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2012 16: 91 originally published online 13 January 2012J Child Health CareDuncan Randall

community nursingChildren's regard for nurses and nursing: A mosaic of children's views on

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Article

Childrens regard for nurses

and nursing: A mosaic ofchildrens views oncommunity nursing

Duncan RandallNursing and Physiotherapy, School of Health and Population Sciences, College of

Medical and Dental Sciences, University of Birmingham, UK

Abstract

In thepast decade there has been both an increase in the number of children who receive nursing care intheir communities rather than in hospitals, and an increasing willingness to listen to children. Thisqualitative study used Clarks Mosaic approach to elicit childrens views of community childrensnursing. Twenty-one children took part in total, with seven children making up a core group who par-ticipated in a number of activities for over a year. A non-core group of 14 children were observedreceiving care from six communitychildrens nurses. The children haddiverse medical conditions, wereaged from 11 months to 17 years old and came from diverse social, ethnic and cultural backgrounds.Some children expresseda positive regardfornurses and nursing. Some children a negative regard, oth-ers were ambiguous.From these data it is proposed that there is a continuum of regard for nurses. Howchildren regarded nurses did not seem to be related to the nurses actions, but to the childs under-standing of their illness and their involvement in care. Further study is required to clarify the conceptand should focus on what effect childrens regard for nurses and nursing has on health outcomes.

Keywords

community care, nursepatient relationship, patient participation, qualitative approaches

Introduction

Much of the research on childrens views of nursing comes from hospital settings (Carney et al.,

2003; Coyne, 2006), even though more children are now surviving previously fatal illness, trauma

and medical procedures, and requiring ongoing nursing care in their communities (Glendinning

Corresponding author:

Duncan Randall, Nursing and Physiotherapy, School of Health and Population Sciences, College of Medical and Dental

Sciences, University of Birmingham, 52 Pritchatts Road, Edgbaston, Birmingham B15 2TT, UKEmail: [email protected]

Journal of Child Health Care

16(1) 91104

The Author(s) 2012Reprints and permission:

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et al., 2001; Earle et al., 2006). It might be expected that children receiving care in community

settings, often at home, would have a different experience of nursing than children on a hospital

ward, but very little research has focused on how the community setting influences how children

receive nursing care. The concept of community childrens nursing may be particularly British,

however, in many other countries children live at home and receive ongoing nursing care (Earleet al., 2006; Oktem et al., 2008).

Background

Over the past decade there has been a growing willingness to listen to children when considering

how to develop health services (Coad and Shaw, 2008). In part this has been influenced, in the UK,

by the public patient involvement agenda (DH, 2002, 2004, 2007) and in part it has been facilitated

by research which has shown that children can provide sophisticated and useful insights into their

social worlds and nursing care (Prout, 2001; Carter; 2005; Coyne; 2006; Moules, 2009). An accep-

tance that children are competent commentators on the services that they receive underpins Clarks(2005) mosaic approach which was used in this study. Clark sets out three aspects which give the-

oretical support to her approach, these are that children are competent to comment on their own

social worlds (Prout, 2001; Mayall, 2002); that participatory methods can empower children (Inter-

national Institute for Education and Development, 2001; Kemmis and McTaggart, 2005); and that

understanding about childrens social world is co-created between adults and children (Edwards

et al., 1998)

A search of the literature using Parahoos (2006: 137) suggested steps identified very few stud-

ies, in the main studies were identified by the authors own experience and connections as a lec-

turer rather than by the search strategy. The lack of previous studies perhaps forced a more

exploratory approach, rather than allowing a more restricted or targeted approach. The reviewof the literature did identify three issues which challenge the quality of the evidence presented

in previous studies of childrens perceptions of receiving care in community settings. Firstly, very

few of these studies detail how the research relationships between children and adults were man-

aged. Secondly, the rigour of these studies is highly variable. Often the method is poorly described

and none of the studies state whether the data analysis was open to independent review. Thirdly,

most of these studies use methods adapted from adult research, such as interviewing, rather than

methods which might use childrens cultures of communication (Christensen, 2004).

The literature on childrens views of nursing has been focused more on hospital studies (Carney

et al., 2003; Coyne, 2006) than community settings. Of those studies that do deal with community

settings only Carter (2005) provides a discussion of the research relationships between adults and

children. None of these studies takes a mosaic approach that includes the observation of nurses

practice in community settings as well as participatory methods.

