The purpose of the study was to describe and explain the quality of pediatric care in EDs by assessments of children, parents, and nursing staff and with a view of administrative data. The results of this study provided a picture of the quality of child emergency care in all aspects of the Donabedian (1966) model.
The study was described the structural factors, process, and outcomes of pediatric care. There was observed similarities among these components, but based on this study methods, direct causal relationships cannot be drawn.
These results, obtained in Finland, are novel findings on the subject, so this study offers an initial explanation for the quality of pediatric care and challenges nursing research to continue with this topic.
The nursing staff perceptions of care quality in general and pediatric EDs
Nursing staff’s perceptions about pediatric care quality in four EDs in Finland were at a good level, except for the perception of the EDs’ human resources departments. In Phonbruk et al. (2018), nurses’ limited time resources for parental guidance were cited as a reason parents had difficulty understanding discharge instructions. The nursing staff’s satisfaction with pediatric care was increased by positive assessments of professionalism, cooperation, and human resources. These findings could be an opportunity to develop pediatric care in EDs via staff training. Training staff by adding their knowledge and positive feedback about pediatric care has shown great influence (Peeler et al. 2016).
Therefore, EDs should increase staff members’ skills and knowledge, especially in the study addressing areas that increased nurses’ satisfaction with pediatric care: pediatric emergency nursing and multiprofessional work in EDs with pediatric patients. As the share of pediatric patients varies among EDs, in addition to local training, national training in pediatric emergency care should be provided.
The study was examined the element of the type of care structure in which emergency care was organized. This study’s confirmatory finding (i.e. Goldman et al.2018) was that working at a general ED was associated with lower nurse assessments of pediatric care quality. The previous finding of nurses’ perceived lack of competence in caring for pediatric patients had been made in a study in
which general ED staff moved to work in a separate PED (Peeler et al. 2016).
These factors together may indicate that general ED nurses have relatively little experience in the care of pediatric patients, in which case there is no
competence gained through repetition, as STM (2017) stated in the memo of the Emergency Service Act. To achieve repetition with the care of pediatric patients, it would be worthwhile to carry out the centralization of pediatric patients within the general ED. That could be done, regardless of staff members’ medical specialty, in a separate pediatric area or track with permanent nursing staff and medical specialists.
Children’s and parents’ assessments of the quality of pediatric care in EDs
Children and parents rated the quality of care in the top third of the scale, so it can be said that emergency care was perceived as high quality. In previous studies of adolescents satisfaction with care and factors related to privacy in emergency care have been identified as areas for development (Shefrin et al.
2012). The same situation was highlighted in findings according to lower assessments of the quality of emergency care for the realization of a bilateral encounter between a child and the staff. Therefore, during emergency care, the child’s need for a conversation with a professional should be identified and the child should be allowed to meet with a professional without a parent present.
This can be an opportunity for emergency nursing to improve children’s satisfaction with care (ENA 2013).
There were found differences between parents' and children’s assessments at the item level. Children assessed participation in their care, pain
management, and fulfillment of their physical needs at lower levels compared to their parents’ assessments. This supported earlier findings of the importance of children’s involvement in care and care featuring frequent interactions with nurses (Grahn et al. 2016). Based on these it can be stated that children’s involvement in care is a particularly relevant factor in a child’s experience of care quality and more importantly both the child’s and the parents’ assessments of care should be considered individually.
Care process factors relationship with children and parents assessed care quality
According to the emergency process, was found that children’s and parents’
assessments of care quality or satisfaction did not relate to children’s ED LOS.
In that respect, the results were confirmed earlier findings (Rutherford et al.
2010) on the lack of a relationship between child and parent satisfaction with
care and LOS. Also, these results confirm the meaning of LOS as an ED process measurement describing process efficiency (Alessandrini et al. 2011).
Instead of concluding that children’s and parents’ satisfaction with care was related to the number of procedures, patient acuity, and pediatrician care track, one might think that altogether these factors describe the importance of nurses’
and other staff members’ interactions with children and parents in EDs (Grahan et al. 2017). Based on this study’s results, pediatric care content is related to children’s satisfaction with care and fulfillment of parents’ expectations by certain procedures. For pediatric emergency care quality, this is something that can be influenced by nursing.
Nurse staffing relationship to patients’ ED length of stay and the number of patients who left before treatment was completed New information was provided on PED nurse staffing and its relationship with patients’ LOS and LBTC patients. Michelson et al. (2016) addressed the relation between LOS increase and times with limited PED staff resources and Krinsky-Diener et al. (2017) was indicating that the number of pediatric patients is lower during a holiday. Previous and findings concerning the number of pediatric patients daily fluctuating encourage the development of flexible staffing models that can adjust the numbers and competence of nursing staff based on predicted need.
The rate of LBTC patients in the PED was rather low compared to Doan et al. (2014). However, these numbers cannot be compared directly because of measurement differences: the researcher used the LBTC criterion, whereas Doan et al. (2014) analyzed the number of patients who left before seeing a physician. One criterion measures how many patients missed the emergency care process, and the other how many left without seeing a physician. Finnish emergency care quality standards (STM 2014) measure LBTC patients. This is a more accurate measurement in Finnish emergency and pediatric emergency care, as ED professionals are both nurses and physicians.
This study and previous studies (Gaucher et al. 2011; Doan et al. 2014) addressed the relationship between number of LBTC patients and lower-acuity triage levels (ESI 4–5, CTAS 3–5). When there was analyzed PED nurse staffing, this study findings confirmed the findings of Doan et al. (2014) and Benahmed et al. (2012) regarding a relatively large number of low-urgency pediatric patients seeking emergency care in the evenings. This phenomenon
demonstrates families’ use of emergency services in minor acute conditions.
This trend poses an opportunity to increase nurses’ independent practices in PEDs (see Doyle et al. 2012) to provide care and counseling to families in the
the number of LBTC patients who leave while awaiting a response to their emergency care needs.
Differences in care quality assessments among nursing staff, children, and parents
Nurses’ assessments of care quality were lower than children’s and parents’ in four subscales: interdisciplinary collaboration, professional practice, information and participation in own care, and human resources. According to current knowledge, this kind of comparison has not been done in previous studies even though the multiperspective view of care quality allows new insights
(Donabebian 1966). However, the period of assessment might be significant to explain why nurses more critically assessed pediatric care quality. Children and parents share a relatively short time period in EDs; nurses’ perception is based on several findings and different patient processes. ENA (2013) stated that the emergency environment is unique, and therefore developing quality care can be challenging. The study was found that the predictors of children’s and parents’
satisfaction with care included fewer or no previous ED visits. This may also suggest that sometimes, satisfaction with care may be increased by the fact that it is a family’s first experience and there is no prior expectation of
emergency care. Given that the prevalence of ED visits in children is high (Riva et al. 2018), attention should be paid to the quality of care provided at all pediatric emergency visits, for example by developing standardized emergency processes for children.