Nursing students experiences of caring for hospitalized children : A qualitative study in Danang, Vietnam

Main area: Nursing

Authors: Natalia Olsson & Stina Hallerfelt Supervisor: Ingalill Gimbler Berglund Jönköping 2019 January

Nursing students experiences of

caring for hospitalized children

Sammanfattning

Titel: Sjuksköterskestudenters upplevelser av att vårda barn på sjukhus

Syfte: Att beskriva sjuksköterskestudenters erfarenheter av att vårda barn mellan 0–5 år på sjukhus.

Bakgrund: Barndödlighet är vanligast i åldrarna mellan 0–5 år. Trots den positiva utvecklingen i Vietnam under de senaste åren är barn fortfarande en utsatt grupp. Studier visar att det finns utmaningar i Vietnam inom vårdandet av barn och att det behövs forskning för att lyfta sjuksköterskors erfarenheter men också för att öka medvetenheten om barndödlighet.

Metod: Semistrukturerade intervjuer genomfördes med tio sjuksköterskestudenter som hade haft praktik med barn mellan 0–5 år. Data analyserades genom kvalitativ innehållsanalys med induktiv ansats.

Resultat: Sjuksköterskestudenterna upplevde tacksamhet när de kunde stödja barnen och barnens föräldrar. Studenterna fick ökad kunskap om specifika uppgifter och beskrev föräldrarna som betydande och stöttande i vården.

Slutsats: Att vårda barn är utmanande och genererar olika känslor. En viktig faktor inom vårdandet av barn är att involvera barnens föräldrar.

Summary

Aim: To describe nursing students experiences of caring for hospitalized children between 0-5 years old.

Background: Child mortality is most common in the ages between 0-5 years old. Despite the positive development in Vietnam during the last years, children are still a vulnerable group. Studies show that there are challenges in pediatric nursing in Vietnam and research is required to highlight the experiences to increase awareness of pediatric nursing and child mortality.

Method: Semi-structured interviews were conducted with ten nursing students who had practice with children between 0-5 years old. The data were analyzed by qualitative content analysis with an inductive approach.

Results: The students felt gratefulness when they could support the children and the parents of the children. The students received new knowledge about specific tasks and described parents as essential and supporting in the care.

Conclusion: It appeared that pediatric nursing is challenging and generates different emotions. An important factor in pediatric nursing is to involve parents.

Content

2.4NURSE EDUCATION IN VIETNAM ... 2

2.5NURSING ... 3

2.6FAMILY-FOCUSED CARE ... 3

2.7PEDIATRIC NURSING IN VIETNAM ... 4

3.0 AIM ... 4 4.0 RESEARCH METHODOLOGY ... 4 4.1DESIGN ... 4 4.2PARTICIPANTS ... 4 4.3DATA COLLECTION... 5 4.4DATA ANALYSIS ... 5 4.5RESEARCH ETHICS ... 6 5.0 RESULT ... 7

5.1AN EDUCATIONAL AND SATISFYING PRACTICE ... 7

5.1.1To give support ... 7

5.1.2 Learning experience ... 8 5.1.3 Feeling grateful ... 8 5.2ACHALLENGING CARE ... 9 5.2.1 Emotional burden ... 9 5.2.2 Difficult tasks ... 9 5.2.3 Environmental conditions ... 10

5.3COLLABORATION IN PEDIATRIC NURSING... 11

5.3.1 Parents involvement ... 11

5.3.2 Interprofessional collaboration ... 11

6.0 DISCUSSION ... 12

6.1METHOD DISCUSSION ... 12

6.2RESULT DISCUSSION ... 13

6.2.1 An educational and satisfying practice ... 13

6.2.2 A challenging care ... 14

6.2.3 Collaboration in pediatric nursing ... 15

7.0 CLINICAL IMPLICATIONS ... 16

8.0 CONCLUSION ... 17

9.0 REFERENCES ... 18

10.0 ATTACHMENTS

10.1 ATTACHMENT 1: INTERVIEW GUIDE 10.2 ATTACHMENT 2: INFORMATION LETTER

1.0 Introduction

Child mortality is most common in the age group between 0-5 years old, with 90 percent of all child mortality taking place before the age of five. The third goal of the United Nations Sustainable Development Goals by 2030 is “Good health and well-being”. The goal is to ensure healthy lives and promoting well-being at all ages. Statistics from the goal state that no child under the age of five shall die for reasons that may be prevented (United Nations [UN], 2017a). The convention on the right of the child presents that every child is entitled to good health and have right to medical care (United Nations [UN], 2018a) Vietnam has made significant progress in reducing child mortality. However, the whole country faces challenges when it comes to healthcare situation of children (United Nations Children’s Fund [UNICEF], 2010). The work with children is challenging (Ljusegren, Johansson, Gimbler Berglund & Enskär, 2012) and nurses experience a range of emotions while taking care of seriously ill children in hospital (Costello & Trinder-Brook, 2000). To improve children’s health, systems need to be strengthened through more sustainable structures and quality (World health organization [WHO], 2017b). An important part in the pediatric nursing is to involve the family (The Children’s Hospital Association [CHA], 2018; Hopia, Tomlinson, Paavilainen & Åstedt-Kurki, 2005). Parents' involvement promotes children's health and is a significant resource to the nurse who provides information, show encouragement and empathy. Nurses are those who have the closest contact with children and parents in hospitals. They play a significant role in preventing and reducing child mortality (Gallagher, Patridge, Tran, Lubran & Macrae, 2017). That is why this study will highlight nursing students experience of working with pediatric nursing in order to promote good healthcare.

