A study of role negotiation between nurses and the parents of hospitalized children

The role of the parent of a hospitalized child has changed considerably over the past 30 years. Where parents were previously expected to had responsibility for care over to their child's nurses, there is now an expectation that parents will be extensively involved in the care of their hospitalized children. The negotiation of roles between nurses and parents has been advocated by workers concerned about conflicts between nurses and parents. However, it is not known whether such negotiation takes place between nurses and parents. It is clear that power is not evenly distributed between nurses and parents: issues of territory, stress, anxiety, uncertainty, control and conflicts arising from parental competence all place the parent in a weaker position. It is argued that the nurse holds the initiative in the decision about whether negotiation takes place. A small study is described in which nurses were invited to describes their response to their perception that a parent wanted to increase or decrease her or his involvement in her or his child's care. The critical incident technique (Flanagan 1954) was used to collect data. Nurses' responses were categorized into categories of 'encouragement', 'explanation/advice' and 'negotiation'. Responses were then placed in more specific subcategories. The inter-rater reliability of the categorization was measured. Owing to the limitations of the study, the results can only be regarded as suggestive. Nevertheless, significant association was found between the category of response and the grade of staff, with a stratified pattern of category of response demonstrated. The implications of the study for future research are discussed.     

Parents' support and satisfaction with their child's postoperative care

It is recognized that parents' presence during their child's hospitalization is of benefit to the parents and the child. However, the level of parental involvement in their child's care may be influenced by many factors, such as the amount of support nurses provide for parents. This article reports on two themes from the findings of a larger study on parental involvement in children's postoperative pain management - parental support and parents' satisfaction with their child's postoperative pain management. The aim of the larger study was to explore both nurses' and parents' perceptions of parental involvement in their child's postoperative pain management. The methods used were both qualitative and quantitative. The qualitative method of phenomenology was used to guide 20 nurse and 20 parent interviews. Quantitative methods involved surveying the nurses and parents on their perceptions of how supportive the nurses were towards the parents. The charts of 20 children were reviewed for pain-related data. This article reports on the issues of parent support from the results of the survey, and on satisfaction relating to their child's postoperative pain management from the parent interviews. The findings demonstrated that nurses perceived that parents were receiving more support from them than that which parents felt they were receiving. Parents were more satisfied with their child's pain management and children received more analgesia when they were cared for by a lower grade nurse.     

Parent involvement in children''s pain care: views of parents and nurses

AIM OF THE STUDY: This study investigated the views of parents and nurses about the involvement of parents in the management of their child's pain during the first 48 hours after surgery. BACKGROUND: Children's pain management has been found to be problematic and in need of improvement. Nurses are the key health care professionals with responsibility for managing children's pain. Parents can make important contributions to assessment and management of their child's pain. METHODS: Using a phenomenological approach, nurses and parents were interviewed about their perceptions of parent involvement in pain management. FINDINGS: The findings indicated that parental involvement in their child's pain management is superficial and limited in nature. Parents described a passive role in relation to their child's pain care and conveyed feelings of frustration. Only a minority of parents expressed satisfaction with their child's pain care. Nurses perceived that there was adequate involvement of parents and adequate pain management for children. CONCLUSIONS: These findings may be somewhat explained by differing views and a lack of effective communication between parents and nurses. There is a clear need for nurses to discuss parent involvement with parents and negotiate roles in relation to pain management.     

Nurses' perceptions of parental involvement in hospital care

Parental involvement is an essential element of quality of care for children in hospital. However, there is often confusion in role perception between parents and nurses which may be affected by nurses' attitudes, their ability to provide information, their communication and interpersonal skills and willingness to relinquish control. AIM: This study examined nurses' perceptions of parental involvement and communication with parents of children in hospital and explored differences in perceptions of recent graduate nurses and more experienced nurses. METHOD: Two focus groups were carried out at a university paediatric hospital in Sweden, one with experienced paediatric nurses (n = 7) and one with recent nursing graduates (n = 6). FINDINGS: Analysis of the discussions identified five themes: clarifying roles, information, work environment, support and clinical competence. These nurses confirmed the belief that involving parents in the child's care is an important part of nursing in paediatric care and suggested that the nurses should play the role of being the communicator with the parents. CONCLUSION: Nurses need to be aware of the impact their communication has on parents and help them to clarify their role as parents in hospital.     

