Journal of Clinical Nursing 1993; 2: 279-286

Nursing diagnosis in sick children's nursing

CHRISTINE WEBB BA, MSc, PhD, SRN, RSCN, RNTProfessor of Nursing, The University, Manchester M13 9PT, UK

GERALDINE MASON BA, CNS, RSCN, RGN, RCNT, RNTNurse Teacher, North Manchester College of Health Studies, Manchester M86RL, UK

Accepted for publication 11 March 1993

ii,(r,. o!, Rs .•j

Summary

• The North American Nursing Diagnosis Association (NANDA) is receivingincreasing attention in the UK, following 40 years of development in the USA.

• A study of care plans in children's wards shows that nurses fail to identifycomprehensively children's and families' nursing needs.

• The potential of using a system of nursing diagnoses to facilitate nursingassessment in children's wards is discussed.

Keywords: care plans, need, nursing diagnosis, patient allocation.

Introduction

This article begins with a review of the literature relatingto the use of nursing diagnoses as a stage in care planningin paediatric nursing. Nursing diagnoses have been de-veloped in the USA over the past 40 years, and theAmerican literature focuses on establishing the role of thenurse as a diagnostician, and on identifying, classifying andvalidating nursing diagnoses.

The leading organization for nursing diagnosis develop-ment in the USA is the North American Nursing Dia-gnosis Association (NANDA), which meets regularly toreview and update its taxonomy of nursing diagnoses. Amore detailed review of the literature relating to nursingdiagnosis in general has previously been published hyMason & Webb (1993).

The article then reports on a study which was carriedout in the UK. It involved a care plan analysis in children'swards to investigate the identification by nurses of chil-dren's and their families' nursing needs, in order toascertain whether the use of nursing diagnoses might bedesirable.

The identification of hospitalized children's (andtheir families') nursing needs, using nursingdiagnoses

Children's nursing needs diflfer from those of other patientpopulations because of their physical and psychologicalimmaturity. A paediatric nurse's ability to identify ahospitalized child's (family's) nursing needs is fundamen-tal for initiating the appropriate interventions, and evaluat-ing the quality of care that is provided. In spite of this,very few studies have been undertaken to ascertain whatneeds of such children are amenable to nursing manage-ment. Studies in North America suggest that paediatricnurses are increasingly using the concept of nursingdiagnosis for this purpose (for example Burns & Thomp-son, 1984; Hauck & Roth, 1984; Derechin, 1987; Kenner &Hern, 1988; Starn & Niederhauser, 1990). According toHauck & Roth (1984), it allows nurses to highlight qualitynursing care that would otherwise be unidentified andundocumented. t

Nursing diagnosis follows assessment in the nursingprocess cycle. It involves the interpretation of assessment

279

280 C. Webb and G. Mason C : S JQiH

data to identify the needs or problems of clients, which areamenable to nursing care. The development of a nursingdiagnosis association in North America (NANDA) hasprompted nurses in all clinical spheres to analyse theirpractices in the identification of clients' problems or needs(Carroll-Johnson, 1989). NANDA offers a taxonomy ofnursing diagnoses which American nurses use in clinicalpractice.

In the UK several writers have indicated that paediatricnurses are applying the principles of nursing models,nursing process and primary nursing to their clinicalpractice (for example, Glasper, 1990; Gahan, 1991; While,1991). However, there is no research evidence to show thatthe principles of needs identification are widely utilized inchildren's hospital wards, and no mention is made ofnursing diagnosis. In order to determine the utility ofnursing diagnosis for UK paediatric hospital practice,three areas will be addressed:• paediatric nursing diagnosis in the USA,• studies which are associated with children's needs iden-

tification in the UK,• evidence of fieldwork conducted at one children's hos-

pital in the north of England.I ' b '

Paediatric nursing diagnosis in the USA un

Several authors have recently adopted and/or developednursing diagnoses for use in the paediatric clinical setting.The intention, it appears, is to demonstrate how children'snursing needs can be identified using NANDA-type classi-fication systems (Hauck & Roth, 1984; Burns & Thomp-son, 1984; LeBoeuf & Greco-Gallagher, 1987; Derechin,1987; Kenner & Hern, 1988; Holden & Klingner, 1988;Burns, 1991). Some authors provide diagnoses for aspecific situation. For instance, Holden & Klingner (1988)examined the differences in how inexperienced and expertnurses diagnose why an infant is crying. The studyprovides a good example of how nursing and parentaldiagnoses are used to determine the cause of an infant'scrying behaviour. It also illustrates the benefits of includ-ing parents in nursing diagnostic activities.