2.0 Background

2.1 Children’s rights

Since 1977, Vietnam is a member of the United Nations, which includes the UN Convention on the Rights of the Child (UN, 2018a). The UN convention on the right of the child is presenting 54 articles that every state of the UN convention need to consider. The convention is dealing with the human rights of the children and states that every child has their value and rights, that children should be in the front in every decision that affects them and that the parents have the primary responsibility for the children. The convention claims that every child is entitled to live, to good health and to have medical care (United Nations, 2018b). The Sustainable Development Goals refers to realizing human rights and the third goal is to ensure that everyone can live a healthy life and work for all people’s well-being at all ages. A sub-goal of goal three is to ensure that no infant or child under the age of five dies for reasons that may be prevented. All countries strive to reduce the neonatal mortality to no more than 12 deaths per 1,000 live births and mortality among children under five years to a maximum of 25 deaths per 1,000 live-born. Another sub-goal is to strengthen the funding of health care as well as efforts to recruit, develop, educate and retain healthcare professionals in developing countries, especially in the least developed countries. Additional efforts are to ensure that everyone has access to healthcare, safety, affordable medicines and vaccines (UN, 2018a.)

2.2 Child Mortality

More than half of all deaths of children under the age of five are due to diseases that could be prevented and treated through simple and affordable actions. By

strengthening health systems for children, many lives could be saved. To prevent these deaths, improvements in the quality of care, during the childbirth for mothers and their newborns are required. There are approximately 7,000 deaths among

newborns each day, which represents 46% of all deaths in children under the age of five (Word health organization [WHO], 2017a). Detecting and treating illness in children is essential due to the facts that newborns can quickly become ill and die if diseases are not recognized or treated promptly. It is vital that ill children are treated by trained health care providers (WHO, 2017a). Infant and child mortality rates are the highest in countries which are controlled by civil strife, weak governance,

underfunded public health systems and inadequate physical infrastructure (UNICEF, 2014). Child mortality is a crucial indicator of children’s health and well-being, but it is also an indicator of overall progress towards the Sustainable Development Goals (UN, 2017b). An objective of the third goal is to reduce child mortality to 25 deaths per 1000 live births in every country (WHO, 2017a). Over time, Vietnam has made significant mortality. In 2017, the child mortality under five was 20,9 per 1000 live births (The world bank, 2017).

2.3 Healthcare in Vietnam

There have been significant improvements in recent years related to early childhood care in Vietnam. A comprehensive range of national guidelines, programs, decisions, and standards have been developed to support healthcare and children’s right to health (UNICEF, 2010). The historical circumstances in Vietnam have led to numerous challenges to the development of nursing as a profession (Crow & Thuc, 2011). At the beginning of the 90’s new education programs were established as priority training for medical staff and healthcare in Vietnam. Increased education and research led to improved skills and knowledge of the healthcare staff, and the number of deaths decreased significantly (Anh & Tram, 1995). Statistics show that in the member states of the Association of Southeast Asian Nations (ASEAN), Vietnam is one of the countries in ASEAN that have a sufficient number of doctors, nurses and midwives (Efendi, Nursalam, Kurniati & Gunawan, 2018). However, the healthcare in Vietnam has been different for people in the country depending on the economic status (Nguyen et al., 2012a).

2.4 Nurse education in Vietnam

The Vietnam Nurses Association (VNA) is a national association in Vietnam consisting of nurses, medical technicians, and midwives. Through the achievements of VNA, Vietnam was able to establish the first University program for nursing. The program helped develop common norms and knowledge within the nursing profession (Canadian Nurses Association CNA, 2018). In Vietnam, the duration of the nursing program is four years for a bachelor’s degree (Efendi et al., 2018). The nursing program contains four parts, general subjects, basic science, basic medical science and specialized subjects (Van der Velden, Van, Quoc, Van & Baron, 2010). VNA has the legal responsibility to represent all nurses, and their primary goal is to improve the quality of life for the patient through developing standards of healthcare. VNA explains the nursing profession as a humanistic giving of holistic care to people to prevent illness, maintain and promote health, and provide rehabilitation for individuals, families, and communities. VNA tries to describe the nursing and the caregiver function. One side refers cooperation with the physician, and the other side refers the nurse as a health counselor (Jones, O’toole, Ngyen, Tran & Pham, 2000).

To provide equivalent nursing qualifications, standards and increase the availability of the nursing workforce has become a challenge for the ASEAN members (Efendi et al., 2018). Nurses in Vietnam has made significant progress in the past decade. However, issues with the nursing role remains, such as shortages of qualified faculty, a lack of teaching resources and no standardized nursing procedures (Gallagher et al., 2017). Studies show that the use of the nurse’ caring knowledge has decreased in Vietnam. (Jarrett, Hummel & Whitney, 2005) Vietnamese nurses do not have any national standards for their practice and education is largely controlled and influenced by physicians (Crow & Thuc, 2011; Jarett, Hummel & Whitney, 2005).

2.5 Nursing

Promoting health, preventing illness, restoring health and alleviating suffering are the four responsibilities that a nurse has, according to the International Council of Nurses (ICN). ICN’s code of ethics for nurses outlines that nurses must respect human rights and provide care that is unrestricted regarding age, color, culture, disability, nationality, and gender. The nursing profession has a responsibility to provide care to people in need and promote health service to individuals, families, and communities. A part of nursing care is to ensure that patients are provided with correct and understandable information. Nurses should maintain a culture of practical work that promotes an ethical approach and an open dialogue. They are also expected to actively contribute to maintaining nursing values and evidence-based knowledge (International Council of Nurses, 2012). The nursing profession involves health promotions and preventions to achieve equal and good health care for the entire population (Willman, 2014).

