Research and Theory for Nursing Practice: An International Journal, Vol. 26, No.

3, 2012

Caring in Pediatric
EmergencyNursing
Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CPEN, FAEN
University of Cincinnati College of Nursing

Melanie Hounchell, BA, CCRC

Cincinnati Childrens Hospital Medical Center

Jeanne Pettinichi, BSN, RN, CPN, CPEN

Childrens National Medical Center

Jennifer Mattei, MSN, RN, CPN

Cincinnati Childrens Hospital Medical Center

Lindsay Rose, RN
Miami University Department of Nursing

An environment committed to providing family-centered care to children must be

aware of the nurse caring behaviors important to parents of children. This descriptive study assessed the psychometrics of a revised version of the Caring Behaviors
Assessment (CBA) and examined nurse caring behaviors identified as important
to the parents of pediatric patients in a pediatric emergency department. Jean
Watsons theory of human caring provided the studys theoretical underpinnings.
The instrument psychometrics was determined through an index of content validity (CVI) and internal consistency reliability. The instrument was determined to be
valid (CVI 53.75) and reliable (Cronbachs alpha 5 .971). The revised instrument
was completed by a stratified, systematic random sample of 300 parents of pediatric
emergency patients. Participants rated the importance of each item for making the
child feel cared for by nurses. Individual survey item means were computed. Items
with the highest means represented the most important nurse caring behaviors.
Leading nurse caring behaviors centered on carative factors of human needs

216

2012 Springer Publishing Company

http://dx.doi.org/10.1891/1541-6577.26.3.216

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assistance and sensitivity to self and others. Nearly all nurse caring behaviors
were important to the parents of pediatric patients, although some behaviors were
not priority. It is important for nurses to provide family-centered care in a way that
demonstrates nurse caring.

Keywords: theory of human caring; caring; pediatrics; emergency

nursing; caring behaviors assessment

mergency nurses are responsible for providing family-centered care in

pediatric settings. The priorities of patient care are likely to be dependent
on the findings identified during the nursing assessment and the treatment
plan requested by emergency physicians and midlevel providers. The priorities
of patient care may not reflect the wants and needs of the family unit, possibly
leaving the family with a perception that nurses are uncaring. For example,
Weman and Fagerberg (2006) reported that nurses preferred patients and families to choose patient care options from a list presented by the nurses. Nurses
did not like patients or family members to identify care options that were not
among those presented. This accentuates a potential disconnect between nurses
and nurse caring.
The purpose of this study was to examine nurse caring behaviors identified as important to the parents of pediatric patients in a pediatric emergency
department. This study will answer the following research questions: (a) What
is the validity and reliability of the Caring Behaviors Assessment (CBA) instrument when adapted for use with parents of pediatric emergency patients? and
(b) What nurse caring behaviors are most important to the parents of pediatric
emergency patients?
An environment committed to providing family-centered care to children must
be aware of the nurse caring behaviors important to the parents of children. An
appropriate instrument must be identified that can be used to measure the priority
nurse caring behaviors that parents desire for their children when receiving nursing
care. The CBA (Cronin & Harrison, 1988) was developed to measure patient perceptions of nurse caring behaviors. The CBA was intended for use with adult patients;
therefore, the CBA was adapted for use in this study. Validity and reliability testing
need to be done before the revised instrument could be used to identify priority
nurse caring behaviors in the pediatric emergency population.
The significance of this study in relation to human health and nursing is that
identification of priority nurse caring behaviors may be used to develop and
implement systems that will increase the demonstration of such nurse caring
behaviors in the pediatric emergency setting. Nurses that routinely demonstrate
the priority nurse caring behaviors may be perceived as more caring and, in
turn, more readily foster a positive nursepatientfamily relationship. This study
provided additional clarification to the priority of caring behaviors in the pediatric emergency setting by determining if a variance existed based on patient
acuity level.