In comparison, Kenner & Hern (1988) offered anexample of how to use nursing diagnoses to describe thenursing needs of a child who has complex, medically basedproblems. However, the nursing diagnoses given weremainly physiological (five out of seven with a sixth relatingto impaired physiological development) and they alsoincorporated medical diagnoses, which can be confusing.

Hauck & Roth (1984) proposed that 'hunches and vagueassessments' can be transformed into nursing diagnoses if

nurses are encouraged to think about assessment data anduse their professional judgement to decide upon appropri-ate actions. Their work was based on early diagnosticcategories identified by NANDA and provides an excellentexample of successful application of nursing diagnoses tothe paediatric setting. Using a case study approach of a'typical' family seen at the clinic, Hauck & Roth (1984)highlighted a family with multiple nursing needs, many ofwhich could be overlooked if nurses follow a medicalrather than a nursing approach to their care.

Burns & Thompson (1984) and Burns (1991) are theonly authors reviewed who have devised and tested anursing diagnosis classification system for paediatricnurses [specifically Paediatric Nurse Practitioners (PNPs)]based on the Omaha Visiting Nurse Association (VNA)Taxonomy (Simmons, 1980); the Minnesota Child &Youth Projects Nursing Problem Scheme (US Depart-ment of Health & Human Services, 1977) and a selectednumber of medical diagnoses utilized by PNPs, taken fromthe International Classification of Diseases System (ICD,1978—cited in Burns & Thompson, 1984).

Finally, Burns (1991) has recently published a newtaxonomy for PNPs which she stated can be adapted toother specialties. She argued that: 'Documentation of thescope of diagnostic practice is important to nursing forreimbursement, legal protection, research, and purposes ofstaffing needs assessment' (p. 93). Once again this emphas-izes how US nurses perceive diagnostic activity as partrepresentative of their raison d'etre. Several eonclusionscan be drawn from this study. It shows that PNPs arestarting to delineate their role parameters through dia-gnostic reasoning and this appears to advance their qualityof patient care (Burns & Thompson, 1984). It demon-strates that, by focusing on the identification of a person'sneeds, nurses are increasingly in a position to describetheir independent functions (Burns, 1991). It also shows,however, the extent of overlap between medical andnursing care provision. This is highlighted by the largenumber of disease/physiological diagnoses and may beexacerbated by the rapidly extending role of the US nurse.Burns (1991) argued that this problem can be minimizedby defining needs from the patient rather than the profes-sional perspective.

To conclude, it appears that the introduction of paedia-tric nursing diagnoses and diagnostic classificationschemes are positively regarded in tbe USA. Tbe authorscited in this article describe how such schemes enhanceclinical practice, and they make recommendations forfurther developments. They also provide a foundation fordebate regarding tbe introduction of paediatric nursingdiagnoses in the UK.

' • ; • (

Nursing diagnosis in sick children's nursing 281

Identification of hospitalized children's(families') nursing needs in the UK

In the UK, very litde research pertains to the identifica-tion of hospitalized children's (and their families') nursingneeds. One possible reason for this is that up to the presenttime no conceptual framework has been designed exclu-sively for the paediatric setting. Instead, authors havetended to concentrate upon adapting general nursingmodels (Galligan, 1979; Cheetham, 1988), In addition tothis, it is claimed that the medical focus of care stillpredominates in paediatric hospital practice (Miles, 1985),This has probably discouraged a proper analysis of theRSCNs (Registered Sick Children's Nurse) role in identi-fying and responding to children's nursing needs which donot arise from a medical diagnosis.

Four studies provide some background insight into thepractices of paediatric nurses in identifying children'snursing needs. The first three (Hawthorne, 1974; Don-nelly, 1986a,b; Oates, 1992) concentrated more uponactual care that is given, whilst the fourth (Long, 1991)attempted to define the functions of a children's nurse.