2.6 Family-focused care

Caring for children and adolescents within the context of their families describes family-focused pediatrics (Coleman, 2002). A significant part of nursing is to promote family health during child hospitalization. This includes helping the parents to look after the childs’ welfare, to share the emotional burden, support in the coping of everyday life and create confidential care relationship (Hopia, Tomlinson, Paavilainen & Åstedt-Kurki, 2005). Examples of strategies to engage families are adaption of communication and assessment of where the family stands to enable the best support. Another strategy is to understand families’ ability to participate in the care of the child (Stoffel et al., 2017).

A significant part in the nurse’s collaboration with the family is to build a trusting relationship. The child and the parents can feel more confident when the collaboration between the nurse and parents are good. The ability to communicate and cooperate with the family can form a sense of confidence and trust. Parents can facilitate and assist the nurse in the care procedures of their child (Samuelson, Willén & Bratt, 2015). Other ways to strengthen the cooperation with parents are through knowledge, guidance, and reflective experiences. The education of the nurse makes the parents gain more confidence about the care of their child (Bettle, Latimer, Fernandez & Hughes, 2017). To consider the culture, background, and values of the families are essential to form trust and respect to families of the ill children (Stoffel et al., 2017). The connection between a mother and a child after birth is an important psychological and physiological process. Parents’ involvement is considered to be of great importance already at the beginning of the child's first time in life. Parent’s involvement in care can be challenging. However, the collaboration is a big support to

the parents and families. The healthcare professionals provide parents with increased skills and participation in medical decisions. It optimizes the collaboration between healthcare professionals and parents. Strong parenting can have positive effects on the sense of safety for the children, and parents' attendance protects the immature children from adverse stress reactions from the high-tech intensive care in hospitals (Meberg & Wataker, 2010).

2.7 Pediatric nursing in Vietnam

The healthcare in Vietnam's community is focusing on people who are vulnerable, such as children (Socialist Republic of Vietnam, 2012). Despite the positive development in Vietnam during the last years, children are still a vulnerable group (Regeringskansliet, 2016). In 2006, the Vietnamese government decided that the universities in Vietnam would change and extend the medical education. One of the dilemmas was pediatric care (Van der Velden et al., 2010). In neonatal nursing, staff are often sent from other units within the hospital and do not receive any neonatal training. Reductions in neonatal mortality can be hard to achieve without knowledge in newborn care (Gallagher et al., 2017). The infant mortality statistics in 1990 was 130 per 100 000 live births. Because of increased attention to prenatal care in 2007, the number fell to 75 per 100 000 live births, which is a dramatic decrease (Crow & Thuc, 2011). A study presented nursing and parental perceptions of neonatal care in central Vietnam where the parents have an overall desire for more participation in their infants' care. It also showed that nurses have a growing awareness of their role along with their ethical issues and challenges in the pediatric nursing. Research is needed to continue improve and highlight the experiences of nurses and parents. Additional research is also required to create awareness of how these areas could reduce child mortality and morbidity in Vietnam (Gallagher et al., 2017).

3.0 Aim

To describe nursing students experiences of caring for hospitalized children between 0–5 years old in Vietnam.

4.0 Research methodology

4.1 Design

This thesis is an empirical study based on a qualitative design (Henricson & Billhult, 2017). Data were collected using semi-structed individual interviews. The design was discussed with the supervisor in Da Nang. After consultation, it was clarified that the study would focus on nursing students experiences. A qualitative design is based on studying people’s lived experiences of a phenomenon (Henricson & Billhult, 2017).

4.2 Participants

The participants were nursing students from Danang University of Medical Technology and Pharmacy. The selection was strategically chosen and ten nursing students were asked to participate. A strategic selection means selecting people who can provide rich information and descriptions of a phenomenon that responds to the purpose (Henricson & Billhult, 2017). The inclusions criteria were that the nursing students studied their last year of the nursing program and had at least one practice with children in the age between 0-5 years old. The supervisor contacted the participants and made the selection based on the criteria’s. The chosen participants were in the ages between 21-24 years old, and all of them were females. The level of practice experience varied between the nursing students. The practice ranged from two

to eight weeks and took place in different types of departments. Examples of departments were neonatal intensive care unit, digestive department, respiratory department, and postnatal department. The participants received an information letter after the selection (attachment 2). The supervisor translated the written information letter into Vietnamese to make sure the participants understood their participation in the study. An information letter is a process for protecting the participants' freedom and self-determination (Kjellström, 2017). It was important that the participants understood the information and could decide whether or not they wanted to participate, that the participation was voluntary and could be terminated at any time. Before the interviews started, the participants received information about the study and its aim once again. At the same time, the participants gave verbal consent to participate.

4.3 Data collection

The data collection was made through semi-structed individual interviews with open questions. Feelings, experiences, and perceptions of participants appear easily by asking open questions (Henricson & Billhult, 2017). Semi-structured interviews were chosen because the questions are formulated in a particular structure and can be asked without any specific order. The interviewer adapts to what appears during the interview and uses an interview guide as support. The interview guide contains specific questions and follow-up questions. Moreover, an interview needs a good atmosphere and calm environment that creates safety for the participants (Danielsson, 2017). During the interviews it was essential to establish a relationship to encourage an optimal conversational climate between the participants and the authors.

