Factors Creating Trust in Hospitalized Children's Mothers towards Nurses.

OBJECTIVE: Trust is proposed as the necessary foundation to achieve better performance in the nursing of children. In this regard, Pediatric nurses need to achieve a deeper understanding of parents' experiences, and find out how these experiences are being related to the nursing practice. So to increase nurses' understanding of this concept based on the experiences of the recipients of nursing, the present study aims to express the factors that affect the formation of trust in mothers of hospitalized children towards the nurses.
METHODS: In this study, a qualitative design, conventional content analysis, was used. Pediatric Ward of hospitals in Yazd, Iran were the research environment. 14 mothers whose children were hospitalized in pediatric wards were selected through purposive sampling. They were deeply interviewed and data was analyzed with conventional content analysis.
FINDINGS: Data analysis led to emerging a major category "nurses' attempt for professional nursing" which includes sub-categories of commitment and empathetic caring, skill in performing duties, mothers' participation in the process of caring, being interested in pediatric nursing and establishing effective communication.
CONCLUSION: Findings from the study showed that mothers know different factors involved in establishing confidence in nurses. Managers and people in charge in the field of nursing - regarding these findings - can design and perform necessary training programs to increase knowledge and skills for pediatric nursing, to win the trust of mothers and children in hospital for an effective step towards providing a better nursing care.

Introduction

Pediatric nursing history goes back to 1960. Parents with children in hospitals were allowed to visit their children once a week and for a short time. In late 1970, a change occurred in the attitude of hospitalizing children in hospitals [ and parents visiting hours from children were declared open [ .

Parental participation in caring is not only considered as a way but also a structured process allowing parents being committed to cooperating with the nurses in child care and it leads to clarifying the needs of children and improvement of the efficiency of negotiation between nurses and parents as the main base for the participation of parents and nurses, is communication [ . In fact, the relationship between a nurse and the child-parent is a relationship that has been occurring in the pediatric ward [ and primary contact of the nurse with the parent and child is vital [ .

Trust is the evolution factor of the relationship between nurses with parent and child [ and it has mostly been provided based on nursing care which the parents had been its observers [ and parents’ confidence toward nurses makes the parents sure that they will be respected by nurses, they will be trained and nurses will be correctly responsive to them [ and it has also been influential on acceptance of parents towards care provided by nurses under the terms of emergency [ and parents would indisputably accept nursing care and they will dare to distance themselves from their children [ .

Trust will also have a profound effect on the parent, the child and the subsequent acceptance, and its creation and retention is essential for increasing the benefits gained from the relation of nurses and parents and can lead to considering the parent, the nurse and the child as a whole [ and increases the recipients satisfaction with nursing care and neglecting the occurred errors [ , in addition leads to self-fulfillment [ .

But when nursing care is not matched with their expectations in the health care field, their trust towards nurses will be undermined. On the other hand, parents with hospitalized children feel danger that can be derived from the nurses, their intentions and their future actions in nursing a child whose parents are dependent on him/her [ and it is important to know that the sick child before being simply considered as a patient is someone who has a significant role in developing a trustworthy relation between the parent and the nurse.

Hence to gain the parents’ trust, it is necessary to gain the child’s trust; as the relation between the nurses and the children usually happens in a situation that is unfamiliar to the child and an unknown person (nurse) wants to take some measures which are probably painful and anti-relaxing for the child [ .

Therefore, nurses are expected to develop trust between themselves and the children along with developing trust between themselves and the parents and providing the opportunity of a reliable relation and consider that the lack of confidence in children will lead to a lack of cooperation with nurses [ . So creating trust is proposed as the necessary and essential foundation to achieve better performance in pediatric nursing [ . Focusing on this issue that one of the affecting factors on the issue of trust is cultural differences, and individuals in different countries and different health care systems have different views about trust [ , but studies suggest that this concept has rarely been studied carefully [ , specifically, qualitative studies in this area are very limited [ ; while qualitative studies greatly help understand the care recipients experiences about trust [ . So to increase the nurses’ understanding of this concept based on the experiences of care recipients, the present study has been done in order to express the factors that affect the formation of trust in mothers with hospitalized children towards the nurses.