Hawthorne's (1974) now famous study of the nursingcare of children in hospital identified two importantconsiderations for clinical practice. The first was that largenumbers of staff are involved in the daily care of eachchild, and the second was that nursing stafi" do not alwaysunderstand the needs of children. Essentially she showedthat nurses provided task-orientated rather than patient-centred care, and it is evident from Hawthorne's (1974)conclusions that nurses neglected to identify properly thenon-medical nursing needs of children in their care. Thisresearch represents an important milestone for children'snursing. It has become very infiuential in the reform ofnurse education and practice, because it forced nurses toexamine the effects of their actions on children and theirfamilies.

Donnelly's (1986a,b) study was set up under the aus-pices of a health authority in the north of England andfocused upon the quality of care that children receive. Itaimed to show that the provision of good quality nursingcare was not necessarily dependent upon increasing thenumbers of staff in a given unit. In order to do this,observers were used to assess the type of care whichchildren receive and the extent to which they are depend-ent on nursing staff to meet their needs. A high quality ofnursing care was reported and recommendations centredon better management of nursing resources.

Oates (1992) offered a fresh approach to the investiga-tion of quality child care by carrying out a survey amongstparents in one hospital ward. She aimed to measure the

quality of care, improve parent-staff relations and high-light areas of excellence and areas which are in need ofimprovement. Oates (1992) identified several areas ofexcellence, for example, the basic facilities which areoffered to parents. She also found that parents want to beinvolved in the treatment of their children (she did notspecify what type of treatment), but that only half of thosesurveyed actually were. Furthermore Oates consideredthat nurses may not be identifying all of a family's needs.Her recommendations related to the unit where the re-search was undertaken but are likely to be applicable toother children's hospital wards. By focusing on specificareas of practice, however, the study does not offer ageneral system for improvement or maintenance of highstandards that can be generalized to any aspect of care.

Finally Long (1991) devised a small-scale inductiveStudy, in which he hoped to define the complete role of thechildren's nurse. From this, he offered 10 categories whichtogether, he claimed, provided such a definition.• Advocacy, • Care by the family,• Psychological care, • Screening,• Problems peculiar to children, • Awareness,• Interpersonal skills, • Family dynamics,• Other workers, • Ethics.He believed that non-RSCN managers might functionmore effectively if they were made aware of his criteria.Whilst this could be investigated. Long's findings shouldbe tested for their validity and reliability in other paedia-tric settings.

To summarize, these four studies represent the efforts ofmany RSCNs to define their clinical practice. Theydemonstrate how children's nursing is moving away from aprimarily 'medical/assisting' role, to one of greater auton-omy in which nurses initiate and manage several aspects ofa child's (family's) health care. Long's (1991) work isparticularly useful in that it represents an up-to-date,research-based attempt to provide a conceptual definitionof children's nursing.

In spite of such efforts, it is disappointing that noresearch-based examples of specific nursing needs areavailable in the UK. These would be of particular benefitin education and practice, to assist RSCNs (and students)to focus upon nursing as well as medical care. With this inmind, it is tempting to recommend the adaptation of USpaediatric nursing diagnoses (for example, Hauck & Roth,1984) to suit the UK setting. However, it has not beenascertained that RSCNs are omitting to identify hospita-lized children's (families') nursing needs, using their pre-sent methods of work organization. Consequently a care-plan analysis was carried out in six wards in one children's

282 C. Webb and G. Mason KJs

hospital in the north of England, to determine what needsof children (families) are written into nursing care plans.

Care-plan analysis

Six wards in one paediatric hospital in the north-westregion of England were selected for care-plan analysisbecause they use Roper's (1985) model for nursing to guidetheir practice. The reason for this was to reduce thenumber of potential variables between the wards, inrelation to their care-planning practices. Roper et al.(1985) used a problem-orientated approach to nursing.They view nursing as 'Helping patients to prevent, solve,alleviate or cope with problems with the Activities ofLiving' (p. 65). They also stated that nursing diagnoses aredescriptions of patients' problems. Consequently tbis care-plan analysis will refer to children's (families') nursingneeds as problems or patient problems.