The interviews were taken place at one of the nursing student’s home, in a room that was recommended by the supervisor. The interview layout was presented to the participants, and the interviews were held in sequence, from student 1 to 10. The interviews took between 15-30 minutes, and the supervisor was an interpreter. The authors were interviewers, one asked the questions and one took notes and recorded. The interviews followed the interview guide (attachment 1), and the participants were encouraged to answer the questions as detailed as possible. The aim was to hold the interviews in English. As it appeared, some participants had difficulties with expressing themselves in English, which required help from the interpreter. The interviews were recorded using a Dictaphone.

4.4 Data analysis

The result is based on an inductive approach and a qualitative content analysis. An inductive approach is when the research is based on the participants’ lived experiences with a focus on the chosen phenomena (Priebe & Landström, 2017; Henricson & Billhult, 2017). Moreover, an inductive approach means that the material is treated without prejudice and preconceived assumptions during the analysis (Mårtensson & Fridlund, 2017). The analysis process was based on the content of the collected material. The interviews were done through verbal time transcription and the recorded material were transferred from one dictaphone into computers. The first step was a transcription, where the interview answers were written in text (Danielsson, 2017). The following step was to read all of the text material and to go through it several times (Henricsson & Billhult, 2017). The analysis was continued with finding meaning units (Danielsson, 2017). The meaning units are text segments of the interview material, which is several words or one meaning with the same messages that answers the aim

(Henricsson & Billhult, 2017). The meaning units were simplified into condensed meanings and were written on post-it notes. The post-it-notes made it easier to find codes, which are small fragments of the meaning units. The focus under the process was to find similarities, differences and patterns of the material (Kristensson, 2014). The codes were paired together based on which content they represented and formed categories. When the categories were found it was easier to decide suitable sub-categories. The analysis process consisted largely of processing of categories and subcategories. The selection of appropriate categories and subcategories was changed several times depending on the content.

4.5 Research ethics

Regarding research ethics, human rights, fundamental freedoms, health, safety, and personal integrity was considered (Kjellström, 2017). To protect individual humanity and respect for human rights, the fundamental ethical principles were taken into consideration. These principles include human dignity, the principle of autonomy, the principle of make-good and the principle of justice (The Council for the International Organizations of Medical science CIOMS, 2016; Kjellström, 2017). In a developing country or a community in low-resource settings, it is essential to consider the health needs and priorities in the community (CIOMS, 2016).

Before the interview started, the participants were informed about confidentiality and that their participation was optional and could be terminated whenever they wished to (Kristensson, 2014). To ensure confidentiality during the whole process, the material was stored on the computers of the authors with passwords and no unauthorized person would have access to it. Confidentiality is also ensured by presenting the result in a way so no one can know who has given the answers from the collected material. The participants were informed about the study’s aim and that it would be used in Sweden for a bachelor degree thesis (Attachment 2). In order to ensure the participant’s awareness of the use of the study, they were informed that all collected material would only be used for research purpose. After completed study, the recorded interviews will be stored at the School of Health and Welfare in Jönköping for 10 years. Before the study was conducted, a pre-understanding was taken into account. Pre-understanding is knowledge, experience, and values that exist before a study begins. It also concerns values and experiences from other than academic experience (Priebe & Landström, 2017). The pre-understanding of the authors is knowledge from nursing education, internship, work- and life experiences. Before the interviews started it was important to be aware of the pre-understanding in order to not influence the participants.

5.0 Result

Table 1. Summary of the three categories and eight subcategories describing nursing students’ experiences of caring for hospitalized children between 0-5 years old.

The result consists of the category an educational and satisfying practice followed by the sub-categories to give support, learning experiences and feeling grateful (table 1). The nursing students received a lot of knowledge within various fields during their practice. The majority of the students described their practice in positive terms thanks to the increased knowledge that they received. The second category is a challenging care, which includes emotional burden, difficult tasks and environmental conditions (table 1). Numerous students thought the pediatric nursing was challenging and described their experiences with different feelings. The third category is collaboration in pediatric nursing with the sub-categories parents involvement and interprofessional collaboration (table 1). The nursing students described the opportunity to work with parents and collaborate with other healthcare professionals as satisfying.

5.1 An educational and satisfying practice

5.1.1To give support

The nursing students met children with several diseases who needed support in different ways. Some of the students experienced how to calculate medicine, inject medicine and observe the effect of the medicine. Other responsibilities were checking the vital signs of the children, feed them, change their diaper, help them drink breastmilk and bathe them. It was essential to keep the baby warm and support them with their breathing. Other ways to meet the basic needs of the children were to give them safety, help them with everyday activities and to give them closeness.

“I had the responsibility of feeding, change the diaper, taking baths and so on.” Student 6

In the neonatal intensive care unit some nursing students supported children in severe conditions. It was described that the children were supported 24 hours per day and breathing problems, high fever, infections, and skin problems were conditions among the children. It was described that other methods needed to be found to reduce for example high fever or illness.

“Many premature and newborns have many kinds of diseases and they need support from the machines or incubators.” Student 1

An educational and satisfying

practice

• To give support • Learning experience • Feeling grateful

A challenging care

• Difficult tasks • Environmental conditions

Collaboration in pediatric

nursing

It was described that a way to support both the parents and the child was to give information about the kangaroo mother care and to show the parents how to do it. The nursing students who had practice at a digestive unit experienced how to document and how to make caring plans for the children. It was expressed that careful hygiene was important. A significant part of the students described that good pediatric nursing is when the basic needs of the children are stimulated. Another description was that good pediatric nursing is when you try your best for the children. Additional things that were described as necessary for the support were to adapt to the environment, to be kind to the children, to communicate and to be careful to them.

