A Child's-Eye View of Nursing Comes into Focus

INQRI-funded study takes first-ever systematic look at hospitalized children's perceptions of the quality of their care.

    • September 29, 2011

Something seemed amiss to Nancy Ryan-Wenger when she started working at Nationwide Children’s Hospital several years ago: The patient satisfaction surveys weren’t actually being completed by the patients.

What she found instead was that the pediatric powerhouse in Columbus, Ohio, was getting surveys completed by parents weeks after a child’s hospitalization. “I knew from my previous research that parents do not always know what their children are thinking, feeling or experiencing,” says Ryan-Wenger. She had earlier looked at stress, coping and stress-related symptoms in children, “with an emphasis on asking the children themselves, rather than their parents, about how they are feeling.”

Ryan-Wenger, PhD, RN, CPNP, FAAN, serves as Nationwide’s director of nursing research and an investigator for its Research Institute’s Center for Innovation in Pediatric Practice. She teamed with William Gardner, PhD — a fellow investigator at the center and a professor of pediatrics, psychology and psychiatry at the Ohio State University College of Medicine—to lead a groundbreaking study funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI).

The study is the first-ever to systematically elicit the views of hospitalized children and adolescents – of whom there are approximately 3 million every year – on the quality of their nursing care. It is also the first to evaluate children’s perceptions of nurses’ behavior for evidence of any disparities across demographic groups. The results of the study, to be published in the January 2012 issue of the Journal of Nursing Quality (now available online) reveal that soliciting children’s perspectives on their nursing care can be helpful in evaluating and identifying ways to improve that care.

The study included 496 children and youth, ages 6 to 21, who were treated at Nationwide, a freestanding children’s hospital. They were asked two questions about their care: “What do you like most about your nurses and what they do for you, and how does that make you feel?”; and “What don’t you like about your nurses and what they do for you, and how does that make you feel?”

The children wrote their responses on tablet computers, with help from the research assistants for the younger children. Their responses were sorted into 18 categories of nurse behaviors, 12 that were regarded as positive (such as “gives me what I need when I need it,” “checks on me often,” “talks and listens to me” and “is nice and friendly to me”). These positive behaviors made the children feel cared about, safe and happy. Six categories were regarded as negative (such as “wakes me up” or “doesn’t give me what I need when I need it”).

The research team found that, overall, children felt that their nurses cared about them, regardless of how many behaviors they did or did not like. “When I cried, my nurse cried, too,” one child told the evaluators.

Nearly two-thirds of the children reported that they did not like it when nurses did things that hurt or were uncomfortable, and they reported that these kinds of negative nurse behaviors made them feel sad, bad, mad, scared or annoyed.

“Children’s experiences in the hospital can influence their attitudes toward health care for the rest of their lives, their decisions about receiving health care, or even [whether they choose] a career as a health care provider,” says Ryan-Wenger. “We can help improve those experiences by listening to pediatric patients. We found that children can accurately report their feelings about quality of care, and these findings strongly suggest that when children are hospitalized, their perspectives on the care they received should be elicited and considered when evaluating nursing practices and procedures.”

Although the demographics of the participants limited researchers to comparing responses only of Black and White patients, the study revealed that race and gender did not have an impact on their perceptions of nurses’ behavior. Household income did seem to play a role in some cases, however. Children from low-income neighborhoods more often reported that a nurse woke them up (which was identified as a negative nurse behavior), and were more likely to report that nurses gave them things to do (a positive behavior) than their counterparts from higher-income neighborhoods.

The researchers’ recommendations include:

  • Providing pediatric patients with systematic opportunities to evaluate the quality of their care during hospitalization and other types of health care visits;
  • Holding nurses accountable for timely and appropriate responses to children’s concerns about their care, and for communicating those concerns to other staff; and
  • Continuing research to evaluate the link between children’s perspectives on the quality of their care and the outcomes of that care.

“The children were quite happy to share their experiences,” says Ryan-Wenger, and there were very few similarities between child and parent feedback, “which lends support to our belief that the children’s perspectives on their experiences are equally important as parental perspectives.”

Next, Ryan-Wenger hopes to secure funding to conduct a clinical trial utilizing a patient experience form for hospitalized children that can be a “Sixth Vital Sign” assessed by nurses at least once per day.

“The children will evaluate what is going well and what is not going so well for them that day,” she says. “Nurses will respond to that information by changing a care plan, communicating the issue to other staff, or by providing simple reassurance. We hope to see the Sixth Vital Sign become standard in the daily care of pediatric patients.”

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