children view of good nurse

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Hospitalized Childrens Views of

the Good NurseMary Brady

Key words: communication; hospitalizedchildren; professionalcompetence; professionalappearance; safety; virtues

Researchrelating topatients viewsofthegoodnursehasmainly focusedontheperspec-tivesofadultpatients, withlittleexploring theperceptionsofchildren. Thisarticlepresentsfindingsfrom aqualitativestudy thatexploredviewsofthegoodnursefrom theperspectiveofhospitalized children. Theaimsof thestudy were threefold: to remedy agap in theliterature; toidentify characteristicsofthegoodnursefrom theperspectiveofchildreninhospital; andtoinform childrensnursing practice. Twenty-twochildrenwereinterviewedusing anadapted drawandwrite technique. Five themesrelating to childrens viewsofthegoodnurseemergedfrom theanalysis: communication; professionalcompetence;safety; professionalappearance; andvirtues. Eachofthesewillbediscussedinrelationtogoodnurseliteratureandrecommendationsmadeforchildrensnursing practice.

IntroductionAnaspirationtobea goodnurse isanethical imperativeforthosewithinthepro-

fession. Ethicalnursing, ithas beenargued, occurswhen goodnursesdo the rightthing.1However, itisnotalwaysclearwhatismeantby agoodnurse. Professionalcodes, forexample, detailthedutiesandvirtuesofthegoodnursefrom theperspectiveofprofessionalorganizations. Increasingly, thereisrecognitionthatpatients viewsofthegoodnurseare important. Previousresearchhas focusedon theperspectivesofadultpatientsandtherehasbeenlittleexplorationoftheviewsofchildren.

Inthisarticle, findingsfrom aqualitativeresearchprojectusing anadaptedform ofthedrawandwrite techniquewillbeoutlined. Twenty-twochildren, agedbetweensevenand12 years, whowereinpatientsonapaediatric unitinEngland, participatedintheproject. Thethemesthatemergedfrom thedataanalysisandimplicationsofthefindingsforchildrensnursing practicewillbediscussed.

Addressforcorrespondence: Mary Brady, Faculty ofHealthandSocialCareSciences, KingstonUniversity & St Georges University of London, Cranmer Terrace, London SW17 0RE, UK.Tel: +44 (0)20 8725 0815; Fax: +44 (0)20 8725 2248; E-mail: [email protected]

Nursing Ethics 2009 16 (5) TheAuthor(s), 2009. 10.1177/0969733009106648Reprintsandpermissions: http://www.sagepub.co.uk/journalsPermissions.nav

by Made Sumarwati on October 7, 2009http://nej.sagepub.comDownloaded from
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Nursing Ethics 2009 16 (5)

BackgroundThe conceptof the goodnurse isdynamic andsubject to the influencesofsociety,cultureandpoliticalreform.2,3Viewsofthegoodnurseare, therefore, likely tovaryacross culturesand may evolve slowly over time. Historicalportrayalsof the goodnurseemphasizing, forexample, virtuesandexcellencessuchasdevotion, obedienceand meekness,4 seem out of stepwith contemporary portrayalsof the goodnurse.

Professionalcodesprovideguidanceontheprofileofthegoodnurse, generally intheform ofduties, responsibilitiesandvirtues. TheUKsNursing andMidwifery Councilcode,5forexample, requiresnursestoberespectfulofthe individuality, dignity andconfidentiality ofpatientsandtobetrustworthy andtoactwithintegrity. Thiscodealsorequiresnursestokeeptheirknowledgeandskillsuptodateandtobasetheirpracticeonthebestevidence. TheInternationalCouncilofNurses6codeofethicsemphasizesnurses responsibilities to people, practice, the profession and co-workers. Helpfulas theguidance in codesmay be, it isgeneric anddoesnotand cannotaddress theparticularitiesandnuancesofchildrensnursing practice, nordoesitprovideinsightintoviewsofthegoodnursefrom theperspectiveofparticularpatientgroups.

Research exploring patient perspectives on the good nurse has focused on the

viewsofadultpatients.1, 2Findingsfrom theseprojectsdetailawiderangeoffeaturesof the goodnurse, most commonly in relation to knowledge, skills, characteristics,attributesorqualities. RushandCooks3findingshighlightedtheimportanceofgoodcommunication, respectful attitudes, attributes and behaviour (e.g. looking smart),having appropriate clinicalskillsandknowledge. Thatstudy surveyedtheviewsofpatientsofallagesandcarers; however, thechildrenconsultedwereschoolchildrenandmay nothavehadhospitalexperience. Thelargeststudy of(adult) cancerpatientsviewsof the goodnursehas been inprogress in five countries since 2004 andhasdetailedgoodnursevirtues, goodnursework andtheimpactofthegoodnurse.7