5.1.2 Learning experience

The nursing students were able to learn many things about the care of children. During the practice the students received new knowledge about modern skills, how to monitor the children and handle medical equipment. The students received experience of taking care of tiny children, giving injections and providing support. Other learned by observing the nurses and doctors and were fascinated by their work. Their skills and knowledge about pediatric nursing were described as impressive. It was claimed that nursing students need to observe much of the care of the children under five years old. Some students experienced that they had a lack of knowledge before they went to practice. It was described that the knowledge about pediatric nursing increased each day. Some students were able to practice their knowledge from school, and some got knowledge about how to educate and inform the parents. The students wanted to learn more about kangaroo mother care.

“Many nurses and doctors have many good skills and have studied in different countries to take care of newborns. I can learn from them and their

knowledge.” Student 1

Some of the nursing students had practice at the neonatal intensive care unit, which was described as very educational, interesting and satisfying. The students expressed that they did not have enough knowledge about the intensive care unit. It was mentioned that the neonatal intensive care unit did not include parent's involvement, although the students would like to get more knowledge about their relationship and their impact on the children. Many of the nursing students wanted to learn more about the profession, gather more knowledge and skills about pediatric nursing. It was claimed that nursing students do not have all skills required to take care of the children and some expressed a lack of knowledge about the pediatric nursing. Several students had ambition to work with children later and described their practice as rewarding and a big lesson for the future.

“I will search more information and skills for taking care of children. Also, I want to be able to explain more about good care for the children in the future.” Student 9

5.1.3 Feeling grateful

The nursing students described many positive feelings while caring for hospitalized children between 0-5 years old. Repeated feelings that appeared were feeling grateful, happy, excited, helpful and supportive.

“I feel happy when I go to the hospital every day. I can help the children. When I work with the children I feel better because I can help them“ Student 3

The nursing students felt happy to be able to help the children recover, to give treatment, to discover illness in time and recognize changing symptoms. Even if the children were small and could not communicate, several of the students experienced a connection to the children. The connection was described trough skin-by-skin contact, playing activities and talking to the children. It was commonly expressed that the opportunity to help the children feel safe and give them support was satisfying. The students described that positive feelings appeared when the children and parents were satisfied with the care. Some of the students felt grateful for having a good communication and connection with the parents. The nursing students experienced gratefulness from working with children and loved taking care of them. The students felt happy to work with children because the caring felt meaningful, which gave them a positive experience. Some felt appreciated for the work and grateful when the children received good care.

“ I feel very grateful and happy when I can help the children to recover well during the time they stay at the hospital.” Student 4

5.2 A Challenging care

5.2.1 Emotional burden

The nursing students expressed that caring for children brought a lot of worry and stressful emotions. The children were described as small, fragile and vulnerable. The size of the children and their severe conditions, such as breathing problems, made the students feel afraid. The students expressed fear of hurting the children, for instances while injecting medicine or taking a blood sample. The students experienced fear to make mistakes and do something wrong with the machines that supported the children. The nursing students were stressed when the conditions of the children were changing quickly and when their work were not carefully done. Things that made the students not feel good enough was when they had lack of time or could not do more for the children.

“Sometimes I think I do not have enough time to show how to support the children that make me feel not good enough.” Student 4

The nursing students felt sad when they experienced anomalies, disabilities, and deaths of the children. To see many ill children at the hospital with severe conditions was sad. It was claimed that the children received much medication and had a lot of pain. Another interviewee had experience from the neonatal intensive care unit and described it as shocking to see the ill children.

“I practice for two weeks in the neonatal intensive care unit. First I was very shocked because many of the children were in bad conditions. I saw a lot of sick children in bad conditions.” Student 7

5.2.2 Difficult tasks

The nursing students claimed that taking care of children is hard work and can be difficult in many ways. Some argued that it is difficult because of their small size. The students claimed that their critical conditions could be hard to manage. Difficult tasks according to the students were when the children cried or were in pain. It was described to be difficult to not know why they cried or to not know where the pain was located. When the children were crying, it was difficult to calm them. The students expressed

that it sometimes can be challenging when the child cannot communicate. Further difficulties were when the children did not want to listen or were naughty. Some nursing students experienced that the children refused needles and medication sometimes. When they refused to follow the treatment plan, the students claimed that it was hard to manage them. Sometimes the children did not want to eat or drink. It appeared difficult to convince the child to eat to gain weight.

“Sometimes it is not easy to work with children. They vomit because they don’t want to drink water. Some children are naughty and some children refuse needles, so it is difficult to give them medication.” Student 9

Some nursing students experienced the cooperation with the parents of the children as difficult. Sometimes the parents did not allow the nursing students to take care of their children. In the neonatal intensive care unit, it was described that the parents and families could be very worried. It was claimed that it could be challenging to calm the parents. Several students experienced difficulties with annoyed and worried parents. It was described that the work at the neonatal intensive care unit was entirely different from earlier experiences. To work with bigger children at the maternity care was easier than working with premature babies. It was difficult and complicated to handle children who needed care 24 hours per day. Further experiences in neonatal care were that the medical machines were difficult and the diseases were difficult to treat. Some expressed that it was hard because of their lack of knowledge and others experienced difficulties while taking care of children with breathing problems, skin problems, high fever, constipation problems and a lot of pain. It was described as challenging to give medicine to these children because they could have many medications.