Subjects and Methods

This study is a qualitative research with the approach of conventional content analysis. The research environment was pediatric ward of hospitals in Yazd.

14 mothers (the participants’ characteristics are shown in Table 1) whose children were hospitalized in hospitals and were being discharged, were capable of communicating, had the reasoning ability to express their experience and were able to answer the questions carefully in the interviews, were selected based on purposive sampling.

Table 1:

Participants’ characteristics

Parent	Age	Occupation	Education	Residence	Children’s illness	Days of children’s hospital stay	Children’s age	Children’s sex	Hospital type
Mother 1	30	Housewife	High school diploma	Yazd	Leukemia	32	2.5 years old	Male	Academic hospital
Mother 2	35	Teacher	Associate degree	Rafsanjan	Kawasaki	4	10 years old	Male	Academic hospital
Mother 3	24	Housewife	Diploma	Yazd	Febrile Convulsion	3	2.5 years old	Female	Academic hospital
Mother 4	22	Housewife	Fifth grade	Shahre-kord	Brain Tumor	6	2.5 years old	Male	Academic hospital
Mother 5	28	Housewife	Associate degree	Fars	Fever	3	20 months	Female	Academic hospital
Mother 6	27	Housewife	Fifth grade	Tabas	Diabetes	5	18 months	Female	Academic hospital
Mother 7	37	Housewife	Fifth grade	Yazd	Diarrhea and vomiting	6	6 years old	Female	Hospitals of The Social Security Organization
Mother 8	30	Housewife	Diploma	Kerman	Esophageal varices	4	1.5 years old	Male	Hospitals of The Social Security Organization
Mother 9	28	Housewife	Fifth grade	Yazd	Fever	3	3 years old	Female	Hospitals of The Social Security Organization
Mother 10	32	Housewife	Diploma	Yazd	Pneumonia	8	2 months	Female	Private hospital
Mother 11	35	Housewife	Diploma	Eqlid	Lymphoma	7	12 years old	Female	Academic hospital
Mother 12	42	Housewife	Fifth grade	Yazd	Pneumonia	4	7 years old	Female	Private hospital
Mother 13	26	Nurse	Bachelors	Yazd	Pneumonia	3	3 years old	Male	Private hospital
Mother 14	35	Housewife	Diploma	Bandar-abbas	Growth failure	6	14 months	Female	Academic hospital

Data was collected using semi-structured interviews with open questions. The interview locations were in the conference rooms, at homes or at the workplaces.

The beginning questions of the interview were:

“Please talk about your sense of trust in nurses.”

“What nursing care causes the trust?”

“Why such feeling has been formed in you?”

“What other factors have been effective for you in forming trust in nurses?”

“Why are these factors important to build trust?”

After recording all interviews, they were immediately transcribed verbatim. Each interview was rewritten and analyzed before the next interview. The average time for each interview was about 40 minutes and the interviews continued until achieving data saturation.

All ethical considerations including maintaining anonymity, data confidentiality, informed consent, having the right to withdraw from the study were kept. Before the interview, the written consent forms, which were signed after explaining the purpose of study and the process of the research, were prepared for the informed and voluntary participating of all participants. The participants were assured that in the whole entire process of the research, data provided by them would remain confidential. And during the study, participants were asked for permission to record their statements.

The participants were explained that at each stage of the study, they could withdraw in case of lack of willingness to continue participating in the study. The time and the place of the interviews were determined by the agreement of the participants. Conventional content analysis approach for data analysis was used.

At first, all recorded interviews were transcribed in texts. Then the texts were read several times and semantic units were identified, in the next stage semantically similar codes were located on the same category and then combining together, these categories created larger categories. And finally the categories were abstracted in an interpretation level, in order to reveal their implicit implications.

