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MacKay LJ, Chang U, Kreiter E, Nickel E, Kamke J, Bahia R, Shantz S, Meyerhoff H. Exploration of trust between pediatric nurses and children with a medical diagnosis and their caregivers on inpatient care units: A scoping review. J Pediatr Nurs 2024; 78:e1-e30. [PMID: 39085007 DOI: 10.1016/j.pedn.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/26/2024] [Accepted: 05/26/2024] [Indexed: 08/02/2024]
Abstract
PROBLEM Trust is central to the development of nurse-patient relationships. Pediatric nurses encounter difficulties developing trust with children and their caregivers. The purpose of this scoping review was to identify, examine, and summarize available evidence on the concept of trust among nurses and children/caregivers when admitted to hospital inpatient care units. ELIGIBILITY CRITERIA Using the Joanna Briggs Institute (JBI) methodology for conducing and reporting scoping reviews, CINAHL, MEDLINE, PsycINFO, Cochrane DSR, Cochrane Central, and JBI EBP were searched for qualitative, quantitative, mixed methods, and review studies with no time limits published in English. Included studies presented findings on the experiences of developing trust between pediatric nurses and children under 18 years of age and their caregivers within inpatient care units. RESULTS A total of 12,269 titles and abstracts were reviewed independently by two reviewers. 366 full-text articles were retrieved, a final of 81 studies were included in the review. CONCLUSIONS Trust was bi-directional between nurses and children/caregivers, developed over time during multiple interactions, and foundational to the development of relationships. Distinct facilitators and barriers to the development of trust between nurses and children/caregivers were identified. The development of trust was rewarding and enriching for both nurses and children/caregivers and was the fundamental to the provision of safe and high-quality nursing care. IMPLICATIONS Findings provide nurses with direction and strategies on how to develop and maintain trust with children/caregivers on inpatient care units. The development of training programs and interventions geared at equipping nurses with the skills to develop trust with children/caregivers is needed.
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Affiliation(s)
- Lyndsay Jerusha MacKay
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
| | - Una Chang
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
| | - Elizabeth Kreiter
- Norma Marion Alloway Library, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
| | - Emma Nickel
- Alberta Children's Hospital, 28 Oki Drive, Calgary, Alberta T3B 6A8, Canada.
| | - Janice Kamke
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
| | - Rubinder Bahia
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
| | - Sarah Shantz
- Alberta Children's Hospital, 28 Oki Drive, Calgary, Alberta T3B 6A8, Canada.
| | - Heather Meyerhoff
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, British Columbia V2Y 1Y1, Canada.
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Hjelmgren H, Ygge BM, Nordlund B, Andersson N. Nurses' experiences of blood sample collection from children: a qualitative study from Swedish paediatric hospital care. BMC Nurs 2022; 21:62. [PMID: 35292007 PMCID: PMC8922753 DOI: 10.1186/s12912-022-00840-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Nurses play an active role in supporting the children with the blood sampling experience. Unfortunately, the blood sampling collection procedure is often affected by pre-analytical errors, leading to consequences such as delayed diagnosis as well as repeated sampling. Moreover, children state that needle procedures are the worst experience of their hospital stay. The nurses’ experiences of errors occurring during blood sample collection is unknown. Therefore, the aim of this study therefore was to describe paediatric nurses’ experiences of blood sampling collections from children. Method We used a qualitative study design with a (reflexive) thematic analysis (TA) method described by Braun and Clarke. Three focus group interviews were conducted, with 19 nurses collected by purposeful sampling from Sweden working at two different paediatric hospitals, focusing on their experiences of the blood sample collection procedure. Results From the three focus group interviews we analysed patterns and meanings of the following main theme Paediatric blood sampling is a challenge for the nurses and the four subthemes Nurses’ feelings of frustration with unsuccessful samplings, Nurses believe in team work, Venous blood sampling was experienced as the best option, and Nurses’ thoughts and needs regarding skills development in paediatric blood sampling. Conclusion The narrative results of this study illustrate that nurses working in paediatric hospital care face a big challenge in blood sampling collection from children. The nurses felt frustrated due to unsuccessful blood samplings and frequently could not understand why pre-analytical errors occurred. Nevertheless, they felt strengthened by colleagues in their team and shared feelings of responsibility to help each other with this complex procedure. The implications of this study are that paediatric hospital care needs to focus on improving guidelines for and increasing competence in blood sampling children and helping nurses to understand why samplings may be unsuccessful and how this can be avoided.