“The children got many medications under the time I had my practice at neonatal intensive care unit, unfortunately. So that was hard to see.” Student 7

5.2.3 Environmental conditions

The hospitals in Vietnam was described as very crowded with many children at the same time. It was described that it could be between 30 - 40 children in one department with only two nurses. The nursing students experienced that some children needed to share a bed and that there was a lack of nurses and doctors for the high number of children. One consequence of the lack of healthcare professionals was that sometimes the children got their medications late. It was claimed that the environment was inappropriate for the children. It was described how children with different diseases shared room and children who got an infection were in a separate area but still in the same room as the other children. The students explained that it makes them feel uncomfortable. Some argued that these environmental conditions and children with severe diseases could increase the risk of being exposed to an infection. It was claimed that the hospital needed to have a separate room for the children with infections.

“It is many children at the hospital at the same time, and it is very crowded.

Sometimes the children need to share a bed. Sometimes children who had different diseases share a bed. It is not good because they can infect each other and can feel very uncomfortable.” Student 9

The ones who experienced the neonatal care unit described that the department contained a lot of medical equipment, many modern and advanced machines. The nursing students experienced that the nurse must manage the equipment. Some students explained that the children had much medication and many machines were connected to them.

5.3 Collaboration in pediatric nursing

5.3.1 Parents involvement

The opinions among the nursing students were that parent’s involvement in pediatric nursing is crucial. It was claimed that the parents understood their child better, could see if the child’s condition is changing and could recognize if something is wrong. The parents were described as important when the children could not speak by themselves. “It is very important to have the parents in the hospital. They play a very big role in the care.” Student 7

The nursing students experienced that the parents could give much information to the nurse about their child and the nurse could give information to the parents. This was described as essential in the care of the child. Some got to experience how it was to give information to the parents about the child’s medication. The students experienced that the children were satisfied when the parents were close and were supportive during the treatment of the child.

“Me and the nurse can ask questions about the child. The parents understand the children better than the healthcare staff and can give much information about their child to the nurse.” Student 5

The parent's involvement was described as important in the care and as a significant support to the nurses and the doctors. The nursing students experienced that the parents could support their child when the nurses did not have enough time. For instance, the parents could check the vital signs on the baby. Additional experiences were that the parent’s involvement also were good for the child’s safety. It was claimed that good communication with the parents provided good care and made the parents feel less worried. It was also mentioned that good communication with the parents strengthens the health care system and the healthcare staff. Several of the students felt comfortable to speak with the parents about their child. The students experienced how to provide kangaroo mother care. The opinions about kangaroo mother care were positive and was expressed to be a good example of involving the parents in the care. It was explained that this type of care was necessary for the connection between the mother and the child because the child could easily breastfeed after learning kangaroo mother care.

“I have experienced the kangaroo care once. I think when the mother or the father hug the child it is like a mental drug to them.” Student 10

5.3.2 Interprofessional collaboration

The collaboration between the nurses and doctors was described as good because they supported the children together. It was expressed that the nurses and doctors had good skills to provide proper care and could meet the basic needs of the children. It was described that it was good when the healthcare providers discovered the children’s

severe conditions and gave treatment in time. Some of the students who experienced the neonatal care unit claimed that the doctors and nurses had much knowledge to take care of the children. It was claimed that the team could provide care quickly.

“A good experience is that the nurses and doctors and the nursing students collaborating very good. We make sure we can support the child, recognize the symptoms of the child and give the medicine in time.” Student 9

It appeared that the collaboration between parents and health care providers is not always good. However, several expressed the collaboration between the doctors, nurses, and parents as good. Some experienced the parents and nurses interwork as good. The students claimed that collaboration between the doctors and nurses could reduce the worried feelings of the parents and act as support when the parents did not feel happy about their child.

“The nurses, doctors and the nursing students can reduce the angry feelings and give support to the parents, so they feel less worried.” Student 9

The nursing students felt that they were included in the healthcare staff as a part of the collaboration. The students helped the nurses during their practice and it was described that the guidance from the nurse was very good. Sometime the students helped the doctors and other professionals. It was claimed that everyone in the interprofessional team needed to help each other to provide the best care for the hospitalized children.

6.0 Discussion

6.1 Method discussion

A strength with qualitative design and inductive approach is that it creates understanding and insight of people’s lived experiences (Henricson & Billhult, 2017). With semi-structured interviews, the interviewer can adapt to the specific interview, which is a benefit. The number of participants were ten nursing students, which can be both a limitation and an advantage (Danielson, 2017). Another potential method could have been focus group interviews, where the nursing students could have discussed in group and agreed on common conclusions about the given topic. An advantage of focus group interviews is that it can give many different opinions (Wibeck, 2017). After discussing the method, the authors decided that individual interviews were the most suitable method to use.

Limitations in the selection were that there were only females who participated and that the supervisor may have chosen only top students, this could affect the credibility and the dependability of the study. If the authors’ made the selection, it may have looked differently. Strengths with the selection were that all participants had the knowledge about and experience of the topic. They had practiced in different departments, were in different ages and the length of the practice varied between two to eight weeks. This is seen as a strength since few people with different experiences can provide better descriptions of the phenomenon than a large number of people with the same experiences (Henricsson & Billhult, 2017). The inclusion criteria were sufficient in order to answer the aim. However, if there had been bigger differences in age, gender, and socioeconomic status, it would have increased the credibility more (Henricsson & Billhult, 2017).