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BACKGROUND
Perception of Caring by Nurses
McCance, McKenna, and Boore (1997) conducted a concept analysis of caring
and identified four defining attributes of caring: serious attention to the patient,
concern for the patient, providing for the patient, and getting to know the patients
wants and needs. In addition, there were two antecedents that needed to occur with
nursing before caring could take place: having a respect for patients and having
time to be involved with the patients.
Prior studies with nursing populations have used qualitative designs to identify the
themes of nurse caring. The themes of nurse caring as reported by Cheung (1998)
included the following: caring is a way of being, caring gives nurses motivation,
caring gives nurses focus and direction, caring is to protect the patients, caring as
an experience, and caring as a process. These findings reflect nursings perspective
of the nursing discipline to deliver nursing-centered care.

Perception of Caring by Patients

Chinese patients with cancer have identified caring attitudes, professional
responsibility by the nurse, emotional support, and being knowledgeable and
skilled as key behaviors that define nurse caring (Liu, Mok, & Wong, 2006).
When assessed in the perioperative setting, nurse caring behaviors of most
importance were a reassuring presence by the nurse, verbal reassurance, and
an attention to comfort control (Parsons, Kee, & Gray, 1993). This reflects that
the priority nurse caring behaviors may vary by the clinical setting. Baldursdottir
and Jonsdottir (2002) found that priority behaviors using the CBA with Icelandic
emergency care patients were nurses needing to be competent, knowledgeable,
and show respect, honesty, and compassion. These studies all targeted adult
populations.

Perception of Caring by Families

Nurses need to connect with patients and include the patients family while providing care (Weman & Fagerberg, 2006; Wilkin & Slevin, 2004). An environment where
family-centered care occurs is an ideal environment for a study focused on nurse
caring behaviors. Care delivery should reflect nurse caring deemed most important
to patients and patient families (Frazee, 2011). In a pediatric setting, family members may be the historian and the person providing consent for nursing care. Inthis
environment, it is important for nurses to understand what is most important to
the families of the pediatric patient in order for care to be family centered and not
just patient centered.
Harbaugh, Tomlinson, and Kirschbaum (2004) found in their qualitative study that
what parents desired most from nurses providing care to their children were affection, caring, watching, and protecting. Parents wanted the nurses to demonstrate

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qualities similar to that of parenting. Desired nurse caring behaviors were providing
information, including the parent, family presence, appreciating the uniqueness of
the child, and providing competent patient care. Negative attributes that did not
reflect nurse caring behaviors reported by the parents were poor communication,
separating the parent from the pediatric patient, and a lack of affection and protection for the pediatric patient. Scott (1998) reported that for an environment to be
family centered, an organization needs to be aware of parental needs in addition
to that of providing patient-centered care.

Summary
There is a difference in nurse caring behaviors deemed most important among
nurses, patients, and patients families. Although patients are more concerned
with the knowledge and technical skills of nurses, nurses themselves believe
that experience, spending time with patients, and patients safety were more
important (Baldursdottir & Jonsdottir, 2002; Liu et al., 2006; McCance et al.,
1997; Parsons etal., 1993). Scott (1998) found that parents believed they were
important to a childs illness recovery significantly more often than nurses. This
reflects a critical mismatch between nurses and patients/parents. Therefore, it
is important to determine the parental perception for the nurse caring behaviors most important for nurses to demonstrate when providing care to pediatric
patients.

THEORETICAL PERSPECTIVE
Jean Watsons theory of human caring provides the theoretical underpinnings for
this study. The theory of human caring is a holistic theory that guides the practice of
nursing. A key concept in the theory of human caring is that caring is an essential
component of a healing environment and represents the essence of nursing (Watson,
1985). Watson identified 10 carative factors for nurse caring: (a)humanistic-altruistic
system of values; (b) faith and hope; (c) sensitivity to self and others; (d) helpingtrusting, human care relationship; (e) expressing positive and negative feelings;
(f)creative problem-solving caring process; (g) transpersonal teaching and learning; (h) supportive, protective, or corrective mental, physical, societal, and spiritual
environment; (i) human needs assistance; and (j) existential, phenomenological,
and spiritual forces.
Any interactions between nurses and patients occur in the presence of human
caring (Watson, 1985). Nursing has always held a human care and caring stance
regarding people with health-illness concerns. Caring has become such a key part
of nursing that caring and nursing are now synonymous and a unifying focus for
nursing practice in some settings (McCance et al., 1997; Watson, 1985). Human
care can be effectively demonstrated and practiced only interpersonally, and the
intersubjective human process keeps alive a common sense of humanity teaching
us how to be human as we identify ourselves with others.