Method

Design

In this study Clarks (2004, 2005) mosaic of methods was extended to a mosaic of methodologies.

Phenomenology, ethnography and visual methodologies were used to capture different aspects of

childrens experiences and to offer children different ways in which they could participate in the

study. All of these methodologies come from a qualitative interpretive tradition (Parahoo, 2006)which offers a unifying framework for the use of these methodologies.

92 Journal of Child Health Care 16(1)

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This study was approved by a Local Research Ethics Committee (ref. 05/Q2706/53) under the

Central Office for Research Ethics Committees framework, a predecessor of the National Research

Ethics Service. It was also approved by three NHS research and development departments in sep-

arate NHS institutions. The work of the principal investigator (PI) was overseen by a supervisory

team from the University of Warwick.Because this study was about childrens experience of receiving nursing care, a purposive sample

of children aged 512, who had ongoing experiences of nursing was sought. To be included in the

study the children had to live in the study area and receive more than one visit from the nurse per

month, and to have been doing so for more than six months. The initial approach to children and fam-

ilies was made by nurses working with the children. Children were excluded from the study if the

nurses working with the children felt that participation may be harmful to the child or their family.

These inclusion and exclusion criteria were designed to allow as many children as possible to take

part. The criteria did not focus on medical conditions. Interpreter services and communication

experts were available to facilitate childrens communication. Although the sample is not large in

number (n 21), the data collected gave rich insights into the childrens lives (Reitmanova, 2008).

Data collection

The use of a mosaic of methodologies in a framework of qualitative research gave rise to a mosaic

of methods. Although in practice these methods to some extent influenced each other they can be

grouped into the following stages: researcher bracketing interviews; first arts-based group activi-

ties; photo talk diary; observation visits; second arts-based group activities; and observation of

nurses working days.

Researcher bracketing interviews. Two interviews involving the principal investigator and an insight-ful and critical colleague were undertaken, each lasting approximately one hour. The interviews

were recorded and transcribed.

Arts-based group activities (core group children). Two groups were held with the core group children.

Both groups were preceded by a social trust building event hosted by the research team to which

children and their parents were invited (an evening of bowling with a snack meal), both groups

were held in an arts venue with no connection to healthcare services (a regional theatre). A range

of arts-based activities were used including word selection, ranking helpful people, drawing, pup-

pet making, six-part story creation and other theatre-based activities. The groups were facilitated

with help from co-workers (CWs) who were either student childrens nurses or specialist arts thera-pists. The research team (principal investigator and co-workers) met before and after each group to

ensure a consistent approach and to debrief.

Photo talk diary. Core group children were asked by the principal investigator to complete a diary of

their nurses visits. To help them in this each child was given an activity book with a series of activ-

ities to guide their diary making. Each child was also given a disposable camera with 24 exposures,

and a digital dictaphone. The children were encouraged to use the camera and the dictaphone in

any way they liked to record how they felt about their nurses visits. The children were given a

two-week period, or at least enough time for two nurse visits to make their diary. Parents were

encouraged to help their children in making their diary, but reminded that it should be the chil-drens own work. Once the diaries were complete they were collected and copied, by the principal

Randall 93

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investigator, before being returned to the child. The child was then interviewed about the diary.

This interview was conducted in the childs own home away from their main carer, privacy for the

child was negotiated with other people living in the house, a co-worker sat in on these interviews.

Observation visits. Early analysis of data showed that some aspects of nursing were not reported bythe children (e.g. how nurses taught parents to deliver care). To determine whether these aspects

were present, but not the focus of childrens talk, participant observation was used. Four of the core

group children, two with negative and two with positive regard for nurses, were observed by the

principal investigator before, during and after receiving care at home.

Separately, six nurses were also observed by the principal investigator over their working day

(8am5pm). The children observed in the course of observing the nurses made up the non-core

group of children. These children were observed receiving care, but not formally interviewed.

Because of a lack of previous observation studies no observation schedule was used, instead exten-

sive notes were taken both in the field and immediately after the observation periods. Core group

children and the six observation nurses were interviewed immediately after the observation period.In these post-observation interviews one child was interviewed with his mother present, but for the

other three mothers were either not present or were in the background.

All interviews were recorded on audio tape with the participants consent. Where children made

images these were copied and a copy given to the child. The data were collected between August

2005 and October 2007.