The authors’ formed a relationship to build trust with the participants through several meetings. This was a strength because it is essential to have a good interaction in an interview situation. The interview location was undisturbed, which made the participants feel safe to participate (Danielson, 2017). An identified limitation during the interviews was to have a non-licensed interpreter. This may have led to misunderstandings in the translations of questions and answers. Further limitation is that English is not the native language of the authors’, nor the interpreter or the participants. The time of the interviews was limited to 30 minutes per student. This could have affected both the authors’ and the participants’. More time could have been spent in the preparatory phase with the questions, the layout, and technical equipment (Danielson, 2017). Since the authors’ conducted interviews for the first time, a benefit had been to practice sample interviews before. However, the process was described in the method as precisely as it was, which reinforce the dependability (Mårtensson & Fridlund, 2017).

A strength regarding the ethical approach is that the participant’s names were rewritten into a number between 1-10 to maintain confidentially and the participants had the opportunity to finish whenever they wanted (Kjellström, 2017). The interviews were transcribed precisely to do the analysis as correct as possible. The quotes in the result were marked with the number of each student, this is seen as a strength because it shows that there are quotes from different students and not only from one. The authors’ were aware of their pre-understanding and how it could affect the study which increase the dependability and confirmability of the study (Priebe & Landström, 2017). The analysis process was clearly described in the method, this confirm the confirmability and trustworthiness. The text was processed several times to make sure the result from the data answered the aim (Danielson, 2017). This is also a strength regarding the dependability of the study. To make sure the confirmability and dependability, the analysis and the result were reviewed by the two authors’ and the supervisor to make sure the analysis was based on the collected data (Mårtensson & Fridlund, 2017). Transferability means the level of how the thesis results can be transferred to similar groups. In order to be able to assess whether the result is transferable, a clear description is required and the concept of credibility need to be secured (Mårtensson & Fridlund, 2017). The number of participants were 10, which can be seen as few and therefore be a limitation regarding the transferability.

6.2 Result discussion

6.2.1 An educational and satisfying practice

The result showed different ways to give support in the care. The nursing students’ views of giving support was to do their best. Some explained different ways of meeting the basic needs of the children, such as communicate with them and feed them. This is in line with an earlier study by Ljusegren et al. (2012) which explains that novice nurses do their best to meet the patient's basic needs and that they carry out primary nursing activities. To provide effective treatment and supportive care for the child, family members and nurses must form a partnership. The nurse needs to be aware of the family’s experienced health problems as well as the health problems of the child (Tsuruta, Kusaba, Yamada, Murakata & Nakatomi, 2005).

The result showed that during the nursing students practice, they received a lot of new skills. However, they wanted to learn more and had a lack of knowledge in several

areas. Ljusegren et al. (2012) claim that novice nurses blame themselves for lack of knowledge and feel that it is their responsibility to learn more. Knowledge and skills training can empower the healthcare providers and ensure the process of training for nurses (Gallagher et al., 2017).

Another thing that appeared in the result was that the nursing students learned new things through performing various tasks in practice. The students learned through practicing what they studied in school. To be able to learn new skills there must exist opportunities to try new things and time for the students to practice (Wright, 2012). According to the result, the nursing students increased their knowledge of pediatric nursing through observation. According to Ljusegren et al. (2012) it is essential to watch and listen to children. The study present that nurses observe children and base their decisions to take action on the observations. Another study shows that knowledge and skills are developed through experiences (Hillard & O´Neil, 2010). The result showed that guidance from the nurse helped the nursing students feel more comfortable, helped the nursing students develop new skills and it was seen as positive. Guidance is essential and senior nurses are valuable to junior nurses (Hillard & O’Neil, 2010; Samuelson et al., 2015). Available resources make it possible for the students to spend time repeating their skills (Wright, 2012).

The result showed that nursing students loved their practice and had a desire to work with children in the future. Bagay (2014) confirms that nurses and nursing students have a passion for pediatric nursing and that nursing students have an ambition to work with children and their families. The result presented that the nursing students felt happy to be able to give support and help the children recover. This is in line with a study of Hillard and O’Neil (2010) which describes that nurses feel satisfaction when children recover. This gives meaning to their work and help them feel confidence in their role. In the result, numerous of the nursing students experienced feelings of happiness, gratefulness, supportiveness and helpfulness when working with children. The mood of the nurse has an impact on the children and their parents (Ljusegren et al., 2012). By finding the work satisfying, it provides positive effects on the quality of care (Boamah, Read & Spence Laschinger, 2016).

6.2.2 A challenging care

Difficulties that the nursing students experienced were to manage the severe conditions of the children, handle children in pain or who cried. Ljusegren et al. (2012) claim that nurses can feel powerless when children do not respond to the treatments despite all their efforts, are expose to painful procedures and when children cry. The result showed that some nursing students experienced difficulties with annoyed and worried parents and expressed that cooperation can be hard. Hillard and O’Neil (2010) explain that the parents of the child can be distressed and sometimes the parents need as much support as the child. Hillard and O’Neil (2010) describe that it can be hard to satisfy the parents as a nurse. If the family feels ignored or not receive information about the child it compromises the physical and mental well-being of the family. It also increases their anxiety and stress which leads to less good communication and interaction between professionals and patients (Santos et al., 2015). Lack of communication can create insecurity and mistrust of the health care professionals. Family focused care requires good communication and the parents are dependent on the knowledge of the health care professionals as well as the professionals are dependent on the emotional connection between parents and children (Mikkelsen & Frederiksen, 2010).

The nursing students experienced an emotional burden while taking care of children. Feelings that appeared were fear to hurt the child, worry, and stress. The nursing students expressed feelings of not being good enough when they were insufficient for the children. Ljusegren et al. (2012) strengthen this and describe that novice nurses can find it challenging to face a child and know that there is no more help to give. Hillard and O’Neil (2010) argue that nurses could feel helplessness when they cannot satisfy the children. In family focused care it is important for the nurse to see the parents’ as an active member in the team. Parents can give information about the child that can facilitate the care (Mikkelsen & Frederiksen, 2010).