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METHODS
Study Design and Setting
A nonexperimental descriptive design was used for this study. The study itself was
conducted at a large Midwestern U.S. pediatric health center. The emergency department for this health center where data were collected delivers family-centered care
to more than 80,000 patients per year.

Study Population
Participants were at least 18 years old and the parent or legal guardian of a patient
from birth up to the patients 18th birthday. Because of the absence of the survey
tool being available in Spanish or other languages, only parents who could read
English were included. Parents of patients being treated in the express care/
short-stay emergency department for nonurgent illnesses or in the shock-trauma
suite for life-threatening conditions were also excluded.
Stratified random sampling was conducted to obtain 100 parents of children in
each of the three nurse-assigned acuity levels: emergent, urgent, and nonurgent.
Recruitment for participants continued with the parent of every second emergent
patient and every fourth urgent or nonurgent patient until the sample quota was
achieved. The data were reviewed for quality after 100 total participants had completed
the survey; no changes to the randomization process were needed.
Sample size was determined based on DeVellis (2003) criteria for instrument
development: 10 participants per question up to 300 participants. Because there were
more than 30 questions on the study survey, a sample size of 300 was chosen.

Instrumentation
The instrument used for this study was the CBA developed by Cronin and Harrison
(1988) to determine the behaviors of caring that were most important to patients
following a myocardial infarction. The researchers reported that face and content
validity were established by a panel of four content specialists familiar with Jean
Watsons theory of human caring (Cronin & Harrison, 1988). The panel of experts
rated each survey item to a subscale. Any item not designated to a single subscale
by at least three of the four experts was recategorized into a more appropriate
subscale (Cronin & Harrison, 1988). The CBA demonstrated strong validity and
reliability in the literature with internal consistency reliabilities of .93.96 for adult
study samples (Cronin & Harrison, 1988; Schultz, Bridgham, Smith, & Higgins,
1998; Stanfield, 1991).
Stanfield (1991) tested the CBA with adult medical-surgical inpatients. Internal
consistency reliabilities were reported for the subscales ranging from .78 to .89and
an overall reliability of the data at .96. Construct validity was established with
factor analysis. Schultz et al. (1998) tested the instrument with antepartum and
postpartum patients. Reliability was reported for the subscales ranging from .71 to
.88. The overall scale reliability was .93. Marini (1999) tested the instrument with

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long-term care residents in an assisted living facility. Correlations between instrument subscales and gender were reported: up to .89 for women and .85 for men.
Manogin, Bechtel, and Rami (2000) tested the instrument with women hospitalized
for uncomplicated labor and delivery. The researchers determined that the instrument had content validity based on an expert panel. Reliability for the subscales
ranged from .66 to .90.
The original instrument was a 63-item self-report survey with participants indicating the importance of each item on a 5-point Likert scale with 1 being of little
importance and 5 being of much importance. Items from the CBA were reworded
to focus the items on the parent and child because the instrument was originally
created to measure the perception of the adult patient. For example, the original
item Ask me how I like things done was reworded as Ask me how my child and
I like things done.

Procedures
Patients were assessed in the triage area by a registered nurse in the pediatric
emergency department and assigned an acuity level: shock/trauma (highest
acuity), emergent, urgent, and nonurgent (lowest acuity). Triage nurses were
previously trained to assign an acuity level based on triage guidelines. Examples
of patients assigned to the shock/trauma acuity level were patients actively
seizing, in supraventricular tachycardia, and/or with a penetrating injury to
the head or torso. Examples of patients assigned to the emergent acuity level
were patients in sickle cell crisis, significant respiratory distress, newborns
with high fevers, and patients with obvious extremity deformities. Examples of
patients assigned to the urgent acuity level were patients with moderate respiratory distress, toddlers with high fevers, and patients with signs of dehydration.
Examples of patients assigned to the nonurgent acuity level were patients with
rashes, dental pain, and patients whose symptoms resolved prior to emergency
department arrival.
A trained clinical research coordinator approached family units to discuss the
purpose of the study after placement into a treatment room. Parents were informed
that participation was strictly voluntary, and the patients care would not be altered
based on study participation. Following informed consent, the clinical research
coordinator connected the parent to an Internet-based version of the study survey
on a study laptop. SurveyMonkey is an Internet-based survey system that administers
survey questionnaires and stores data confidentially. Connection to the instrument
required a unique Web address and limited access password known only to the
study team and clinical research coordinators. The survey was self-guided and
closed upon study completion.