Three surgical and three medical wards participated inthe study. The care plans which were analysed came fromclients who had been in-patients for 48 hours or more.This was thought to allow enough time for the mainnursing needs of the clients to he identified and docu-mented. A total of 58 care plans was assessed and, of these,43 were used for analysis. The remaining 15 were rejectedbecause they belonged to clients who had either been inhospital for less than 48 hours, or had very recentlyreturned from a unit of high dependency. The 43 childrenwhose care plans were analysed belonged to five age-groups (Table 1).

SURGICAL WARDS

Eighteen children's care plans were analysed. Seven ofthechildren had one or both parents resident in hospital withthem. A total of 88 problems were written into the careplans, of which 23 were standardized and accounted for 51ofthe total problems identified. The care plans written forchildren with resident parents contained two problemswhich related to the family. One was a standardizedproblem concerning the prevention of family stress and

Table 1 Age-groups of children whose care plans were analysed

Age No. of care plans

0—12 months1-5 years6-10 years11-15 years16+ years

208771

was evident in two of the care plans. The other related tothe social circumstances of one family.

The care plans written for children without residentparents contained four problems which related to thefamily. One was the same standardized problem relating tostress prevention and was evident in two care plans. Thethird and fourth identified actual stress for two otherfamilies.

MEDICAL WARDS

Twenty-five care plans were analysed. Thirteen of thechildren had one or both parents resident in hospital withthem. A total of 92 prohlems were written into the careplans, none of which were standardized. The care planswritten for children with resident parents contained threeproblems which related to the family. One indicated thepresence of parental anxiety and two were concerned withparental involvement in nursing care. The care planswritten for children without resident parents containedtwo problems which related to the family. One referred toparental anxiety and the other to parental involvement innursing care.

CARE PLANS.zfi [,:nni{-j it)!

The care plans were analysed using Roper's (1985) five

conceptual categories which describe factors that influence

a person's activities of living (Table 2).

In addition, a framework for content analysis (see Table

3) was taken from Krippendorf (1980) and adapted for use

in this study. ;..>:- .>•

The combination of care plans from all six wards

incorporated a total of 180 patient problems, which have

been categorized as follows:

• physical (139),

• psychological (27),

• sociocultural (12),

• politico-economic (1),

• environmental (1).

The number of problems which were identified suggest

that there is an average of 4-5 problems for each patient. In

reality, however, nine ofthe children on surgical wards had

been given standardized care plans with seven actual and/

or potential problems already listed, whilst another 16

children (from all wards) had only one or two problems

written into their care plans. A sample of the needs which

were incorporated into one ofthe care plans is presented in

Figure 1.

The care plan analysis shows that RSCNs are omitting

to identify all of the nursing needs of hospitalized children

Nursing diagnosis in sick children's nursing 283

Table 2 Roper's 12 activities ofliving and factors which influence thoseactivities (adapted from Roper et al.[1985] p. 26)

Table 3 Framework for contentanalysis (adapted from Krippendorf[1980] pp. 25-28)

• v . . 1 ; ' i • . . > ! L ' i

Activities of living Factors influencing activities of living

Maintaining a safe environmentCommunicatingBreathingEating and drinkingEliminatingPersonal cleansing and dressingControlling body temperatureMobilizingWorking and playingExpressing sexualitySleepingDying

PhysicalFunctional/body processes

PsychologicalEmotional and intellectual factors

SocioculturalEffects of society and local cultures

Politico-economicEffects of law and state legislation

EnvironmentalGeographical position/climate availability of foodwater, ete.

Basic concepts Considerations

Data as communicated to theanalystThe context of the data

How the analyst's knowledgepartitions his reality

The target of content analysis

Inference as the basic intellectualtask

Validity as the ultimate criteria ofsuccess

Must be clear which data are analysed, how they aredefined and from which population they are drawnThe context relative to which data are analysed,must be made explicitA content analyst should have knowledge about theorigin of the data, and reveal the assumptions thatare made about how data and their environmentinteractThe aim or target of the inferences must be clearlystatedA content analyst must have available (or constructan operational theory of) the relatively stabledata/context relationshipsEvidence to validate results must be specified inadvance

and their families. In general the plans were concise, wellwritten and easy to understand. However, too few prob-lems were identified in contrast to the actual nursing carewhich was seen (by Mason) to be provided.