Data analysis

The data generated in this study were both textual (transcripts from interviews, dictaphones, obser-

vation field notes, text written by children) and visual (images made by the children including

photographs, video images and drawings). Visual images were analysed in their own right, using

text descriptions of the image, detailing the images, method of production, content and intended

audience, as suggested by Harper (2003). The textual analysis was aided by the use of Nvivo (ver-

sion 7) computer software.

The textual and visual data were analysed together using Colaizzis framework (1978) as set out

by Beck (1994). All of the data were reviewed in an iterative process in which codes were created

each with an inclusion and exclusion criteria, new data was allocated to codes according to these

criteria. The codes were then organised into an axial or tree structure. Counter cases were consid-

ered. Finally short statements were generated which attempted to encapsulate the early findings,

and these were put to the core group children at the final group, as a part of participant verification.

Findings

Participants

Twenty-one children took part in this study; seven children made up a core group and these

children were recruited by community childrens nurses and took part in the arts-based group

activities, photo talk diaries and four were observed receiving care. A separate non-core group

of 14 children were observed receiving care during the observations of the six nurses working day.

In the core group childrens participation was variable. One child participated in all aspects of the

study, but others declined some activities and some children on occasions were too ill toparticipate. The seven children who made up a core group had a variety of medical diagnosis, and


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came from different family, cultural and ethnic backgrounds and have experience of different

nursing interventions (see Tables 1 and 2, the names used are research pseudonyms chosen by the

children themselves). In the exemplar extracts, the principal investigator is denoted as PI.

In addition to this a non-core group of 14 children were observed receiving nursing care during

participant observation studies of six nurses during their working day. The nurses and childrencame from two study areas one urban area and one rural area with large settlements. These

non-core group children also had diverse backgrounds and received a variety of nursing interven-

tions (see Table 3).

Context

The concept of childrens regard for nurses and nursing put forward here needs to be seen in context.

The children in the study presented themselves as like other children (Randall, 2011). The first thing

they spoke about was their family, their friends and their school and communities. The childrenendorsed the following participant verification statements derived from early data analysis:

I dont like to think about being ill. I prefer to think about playing with my friends and being with my

family.

I would rather have my mum or dad do all the things I need to keep me well, than have nurses visit me

at home.

The children did not endorse the statement that:

A good nurse is fun, but also knows how to do things right to make me better, they respect me as a

person and work with my family and friends.

Children with positive regard for nurses

The focus in this paper is to report on the concept of regard for nurses and nursing, other aspects of

this study are reported elsewhere (Randall, 2010, 2011) The data quoted below shows how some of

the children had a positive regard for nurses. These children understood and were able to articulate

the reasons they had a nurse visit them (see Figure 1). They also seemed to have a better under-

standing of their illness:

PI Why does a nurse come and see you?

Nanny To have my needle.

PI You have a needle? OK why do you have a needle?

Nanny Cause I have growing spurts.

PI You have growing spurts. So what does the needle do?

Nanny Makes me not grow as quickly.

PI Right OK, so is there something, is it a medicine that you have?

Nanny Yeah.

PI Right OK.

Nanny Its like medicine in the needle.

(Nanny: photo talk diary interview)

Randall 95

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Table1.

Coregroupchildrensdem

ographicdetails

AgeGenderEthnicity

Religion

Familystructure

(liveswith)

Household

income()

Housetenure

Maternaleducation

(agelefteducation)

Paternaleducation

(agelefteducation)

Hon

ey

7

Female

Mixed

Muslim

Mother&younger

brother

18,2

0031,200Mortgage

Degree(21)

GCSE

(16)

Nan

ny

8

Female

White

ChristianFosterparents

31,2

0052,000Mortgage

Diploma(18)

Degre

e(22)

Mohammed6

Male

Asian/As

ian

British

Muslim

Bothbiological

Parents&2older

Brothers

18,2

0031,200Own

NVQ2(18)

Certificate(16)

Gizzmo

6

Male

White

ChristianMother&2older

brothers

5,20018,2

00

NonrentLo

cal

Authority

None(16)

None

(16)

Kelly

9

Female

White

None

Mother&younger

brother

5,20018,2

00

NonrentLo

cal

Authority

BETEC(18)

None

(16)

Joan

ne

12

Female

Asian/Asian

British

Muslim

Bothbiological

Parents&

extendedfamily

10siblings

5,20018,2

00

Mortgage

GCSE(18)

Aleve

l(18)

Note:Rabbitattendedgroupactivitiesbutnodemographicdetailswerecollected.