Human Subjects Protections

The study protocol was approved by the local institutional review board prior to
any study procedures. Study participation was completely anonymous. No record
was generated that tracked parents who participated or opted to not participate.

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No names of study participants (parents) or patients were included in the database

associated with this study. Data confidentiality was protected at all times. The limited
access password provided to the clinical research coordinators granted access to
the instrument only, not to the raw data.

Data Analysis
Research Question 1. Content validity of the revised instrument was determined
through a CVI (Beck & Gable, 2001). Five content experts evaluated the content
of the revised study instrument to measure nurse caring behaviors with parents
of pediatric emergency patients. Each expert rated the revised individual survey
items as they pertained to nurse caring behaviors on a scale from 1 (not relevant) to
4(very relevant). A Cronbachs alpha was computed to determine the adequacy of
reliability for the revised CBA with the population of parents of pediatric patients.
Cronbachs alpha of .70 or greater reflects good internal consistency reliability
(DeVellis, 2003).
Research Question 2. Individual survey item means were computed for the
total sample. Items were ranked from highest mean to lowest mean. Items with
the highest means represent items that were the most important nurse caring
behaviors to parents of pediatric patients. Subscale means for level of importance (ranging from 1 [little importance] to 5 [much importance]) were computed
for each of the seven instrument subscales. A multiple analysis of variance
(MANOVA) was computed to determine if there was a significant difference
between nurse-assigned patient acuity level (emergent, urgent, nonurgent)
and parent-perceived acuity level (emergent, urgent, nonurgent) for subscales.
Alpha was set at .05.

RESULTS
The Study Sample
Five hundred seven family units were approached to participate in this study. There
was 41% attrition to achieve the sample size of 300 participants. The leading reason
stated for nonparticipation was the parent was holding the patient and did not want
to lay down the child to participate. Participant demographic data are provided in
Table 1. The mean age of participants was 35 years ranging from 18 to 73 years.
Most were women (83%) and the patients mother (80%). Sixty-nine percent of
participants were White, non-Hispanic; and 25% were Black, non-Hispanic. The
pediatric patients mean age was 8 years ranging from 7 days to 18 years. There
was an even split for the patients sex.
Research Question 1. The first research question aimed to determine the validity
and reliability of the revised CBA. The instrument CVI showed that two items had
an average rating less than 3 and were therefore omitted from the study instrument.
The two deleted items were the following: talk to my child and me about my childs
life outside the hospital and visit my child if my child moves to another hospital

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TABLE 1. Participant Demographics

Characteristic

%a

Sex
Female
244
83
Male 51
17
Race
White, non-Hispanic
200
69
Black, non-Hispanic 72
25
Multiple races 14 5
Other races 6 2
Relationship to patient
Mother
234
80
Father 47
16
Grandparent 8 3
Aunt, sibling, foster parent 3 1
Patients sex
Female (girls)
144
50
Male (boys)
147
50
Numbers may not add to 100% because of rounding.