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Affiliation(s)
- Henrik Hjelmgren
- Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Stockholm, Sweden. .,Department of Women's and Children's Health, Karolinska Institute, 171 77, Stockholm, Sweden.
| | - Britt-Marie Ygge
- Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institute, 171 77, Stockholm, Sweden
| | - Björn Nordlund
- Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institute, 171 77, Stockholm, Sweden
| | - Nina Andersson
- Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institute, 171 77, Stockholm, Sweden
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Oliveira TGPD, Diniz CG, Carvalho MPM, Corrêa ADR, Rocha PK, Manzo BF. Involvement of companions in patient safety in pediatric and neonatal units: scope review. Rev Bras Enferm 2022; 75:e20210504. [DOI: 10.1590/0034-7167-2021-0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objectives: to describe scientific evidence on the involvement of companions in patient safety, from their own perspective and health professionals’ perspective in neonatal and pediatric units. Methods: scoping review carried out according to The Joanna Briggs Institute’s recommendations, in eight databases, following the Preferred Reporting Items checklist for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist, between 2011 and 2021. Results: the 13 studies included highlighted the importance of companions’ involvement in patient safety and the prevention of adverse events. However, they pointed out failures in communication and weakness in the training of professionals, which were obstacles to their involvement. The strengthening of health education, multidisciplinary rounds and educational technologies were highlighted as strategies to expand the involvement of companions. Final Considerations: this study directs elements for health professionals and managers to rethink the companions’ role in patient safety and development of collective strategies.
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Levin AB, Cartron AM, Siems A, Kelly KP. A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance. Hosp Pediatr 2021:hpeds.2021-006062. [PMID: 34807985 DOI: 10.1542/hpeds.2021-006062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs. METHODS Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs. RESULTS Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance. CONCLUSIONS Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.
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Affiliation(s)
- Amanda B Levin
- Department of Anesthesiology and Critical Care Medicine, Bloomberg Children's Center, Johns Hopkins University, Baltimore, Maryland
| | | | - Ashley Siems
- Department of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Katherine Patterson Kelly
- Department of Nursing Science, Professional Practice, and Quality: Nursing Research and Translation, Children's National Hospital, Washington, District of Columbia
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Triplett P, Dyer H, Pascoe J. Partnership between parents/caregivers and pediatricians when children are hospitalized: Parents' perspective. Curr Probl Pediatr Adolesc Health Care 2021; 51:100999. [PMID: 34099412 DOI: 10.1016/j.cppeds.2021.100999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The relationship between children's caregivers and pediatricians is both complex and critical to the well-being of patients. A strong partnership has been shown to improve children's health outcomes 1. Patient and family engagement has been defined as patients, families/guardians, and health care professionals working together in an active partnership to improve patients' health outcomes 1. The caregiver and pediatric clinician partnership has been examined for children in outpatient settings 2. However, the partnership between children's caregivers and pediatric hospitalists, has not been carefully examined 2. The partnership between children's caregiver and pediatrician is especially challenging in the inpatient setting as the initial therapeutic relationship is often established during a time of acute stress for the family. Further investigation and analysis of this partnership will offer key insights into the therapeutic relationships, patient care and safety, and the overall patient/family experience in the inpatient environment.
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Affiliation(s)
- Paige Triplett
- Associate Division Chief of Pediatric Hospital Medicine, Dayton Children's Hospital, Assistant Professor in Pediatrics, Boonshoft School of Medicine at Wright State University.