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Table 2. Nursing care received by core group children

Numberof named

nurses

Numberof nurses

visiting

Timereceiving

care (years) Frequency of visitsCaretasks Pain

Honey 2 4 1.5 Fortnightly Multiple Sometimes PainfulNanny 1 5 0.75 Monthly Injection Painful procedureMohammed 0 4 5 Three times per week Dressings Sometimes PainfulGizzmo 2 3 0.5 Fortnightly Multiple Sometimes PainfulKelly 1 6 1 Weekly Injections Painful procedure

Joanne 1 2 2 Weekly Injection Painful procedure

Table 3. Non-core group childrens demographic details

Age (yrs) Gender Reason for receiving nursing care Nursing interventions observed

8 Female Oncology condition Flushing of long line17 Female Oncology condition Thumb prick test0.9 Female Complex health needs sequela to

prematurityRespite including enteral feeding, parental advice

3 Female Liver disease Taking off total parental nutrition2 Male Tracheostomy Respite including suction-health advice to parents16 Male Oncology condition Flushing of long line12 Female Cerebral Palsy (profound)

disabilityJoint visit with social worker, weight, enteral feeding

advice10 Female Arthritis Injection16 Male Abscess Dressing

4 Male Metabolic disorder Injection2.5 Female Oncology condition Flushing of long line14 Male Abscess Dressing6 Male Constipation Advice3 Female Abscess Dressing

Figure 1. Image from Nannys photo talk diary

Randall 97

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PI What if we did this thing from sort of 10 is the well, the best you could be, and zero is like

very, very ill.

Kelly I wouldnt think I was like really ill. I wouldnt think I was that.

PI What would you say what sort of number would you put on it?

Kelly I would like, just, just over 5PI OK put a cross or something.

Kelly About 7.

PI A 7, oh OK. So what makes you well do you think?

Kelly Umm, like my needles make me well.

. . .

PI If you didnt have the nurses where do you think you would be on that nought to 10?

Kelly I would be about on number, on number 3.

(Kelly: interview after observation)

These childrens mothers and nurses allowed them to be involved in receiving care. This invol-vement took different forms. For example, Kelly used an ice pack which she got for herself and

placed on the injection site with no prompting, while Nanny used counting to control when the

injection was given.

Children with a positive regard for nurses found it difficult to suggest ways in which nursing

services could be improved. As can be seen from the data quotes below both Kelly and Nanny

continued to express positive regard for their nurses, despite their view of the nurses being

challenged:

PI In your diary you were talking about how when your nurses came and they had real

fun with you they tickled you, but when [names CCN] came today she didnt dothat, she didnt tickle you didnt play any games with you or [names brother] she

pretty much came, gave you your injection, wrote the notes . . .

Kelly . . . and went

PI and went yeah

Kelly because sometimes like the nurses that tickle me like theyve been to every single

house and Im like the last one so

(Kelly: interview after observation)

Co-worker 4 Yeah but what about the not so good nurse?

Nanny Ive never had a not so good nurse.

Co-worker 4 . . . You must know what makes a good nurse, so what do you think would make anot so good nurse? Can you think of anything that you wouldnt like?

Nanny Well I had a doctor put a needlein me when he saidI promise I wontdo it, and he did it.

(2nd childrens group)

Children with a negative regard

Other children in the study had a negative regard for nurses. The data quote below from a post

observation interview with Gizmo is perhaps typical of how these children were less clear about

why they were visited by nurses and did not seem to have as good an understanding of their illness,

as children with a positive regard.


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PI Because you go to the hospital a lot dont you?

Gizmo Yep.

PI . . . and you go see a doctor?

Gizmo Yep.

PI . . . and you have nurses come?Gizmo Yep, its stupid.

PI You dont need them really. Because you are perfectly well? No [Gizmo shakes head]

You do need them, yeah [he nods]. Because you are poorly yeah [he nods].

. . .

PI Why do you think you are poorly?

Gizmo Because I am.

PI Because you are, what is it that makes you poorly do you think?

Gizmo Mmm, one answer.

PI One answer, yep.

Gizmo I dont know.(Gizmo: interview after observation)

These children were often difficult to engage when talking about nurses or nursing. Honey, for

instance, made no images of her nurse, and often answered only with a nod or shake of her head.

However, she was a keen artist and was able to engage with the researchers in social activities:

PI Why didnt you like doing it [the photo talk diary]? Because you love drawing dont you? . . .