Five of the wards in the study use a system of patientallocation, whilst the sixth has implemented primary nurs-ing. They each describe a commitment to family-centredcare and it was also observed that qualified and unqualifiednursing staff consistently responded to the psychologicalneeds of their clients. In spite of this, the patient problemswritten into the care plans focused mainly on patients'physiological needs. Major omissions included the psycho-logical welfare of young children and the social, politico-economic and environmental needs of all patients. • i;

Discussion

The fieldwork leads to the conclusion that nursing practiceis mainly concerned with meeting the physical/medicalneeds of hospitalized children. However, nursing care as it

is actually practised in the wards used for the study doesnot always refiect this, as was revealed by observationsmade as a clinical teacher working on the same wards.

For example, it became clear that parents were provid-ing far more care than was indicated in the care plans. Inaddition, nurses often acted in the capacity of a supportivehealth educator. No mention is made in the care plans ofthe considerable work being done by nursery nurses topromote normal physical and psychosocial development.Finally, no mention is made of the work conducted bynurses in areas of health promotion and in co-ordinatingcollaborative care. From these findings, the followingconclusions may be drawn.

• The organization of nursing care (i.e. patient allocationor primary nursing) indicates that nurses are attemptingto provide holistic child/family care. This is supportedin the studies conducted by Oates (1992) and Eong(1991) and responds to the recommendations made bythe Platt Report (Ministry of Health, 1959), Hawthorne(1974) and the Department of Health (DoH, 1991).

284 C. Webb and G. Mason

Care p lan a n a l y s i s formClient detailsAge 2i YEARSSex FEMALEResident parent NOWard (med. or surg. ) SURGICAL

Medical diagnosis HEAD INJURY

Dates time 30/J2/9J 2.30 pm

Identified (Data asnursing communi-need catedto

(incl. date analyst)identified)

30/12/91Andrea is in a strangeenvironment with strangepeople

Parents very upset re.admission

Andrea is unable to swallow

Andrea is immobile

Andrea is constipated

Andrea gets upsetwhen handled by strangers

(Potential) Post-head injury trauma

Roper et ai . 's factors influencing a .person's activities of living

Physica:

^/

V

V

Psychologica; Environmenta;

\ /

Sociocultural

• v

•}f\). hrjiVM (ti .>

Pol i t ico-economic

Context of data ( i . e . , who wrote careplan, e tc . )

Staff Nurse(first Level Nurse)

Validity—(not being sought at th is time ]BUT-

check for meaning of any ambiguousstatements in care plans

Target of analysis-to ascertain whatnursing needs of hospitalized children(and their families) are identified

Describe stable factors (e.g. method ofcare delivery; child's routine)

Primary Nursing

what assumptions are beingmade re data and their environment?-nursing staff are using the same conceptual model to guide their practice—nursing staff are attempting to provide holistic child/family care

Figure 1 An example of an analysis of a care plan included in the study.

Nursing diagnosis in sick children's nursing 285

• Parents, particularly those who are resident, provide alarge proportion of the nursing care their childrenrequire. In some cases they also provide medicallyprescribed treatment, for example, nasogastric feeds.

• Children often participate in their own nursing care andmedical treatment if they are physically and develop-mentally able to do so.

• The role ofthe RSCN as it extends beyond the boundar-ies of assisting medical staff is usually unrecorded.Consequently it often remains unidentified and unrecog-nized by families and by other health professionals. Thisfactor was highlighted by Hauck & Roth (1984) as areason for introducing nursing diagnosis as an element ofPNP clinical practice in the USA.

• Care by parents, children and nursery nurses is mostlyunrecorded.