Todate, therehasbeenlittleexplicitattentiontotheperspectiveofchildrenandtothe featuresof thegood childrensnurse. A qualitativestudy by Carter,8whichdid

notfocusexplicitly onthegoodnurse, involvedinterviewswith10 childrenaged213years, intheirhomes, regarding theirperceptionsofachildrenscommunity nursingteam. Sheusedavariety ofimaginativemethods(e.g. scrapbooks, photographs, inter-views, storiesandpoems) toelicit valuable information. For instance, although thechildren(whoallhadcomplex needsorsiblingswithcomplex needs) valuedtechnicalexpertise, they alsowantedanursewhowas nice and fun. Listening wasanotherimportantissueforthesechildrenandthiswasalsohighlightedby Forsneret al.,9whoreportedthatnotbeing listenedto madethehospitalexperiencevery unpleasant.

Childrensnursing hasmuchincommonwithotherbranchesoftheprofessionbuttherearealsodifferences. Childrensnurseshaveknowledgeofthepsychosocialandbiologicaldevelopmentofchildrenand, incommonwithallnurses, they areacom-

municationconduitowing totheircontactwithmembersofthemultidisciplinary team.Childrenand familiesarean integralpartof that team, facilitatedby the childrensnurse, whoworksinpartnershipwiththem toprovidecare. Thisfocusonworking inpartnershipunderpinsthecurrentphilosophy ofUK childrensnursing andhasbeenincorporatedintomuchofthecurrentchildnursing literaturetoenhanceandadvancenursing care.1012Inaddition, currentguidanceinEnglandplaceschildrenatthecentreofcareprovision, forexample, theChildrenAct13,14andtheNationalServiceFrameworkforchildren, young peopleandmaternity services.15Furthermore, itisrecognizedthatchildrenarefrequenthealthserviceusers, accounting foraboutonethirdofaccident

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andemergency departmentattendances,16yetthey arerarely consultedandtheirviewsareoftenmisinterpreted.17

Thestudy describedhere, therefore, setouttoexplorehospitalizedchildrensviewsofthegoodnurse. Theaimsweretoremedy agapintheliterature, identify thechar-acteristicsofagoodnursefrom theperspectiveofchildreninhospitalandtoinformchildrensnursing practice, thereby facilitating theprovisionof care that meets theneedsofhospitalizedchildren.

MethodThisstudyusedagroundedtheory approach, inwhichtheory isdiscoveredby collectingandanalysing datarelating toaphenomenon.18Groundedtheory wasdevelopedbyGlaserandStrauss.19Theiroriginalmethodology waschosenbecauseitfocusesonthedescriptionandgenerationoftheory from databy anongoing processofcomparativeanalysisusing openandtheoreticalcoding thatallowscodestoemerge. Thispermitstheory tobegeneratedwithouttherigidity ofotherresearchmethods. Asaninductive(bottom-up) process, itisamethodthatfacilitatestheidentificationoftheconcernsof

theresearchparticipantsratherthantheresearcherandtheseemerging ideascanbedescribedasgroundedinreality. Itenablesnewtheory tobediscoveredandgeneratedwithoutbiasing theprocess. Thustherationaleforchoosing thismethodwasitssuit-ability forassisting children20toarticulateissuesthatareimportanttothem.

Theuseofartwork canfacilitatedatacollectionfrom childrenabouttheirlivedex-perience. Artwork isrecognizedasapowerfulcommunicationtool21thatpromotesthebuilding ofarapportbetweenthechildandtheresearcher, thusenabling emotionsandthoughtstobeexpressedandempowering thechildresearchparticipant.22,23Inparti-cularthedrawandwrite techniquehasbeengaining popularity withresearchers.8,24,25

Thisisamethodwhereby theparticipantdrawsapictureandtheresearcherusesthatdrawing asabasisforhisorherquestions. Thedrawing isnotsubjecttodeepana-lysis.26Instead, itisvisually analysedandusedasthefocusfortheinterviewwiththechild. In Sartain et al.s27 study of six children aged 712 years, drawing enhancedthechildrensability totalk abouttheirexperiencesofchronic illness. However, theyobserved that older childrendid not enjoy the same experience. Furthermore, NicGabhainnandKelleher28observedintheirstudy thatgirlswerekeenertodrawthan

boys. Driessnacks20 meta-analysis of the draw andwrite technique appraised sixfairly smallstudies(averagecohort40) anddemonstratedthatthismethodwasusefulforfacilitating informationretrievalfrom childrensmemories, whichfurtherstrength-eneditspotentialforuseinthisstudy.