Yeah. Was it because it was about nurses? Yeah. Do you not like your nurses? No, youre

shaking your head.

(Honey: photo talk diary interview)

The children with a negative regard appeared to be less involved in the care they received. Dur-

ing the observation of Gizmo he was held by his mother while a nasogastric tube was passed. The

children were not passive in receiving care, Gizmo wanted the tube put into the same nostril, but

was overruled by the nurse (see field notes below). The involvement allowed by adults (parents and

nurses) was often restricted for children and this seemed to be especially so for children with a

negative regard:

CCN ready, suggested Gizmo taken on to Mothers lap, Mother cradles Gizmo restraining his arms as

she removes his old tube. CCN suggests different nostril for NG tube. Gizmo upset wants the same side.

CCN insists, some explanation, do not want to get sore. Mother restrains Gizmo while tube is inserted,

Gizmo very upset crying. States he hates nurse. When over cuddles into Mother. (Field notes observa-

tion Gizmo)

Like the children with a positive regard, children with a negative regard also found it difficult to

articulate how nurses could improve the services they offered. As the data quote below with Gizmo

shows, perceptions of the care they received also did not change, despite being challenged by the

researcher:

PI How are the ones [the nurses] who come and see you at home different then do you think?

Gizmo Dont like them I hate them.

Randall 99

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PI I know, I know, you said that. Why is that?

Gizmo Pulling my tube.

PI What about when they come and give wiggly* a drink whats that like?

Gizmo The same.

PI Yeah [pause].Gizmo Put that one on as well.

PI How do you think they could make it better for you, the nurses?

Gizmo By playing.

PI By playing a bit more [names CCN] did didnt she? When she came in you were playing

doggie, you were hiding in there, yeah. She came and tickled you didnt she?

Gizmo She made me laugh.

PI Do you remember that?

Gizmo She never found me though.

PI She did ! She was playing a game with you though wasnt she?

Gizmo Yeah, but the idea is to play more games than one game.PI Yeah spend a bit longer with you, would that help mmm . . .

Gizmo But not the tube.

PI No the tubes do, dont like the tube, but does the tube make you better?

Gizmo Yeah.

PI Yeah and it has to be changed doesnt it?

Gizmo I hate it though.

(Gizmo: interview after observation)

* Wiggly is a common name for a central venous catheter

A continuum of regard for nurses

These children from the core group with positive and negative regard for nurses perhaps mark the

extremes of regard for nurses. Other children in the core group like Mohammed, Joanne and Rabbit

were ambivalent about nurses or had a mixture of more positive and more negative regard. The

extract below points to how Mohammed understood his illness but did not hold nurses in either

particularly positive or negative regard.

PI Why do they come and do dressings?

Mohammed Because I got poorly skin.

PI Poorly skin? How long have you had poorly skin?Mohammed For a hundred years

PI Hundred years?

Mohammed Since I was born new baby

(Mohammed: photo talk diary interview)

PI When a nurse comes to see you at home, what happens?

Mohammed They dont come Monday, Tuesday, Wednesday

PI What sort of thing happens when they come, what they do?

Mohammed Nothing.

PI Nothing?

Mohammed They just do my dressings.(1st childrens group)


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Childrens position on this continuum of regard for nurses and nursing may be determined by

their understanding of their illness and the extent to which adults allow them to be involved in

receiving care (see Figure 2).

In this study the childrens regard for nurses did not seem to be influenced by whether theintervention they received was painful. Children with both positive and negative regard stated

that what nurses did was painful. Nor did a difficult diagnosis seem to affect childrens views,

both Kelly and Honeys mothers reported that the girls had symptoms which went untreated for

some time before eventually being diagnosed and accessing treatment, but they had different

regard for nurses.

Eliciting the understanding of children in the non-core group was more difficult because of

the short period of observation. The opportunities to address the relationship between children

and the researcher as an adult were restricted by the nature of the observations of nurses

work. The time spent with the children was determined by the nurses and was often brief.