• Care-planning practices are still based on a medicalmodel of care.It is acknowledged that this care-plan analysis has a

number of limitations. It is based on a small conveniencesample taken from one hospital in a particular health-careregion. It was conceived as an exploration of a possiblepractice issue and not as a rigorous research project. Thelatter would require a more systematic approach to sam-pling, a longer and more broadly drawn sample, andinterrater reliability testing of coding. Nevertheless, it isconsidered that the approach used was appropriate for thepurposes stated, and no claims are tnade that the findingsare generalizable. However, the wards used are located in aspecialist children's hospital approved by the ENB forRSCN training. It is likely, therefore, that the findings area reasonable refiection of sick children's care in othersimilar settings.

Recommendat ions

The introduction of nursing diagnosis and the NANDATaxonomy I has created a nursing focus for health care inthe USA (Carroll-Johnson, 1989). It is gaining the supportof medical personnel (Turkoski, 1988) and provides nurseswith the means to identify their independent functions.These are also desirable elements fbr UK nursing practice.

In the case of children's nursing, studies by Hauck &Roth (1984), Burns & Thompson (1984) and Burns (1991)indicate that the concept of nursing diagnosis is helping tohighlight a family-centred focus of nursing care for paedia-tric practice. This is certainly the aim of the children'snurses in the present study.

Nevertheless, the adoption of a US nursing diagnosistaxonomy for UK children's nursing is not recommendedat the present time. It is felt that the US taxonomies do notrefiect the provisioti of health-care services for children in

the UK, the role of the RSCN, the role of nursery nurses,or the contributions made by families of hospitalizedchildren. Finally, the conceptual frameworks forming thebasis of existing nursing diagnoses do not appear to bewidely used by RSCNs (While, 1991). Their introductionmight add to the difficulties of care-planning practices andthus deter a majority of RSCNs from accepting theconcept of a nursing diagnostic role.

On the other hand, it would be a mistake to disregardthe potential of nursing diagnosis, and the followingrecommendations are made for further work to promotethe development of care planning in paediatric nursing.• To determine how RSCNs view their role in the identifi-

cation of hospitalized children's nursing needs. This canbe achieved by following a qualitative research approachusing (for example) 'Grounded Theory' after Glaser &Strauss (1967). This is an inductive method of discover-ing theory grounded in data (Simms, 1981) and isconsidered to be a suitable research strategy if little isknown about the phenomena to be investigated (Simms,1981; Fawcett & Downs, 1986). It is increasinglyfavoured as a method of choice for nurse researchers,because it encourages the exploration of traditionalnursing practices which are often poorly understood ordefined (Simms, 1981; Melia, 1982; Field & Morse,1985).

• To devise a conceptual framework for the developmentof paediatric nursing diagnoses. This should be basedupon the study discussed in the point above and otherrelevant UK studies (for example. Long, 1991).

• To develop a provisional list of paediatric nursingdiagnoses, within the conceptual framework. The diag-noses should include categories which recognize paren-tal, child and nursery nurse activities that should easilybe incorporated into nursing care plans.

• To promote and evaluate the development and valida-tion of paediatric nursing diagnoses at a national level.Children's nurses have made considerable advances in

establishing their role since Hawthorne (1974) publishedher research findings. In spite of this, many RSCNs facedifficulties because of changes in health care provision(DoH, 1989) and the continued problem of staffing levels.Nevertheless they should not be deterred from their aim ofpromoting and providing familj'-centred care. The con-cept of nursing diagnosis, suitably adapted for the UKsetting, offers a practical step in that direction.

References

Burns C. (1991) Development and content validity testing of acompreiiensive classification of diagnoses for Paediatrie NursePractitioners. Nursing Diagnosis 2(3), 93—104.

286 C. Webb and G. Mason

Burns C. & Thompson M.K. (1984) Developing a nursing diagnosisclassification system for PNPs. Paediatric Nursing 10 (Nov-Dec),411-414.

Carroll-Johnson R. (Ed.). (1989) Classification of Nursing Dia-gnoses—Proceedings ofthe Eighth Conference. J.B. Lippincott Co,Philadelphia.

Cheetham T. (1988) Model care in the surgical ward. Senior Nurse8(4), 10-12.

Department of Health. (1989) Working For Patients (White Paper).Cmnd 555. HMSO, London.

Department of Health. (1991) Welfare of Children and Young Peoplein Hospital. HMSO, London.