Inthepresentstudy, theresearcherprovidedapencilandsomepaperandaskedthechildparticipantstodrawapictureofagoodandabadnurse. Oncethechildrenhadcompletedtheirpicture, sheusedamixtureofclosedandopen-endedquestionstoexplore thedrawings, suchas: Tellmewhatsortofdress thenurse iswearing,Whatisthenursedoing? and, Why isshedoing ... ? Theseinterviewsweretapedandtranscribedafterwardsby theresearcher. Attimesduring theinterviewsachilddescribed characteristics that led the researcher instinctively to reflect back on toherownpracticeandsheenteredthesepointsinherfieldnotesforlateruseduringthe analysisphase. Theuse of fieldnoteshelped to capture the childsnon-verbalexpressionsandhowtheresearcherfeltatthetime.



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Ethical considerations

Theprojectwas scrutinized by a local research ethics committee and it received afavourableethicalopinion. ThehospitalResearchandDevelopmentCommitteealsograntedapprovalforthestudy. ThesupportoftheDirectorofNursing Servicesandtheseniornursesinthepaediatric departmentwasalsosoughtandobtained.

Issuesofconsentand confidentiality are cornerstonesofethicalresearchpractice.

Theresearcherwasawarethatchildrenoftenhavethecapacity toconsentandmakedecisionsaboutparticipating inresearch, despitebeing unabletogivelegalconsent.13Toaiddecisionmaking, informationleafletsaboutthestudy wereproducedinseveralformats(fortheparents, childrenandstaff). Inaddition, anassentform wasdevelopedtoobtainproofof the childrensunderstanding andwillingness toparticipate. Datafrom theprojectwasanonymisedandtheconfidentiality ofparticipantsrespected.

Data collection and analysis

Priortorecruitmentanddatacollectiontheresearcherbriefedtheseniornursesinthepaediatric departmentaboutthestudy andsentaninformationsheetwithacovering

letter toeachmemberof thewardstaff. Theresearchervisitedthepaediatric wardsseveraltimeseachweek andaskedstafftorecommendsuitablechildrentoapproach.Nursing staffwereaskedtoidentify childrenbecauseitwasimportantthatthey hadsufficient cognitive and linguistic skills to understand the study andwere able tocommunicatewiththeresearcher.29,30

Theresearcherfirstintroducedherselfandthestudy topotentialchildparticipantsandtheirfamilies. Ifthey wereinterestedshediscussedthestudy furtherwiththemandprovided somewritten information. Any questionswereaddressedand itwasstressed that the childrenwerenot obliged toparticipate. The researcher arrangedto returnwhen they hadhad theopportunity to consider taking part. Consentandassentwereobtainedatthissecondmeeting. Crucially, thechildrenhadtobewilling

toparticipateinthestudy.

Participants

Thechildrenwereselectedfrom alargepaediatric departmentinoneNHS trustsituatedinamulticulturalcity inSoutheastEngland. Withgroundedtheory itisdifficulttopre-settheamountofdatatobesoughtbecausetheresearchershouldaim forsaturation, apointwherenonewdataareobtained.31,32However, sincetheresearcherwaslimitedtoafour-monthtimeframe, itwasthisratherthansaturationthatinfluencedtheamountofdataobtained.

Inclusionandexclusioncriteriaweredevelopedtofocusonagroupofchildrenwhopossessedthecognitiveability andphysicalskillstotakepartinthisstudy andwhowerewilling toparticipate.

Twenty-two children (11 boysand11 girls) were interviewedandfiveandahalfhoursofinterviewdatawereobtainedoverafour-monthperiodduring thewinterof20062007. Thechildrenwerefrom avariety ofethnic backgroundswithanaverageageof9.9 yearsandhadbeenhospitalizedforavariety ofreasons(Table1).

Providedthatthetiming wasconvenientforthechild, theresearcheraskedthechildtodrawapictureofagoodandabadnurse. Afterwardssheusedthisdrawing asa

basisforherquestions. Theresearcherdidnotprovideadefinitionofgood orbad

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forthechildbecauseshewantedtogatherthechildsinterpretationwithoutinfluenc-ing thechildsideas. Theinterviewwastapedandtranscribedby theauthor, whothenanalysedthedatawiththehelpofanexperiencedresearcher. Theinitialinterviewactedasapilotand, sincenochangesweresubsequently madetotheinterviewprocess, thiswasincludedinthedata.

Seventeenparticipantsdrewpictures. Theremaining five(Table2)werealsokeentocontribute: onewroteandtheotherswereinterviewedandaskedtoimaginewhattheywouldhavedrawnanddescribe that. Althoughdrawing may havehelped tobuildrapportwiththesechildren, theinterviewscontainedvaluabledata.