Different methods were used to ensure accuracy. In order to increase the reliability of the study, the researcher has used member checking, prolonged engagement and data collation. In order to be sure about the accuracy of the codes and interpretations, some of them were return to the participants for approval.

The researcher has attempted to possibly have more extended meetings and interviews with participants while work experiencing in pediatric ward.

To collate the methods of collecting data and the resources, the researcher attempted to choose her samples with the maximum variety, she also used several different methods such as interviews, observations and noting in context. To be sure about the consistency of the process of data analysis, the researcher has used triangulation and code revision. In this way that the interviews, codes and emerging categories were sent to supervisors, advisors and colleagues familiar with qualitative research and their opinions about the accuracy of the process of analysis and conducted interpretations from interviews were asked. In order to verify again the codes, the researcher also referred to previous coded interviews while coding each interview.

Moreover, to increase the transmissibility of the study, the researcher tried to provide others with the possibility of following up the process of the study by accurate and purposeful descriptions of the process of study and work carried out during the study.

Findings

Data analysis eventually led to the formation of a major category entitled “nurses’ attempt for professional nursing” which includes sub-categories of commitment and empathetic caring, skill in performing duties, mothers’ participation in the process of caring, being interested in pediatric nursing and establishing effective communication. (Main categories and sub-categories are shown in Table 2)

Table 2:

Main categories and sub-categories

Major category	Sub-categories
Nurses’ attempt for professional nursing	Commitment and empathetic caring
	Skill in performing duties
	Mothers’ participation in the process of caring
	Being interested in pediatric nursing
	Establishing effective communication

The first sub-category has been commitment and empathetic caring, that according to participants’ comments it includes soothing, providing vigilant care, trying to meet the needs of both mother and child.

Soothing; meaning sympathy, to give hope, to console and to calm were included as behaviors that reduced mother’s stress, increased the adaptability, let mothers accept the occurred situation and eventually it has been effective in creating trust in mothers. One of the participants says: “they were consoling and saying that I shouldn’t be worried about why it has been like this and there are people that might be here for about a month and that was the way that I was feeling calm”.

Providing vigilant care, means providing the necessary care, providing on time care, being quick, precision, regular checking and responding to requests were the other features of the nurses’ performance that regarding to those mothers were commenting about nurses’ sense of responsibility about doing their duties and they were announced as affecting factors on trusting on nurses by mothers.

A participant says about this: “I saw that he is wheezing, I ran and told it to the nurse immediately, the nurse just came lethargically and said it’s nothing just put the oxygen he would be better, the nurse didn’t have any sense of responsibility.”

The attempt to meet the needs of both mother and child was one of the other factors needed to create trust in mothers towards nurses. This attempt could range from complete neglect of the needs to persistent efforts in order to provide the needs. A participant says about this: “that’s right that nurses are checking children’s affair but what about the mothers? They should finally see what mothers want or what are things that they don’t want and do whatever they could do for them, in this way, mothers would trust them as they find nurses supporting them”.

The second sub-category is skill in performing duty. Participants stated that; sufficient knowledge, experience and skills of nurses are specifically important for mothers. The higher levels of knowledge and skills nurses had, the more trust mothers would have on them; low experienced nurses with no skills in finding young children’s blood vessels have been known as the source of concern and in contrast nurses with knowledge, experience and enough skills specially skill in finding young children’s blood vessels, lead to comforting sense that participants have propounded it the reason for trust on the abilities of nursing performance. One of the participants has said about nurses’ skills: “she’s also skillful in finding blood vessels. If we know that Ms. … is coming tomorrow morning, we will let the kid’s fluids disconnected until the next day so that she’ll come and find the kid’s blood vessel as we are sure that she’ll find it and the kid is not hurt.”

