by acuity levels (emergent, urgent, nonurgent). Lowest ranked nurse caring behaviors were also compared by acuity levels. Lowest ranked nurse caring behaviors for both nurse-assigned and parent-perceived emergent acuity level were the following: (a) help my child and me feel good about ourselves, (b) encourage my child and me to talk about how we feel, and (c) consider my child and my spiritual needs. Lowest ranked nurse caring behaviors for both nurse-assigned and parent-perceived urgent acuity level were the following: (a) help my child and me feel good about ourselves, (b) ask my child and me what my child likes to be called, (c) leave my child's treatment room neat after working with my child, (d) encourage my child and me to talk about how we feel, and (e) consider my child and my spiritual needs. Lowest ranked nurse caring behaviors for both nurse-assigned and parent-perceived nonurgent acuity level were the following: (a) encourage my child and me to talk about how we feel, (b) help my child and me see that our past experiences are important, (c) consider my child and my spiritual needs, and (d) ask my child and me what my child likes to be called.

Subscale means for the revised version of the CBA ranged from 4.743 for "human needs assistance" to 4.212 for "existential/phenomenological/spiritual forces" (see Table 2). A two-way MANOVA was conducted to determine if there was a significant effect of nurse-assigned and parent-perceived patient acuities on the subscale means. Box's test of equality of covariance reflects a lack of homogeneity for equal variances (Box's M 5 347, F[168, 6673] 5 1.722, p , .001). Pillai's trace was used as the MANOVA test statistic because it is robust in circumstances with a lack of homogeneity and extremely unequal sample group sizes (Mertler & Vannatta, 2005). MANOVA results indicated that nurse-assigned triage acuity (Pillai's trace 5 .069, F[14, 522] 5 1.336, p 5 .182) and parental-perceived triage acuity (Pillai's trace 5 .054, F[14, 522] 5 1.031, p 5 .420) were insignificant for affecting subscale means.

DISCUSSION

The CBA continues to be a valid and reliable instrument to measure nurse caring behaviors. The version of the instrument used in this study did undergo minor changes. As with the study conducted by Baldursdottir and Jonsdottir (2002), two items from the original CBA were deleted because of the study setting and population. However, the two items differed. Baldursdottir and Jonsdottir deleted the questions related to what name the patient prefers to be called and visiting the patient on another unit. The items deleted from this study asked about the patient's life outside the hospital and visiting the patient on another unit. Researchers from both teams most likely deleted the item related to visiting the patient on another unit because most patients evaluated in the emergency department are discharged to home; only 14.4% of patients at the study site were admitted from the emergency department in 2010. This admission rate was comparable to the U.S. admission rate of 13.9% (McCaig & Burt, 2005).

Nearly all nurse caring behaviors were important to the parents of pediatric patients, although some behaviors were not priority. The most important nurse caring behaviors were stable across nurse-assigned patient acuities and parentperceived illness severity. Leading nurse caring behaviors centered around two carative factors: human needs assistance and sensitivity to self and others.

Human Needs Assistance

Human needs assistance can be demonstrated by nurses through technical competence. Technical competence itself is a culmination of education, interpretation, and experience in various clinical situations. Graduates of undergraduate nursing programs are prepared to demonstrate technical competency that promotes efficient, safe, and compassionate care (American Association of Colleges of Nursing, 2008). Regarding nurse-assigned acuity, the highest ranked caring behaviors were those based on providing care or assistance to pediatric patients across acuity levels. A consistent priority of nurse caring behaviors was "know how to give shots, IVs, and so forth" followed by "know how to handle equipment." Prior to entering a patient's room, a nurse should be knowledgeable of the use and function of as well as how to operate medical equipment. When the nurse does not have the expertise to use equipment or perform procedures, assistance should be sought by nurses with the needed expertise. Nurses can clearly communicate to patients and parents that the second nurse is there to assist in the delivery of safe patient care. Nurses should never attempt to intervene without the requisite experience or expertise.