Thereisnosinglerecommendedmethodforanalysing qualitativedata, thusensur-ing theaccuracy ofsuchdata isvital if they are tobeofvalue.33 Ideally the chosenmethodshouldproducereliably similardataifrepeatedinsimilarcircumstances. Inaddition, researchersneedtobeawareoftheirownpreconceptionsand, ifpossible,reviewthetranscriptsoftheinterviewswiththeparticipantstoensureclarity, rigourand accuracy.18,34 Unfortunately, the researcherwasnot able todo this, which is alimitationofthisstudy but, whensheinterviewedthechildrenabouttheirdrawings,shewasalsofacilitating clarificationoftheirinterpretationsofthegoodnurse, whilechecking foraccuracy. Inaddition theresearcherkept fieldnotesdetailing herowninterpretations, thenon-verbalbehaviourofthechildrenandany eventsthatoccurredduring theinterviews, suchasvisitsby stafftothechildren.

Table 1 Childrensbackgroundinformation

Name Sex Age(years) Ethnicity Reasonforhospitalization

Freya Female 8 White RenalsurgeryBilal Male 9 Asian AsthmaJohn Male 12 White UnknownJamela Female 8 African SicklecelldiseaseJason Male 11 White Cardiac conditionJane Female 11 White PyleonephritisDonna Female 11 MixedraceAfro-

CaribbeanAsthma

Richie Male 12 Afro-Caribbean Acutelymphoblastic leukaemiaMartin Male 10 White UnknownMatthew Male 8 White ForremovalofcoinSusan Female 9 White UnknownRebecca Female 11 SouthAmerican Weightloss; ?causeLaura Female 11 White EyeoperationLeo Male 10 White Unclear; onbedrestArchie Male 7 MixedraceAfro-

Caribbean

Asthma

Luke Male 12 White AsthmaEloise Female 12 African-Chinese RemovalofovariancystKaren Female 8 Afro-Caribbean FacialpalsyMolly Female 10 White FracturedleftarmDwayne Male 10 Afro-Caribbean Peritonitisfollowing ruptured

appendixAnna Female 11 White EyeinfectionDean Male 7 Afro-Caribbean Ulcerativecolitis, campylobacter

infection



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Results and discussionTheinterviewdataanddrawingswereanalysedforemerging ideasusing aconstantcomparativeapproachtocompareandgrouptogetherthedataundercommonhead-ings. Thisresultedinfivethemesthathighlightedimportantcharacteristicsofthegoodnurse: communication, professionalcompetence, safety, professionalappearanceandvirtues. Eachof thesethemeswillbediscussed inturnusing someof thechildrensdrawingsandquotesforillustration. Toprotecteachchildsidentity pseudonymshavebeenused.

Communication

Communicationhasbeenidentifiedasavitalcomponentofthegoodnursesattributes.3Thechildren in thisstudy reported thatthegoodnurseused termsofendearmentwhencommunicating withthem, forexample:

... shecallsmesweetiepie. (Johnage12)

Hiya, alrightdarling, letsgetyoubetter. (Richieage12)

Thismadethem feelspecialandisincontrasttoresearchrelating toolderparticipantsasdescribedinWoolheadet al.s35qualitativestudy (n= 72), wherebeing overfamiliarwithapatientwasseenasdisrespectful.

Thechildrenappreciatedbeing praisedby thenursefortheirbravery during un-pleasant procedures or when having to take distasteful medicines, which perhapsdemonstratesthenursesempathy withthechild.

... maybe, sometimesjusttoliketellem welldoneforbeing agoodpersonbecausetheyvejusthadaninjectionorsomething anditreally hurt. (Annaage11)

Thechildrenweresensitivetothenursestoneofvoiceandbody language. Manystated thatgoodnursesdidnotshoutanduseda nice, calm, relaxed, cheerful,kind tone of voice to speak to them. The bad nursewas bad tempered, bossy,angry, grumpy, moaning, shouted, anddidnotlistentothem, whereasthegoodnursewaswilling to listenandspend timewith them. For instance, Laura (age 11)observedthatnursesshouldsitdownandmeetchildrenattheireyelevel; this is insupport of current literature.36 Comments about being listened to have previouslybeenhighlightedby Carter8andby Forsner et al.9 Forsner et al.s9participantswere

Table 2 Reasonsforrefusaltodraw

Name Sex Age(years) Reasongivenby child

John Male 12 DidnotlikedrawingSusan Female 9 WroteinsteadRebecca Female 11 NogoodatdrawingDwayne Male 10 DidnotwanttodrawAnna Female 11 Sorenessfrom cannularecently removedfrom hand



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previously well childrenwhodescribed feeling lost in theirbodies. It issuggestedthathospitalizationdisempowerschildren, rendering them helpless.