Negotiation of parental roles within family-centred care: a review of the research

Aims and objectives. To review research published in the past 15 years about how children's nurses’ negotiate with parents in relation to family‐centred care. Background. Family‐centred care is a basic tenet of children's nursing and requires a process of negotiation between health professionals and the family, which results in shared decision‐making about what the child's care will be and who will provide this. The literature highlights inconsistencies in the degree to which nurses are willing to negotiate with parents and allow them to participate in decisions regarding care of their child. There is need to explore further the extent to which nurses communicate and negotiate shared care with children and their parents. Conclusions. Three themes emerged from this review of the literature relating to whether role negotiation occurred in practice, parental expectations of participation in their child's care and issues relating to power and control. Parents wanted to be involved in their child's care but found that nurses’ lack of communication and limited negotiation meant that this did not always occur. Nurses appeared to have clear ideas about what nursing care parents could be involved with and did not routinely negotiate with parents in this context. Relevance to clinical practice. For family‐centred care to be a reality nurses need to negotiate and communicate with children and their families effectively. Parents need to be able to negotiate with health staff what this participation will involve and to negotiate new roles for themselves in sharing care of their sick child. Parents should be involved in the decision‐making process. However, research suggests that a lack of effective communication, professional expectations and issues of power and control often inhibit open and mutual negotiation between families and nurses.     

Negotiation of care by children's nurses: lessons from research

Parental participation and role negotiation are central elements in family-centred care, but research suggests that such negotiation tends to be ad hoc, depending on the relationships developing between the family and health professionals. Lack of effective communication, professional expectations and issues of power and control often prevent open and mutual negotiation between families and health professionals, especially nurses. This article summarises key lessons from a critical review of relevant research literature (Corlett and Twycross 2006) which suggests that nursing staff often control parental participation leaving parents feeling disempowered and deskilled. Poor communication and lack of information sharing exacerbate the situation. Where parents do not comply with nurses' expectations conflict can arise, resulting in more anxiety for already stressed parents. Current health policy requires that health workers listen to children and their families, to actively involve them in the decision-making process and to plan care around their needs and wishes. Nurses need to be aware of the way they interact with parents and the control they may unwittingly exert. A greater emphasis on communication, interpersonal and negotiation skills within nurse education is also needed.     

Development of a family liaison model during operative procedures.

The essence of family-centered care is the provision, by all health professionals, of psychosocially supportive care that fosters family integrity and functioning. Data from a hospital-based satisfaction survey at The Children's Hospital of Philadelphia (CHOP) indicated that the primary reason for parents being "less than completely satisfied" was lack of communication. A search of recent literature suggests also that breakdown in family-centered care in intensive care units is neither new nor unique. The purpose of this article is to describe how efforts to improve communication with parents and families led to the development of a family liaison program and an expanded role for staff nurses in the Cardiac Intensive Care Unit (CICU). The goals of this family liaison program were three-fold: to facilitate establishment of a relationship between CICU nursing staff, parents, and families at the earliest possible point in time; to ensure communication with parents and families at regular intervals during their child's surgery; and to promote practice that incorporates principles of family-centered care within the CICU. The design and implementation of such a program presented nurses in the CICU with both a challenge and an opportunity to take an innovative approach to meeting the fundamental need for information reported by parents and families, and echoed throughout nursing literature. This family liaison program serves to educate parents and families, communicate updates, provide physical and emotional support, and establish continuity of care for the patient and family. Additionally, nurses involved in the program have given positive feedback regarding their expanded role in this family-centered care model.     