The third sub-category of the study is participation of mothers in the process of caring. Based on participants’ statements, when mothers have been informed by nurses, and they were asking help from mothers in prescribing medicine or taking IV line in kids, sense of participation in child care is formed in mothers. Informing means providing the necessary information for mothers about the child’s disease, process of treatment, needed care during hospitalization and after discharge, informing mothers about the ongoing series of interventions for children during hospitalization, and explaining about the reasons of each care which can range from reluctant nurses in informing mothers to self-acted nurses in querying mothers about the existence of the required information. A participant says: “when I came a nurse asked me if I knew what esophageal varicosis was, and I answered no and she said that varicosis was like a balloon and showed me by drawing. When they demonstrate like this we can understand more and better and you feel happy about what the nurse is doing and then I asked her the questions that I had as I was sure that she would answer”.

Getting help from mothers was introduced as one of the other effective factors in creating trust by participants. Mothers tend to have a role in providing child care in order to help protecting their child’s calmness. And the way nurses do this, is extremely important for participants. Regarding this a participant says: “my kid cries a lot and I asked them to let me give her medicine by myself. One or two of the nurses come and do it themselves and I wake up by my kid’s crying and they don’t call me and don’t let me give the medicines, when they are on duty I’m worried but when Ms. .... is on duty I’m sure that she would let me help giving medicine to my kid, I feel relaxed.” The fourth sub-category is being interested in pediatric nursing according to participants’ statements. Interest in nursing profession, in pediatric patients and maternal affection can make the pediatric nurse interested in nursing the children. According to participants’ opinion, a relationship that a nurse has with her profession, that means. the interest in nursing profession from one hand, and the interest in the sick children and maternal affection from the other hand, results in mothers’ trusting the nurse more than a nurse who has been in this profession by force and cannot stand working with sick children, has not experienced yet being a mother and cannot understand the relationship between a mother and her child. A participant in this regard, says: “What I understood is that they all work by force and they just want to finish a duty but when we were in the other hospital, my child knew some of the nurses, they were playing with his toys and they loved nursing children.” Another participant regarding nurses maternal affection stated that: “when the nurse was taking IV said that I can understand what you feel when your child is crying, I’m a mother myself”.

The last sub-category obtained from this study is establishing effective communication which according to participants has the following features: Understandable communication, child age appropriate communication, intimate communication and a communication with ethical approvals (politeness, complaisance, respect, tolerance, altruism). Based on participants’ opinion, establishing an understandable communication is considered extremely important. The use of incomprehensible medical terms or speaking a language other than mothers’ native language leads to lack of understanding nurses’ statement. Not trying to let mothers understand the statements, causes disconnection between mothers and nurses. Regarding this, a participant says: “I can’t understand the accent at all. I have to ask again what she said; I’m worried that I might misunderstand and the nurse herself won’t even ask if I understand what she says.”

Child age appropriate communication was one of the other features proposed by the participants. Mothers pay attention to how nurses communicate with sick children and it is important for them that how a nurse attracts their child’s trust and what reaction the child indicates in front of the nurse and nursing interventions. A participant said in this regard: “nurses often said: when we were sick we wish came to hospital because the hospital gave a beautiful doll to sick kids then kid is getting really happy or they said: so you didn’t go? So today you are going to be discharged and this one would laugh.”

Intimate connection according to participants has a special significance. When nurses begin a communication with greeting mothers and continue to gradually have a friendly communication and even joke with mothers and get closer to them, it would be really helpful in attracting mothers’ trust and continuing the communication. A participant says in this regard: “when Ms..... is on duty, she’s coming to our room for a while and greets me and my child and smiles and waits and says something briefly, she talks about herself and asks about us and our family, which means we are friends.”

A communication with ethical approvals was important for all participants. According to participants, it is not important that just a communication will be established by nurses, but a communication is considered important which values and respects mothers as humans and treats them affably, and nurses stay patient with mothers’ statement and behavior. A participant says in this regard: “there was one of the nurses who was really patient and polite, she was respecting you, she was coming into the room and when you were asking something, she used to answer happily.”

Altruism was one of the moral characteristics of nurses that was mentioned as an effective factor on establishing a relation with nurses and creating a sense of trust in nurses by participants. A participant said: “some of them were really good, one of them told me if your husband comes earlier and takes the test to be done outside, you may be discharged earlier, do you want to call? She even gave me her phone card as I didn’t have a cell phone to call my husband, and I was really happy, a feeling that you can trust her that she could be helpful.”