Technical competence may have been so important to parents because of a fear for patient injury or pain if competency is not demonstrated. For example, parents can experience a situational crisis when multiple attempts are needed to obtain intravascular access. Parents of children who are chronically ill (e.g., sickle-cell anemia, asthma) may also have multiple prior emergency department visits and "know" technical competence when they see it. These parents may also be trained on technical care when providing care to their children (e.g., administering nebulizer treatments or insulin injections). Over time, parents may have become more cognizant of the pain, injury, or delays in care that may occur with a lack of technical competency. This lack of competency would directly impair nurses' ability to provide the nursing care exemplified through the carative factor of human needs assistance.

Another manifestation of human needs assistance is providing timely assessments and interventions. The urgent and time-sensitive work environment in which emergency nurses function must be taken into account when dealing with issues of nurse-patient-family caring relationships and their efficacy. The emergency department is commonly described as a fast-paced environment where a focus is placed on moving patients through the process of emergency care as quickly as possible (Committee on the Future of Emergency Care in the United States Health System, 2007). Given the heavy focus on time and popular culture media attention to emergency care from television shows such as ER (Sachs & Gentile, 1996), patients and parents may expect to arrive, be treated, and discharged from the emergency department in less than an hour. Therefore, it is not surprising that parents want and expect timely assessment and interventions for their children. The timeliness of care may have been of lesser dominance compared to technical competence and respect when evaluating nurse caring behaviors in relation to acuity levels because the family unit may have already been receiving expeditious care or were more concerned about the quality (i.e., technical competence) of care.

Despite attempts to provide timely care to all patients, there will be times when the priority of care delivery will be focused on other children who are more critically ill or injured. Nurses can acknowledge parents' and patients' needs by informing them of the arrival of a critical patient, that their child's care remains a priority for them and will resume as soon as the other patient is stabilized, and their child will not experience an untoward deterioration as a result of the perceived delay in care. In addition, the parents and patients should be notified that the care team is committed to working as a team to expedite the care of all children in the department.

Among the lowest ranked items was "leaving the children's room neat." This item was probably of lesser importance because the parents may anticipate a discharge to home soon. Parents may be more willing to tolerate an untidy room if they can be discharged sooner. This finding may be different for inpatient children where the patient will reside in the same hospital room for several days and have a need to make the room reflect a home environment as much as possible (Evans & Thomas, 2011). Thus, the focus of human needs assistance for the parents of emergency department patients relates to nurses being technically competent and timely.

Sensitivity to Self and Others

Sensitivity to self and others was the most common carative factor identified between the patient acuity levels. Leading behaviors that demonstrate sensitivity were treating others with respect, active listening, being kind and considerate, and keeping promises. Respect is an essential component to developing a quality nurse-patient-family relationship (Malusky, 2005) and can be demonstrated through cultural humility and valuing parents as an expert member of the patient care team. Through active listening, the wants and needs of the family unit can be identified (Frazee, 2011; Malusky, 2005). If the wants and needs are not identified, parents and patients should be explicitly asked for this information. Patient care can then be tailored to address these wants and needs. When the care is not reflective of the family unit preferences, then dissatisfaction with patient care may occur.

Stratton (2004) mentions parents in hospital settings encounter four challenges: facing boundaries, attempting to understand, coping with uncertainty, and seeking reassurance from health care providers. These challenges can be addressed through dialogue-centric caring behaviors such as "keeping my child and me informed of my child's progress" and "answering my child's and my questions clearly." Nurses may need to interpret medical jargon that has been discussed during the emergency department visit. Providing information in words understandable to the family unit shows sensitivity and respect while simultaneously reducing any confusion over the treatment plan and patient condition (Harrison, 2010; Piskosz, 2007). Clarity of explanation in the pediatric field is especially important because any information must be passed on to all members of the family unit (Piskosz, 2007). Evans and Thomas (2011) found that even a simple strategy such as a communication board in the room can be effective at providing ongoing communication with the parents of pediatric patients.

Existential, Phenomenological, and Spiritual Forces

Jean Watson (1985) and the American Association of Colleges of Nursing (2008) believe that a core attribute of nursing practice is spiritual and emotional support of patients and families; however, the parents in this study placed greater value on nurse caring behaviors related to providing assistance and demonstrating sensitivity. There are several reasons that may explain this finding. Patients with chronic illness or long-term inpatient stays may have greater existential needs, as illustrated by Cheung's (1998) study of Chinese patients with cancer. Emergency department patients may be more focused on acute, immediate, medical needs that are representative of the physiological needs at the base of Maslow's hierarchy of needs. Until the basic physiological needs are met within the time-constrained environment of the emergency department, patients are less likely to be concerned with higher level needs such as love/belonging, esteem, and self-actualization, which would be met through the nurse caring behaviors of spiritual and emotional support. Only the patients who are most critically ill or injured, where death is a strong consideration, would the higher level Maslow needs become a focus for emergency department care.