There was little opportunity to talk to children away from their adult carers. Children whodid attempt to express negative views of nurses were often deemed, by nurses as, grumpy

or hospitalised. However, the observation of non-core group children did reveal similar stra-

tegies used by the children to be involved in receiving care as demonstrated in the field notes

below:

[The] Family are tired back from holiday late last night. Mother opens negotiations checking when

ready mentions sing song. CCN 10 distracts by discussing auntys holiday gifts. Mother insists time

for inject; Child C resists protests, child delays talking about future holiday plans. Bribed with cuddle

from dad, threatened with removal of dads cuddle. Child C takes Mr Bump [an ice pack] off throwing

it away and hides beneath cover (gives permission to do injection takes control) injection done. (Fieldnotes observation of CCN10)

ve +ve

Negative regard for nurses

Not rationalised

Associated with poor

understanding

of illness

Less involved in own care

Positive regard for

nurses

Rationalised (they make

me better)

Associated with good

understanding of illness

More involved in own

care

Increasing illness understanding and involvement incare

Increasing positive regard for nurses

Figure 2. Continuum of childrens regard for nurses

Randall 101

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Discussion

Limitations of the study

Guba and Lincoln (1989) suggest that the concepts of credibility, dependability, confirmability and

transferability are used to asses an overall trustworthiness of a piece of qualitative research.Credibility in this study was enhanced by the triangulation of data over time, as data were col-

lected from children at separate times of day, for over a year. The triangulation of space was

addressed by collecting data in group settings as well as in the childs own home, and the triangu-

lation of persons was met by collecting data from children, parents and nurses. The use of parti-

cipant verification also adds to the studys credibility (Polit and Beck, 2004). Dependability and

confirmability were addressed by the triangulation of data and by the researchers interpretations

of the data being scrutinised by two supervisors and an independent childrens nursing expert.

Transferability is addressed by giving a detailed description of the childrens backgrounds (see

Tables 13).

In addition to trustworthiness the actions of gatekeepers, as described by Cree et al. (2002),need to be considered. Some adults, acting as gatekeepers, found the idea of children holding

negative regard for nurses difficult and there was some evidence that adults agreed to childrens

participation only if they felt the child would give a positive view. The findings may therefore

be biased towards a more positive view of nurses and nursing. Staniszewska and Henderson

(2004) found a similar positive bias in their study of adults views of healthcare.

Although it is suggested here that the findings of this study point to a continuum of regard for

nurses and nursing it is also possible that childrens regard is part of an adaptation to living with

illness. Because this was not a cohort study, it is possible that children could be at different stages

of adaptation.

Implications

While hospital studies of childrens views of nursing have focused on the personality and compe-

tency of the nurse (Brady, 2009) and on the disruption to the childs normal life as caused by hos-

pital admission (Coyne, 2006), previous studies have not focused on how children regard nurses.

However, the findings of this study seem to suggest that children receiving care in both hospital

and community settings focus more on their family and friends than they do on nurses and nursing.

Studies conducted in community settings have also focused on the nurses personality and satisfac-

tion with services (Sartain et al., 2000, 2001; Carter, 2005), rather than how childrens understand-ing of care and involvement in care might effect how they receive care. In some studies the

construct of good and not so good (bad) nurse has been used (Carter, 2005; Randall et al.,

2008; Brady, 2009), but the findings of this study would suggest that children with negative regard

for nurses will focus exclusively on the not so good aspects and those with a positive regard will

report only the good aspects.

This study does not indicate whether childrens regard for nurses is an important concept. As

can be seen from the data extract above from the observation of Gizmo, children with negative

regard for nurses, even those who vocalise such a view, still received nursing interventions. There

may be long-term psychological problems which originate from children being forced to receive

care, but as yet there is little evidence to support such a view. Restraining children, which may, in

effect, force treatment on to them, is an accepted practice in childrens nursing (RCN, 2010).


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Guidance for nurses justifies such restrictive physical intervention or therapeutic holding on the

basis that it is in the childs best interests as it facilitates delivery of care (RCN, 2010).

The findings of this study could constitute what Meleis (2007) has described as concept explo-

ration, where a concept not currently within the lexicon of nursing is identified. The concept here is

that children have negative and positive regard for nurses. As Meleis points out, the concept can beone which is familiar to nurses in their daily practice, but which has not been articulated and

explored. The next step is to clarify the concept through further study and research.

Acknowledgements

This study was undertaken as a part of doctoral study at the University of Warwick (Randall,

2010). Thanks are due to Dr Clare Blackburn and Dr Ann Adams, of the University of Warwick

who acted as supervisors and Professor Jane Coad (Coventry University) who advised on the proj-

ect as an independent childrens nursing expert. Thanks are also due to Dr Robert Williams (Uni-

versity of Birmingham) for his help with the researcher bracketing interviews.

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