Rearing the Child Who Is Technology Dependent: Perceptions of Parents and Home Care Nurses

ISSUES AND PURPOSE. Most children who are dependent on technology for survival live with their families at home. This study explores the perceptions of parents and home care nurses regarding rearing the technology-dependent child.
DESIGN AND METHODS. In this qualitative study, interviews were conducted with 16 parents whose child is technology dependent and 15 registered nurses who provided home care.
RESULTS. Rearing the child who is technology dependent is similar to but different from raising other children. Parental communication and negotiation of child-rearing expectations with home care nurses is essential.
PRACTICE IMPLICATIONS. Improved collaboration and communication between parents and nurses may reduce parental stress and enhance development for children who are dependent on technology.     

Negotiating lay and professional roles in the care of children with complex health care needs

BACKGROUND: Children with complex health care needs are now being cared for at home as a result of medical advances and government policies emphasizing community-based care. The parents of these children are involved in providing care of a highly technical and intensive nature that in the past would have been the domain of professionals (particularly nurses). AIMS OF THE PAPER: To assess how the transfer of responsibility from professionals to parents was negotiated, the tensions and contradictions that can ensue, and the implications for professional nursing roles and relationships with parents. DESIGN: Using a Grounded Theory methodology, in-depth interviews were conducted with 23 mothers, 10 fathers and 44 professionals to gain insight into the experience of caring for children and supporting families in the community. FINDINGS: From the parents' perspective, their initial assumption of responsibility for the care of their child was not subject to negotiation with professionals. Prior to discharge, parents' feelings of obligations, their strong desire for their child to come home, and the absence of alternatives to parental care in the community, were the key motivating factors in their acceptance of responsibility for care-giving from professionals. The professionals participating in the study had concerns over whether this group of parents was given a choice in accepting responsibility and the degree of choice they could exercise in the face of professional power. However, it was following the initial discharge, as parents gained experience in caring for their child and in interacting with professionals, that role negotiation appeared to occur. CONCLUSION: This study supports other research that has found that professionals' expectations of parental involvement in the care of sick children role can act as a barrier to negotiation of roles. In this study, parental choice was also constrained initially by parents' feelings of obligation and by the lack of community services. Nurses are ideally placed to play the central role not only in ensuring that role negotiation and discussion actually occurs in practice, but also by asserting the need for appropriate community support services for families. Being on home territory, and in possession of expertise in care-giving and in managing encounters with professionals, provided parents with a sense of control with which to enter negotiations with professionals. It is important that changes in the balance of power does not lead to the development of parent-professional relationships that are characterized by conflict rather than partnership.     

Validity of Parent Ratings as Proxy Measures of Pain in Children with Cognitive Impairment

Parent-assigned pain scores have been used as proxy measures of pain for children, such as those with cognitive impairment (CI), who cannot self-report. However, the accuracy of parent-assigned pain ratings for children with CI has not been studied. This study evaluated the construct and criterion validity of parental pain scores of children with CI. Fifty-two children aged 4 to 19 years with CI and their parents/guardians were included in this observational study. Children were observed and assessed for pain by parents using the Faces, Legs, Activity, Cry, and Consolability (FLACC) observational tool and the 0 to 10 Numbers Scale, and simultaneously by nurses using the FLACC. Children who were cognitively able scored pain using simplified scales. Parent scores decreased after analgesic administration (6.4 +/- 2.5 vs. 3.1 +/- 2.3; p = .004), supporting their construct validity. Parents' FLACC and Numbers ratings correlated well with nurse ratings (intraclass correlation coefficient = 0.78 [confidence interval = 0.63-0.87] and intraclass correlation coefficient = 0.73 [confidence interval = 0.59-0.83], respectively). The parents' coded Numbers ratings correlated moderately with their child's ratings (rho = 0.57; p = .05) and agreed in 20% to 100% of cases (kappa = 0.388). There was better overall agreement between parents' FLACC scores and child ratings (33%-67% agreement; kappa = 0.43). The parent underestimated the child's pain with FLACC ratings in only one case (8%), but overestimated pain in three cases (25%). This study suggests that parents of children with CI provide reasonable estimates of their child's pain, particularly when using a structured pain tool. Parents may, however, tend to overestimate their child's pain during the early postoperative period.     