Itwasevidentthatthechildrenformedopinionsaboutnursesby integrating appear-anceandbody languagewith thespokenword, suchas theirdemeanour (faceandbody), handposition, body postureandgait. Smiling andsmiling eyes, inparticularwere frequently mentioned and the children appeared to be able to differentiatebetweentypesofsmilesandnurses sincerity. Leo(age10) thoughtthatifnurseshad

theirthumbsintheirpocketsthey wouldappearstroppy andthiswouldimply thatthey werenotlistening anddidnotcare. Donna(age11) describedthebadnurseaslouching, by whichshemeanthandsonhips. Herdrawing depictedanursewhowassmiling butnotlistening toherpatient(Figure1).

Ineight-year-oldMatthewsdrawing ofthebadnurse, thenursewasabsentbecausenoonecametodealwithhisempty intravenousfluidbag, whereasthegoodnursewasthepersonwhocameandreplacedthebag (Figure2).

The children observed that sometimes nurses walked promptly to deal with apatient, butthiscouldevokefearormakeachildworse(Donnaage11), whileotherswalkedquickly toavoidthepatientorwithoutpaying muchattentiontotheirwork.

If I wasreally ill, really illas I am now, thenurse, just like, ifshe like, justrushedmearoundand thenshe just leavesmeorrushes todowhatevershehas todo ... make it[asthma] worse. (Donnaage11)

There was also an acknowledgement of the role of reciprocity in childrensrelationshipwithnurses. Bilal(age9) stated:

A goodnurseI think probably like... ifyoutreatherwithlikegoodstuff, ifyoumaybesmile... ifyoulike, dosomething forherorsmileandtakeitshemightlikesmileback toyouandsay thatOhI really likeyou, youareareally niceboy orgirl.

Figure 1 Donna(age11)



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Indiscussing herdrawing, Jane(age11), whosemotherwasahealthcareprofes-sional, talked of the importance of patience and politeness. She also revealed anawarenessofreciprocity, albeitinnegativeterms:

Theyremannersattheendoftheday andyoudontwanttoberudetothem otherwisethey aregonnaberudetoyouanditcausesviolenceandthatswhatthehospitaldoesntwant.

Figure 2 Matthew(age8)



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Professional competence

Previous goodnurse researchhadhighlighted the importanceofprofessional com-petence to patients12 and demonstrating professional knowledge and skills was, itseems, asimportanttochildrenastoadultpatients. Thegoodnursewasexpectedtobeknowledgeable, althoughthechildrenwereoftenunclearwherethisknowledgehadbeenacquired:

... qualified oreducated ... (Leoage10)

... orseeitonthetelevisioninaDoctorfilm. (Archieage7)

Theparticipantsalsoexpectedagoodnursetobeorganizedandabletoperform cer-tainskillscompetently andpromptly, anddothem noharm, asillustratedinFigure3,withthegoodnursecelebrating hercompetency atvenepuncturewitharaisedsyringe,incontrasttothebadnursewhowasunabletotakeblood. Someofthechildrenhadvery specific knowledgeabouthowtheircareshouldbeadministeredandwerecriticalofnurseswhodeviated from this, for instance, by notwashing theirhands, ornot

wearing glovesandaprons.Somechildrendescribedthegoodnurseassomeonewhoadministeredintravenousdrugsslowly andknewwhichdrugswereparticularly painfulforthem toreceive, andmadeeffortstoreducetheunpleasantness. Incontrast, thebadnursegaveintravenousdrugstooquickly. Otherchildrenthoughtthatagoodnursewouldtry togivemorepleasant tasting medicinewherepossibleandmakeaneffort to taketheunpleasanttasteaway afterwards. JasonandRebecca (bothage11) expected thenurses togivemedicationontimeandtocomepromptly whencalled. Eloise(age12) believedthatifanursedidsomething inacarelessway itwouldimply thatthenursedidnotlikeher.

Figure 3 Archie(age7)



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Safety

Safety wasastrong themeinthedataandrelatedtochildrensconcernaboutcross-infection, unsafe behaviour and safeguards to ensure that nurses and otherswerenotfraudulentorfake. Thelatterpointwassupportedby themany referencestotheimportanceofnamebadgesandidentity verification, asexpressedby Martin(age10):

Coslike, I dontknowthem ... I wouldsay showmeyourpassandstuff.

Anna(age11) thoughtthatgoodnursesweresafety consciousandconcentratedontheirwork. Goodorganizationalskillsweredescribedby Susan(age9), whoobservedthatthegoodnursecamepreparedwiththeappropriateequipment.