unit. The CVI of the instrument subscales following the removal of the two items
ranged from 3.27 to 3.89 (see Table 2). The overall CVI of the revised instrument
was 3.75. The internal consistency reliability of the instrument subscales reflected
Cronbachs alphas ranging from .807 to .925. The overall reliability of the revised
instrument was strong at .971. The instrument was thus deemed valid and reliable
for use in this study.
Research Question 2. The most important nurse caring behaviors had a mean
item score ranging from 4.83 to 4.93 (see Table 3). The five leading items were the
following: (a) know what theyre doing; (b) know how to give shots, intravenous
lines (IVs), and so forth; (c) be kind and considerate; (d) really listen to my child
and me when we talk; and (e) give my child treatments and medications on time.
The least important nurse caring behaviors had a mean item score ranging from
3.95 to 4.30. The five least important nurse caring behaviors were the following:
(a) encourage my child and me to talk about how we feel, (b) leave my childs room
neat after working with my child, (c) touch my child when my child needs it for
comfort, (d) ask my child and me what my child likes to be called, and (e) consider
my child and my spiritual needs.
Leading nurse caring behaviors are presented in Table 4 and compared by acuity
levels (emergent, urgent, nonurgent). Lowest ranked nurse caring behaviors were
also compared by acuity levels. Lowest ranked nurse caring behaviors for both
nurse-assigned and parent-perceived emergent acuity level were the following: (a)
help my child and me feel good about ourselves, (b) encourage my child and me to
talk about how we feel, and (c) consider my child and my spiritual needs. Lowest

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TABLE 2. Validity and Reliability of the Revised Version of the Caring

Behaviors Assessment
Subscale
Scores

Subscale
Humanism/faith and hope/
sensitivity
Helping/trust
Expression of positive/
negative feelings
Teaching/learning
Supportive/protective/
corrective environment
Human needs assistance
Existential-phenomenological spiritual forces

Validity
Measures

Reliability
Measure

Index of
Content
Validity

Cronbachs
Alpha

SD

Number
of Items

4.669

.442

16

3.75

.925

4.568
4.273

.486
.796

9
4

3.80
3.60

.807
.866

4.564
4.445

.572
.569

8
12

3.85
3.73

.891
.904

4.743
4.212

.400
.855

9
3

3.89
3.27

.862
.858

TABLE 3. Highest and Lowest Ranked Nurse Caring Behaviors

Caring Behavior
Leading nurse caring behaviors
1. Know what theyre doing
2. Know how to give shots, IVs, etc.
3. Be kind and considerate
4. Really listen to my child and me when we talk
5. Give my child treatments and medications on time
6. Treat my child and me with respect
7. Check my childs condition very closely
8. Know how to handle equipment (e.g., monitors)
9. Keep my child and me informed of my childs progress
10. Know when its necessary to call the doctor
Lowest ranked nurse caring behaviors
1. Help my child and me plan ways to meet those goals
2. Help my child understand his or her feelings
3. Understand when my child and I need to be alone
4. Help my child and me see that our past experiences are important
5. Help my child and me feel good about ourselves
6. Encourage my child and me to talk about how we feel
7. Leave my childs room neat after working with my child
8. Touch my child when my child needs it for comfort
9. Ask my child and me what my child likes to be called
10. Consider my child and my spiritual needs
IVs 5 intravenous lines.

M
4.93
4.89
4.88
4.88
4.88
4.87
4.86
4.85
4.84
4.83
4.30
4.26
4.21
4.18
4.14
4.09
4.07
4.06
3.99
3.95

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TABLE 4. Leading Caring Behaviors Based on Patient Acuity

Acuity
Level

Caring Behaviors Based on Triage

Nurse-Assigned AcuityLevels

Caring Behaviors Based on

Parent-Perceived Acuity Levels

Emergent

1. Know what theyre doing

2.Know how to give shots,
IVs,etc.
3.Treat my child and me with
respect
4.Really listen to my child and
me when we talk
5. Be kind and considerate

1.Treat my child and me with

respect
2.Know how to give shots,
IVs,etc.
3.Be kind and considerate
4.Do what they say they will do
5.Know how to handle
equipment (e.g., monitors)

Urgent

1. Know what theyre doing

2.Give my child treatments and
medications on time
3.Know how to give shots,
IVs,etc.
4.Really listen to my child and
me when we talk
5.Treat my child and me with
respect

1.Know what theyre doing

2.Know how to give shots,
IVs, etc.
3.Really listen to my child
and me when we talk
4.Give my child treatments
and medications on time
5. Be kind and considerate

Nonurgent

1. Know what theyre doing

2.Check my childs condition
very closely
3.Give my child treatments and
medications on time
4. Be kind and considerate
5.Answer my childs and my
questions clearly