Derechin M.E. (1987) Paediatric head injury. Critical Care NursmgQuarterly 10(3), 12-24.

Donnelly P. (1986a) Its the quality that counts. Nursing Times82(26), 59-61.

Donnelly P. (1986b) Staffing a children's unit. Nursing Times 82(39),35-36.

Fawcett J. & Downs F.S. (1986) The Relationship of Theory andResearch. Appleton-Century-Crofts, Connecticut.

Field P.A. & Morse J.M. (1985) Nursing Research- The Applicationof Qualitative Approaches. Chapman & Hall, London.

Gahan B. (1991) Implementing primary nursing. Paediatric Nursing3(9), 20-22.

Galligan A.C. (1979) Using Roy's concept of adaptation to care foryoung children. American Journal of Maternal/Child Nursing 4,24-28.

Glaser B. & Strauss A. (1967) The Discovery of Grounded Theory-Strategies for Qualitative Research. Aldine Publishing Co, Chi-cago.

Glasper A. (1990) A planned approach to nursing children. InModels For Nursing (Salvage J. & Kershaw B., eds). Vol 2.Chapter 10, 89-101. Scutari Press, London.

Hauck M.R. & Roth D. (1984) Application of nursing diagnosis in apaediatric clinic. Paediatric Nursing 10 (Jan-Feb), 49-52.

Hawthorne P. (1974) Nurse—I Want My Mummy! Series 1, No 3.RCN, London.

Holden G.W. & Klingner A.M. (1988) Learning from experience:differences in how novice vs expert nurses diagnose why an infantis crying. Journal of Nursing Education 27(1), 23-29.

ICD. (1978) 9th Revision Clinical Modification 1. Commission ofHospital & Professional Activities. Ann Arbor, Michigan.

ICD. (1981) 9th Revision Clinical Modification (DHSS Pub. No PHS80-1260). US Govt Printing Office, Washington DC.

Kenner C. & Hern M.J. (1988) Writing a nursing diagnosis for acomplex client: the infant with a congenital heart defect. Journalof Paediatric Nursing 3(4), 256-264.

Krippendorf K. (1980) Content Analysis—An Introduction to itsMethodology. Sage Publications Inc., London.

LeBoeuf M.B. & Greco-Gallagher M. (1987) Standardized care planfor the child with bacterial meningitis. Critical Care Nurse 7(5),66-76.

Long T. (1991) Towards a definition of children's nursing. Paedia-tric Nursing 3(9), 12-15.

Mason G. & Webb C. (1993) Nursing diagnosis: a review oftheliterature. Journal of Clinical Nursing 2, 67-74.

Melia K.M. (1982) 'Tell it as it is'—Qualitative methodology andnunsing research: understanding the student nunse's world. j'o«''-nal of Advanced Nursing 7, 327-335.

Miles I. (1985) A suitable case for treatment. Nursing Times 81(18),48-50.

Ministry of Health. (1959) Report ofthe Committee on the Welfare ofChildren in Hospital (Platt Report). HMSO, London.

Oates M. (1992) The quality of child care. Paediatric Nursing 4(3),11-13.

Roper N., Logan W. & Tierney A. (1985) The Elements of Nursing(2nd edition). Churchill Livingstone, London.

Simmons A. (1980) A Classifuatton Scheme for Client Problems inCommunity Health Nursing (DHSS Pub. HRA 80-16). US Deptof Health & Human Services, Division of Nursing, Hyattsville,MD.

Simms L.M. (1981) The grounded theory approach in nursingresearch. Nursing Research 30(6), 356-359.

Starn J. & Niederhauser V. (1990) An MCN model for nursingdiagnosis to focus intervention. American Journal of Maternal!Child Nursing 15(3), 180-183.

Turkoski B.B. (1988) Nursing diagnosis in print, 1950-1985. Nurs-ing Outlook 36(3), 142-144.

US Dept of Health & Human Services, Public Health Services.(1977) Nursing Problem Classification For Children (5 Youth(DHSS Pub. HSA 77-5201). Rockville, MD.

While A. (ed.). (1991) Caring For Children. Edward Arnold, Lon-don.