Being clean andhaving cleanhair appeared to be a common concern for manychildren, whothoughtthatanursewithdirty hairmighthavehead licethatwouldspreadtothechildrenandstaff. Thiscouldrelatetotheirschoollifewhereheadliceareoftenprevalent, withvariousinaccuraciescirculating regarding thepreferenceoflicefordirty hairandtheirassociationwithchildrenfrom moredeprivedbackgrounds.37Thechildrenwerealsoawarethathaircoulddropintofoodorwoundsandthatthis

wouldbeunpleasantandperhapsharm them. Furthermore, Anna (age11) thoughtthatitdependedonthetypeofpatientsthenursewascaring for, becausesmallbabiesmightpullloosehair.

Many of theparticipants, suchas Jason (age 11), wereawareof their vulnerablestatusassick childreninhospital, highlighting handwashing andgeneralcleanlinesstoavoidthespreadofinfection(Figure4).

Someofthechildrenbelievedthatthegoodnurseshouldbearolemodelforgoodhealth, asillustratedby Eloise(age12), whoquestionednurses ability tocareforothersif they wereunhealthy. They were concernedabout thenursehaving avery spottyface, implying thatshewasunhealthy andcouldmakethem unwell, whereasanoverly

Figure 4 Jason(age11)



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made-upnursewas viewedashaving an inappropriateappearance. Jane (age 11)statedthat, ashospitalrepresentatives, they neededtoreflectthisintheirclothing. Forher, thebadnursewasdepictedwearing toomuchmake-upandunhygienic clothingthatwastorn(Figure5).

Typesoffootwearwereoftendiscussedby thechildren, withthegoodnursewear-ing sensible, black, lacedup orwrapover, low-heeled shoesthatwerenon-slip,similartoschoolshoes.

... slip-onshoes... whicharentvery goodtowalk aboutinbecausethey couldjustcomeoffandwhenyouareanurseyouhavetodoalotofwalking abouttogettothepatient, soitwouldntbevery goodifthey keptoncoming off. (Susanage9)

Anna(age11) wasalsoconcernedaboutsafety issuesrelating toyoungerchildrenwhennursescarriedscissorsaroundintheirpockets.

... carry aroundscissors... I dontthink thatsvery goodbecausesomechildrenmight...justtakethem outanddostuff, cutthewires... (Annaage11)

Theemphasisonsafety wasintegraltocompetenceand, itseems, morepronouncedinrelation toanawarenessof thepossibility of infectionandfearof contamination.Certainly, atleastthreeofthechildren(Jason, RichieandSusan) hadahighlevelofawarenessofinfectioncontrolandoftheirownvulnerability toinfectionandcouldbedescribedasexpertpatients.38Hygienewasatopic alsoraisedinRushandCooks3

Figure 5 Jane(age11)



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study, whichsuggeststhatchildrenareacutely awareoftherisk ofinfection, despitelacking anin-depthknowledgeofmicro-organisms.

Appearance

Several of the children had conservative opinions about nurses appearance, forexample, Anna(age11), whodescribedthegoodnurseasgraceful, andDean(age7)

whospokeofthegoodnurseaslooking decent. Themajority expectedthenursetowearauniform thatwasneat, cleanandidentifiedhim orherasahospitalemployee.A fewchildrendrewordescribednurseswearing dressesorskirtswithsocks, whichperhapsreflectsaspectsoftheirownclothing ratherthanthatofanadult.

Sensible andprofessional hairstyleswerefrequently mentionedandtwochildrendrewnurseswithhairstylesthatreflectedastylecurrently popularwithyoung ado-lescents. Others referred to sensible school-type shoesandwereopinionated aboutfashionableclothing. Thismay suggestthatchildrenareaccommodating tocertainas-pectsoffashionableattirefornursesaslong asthey remain, intheiropinion, sensibleor professional. The researcher suggests that the childrenwere comparing currentfashion trendswith their appropriateness for thenurse atwork and making value

judgementsusing theirownlifeexperiences.Crosseswere oftendrawnon thenurseshatoruniform. When questioned, the

childrenstatedthatacrossidentifiedthenurseasbelonging tothehospital; thusitap-pearedtoprovidecorporateidentity. Itisalsointeresting tonotethat, althoughnursesuniformshave changedoverrecentyears, dressing-up clothesand childrensbooksstill depict nurses in traditional attire. The researcher suggests that this may haveinfluencedthechildrensopinions.