1.Check my childs condition

very closely
2.Know when its necessary
to call the doctor
3. Be kind and considerate
4. Know what theyre doing
5.Answer my childs and my
questions clearly

IVs, intravenous lines.

ranked nurse caring behaviors for both nurse-assigned and parent-perceived

urgent acuity level were the following: (a) help my child and me feel good about
ourselves, (b) ask my child and me what my child likes to be called, (c) leave my
childs treatment room neat after working with my child, (d) encourage my child
and me to talk about how we feel, and (e) consider my child and my spiritual needs.
Lowest ranked nurse caring behaviors for both nurse-assigned and parent-perceived
nonurgent acuity level were the following: (a) encourage my child and me to talk
about how we feel, (b) help my child and me see that our past experiences are
important, (c) consider my child and my spiritual needs, and (d) ask my child and
me what my child likes to be called.
Subscale means for the revised version of the CBA ranged from 4.743 for human
needs assistance to 4.212 for existential/phenomenological/spiritual forces
(seeTable 2). A two-way MANOVA was conducted to determine if there was a
significant effect of nurse-assigned and parent-perceived patient acuities on the

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subscale means. Boxs test of equality of covariance reflects a lack of homogeneity for equal variances (Boxs M 5 347, F[168, 6673] 5 1.722, p , .001). Pillais
trace was used as the MANOVA test statistic because it is robust in circumstances
with a lack of homogeneity and extremely unequal sample group sizes (Mertler
& Vannatta, 2005). MANOVA results indicated that nurse-assigned triage acuity
(Pillais trace5.069, F[14, 522] 5 1.336, p 5 .182) and parental-perceived triage
acuity (Pillais trace 5 .054, F[14, 522] 5 1.031, p 5 .420) were insignificant for
affecting subscale means.

DISCUSSION
The CBA continues to be a valid and reliable instrument to measure nurse caring
behaviors. The version of the instrument used in this study did undergo minor
changes. As with the study conducted by Baldursdottir and Jonsdottir (2002), two
items from the original CBA were deleted because of the study setting and population. However, the two items differed. Baldursdottir and Jonsdottir deleted the
questions related to what name the patient prefers to be called and visiting the
patient on another unit. The items deleted from this study asked about the patients
life outside the hospital and visiting the patient on another unit. Researchers from
both teams most likely deleted the item related to visiting the patient on another
unit because most patients evaluated in the emergency department are discharged
to home; only 14.4% of patients at the study site were admitted from the emergency
department in 2010. This admission rate was comparable to the U.S. admission rate
of 13.9% (McCaig & Burt, 2005).
Nearly all nurse caring behaviors were important to the parents of pediatric
patients, although some behaviors were not priority. The most important nurse
caring behaviors were stable across nurse-assigned patient acuities and parentperceived illness severity. Leading nurse caring behaviors centered around two
carative factors: human needs assistance and sensitivity to self and others.

Human Needs Assistance

Human needs assistance can be demonstrated by nurses through technical competence. Technical competence itself is a culmination of education, interpretation,
and experience in various clinical situations. Graduates of undergraduate nursing
programs are prepared to demonstrate technical competency that promotes efficient,
safe, and compassionate care (American Association of Colleges of Nursing, 2008).
Regarding nurse-assigned acuity, the highest ranked caring behaviors were those
based on providing care or assistance to pediatric patients across acuity levels.
Aconsistent priority of nurse caring behaviors was know how to give shots, IVs,
and so forth followed by know how to handle equipment. Prior to entering a
patients room, a nurse should be knowledgeable of the use and function of as
well as how to operate medical equipment. When the nurse does not have the