In general, parents of pediatric patients are less likely to experience the death of the patient in contrast to an adult-focused emergency department. A factor of potentially greater importance is the role of the parent: ensuring that the spiritual and emotional needs of the child are met. Providing the family unit is well adapted, parents are more likely to see themselves as the provider of the child's spiritual and emotional needs versus leaving this role to be fulfilled by the child's nurse. Again, only during times of situational crisis or family dysfunction would it be likely expected that the nurse focus attention to these attributes in the emergency department setting. Nurses can provide spiritual and emotional care by holding a patient's hand, providing comforting words of support, not leaving the child alone, and assisting the parent to contact family members and their family chaplain. The exclusion of parents of patients who are most critically ill in the emergency department may have contributed to the lower priority of existential, phenomenological, and spiritual forces. Although the general parent did not place as great a priority on discussing feelings or emotions, this may not reflect all pediatric patient populations. Patients seeking treatment for anxiety disorder or suicidal ideation may require an in-depth discussion on their feelings and emotions as part of emergency care.

Of particular note was that addressing the patient's and parent's spirituality was the least important behavior. It is possible that the parents of children being treated in the shock-trauma suite for a life-threatening illness or injury may have placed greater importance on this item. Parents who completed the survey may have been more focused on a timely flow through the emergency department to discharge and not concerned with spirituality in the absence of issues with death and dying.

Limitations

This study was limited by its inclusion/exclusion criteria. Parents of patients with the extreme of illness severity and those treated in the short-stay area were excluded. However, all other patients treated in the main emergency department remained eligible. Patients treated in the shock-trauma suite represent a small minority of the emergency department population. In addition, patients treated in the shortstay emergency department were believed to have illnesses of such minor consequence that their stay in the emergency department would be very brief. Nursing encounters with short stay patients would also be minimal in comparison to the main emergency department population. Therefore, the findings from this study would represent the greatest proportion of patients seeking care in a pediatric emergency department.

There was an initial risk that the emergency nurses would interact differently with the eligible participants while the study was being conducted. This limitation was reduced by keeping the nursing staffblind to the study purpose. The clinical research coordinators were instructed to inform nurses, if asked, that the study was focused on patient care. It was later reported by the clinical research coordinators that no nurses asked about the study purpose. Nurses in the study site were used to multiple studies being conducted simultaneously with patient and parent populations.

CONCLUSION

It is important for nurses to provide family-centered care in a way that demonstrates nurse caring while being tailored to individual patients and care situations. Behaviors of nurse caring most desired by the parents of pediatric patients relate to providing timely, competent care (or human needs assistance) and demonstrating sensitivity. Although nurse caring behaviors related to existential, phenomenological, and spiritual forces were of lesser importance in this pediatric emergency department setting, attention should still be given to these needs because they also represent essential attributes of the nursing discipline. Further research is needed to determine if nurses demonstrating the priority nurse caring behaviors are perceived by pediatric patients and their parents as being more caring in comparison to other nurses. Additionally, research should be conducted into the relevance and applicability of Watson's carative factors to nursing practice.

[Reference]

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[Author Affiliation]

Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CPEN, FAEN

University of Cincinnati College of Nursing

Melanie Hounchell, BA, CCRC

Cincinnati Children's Hospital Medical Center

Jeanne Pettinichi, BSN, RN, CPN, CPEN

Children's National Medical Center

Jennifer Mattei, MSN, RN, CPN

Cincinnati Children's Hospital Medical Center

Lindsay Rose, RN

Miami University Department of Nursing

[Author Affiliation]

Correspondence regarding this article should be directed to Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CPEN, FAEN, University of Cincinnati College of Nursing, P.O. Box 210038, Cincinnati, OH 45221-0038. E-mail: gordon.gillespie@uc.edu

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