There appeared to be some confusion about the roles of nurses anddoctors, asreportedby Rossiteret al.,39 whoinvestigatednursing asapossiblecareeroption. Thisconfusioniscontrary tofindingsinMcDonaldandRushforths40 study (n= 63), which,however, addressedtheallocationoftasksby doctorsandnurses. Inthepresentstudy,

somechildrenlinkedgenderandprofession, believing thatalldoctorsweremenandallnurseswerewomen. Thiswasillustratedby Martin(age10) whoclearly thoughtthatdoctorsweremenandwouldthereforenotweardresses:

Whatkindofdoctorwouldcomeininadress? (Martinage10)

Anna(age11) clarifiedthat,althoughinheropinion,womenmightmakemorecarefulsurgeons, shewouldpreferamansurgeon. Thewearing ofastethoscopeappearedtosuggestaroledistinctionforsomechildren: forinstanceLuke(age12) suggestedthatthedifferencebetweennursesanddoctorswasthatnursesdidnotwearstethoscopes,in contrasttoseven-year-oldDean (Figure6), whosedrawingsofthegoodandbad

nurseswereidenticalexceptforthestethoscopewornby thegoodnurse.Theresearchersuggeststhatthechildrenwererelying ontheirlimitedlifeexperience(accesstomediaimages, dressing-upclothes, previoushospitalexperiencesandbooks)todistinguishbetweentheseroles. Additionally, althoughyoung, themajority ofthechildrenexpressedtraditionalandconservativeviewsaboutappearance. Forinstance,oftenthechoiceoffootwearwasinkeeping withguidanceonschooluniform (Anna,age11) andthenursewasexpectedtowearatraditionaluniform andbeneat, tidy,decent andgraceful.



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VirtuesThe children who participated in the project referred to many ethical and socialqualities, charactertraitsandvirtuesofnurses. Virtuescanbedefinedasnetworksofdispositionstofeel, think andactinparticularways, forexample, justly, respectfully orcourageously.41Someofthevirtuesidentifiedinthisstudy haveappearedpreviously intheliterature.3,4244Characteristicssuchashonest, listening, trusting, nice, helpful,gentle, kind, reassuring, polite, cheerful andfriendly werehighlightedby thechildren. They appreciatedhonesty, especially aboutproceduresthatwouldbepainful,andafterwardsbeing praisedfortheirbravery. Thechildrenparticularly valuedthefriendshipand courtesy thatwasextended to theirparentsandother visitors. Thishasnotappearedinpreviousliteraturebutsupportssomeofthework ofSmithet al.45

regarding family-centredcare. Inaddition, thechildrenalsoreferredtosocialvirtuessuchashumourandpoliteness. They highlightedtheimportanceofnursesbeing ableto jokeandhave funwith them andof laughing together. Being politewasalsoanimportantcharacteristic ofthegoodnurse. Asparentsandteachersfrequently expectchildrentobewellbehaved, itispossiblethatthey lookedforthisinotherssuchasthenurseswhocareforthem.

Somechildrenobservedthatgoodnursescouldbebothgoodandbadwhentheyhadtoencouragethechildrentotakeunpleasantmedicineordosomething thatwouldbepainful. Others, suchasLuke (age12) mentioned theevilnurse (Figure7). Theydrewanddescribedextremeexamplesof badness, perhapsowing to their stageofmoraldevelopment, imaginationsorpoorlinguistic ability.

Itissuggestedthatsomechildrenappearedtobalancethegoodandbadcharacteristicsofanindividualnursewhenmaking anoverallvaluejudgement. ThisseemstoreflectKohlbergs46work onmoraldevelopment, inwhichheproposedthat, atabout10 yearsofage(theaverageageofthechildreninthisstudy), childrenbegintomakehigherlevelmoral judgements (conventional morality). At this stage children begin to considerhowactionsmay beviewedby othersratherthanwhetherthey arepunishableormeritareward. However, thisisagradualprocessthatappearstodependonchildrenslifeexperiences, genderandparentalinfluence.47

Figure 6 Stethoscopeby Dean(age7)



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Trustworthinessisanimportantvirtue.41,48Asavulnerablechildinhospital, trustin thegood characterandcompetenceofnurses is important. However, incontrast,childrenarealsoencouragedtobewary ofstrangersinanefforttomaintaintheirownsafety. Severalofthechildrenthoughtthatagoodnursewouldbewearing anidentitybadgeorsignthatdenotedthey werelegitimately working atthehospital. Karen(age8)supportedthisby voicing herconcernsthatthebadnursemightbepretending tobeanurseandhaveevilintentions, manifested, forexample, by giving incorrectamountsofmedicine. Leo(age10) suggestedthatthebadnursemightbedishonestand lacktheability toperform skillsappropriately. For Jane (age11) itwas important toseethepersonshandstoconvey trust; shedislikedseeing menwiththeirhandsintheirpocketsand felt itwasabit suspicious. Two children (Matthew, age 8, andAnna,age11) discussedtheimportanceofthenursetaking herjob seriously, concentrating

andnotmucking about. Onecouldpostulatethat, inthelightofthemalpracticeandnegligenceclaimsagainsthospitalstaffthathavefeaturedinthemedia, childrenmayhaveaheightenedawarenessofsuchissues.