| | - Heather Dyer
- Division Chief of Pediatric Hospital Medicine, Dayton Children's Hospital, Assistant Professor in Pediatrics, Boonshoft School of Medicine at Wright State University
| | - John Pascoe
- Dayton Children's Hospital, Professor in Pediatrics, Boonshoft School of Medicine at Wright State University
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Reeder J, Morris J. Becoming an empowered parent. How do parents successfully take up their role as a collaborative partner in their child's specialist care? J Child Health Care 2021; 25:110-125. [PMID: 32141316 DOI: 10.1177/1367493520910832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this article is to offer an improved understanding of how parents of children with long-term disabilities are empowered to successfully take up their role as decision-making partners in the design and delivery of the care of their child. The intention is to stimulate dialogue, encourage reflection and provide practical suggestions for health professionals working with children and their families. The reported findings are from a study which was guided by a constructivist grounded theory methodology. This involved an iterative process of repeated cycles of data collection and analysis, which comprised 12 semi-structured, in-depth interviews with 14 parents of children accessing paediatric services within a single National Health Service Trust. A novel model, explaining how the power im/balance and the perceived state of the therapeutic relationship influence how successfully a parent takes up their position in the collaborative partnership, is presented and discussed. It is suggested that by thoughtfully addressing the traditional hierarchy that exists within healthcare, health professionals might facilitate the development of a 'truly' therapeutic relationship, which can help promote parental empowerment.
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Affiliation(s)
- Jim Reeder
- East Kent Hospitals University Foundation Trust, Children and Young Person's Therapy Service, Kent, UK
| | - Jane Morris
- School of Health Sciences, University of Brighton, Brighton, UK
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Brady PW, Giambra BK, Sherman SN, Clohessy C, Loechtenfeldt AM, Walsh KE, Shah SS, Lannon C. The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study. Hosp Pediatr 2020; 10:728-742. [PMID: 32788321 DOI: 10.1542/hpeds.2020-0065] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team. METHODS In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes. RESULTS Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep. CONCLUSIONS Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.
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Affiliation(s)
- Patrick W Brady
- Divisions of Hospital Medicine and .,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Barbara K Giambra
- Research in Patient Services, Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Kathleen E Walsh
- James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Samir S Shah
- Divisions of Hospital Medicine and.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and.,Infectious Diseases
| | - Carole Lannon
- James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
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Ramazani S, Bayer ND, Gottfried JA, Wagner J, Leonard MS, Lynn J, Schriefer J. The Value of Family Advisors as Coleaders in Pediatric Quality Improvement Efforts: A Qualitative Theme Analysis. J Patient Exp 2020; 7:1708-1714. [PMID: 33457634 PMCID: PMC7786654 DOI: 10.1177/2374373520939827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Engaging family advisors in pediatric quality improvement (QI) efforts is well-studied in intensive care but less understood in other settings. The purpose of this study was to assess the perceived impact of including a family advisor as a colead on a QI initiative that successfully improved the family-centered timing of routine morning blood tests performed on pediatric inpatients. Five structured written reflections from core QI team members were analyzed using inductive thematic analysis and 3 major themes were identified. The first found that a family advisor's presence from the beginning of a QI initiative helps inform project design. The second determined that family partners working with residents fostered a better shared understanding of the role of trainees and caregivers in improving the quality of care. The third found that a family partner is an effective change agent to enact practice improvement, support professional development, and enhance resident education. Our qualitative analysis showed that engaging a family advisor as a colead influenced the design, implementation, and post-intervention impact of the initiative and improved family-centered outcomes.
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Affiliation(s)
- Suzanne Ramazani
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Nathaniel D Bayer
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Jenna Wagner
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael S Leonard
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Justin Lynn
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jan Schriefer
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Bagnasco A, Dasso N, Rossi S, Timmins F, Watson R, Aleo G, Catania G, Zanini M, Sasso L. A cross-sectional multisite exploration of Italian paediatric nurses' reported burnout and its relationship to perceptions of clinical safety and adverse events using the RN4CAST@IT-Ped. J Adv Nurs 2020. [PMID: 32352176 DOI: 10.1111/jan.14401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/19/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
AIM To explore Italian paediatric nurses' reported burnout and its relationship to their perceptions of safety and adverse events. DESIGN A cross-sectional study using the RN4CAST@IT-Ped database with a web-based survey design. METHODS The RN4CAST@IT-Ped questionnaire was used to collect data in 2017. This comprised three main components: three dimensions (22 items) of the Maslach Burnout Inventory including emotional exhaustion, depersonalization and personal accomplishment. Participants also scored an overall grade of patient safety and estimated the occurrence of adverse clinical events. RESULTS Nurses (N = 2,243) reported high levels of burnout. Most rated clinical safety as high. The risk of adverse events ranged from 1.3-12.4%. The degree of burnout appeared to influence the perception of safety and adverse events. CONCLUSION The association between nurses' burnout and perceptions of higher rates of adverse events and reduced safety in clinical practice is an important finding. However, it is unclear whether this was influenced by a negative state of mind, and whether reduced safety and increased adverse events negatively influenced nurses' well-being, thus leading to burnout. Regardless, the association between nurses' burnout and these quality concepts needs further exploration to examine the effect, if any, on burnout and safety, and identify supportive mechanisms for nurses. IMPACT The association between reported burnout and perception of safety and risk of adverse events in Italian paediatric nurses has been reported for the first time. Nurses reporting burnout are at greater risk of intensely negative perceptions of clinical safety and adverse events. This is an important finding as perceptions can influence practice and behaviours. Quality measures in children's clinical environments need to go beyond obvious indicators to examine nurses' well-being as this also influences quality and safety.