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expertise to use equipment or perform procedures, assistance should be sought

by nurses with the needed expertise. Nurses can clearly communicate to patients
and parents that the second nurse is there to assist in the delivery of safe patient
care. Nurses should never attempt to intervene without the requisite experience
or expertise.
Technical competence may have been so important to parents because of a fear
for patient injury or pain if competency is not demonstrated. For example, parents
can experience a situational crisis when multiple attempts are needed to obtain
intravascular access. Parents of children who are chronically ill (e.g., sickle-cell
anemia, asthma) may also have multiple prior emergency department visits and
know technical competence when they see it. These parents may also be trained
on technical care when providing care to their children (e.g., administering nebulizer treatments or insulin injections). Over time, parents may have become more
cognizant of the pain, injury, or delays in care that may occur with a lack of technical competency. This lack of competency would directly impair nurses ability to
provide the nursing care exemplified through the carative factor of human needs
assistance.
Another manifestation of human needs assistance is providing timely assessments and interventions. The urgent and time-sensitive work environment in which
emergency nurses function must be taken into account when dealing with issues
of nursepatientfamily caring relationships and their efficacy. The emergency
department is commonly described as a fast-paced environment where a focus is
placed on moving patients through the process of emergency care as quickly as
possible (Committee on the Future of Emergency Care in the United States Health
System, 2007). Given the heavy focus on time and popular culture media attention to
emergency care from television shows such as ER (Sachs & Gentile, 1996), patients
and parents may expect to arrive, be treated, and discharged from the emergency
department in less than an hour. Therefore, it is not surprising that parents want
and expect timely assessment and interventions for their children. The timeliness
of care may have been of lesser dominance compared to technical competence and
respect when evaluating nurse caring behaviors in relation to acuity levels because
the family unit may have already been receiving expeditious care or were more
concerned about the quality (i.e., technical competence) of care.
Despite attempts to provide timely care to all patients, there will be times
when the priority of care delivery will be focused on other children who are more
critically ill or injured. Nurses can acknowledge parents and patients needs by
informing them of the arrival of a critical patient, that their childs care remains
a priority for them and will resume as soon as the other patient is stabilized,
and their child will not experience an untoward deterioration as a result of the
perceived delay in care. In addition, the parents and patients should be notified
that the care team is committed to working as a team to expedite the care of all
children in the department.
Among the lowest ranked items was leaving the childrens room neat. This
item was probably of lesser importance because the parents may anticipate a discharge to home soon. Parents may be more willing to tolerate an untidy room if

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they can be discharged sooner. This finding may be different for inpatient children
where the patient will reside in the same hospital room for several days and have
a need to make the room reflect a home environment as much as possible (Evans
& Thomas, 2011). Thus, the focus of human needs assistance for the parents of
emergency department patients relates to nurses being technically competent
and timely.

Sensitivity to Self and Others

Sensitivity to self and others was the most common carative factor identified
between the patient acuity levels. Leading behaviors that demonstrate sensitivity
were treating others with respect, active listening, being kind and considerate,
and keeping promises. Respect is an essential component to developing a quality nursepatientfamily relationship (Malusky, 2005) and can be demonstrated
through cultural humility and valuing parents as an expert member of the patient
care team. Through active listening, the wants and needs of the family unit can
be identified (Frazee, 2011; Malusky, 2005). If the wants and needs are not identified, parents and patients should be explicitly asked for this information. Patient
care can then be tailored to address these wants and needs. When the care is not
reflective of the family unit preferences, then dissatisfaction with patient care
may occur.
Stratton (2004) mentions parents in hospital settings encounter four challenges:
facing boundaries, attempting to understand, coping with uncertainty, and seeking
reassurance from health care providers. These challenges can be addressed through
dialogue-centric caring behaviors such as keeping my child and me informed of
my childs progress and answering my childs and my questions clearly. Nurses
may need to interpret medical jargon that has been discussed during the emergency
department visit. Providing information in words understandable to the family unit
shows sensitivity and respect while simultaneously reducing any confusion over
the treatment plan and patient condition (Harrison, 2010; Piskosz, 2007). Clarity of
explanation in the pediatric field is especially important because any information
must be passed on to all members of the family unit (Piskosz, 2007). Evans and
Thomas (2011) found that even a simple strategy such as a communication board
in the room can be effective at providing ongoing communication with the parents
of pediatric patients.