Discussion

Trust is needed for effective interpersonal relationship and social life, and trust has been achieved from interaction between individuals [ . Based on participants’ statements in this study, commitment and empathetic caring, skill in performing duties, mothers’ participation in the process of caring, being interested in pediatric nursing and establishing effective communication are presented as effective factors in creating trust in mothers toward nurses.

Participants in the study expressed that due to illness in children and stress associated with hospitalization and diagnostic and therapeutic procedures, they need to be protected and the soothing done by nurses was cited as an effective intervention in the creation of a sense of confidence toward nurses. Indeed a mother, who is experiencing hospitalization of her child, is suffering emotional distress. She will have an emotional psychological breakdown and on the other hand, entering an unfamiliar environment will cause anxiety and fear and will be a limitative factor for mothers in expressing their requirements [ .

Parents need to express their feelings, they prefer the nurse to be available for conversation to express their feelings and accept their feelings [ and the nurses who play the supportive role for the mothers are considered as a helping factor in pacifying mothers’ stress and anxiety [ and this nurses’ behavior gains too much trust and satisfaction for mothers [ . It means that when a nurse is considered as a supporter for the mother can build a reliable relation [ .

Participants believe it is necessary that the pediatric nurses in performing their tasks, giving required care, on time care, being precise and fast, on time supervision and responding the requests, pay enough attention so that they can be able to gain the trust of mothers. Attree also insisted on this matter in her study that the nurses being always ready to present any required care, can present high quality of nursing [ .

Potter and Fogel propound these findings in another way, taking a look at papers related to the care behavior of nurses, they have stated that in different papers nurses’ caring behavior such as availability of the nurse, investigation, following up, giving health care, on time pharmaceutical care and giving priority to the patient are the most effective caring behavior in gaining trust [ . Finch reported in his study that following up by nurses in order to meet patients’ expectation will lead to gain trust [ .

Participants in this research believe that one of the characters of a committed and compassionate care is the effort of the nurse to meet the needs of mothers and their hospitalized child. Nursing is a helping profession that a nurse keeps on checking the shortages of the patient and helps the patient to meet her own therapeutic needs [ .

In the Attree’s study which was performed by Grounded Theory, predicting the patient’s need, nurse’s willingness to help the patient and try to meet the requirements is defined as a high quality care [ . Finch in a qualitative study tried to discover patients’ experiences about the care behaviors and found that nurses’ effort in meeting the patient requirements whether physical or emotional, without any patient reminding and initiated by the nurse herself, leads to a sense of care towards the nurse [ and Thompson et al stated that meeting the requirements of the parents by the nurses is necessary and increase the trust of the parents to the nurses [ .

Nurses’ skill in performing the tasks is another reason that mothers trust the nurses. De Raeve reported in her study that trusting the nurse is related to the evaluations of the nurse’s skill [ . Jofee et al stated that skill of a nurse can be a factor to gain trust and Skills are divided into two types: technical and mutual [ . Van Hecke introduces the technical competence as an accelerator for the formation of trust in health care recipient [ .

Lininger stated that getting IV line is a difficult task in pediatric nursing and many hospitals with pediatric wards are looking for nurses with a high experience and skill in getting IV line and the skill and success of the nurse and the number of the times the nurse perforates the blood vessels of the child affects the satisfaction of the patient [ . Calnan and Sanferd also stated that trust of the patients to the nurses is related to the technical skills of the nurses [ .

Mothers’ participation in the process of caring is the third effective sub-category in creating trust. Conner and Nelson also demonstrate this method in this way that for a nurse in order to demonstrate her supportive role, it is necessary to present the essential information and references to the patient, and parents with hospitalized children have the right to receive clear and frankly answers for their questions, and they need complete information during their child hospitalization [ and when the relation between the parent and the nurse is an open information relation, it makes the parent to receive the information related to the pediatric care plan [ .