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Affiliation(s)
| | - Nicoletta Dasso
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Silvia Rossi
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Fiona Timmins
- School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
| | - Roger Watson
- Faculty of Health and Social Care, University of Hull, Hull, UK
| | - Giuseppe Aleo
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Gianluca Catania
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Milko Zanini
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Loredana Sasso
- Department of Health Sciences, University of Genoa, Genoa, Italy
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Shala DR, Brogan F, Cruickshank M, Kornman K, Sheppard-Law S. Exploring Australian parents' knowledge and awareness of pediatric inpatient falls: A qualitative study. J SPEC PEDIATR NURS 2019; 24:e12268. [PMID: 31468705 DOI: 10.1111/jspn.12268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 07/24/2019] [Accepted: 08/05/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE While there has been extensive published research into adult inpatient falls, less is known about pediatric falls in Australia. Falls pose a safety risk to pediatric patients potentially causing harm, increased length of stay, and death. Parents play a central role in reducing falls-related incidents given that, as parents, they provide care and/or oversee care delivered to their child at the bedside. Developing a better understanding of what parents and carers know about falls and associated risks, particularly those hospital-naïve, is central to developing family centered strategies and targeted education to meet the needs of parents. Our study aimed to explore Australian parents' knowledge and awareness of pediatric inpatient falls. DESIGN Qualitative methods utilizing descriptive thematic analysis. METHODS Parents of children and/or young people hospitalized during the last 6 months were eligible to participate. Potential participants attending the outpatient clinics of two tertiary pediatric outpatient clinics hospitals in Sydney, Australia were invited to participate in the study. Willing participants consented to complete a face to face in-depth interview. Open-ended questions sought to explore participants' knowledge, knowledge acquisition, and awareness of inpatient falls. Interviews were digitally recorded and transcribed verbatim. Data familiarization and open coding were completed by researchers independently. Researchers explored and discussed emerging categories until patterns emerged and a consensus of dominant themes were agreed upon. RESULTS Interviews were conducted with mothers (n = 17), fathers ( n = 4), or both parents together (n = 2) of a child or a young person who had been recently hospitalized. Four dominant themes emerged from the data namely: Supervision: falls won't happen, unexpected, parent priorities, and ways of learning about inpatient falls and risks. Despite parents' awareness of falls risk, parents were unaware that falls occur within a hospital setting and did not prioritize "falls prevention" during admission. PRACTICE IMPLICATIONS Findings have implications for nursing practice, particularly in the delivery, content, and timing of falls prevention education.
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Affiliation(s)
- Danielle Ritz Shala
- Nursing Research Unit, Sydney Children's Hospitals Network, Sydney, Australia
| | - Frances Brogan
- Nursing Research Unit, Sydney Children's Hospitals Network, Sydney, Australia
| | - Marilyn Cruickshank
- Nursing Research Unit, Sydney Children's Hospitals Network, Sydney, Australia.,Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Kelly Kornman
- Nursing Research Unit, Sydney Children's Hospitals Network, Sydney, Australia
| | - Suzanne Sheppard-Law
- Nursing Research Unit, Sydney Children's Hospitals Network, Sydney, Australia.,Faculty of Health, University of Technology Sydney, Sydney, Australia
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