Existential, Phenomenological, and Spiritual Forces

Jean Watson (1985) and the American Association of Colleges of Nursing (2008)
believe that a core attribute of nursing practice is spiritual and emotional support
of patients and families; however, the parents in this study placed greater value
on nurse caring behaviors related to providing assistance and demonstrating
sensitivity. There are several reasons that may explain this finding. Patients with
chronic illness or long-term inpatient stays may have greater existential needs, as
illustrated by Cheungs (1998) study of Chinese patients with cancer. Emergency

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229

department patients may be more focused on acute, immediate, medical needs

that are representative of the physiological needs at the base of Maslows hierarchy
of needs. Until the basic physiological needs are met within the time-constrained
environment of the emergency department, patients are less likely to be concerned
with higher level needs such as love/belonging, esteem, and self-actualization,
which would be met through the nurse caring behaviors of spiritual and emotional
support. Only the patients who are most critically ill or injured, where death is a
strong consideration, would the higher level Maslow needs become a focus for
emergency department care.
In general, parents of pediatric patients are less likely to experience the death
of the patient in contrast to an adult-focused emergency department. A factor of
potentially greater importance is the role of the parent: ensuring that the spiritual and emotional needs of the child are met. Providing the family unit is well
adapted, parents are more likely to see themselves as the provider of the childs
spiritual and emotional needs versus leaving this role to be fulfilled by the childs
nurse. Again, only during times of situational crisis or family dysfunction would it
be likely expected that the nurse focus attention to these attributes in the emergency department setting. Nurses can provide spiritual and emotional care by
holding a patients hand, providing comforting words of support, not leaving the
child alone, and assisting the parent to contact family members and their family
chaplain. The exclusion of parents of patients who are most critically ill in the
emergency department may have contributed to the lower priority of existential,
phenomenological, and spiritual forces. Although the general parent did not place
as great a priority on discussing feelings or emotions, this may not reflect all
pediatric patient populations. Patients seeking treatment for anxiety disorder or
suicidal ideation may require an in-depth discussion on their feelings and emotions as part of emergency care.
Of particular note was that addressing the patients and parents spirituality
was the least important behavior. It is possible that the parents of children being
treated in the shock-trauma suite for a life-threatening illness or injury may have
placed greater importance on this item. Parents who completed the survey may
have been more focused on a timely flow through the emergency department to
discharge and not concerned with spirituality in the absence of issues with death
and dying.

Limitations
This study was limited by its inclusion/exclusion criteria. Parents of patients with the
extreme of illness severity and those treated in the short-stay area were excluded.
However, all other patients treated in the main emergency department remained
eligible. Patients treated in the shock-trauma suite represent a small minority of
the emergency department population. In addition, patients treated in the shortstay emergency department were believed to have illnesses of such minor consequence that their stay in the emergency department would be very brief. Nursing
encounters with short stay patients would also be minimal in comparison to the

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main emergency department population. Therefore, the findings from this study
would represent the greatest proportion of patients seeking care in a pediatric
emergency department.
There was an initial risk that the emergency nurses would interact differently
with the eligible participants while the study was being conducted. This limitation
was reduced by keeping the nursing staff blind to the study purpose. The clinical
research coordinators were instructed to inform nurses, if asked, that the study
was focused on patient care. It was later reported by the clinical research coordinators that no nurses asked about the study purpose. Nurses in the study site were
used to multiple studies being conducted simultaneously with patient and parent
populations.

CONCLUSION
It is important for nurses to provide family-centered care in a way that demonstrates nurse caring while being tailored to individual patients and care situations. Behaviors of nurse caring most desired by the parents of pediatric patients
relate to providing timely, competent care (or human needs assistance) and
demonstrating sensitivity. Although nurse caring behaviors related to existential, phenomenological, and spiritual forces were of lesser importance in this
pediatric emergency department setting, attention should still be given to these
needs because they also represent essential attributes of the nursing discipline.
Further research is needed to determine if nurses demonstrating the priority
nurse caring behaviors are perceived by pediatric patients and their parents as
being more caring in comparison to other nurses. Additionally, research should
be conducted into the relevance and applicability of Watsons carative factors
to nursing practice.

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Correspondence regarding this article should be directed to Gordon Lee Gillespie, PhD, RN,
PHCNS-BC, CEN, CPEN, FAEN, University of Cincinnati College of Nursing, P.O. Box 210038,
Cincinnati, OH 45221-0038. E-mail: gordon.gillespie@uc.edu

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