In the result, several of the nursing students described that they were shown how medical equipment and machines are used in the care by nurses.This is in agreement with a study by Bedells and Bevan (2016) who claim that one part of being a nurse and give support is to provide technical nursing care. Some of the nursing students experienced that the high number of children at the hospital created time pressure for the nurses. Nurses did not have enough time which made the parents more involved in the care. When the hospital is full, the health care providers are expecting the parents to be supportive and bring safety to their child (Shuster, Chung & Vetsal, 2011). In one study it appears that investment in adequate nurse staff is vital to enable good working conditions, especially for new graduate nurses (Boamah et al., 2016). The result showed that the environmental conditions of the children were inappropriate, with sharing rooms and beds. A study confirms this, saying that the parents experience opportunities for improvement in the environment of the children. The study claims that the children’s room can be too noisy for resting (Abuqamar, Arabiat & Holmes, 2016). An environment of family embracement can provide good professional interaction and positive emotional climate in the realization of nursing care (Santos et al., 2015).

6.2.3 Collaboration in pediatric nursing

It showed that parents are seen as big support and are essential in the care of the child. Hillard and O’Neil (2010) describe the importance of promoting parent participation in children’s care and how supportive parents can reduce the children’s anxiety. During early childhood, the parents have a significant influence (Schuster & Fuentes-Affick, 2017). In the result it appeared that parents could see if their child’s condition was changing and recognize if something was wrong. In the family focused care, parents support the nurse by giving information about the child (Kelo, Martikainen & Eriksson, 2013).

The result showed that the nursing student experienced information from parents to be essential in the care of the child. When medical staff support the parents, they feel important and never left alone (Hopkins, Gazza & Marazita, 2016). It was described that children were satisfied when the parents were near. Parents are expected to provide most information about the child, comfort the child during examinations and provide emotional support in a way that health care providers are unable to do (Bedells & Bevan, 2016; Shuster et al., 2011). The healthcare providers need the parents to help their child to complete their treatments (Shuster et al., 2011). This was confirmed by the nursing students who experienced the parents as a big support when checking the vital signs on their children.

The result showed that some experienced that the work of the nurses could reduce the worry among parents. Hillard and O’Neil (2010) argue that when nurses are giving care to the children, they could reduce the parents’ anxiety. The result showed that nursing students experienced that the parents felt less worried about their child when the communication was good. Good communication with parents also enable the healthcare staff to do a better job. Bedells and Bevan (2016) highlight this and claim that it is essential for nurses to communicate effectively and appropriately with the children, as well as with the parents and families. Support from the medical staff help to alleviate the parents’ concerns (Hopkins et al., 2016). Communication between the parents and healthcare staff is essential in the family-focused care and give the parents opportunity to be part of the care of the child (Bettle et al., 2017; Samuelson et al., 2015; Tsuruta et al., 2005).

The result showed that the nursing students wanted to achieve good collaboration with the parents. This is in line with Ljusegren et al. (2012) who claim that a nurse strives to collaborate with the parents in the care of the child. The Sustainable Development Goals states that healthcare professionals should be empowered in order to provide good healthcare to the entire population. One important finding was the importance of the environmental conditions for children and nurses. The result showed that nurses do not have enough time for the work required and can be late with medications. The Sustainable Development goal number three deals with this global issue and underlines that every individual should have access to primary quality healthcare and medications (UN, 2018a).

The result showed that the collaboration between nurses is vital in the care of children. Bagay (2014) claims that communication between nurses and nursing students is essential for collaborative work. Additional, support and collaboration among nurses are highly valued (Gallagher et al., 2017; Hillard & O’Neil, 2010). The collaboration between nurses and doctors are important in the same way as the collaboration with the parents of the children (Kelo et al., 2013). The result indicated that the nursing students felt that the collaboration between nurses, doctors, and parents was good. When all members of the family get support from the nurse, the care is family focused (Kelo et al., 2013). The result of this study showed that involvement of parents and information of the kangaroo mother care are a good example of collaboration between nurses and parents. When parents get support by receiving education, medical staff are seen as therapeutic and loving (Hopkins et al., 2016).

7.0 Clinical implications

The result creates awareness and knowledge about hospitalized children and the pediatric nursing in Vietnam. The result can be used by nurses who will guide nursing students during their practices. The result can also be used by nursing students who never had practice on children and want to receive more information. Nurses and nursing students may use the study to get a better understanding of how challenging pediatric nursing is. The result gives insight into how parent involvement and collaboration can contribute to good healthcare. After completed study the authors gained more knowledge about family focused care and received a broader perspective on the importance of nursing. Further research that would be interesting to conduct is to study nurses’ experiences of caring for hospitalized children between 0-5 years old because it may have carried out more profound and detailed answers.

8.0 Conclusion

The pediatric nursing in Vietnam includes various tasks in order to promote good healthcare. For nursing students who never experienced pediatric nursing, the practice can be educational and satisfying. The study shows that the nursing students learn by practical guidance and observation. Pediatric nursing practice can give nursing students many valuable experiences for their future profession. Nursing students received experience with interprofessional collaboration, which was important in the care of the child. The pediatric nursing was seen as challenging but also generated several positive feelings. One part that is emphasized in the result is the involvement of parents. The parents are essential for the wellbeing of the children because they bring safety and can support the nurses. To continue improve and highlight the pediatric nursing more research is needed.

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