Thompson and co-workers’ qualitative study finding shows that when the parents of the sick children receive the required information from the nurses, they trust the nurses [ and Hallas et al stated that making an open and frankly relation leads to gaining more trust [ .

Participation forms a deeper sense of being in care experience of mother from a child and decreases stress and sense of insecurity and improves the sense of satisfaction of the parent from the nursing care and also improves the relation between the parent and the nurse [ . Coyne et al stated that Knafle in his research on 62 families found that 46% of the families reported high trust to the pediatric care team [ . Thompson et al also stated that one of the important factors that gain trust of the parents to the nurses is parents’ participating in pediatric care [ .

Participants stated that being interested in nursing and sick child and maternal affection in a nurse can gain a lot of trust for the nurse. Mechanic and Meyer stated that in the process of nursing, trust means that the trusted person works with interest for the person who has trusted him [ . Jones and Belcher in reply to the question: “which factors are important to build a reliable relation?” indicate that affection to others is an effective factor to create trust between individuals.

Nurses’ tend to take care of and help others can be an effective individual character which can gain trust for the nurse [ .

After a comprehensive surfing in the internet, researchers didn’t find any useful information about nurses’ interest to their profession and maternal affection with creating trust in mothers or patients towards the nurses. It seems that here more investigation will be appropriate..

Establishing an effective communication is the last sub-category of this study that, according to the assessments of participants, plays the most important role in gaining the trust for the nurses. Proposed features are understandable communication, appropriate communication according to child’s age, intimate communication and communication associated with ethical approvals (politeness, complaisance, respect, tolerance, altruism).

Latour et al stated that if the relation will be an understandable and effective communication, it would be useful for the child and with less fear and stress for mothers [ .

Wigert et al stated that if the statements of doctors and nurses are not understandable for parents and they use medical terms, parents will protest against this type of expression [ and creating a good communication can be an important issue to support the parents of the child. Lack of an appropriate relation between nurse and parent can increase fear and stress in parents. And vice versa if a nurse will find the opportunity to talk to the parent, she can invigorate sense of sympathy and understanding in the mother [ .

Participants are paying much attention to ethical approvals by nurses within establishing a communication. And they insist on this matter that affability of nurses in contact with parents and children can gain trust for the nurses.

Conner and Nelson state that parents are expecting an open and honest communication and expect respect from the nurses and communication associated with respect will lead to cooperation improvement with caring team [ and good relation, honesty, respect, and desire of the nurse to help others are main factors to create trust [ .

Appropriate communication according to the child’s age is the feature mentioned by the participants .Thompson believes that talking to the children according to their level of completion and calling them with their first name will simplify gain parents’ trust to nurses [ .

Bricher finds that nurses can gain trust of the children by establishing a relation with an appropriate language, playing with child, preparing sufficient and favorite toys for the children, preparing the child before procedure, presenting sufficient and understandable information and using encouragement for the child [ .

When nurses establish a friendly relation with mothers it makes the mother to continue the relation with the nurse and in order to receive response to their questions and meet their needs and their child’s needs, they prefer to ask the nurses who have friendly relation. Thompson in his interview with parents of hospitalized children, reported that creating a friendly relation will simplify gaining trust in parents to nurse [ . Skirbekk et al noted “more open trust relationship depends on more personal involvement with patient” [ and creating a friendly relationship has been expressed as the facilitator for the formation of trust [

Conclusion

Findings from studies showed that mothers considered different factors in creating trust to the nurses, and most of the findings from the existing study were consistent with the results of previous studies. But some attained concepts were completely new and it means that in order to make these concepts applicable it is necessary to have some researches in this field, especially quantitative researches which check the relation between trust and new concepts such as maternal affection of a nurse and interest in the nursing profession. Results of this study can help the nurses and nursing students create a relation based on trust. Results of this study can help managers and people in charge in the nursing district to organize required educational programs to increase knowledge and skill of the pediatric nurses in order to gain trust of the mothers and hospitalized children and eventually effectively improve the nursing care.