Needs assessment and intervention strategies to reduce lead-poisoning risk among low-income Ohio toddlers

OBJECTIVE: Examine parental receipt of lead-poisoning prevention information and preferred methods of receiving this information. DESIGN: Cross-sectional mailed survey of parents with children 1-2-year-old-enrolled in Medicaid. SAMPLE: Respondents (n=532) were primarily female, white, with at least a high school education, and between the ages of 20-30 years. MEASUREMENTS: Items from the Blood Lead Education and Screening Tool concerning parental receipt of lead-poisoning prevention information, persons with whom parents had discussed lead-poisoning prevention, parental receipt of a reminder about blood lead testing, and parents' preferred methods of obtaining lead-poisoning prevention information. RESULTS: Most respondents had obtained lead-poisoning prevention information, but only 28% reported receiving a reminder to have their child's blood lead level assessed. Brochures and discussions with health care providers were the preferred methods of obtaining lead-poisoning prevention information. More minority respondents preferred receiving information via videos, billboards, and home visits. Younger parents preferred brochures, billboards, and speaking with someone at the health department or women, infants, and children supplemental nutrition (WIC). Most respondents identified multiple means by which they would like to receive lead-poisoning prevention information. CONCLUSIONS: Implementation of individual, community, and system-level interventions by public health nurses are needed for comprehensive lead-poisoning prevention education.     

Family involvement: are we asking too much?

Family involvement has evolved with the child's parents and family now having a much greater presence at their child's hospital bedside. This has caused some problems due to children's nurses misunderstanding what family involvement is, and assuming that parents want to be involved in their child's care. Greater negotiation and recognition that each child and family is unique, with unique health and social care needs, will be required in future to ensure that families are offered family involvement at an appropriate level.     

The Safe Care Framework™: A practical tool for critical thinking

Safe, effective and ethical clinical decision-making in nursing depends on critical thinking, yet there is no consensus on the educational strategies that are most effective in developing and refining this foundational skill. A qualitative inquiry among graduating Bachelor of Science in Nursing students sought to determine whether one such educational strategy, an operationalized critical thinking framework, would assist nursing students to better understand acute care patients' complex profiles. The Safe Care Framework™, consisting of the ‘Concept Map Template’ and the ‘Priority Setting Tool Template’, was developed using a constructivist pedagogical approach. The framework illustrates and operationalizes the systematic critical thinking processes that expert nurses use to provide safe, comprehensive care. Thematic analysis of qualitative survey results revealed the following three main themes; (1) greater organization and understanding of patient data; (2) guiding of assessments and priorities of care; (3) better communication with others, and several subthemes. Thus, the Safe Care Framework™ may be a practical operational tool that can support novice nurses in developing critical thinking skills. This framework adds to the literature on innovative pedagogy for nurse educators.     

The nurse parent support tool

This report describes the development of an instrument, the Nurse-Parent Support Tool (NPST) designed to measure parents' perception of nursing support during their child's hospitalization. The NPST was based on the Nurse Parent Support Model developed from House's conceptualizations of four domains of support. Thus, the 21-item NPST assesses four dimensions of support: (1) supportive communication and provision of information related to the child's illness, treatments, care, and related issues; (2) parental esteem support focused on respecting, enhancing, and supporting the parental role; (3) emotional support to help the parents cope with their own emotional responses and needs related to the child's illness; and (4) caregiving support involving the quality of care provided to the child. Strong support for the content validity of the NPST derives from the steps used in constructing the instrument. This includes use of a conceptual framework, generating items from the literature, using data from interviews with parents of hospitalized children, and pilot testing with parents and experts. Factor analysis provides support for the underlying construct and significant correlations with another instrument measuring a similar construct provides support for the concurrent validity. The internal consistency reliability is very high. The NPST holds promise for use in nursing research and quality improvement programs in pediatric and neonatal in-patient settings.