Carters8study ofchildreninvolvedinacommunity nursing schemedemonstratedthe importanceof thenursebeing fun and nice. Thiswasrepeated in thisstudy,where the childrendescribedhow thegoodnursewatched televisionwith them ormadethem laugh. Ashospitalinpatients, childrenlosesomeoftheirnormalfreedomsandliveinanoftenunfamiliarenvironment. Having funhelpsthem tocopewiththisreality. Sometimesthechildrenimpliedthatthegoodnursedidnotstick totherulesandthereforemadetheirhospitalstay fun. ThishasresonancewithCookes49literaturereviewaboutscapegoating, wheresometimesanunpopularnurseisunpopularwith

colleaguesbutnotwithpatients. Popularity withthepatientsmay bebecausethenurseispatient centredandgives the impressionofbreaking afewrules inpatients bestinterests.

Theimportanceofplay washighlightedby mostoftheparticipantswhosawthegoodnurseas fun and someonewhoplayedor spent timewith them, distractingthem from whatwashappening ontheward. However, therewasanappropriatenessto thehumour, asdenotedby Anna (age11), whostated that thegoodnursecouldhaveafewlaughswiththepatientbutalsohadtoconcentrateandnotmuck about.

Figure 7 Luke(age12)



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ForSusan(age9), thenursewholackedimaginationwasdeemedboring andnotfuntobewith. Jason(age11) hadexperiencedcareinseveralhospitalsandwascriticalofsomewardswherethenursesweretooseriousandnotenoughfun.

Study limitations

Thedata collectionwas conductedoverarelatively shortperiod. More timewouldhaveyieldedmoredatafrom awiderrangeofchildren, althoughoftencertainthemesreappearedandtheamountofnewdatawasbeginning toshrink. Thissuggeststhatthebreadthofthedatawasapproaching itsmaximum.

Ideally, theresearchershouldhave includedareviewof the interview transcriptwitheachchildparticipanttoensurevalidity andreliability.32However, by reviewingthedrawingswiththechildrenshewasclarifying themeaningsbehindthem.

Thestudy excludedanumberofchildrenwhoseinclusionmay haveprovidednewdata, forexample, thosewhowerecritically unwell, mentally orphysically disabled, orhadalimitedability tospeak English. Thissuggestsareasforfutureresearch.

ConclusionThisstudy achieved itsbroadaimsof identifying those characteristics thatareper-ceivedby hospitalizedchildrenasbelonging tothegoodnurse, remedying agapintheliteratureaswellasidentifying implicationsforpractice. Someofthefindingsaresupportedby previousresearchandhighlighttheimportanceofhaving nursing staffthatarerolemodelsforgoodhealth, arecompetentandknowledgeable, andhaveanunderstanding oftheneedsofchildren. A fundamentalneedforhospitalizedchildrenisthattheirfamily isincludedintheircareprovision.45,50 Childrensnursesalsoneedtobeabletocombinetechnicalskillswiththecharacteristicsthatareappreciatedbychildren, suchasbeing funandbeing abletoincorporatefunintocareactivities. Thisisintegraltochildrensnursetraining,wherechilddevelopmentislinkedwiththepracticaluseofage-appropriate toysandactivities, plusdistraction techniques. However, inthepracticeareathiscanbeaforgottenaspectofnurses scopeofknowledgeastheyaddressthemoretechnicalaspectsoftheirrole.

Although children may not have fully developed the linguistic skills necessarytostate theiropinions, this study demonstrates that they haveanunderstanding ofmeaningfulcareby goodnursesandarecapableofcommunicating thistoothers. Inaddition, despitetheirlimitedlifeexperiences, thechildreninthisstudy wereabletodemonstrateinsightsintopossiblereasonsforpoornursing behaviour. Indeed, someofthem hadbeguntoexhibitadeveloping senseofmoral judgementregarding thecomplexitiesofgood andbad. Althoughtrustworthinessofthenursewasvalued,theolder childrenweremorediscerning. Trustworthiness included theability tobetruthfulabout futureunpleasantproceduresand treatments, andalso tobepromptandcompetentindealing withthechildren. Thechildreninthisstudy weresensitivetowhetherornot thenurse liked them. They appeared toappreciate being valuedpositively, asdemonstratedby thenursebeing attentive, spending timewith them,andusing praiseandendearing termswhencommunicating withthem.



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Furtherresearchconcerning theperceptionsofthegoodnursecouldincludemorein-depthstudiesusing abroadersampleofchildren, including thosewithchronic dis-abilitieswhoexperiencefrequentnursing care. Itwouldalsobeofinteresttoaddresswhichcharacteristicsareascribedgreaterimportanceby childrenwhenusing aquanti-tativemethodandtoresearchwhetherthishierarchy ofcharacteristicschangeswithageandmaturity.

Conflict of interest statement

Theauthordeclaresthatthereisnoconflictofinterest.

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