Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 46(2): 161–169.
Building trust to work with children after a severe traumatic accident Julianne Hall and Shoba Nayar* Faculty of Health & Environmental Science, Department of Nursing, School of Health Care Practice, Auckland University of Technology, Auckland, New Zealand; *Faculty of Health & Environmental Science, Department of Occupational Science and Therapy, School of Rehabilitation & Occupation Studies, Auckland University of Technology, Auckland, New Zealand
Abstract: Trust is integral to nursing; yet little is known about how nurses establish trust when working with patients. This grounded theory study explored nurses’ perspectives of how to build trust with a child and family in the context of paediatric acute health care. Seven paediatric acute care nurses were asked what they did when they cared for a child admitted to an acute care ward from emergency department or intensive care unit following a severe traumatic accident. Building trust emerged as the basic social process for an effective working relationship between a nurse and family to promote the rehabilitation of the child. This paper argues that building trust is critical to nurses developing a working relationship with both child and family to promote optimal health, and enables nurses to effectively step out and handover the care of the child to the family.
Keywords: acute care, child, family, rehabilitation, trust
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his article reports the findings of a grounded theory study that explored what acute care nurses do to promote the recovery of children who had severe injuries caused by a traumatic accident. For the purpose of this study a traumatic accident is defined as an unintentional accident that results in severe injury requiring hospitalisation and ongoing rehabilitation. The participants in this study were Registered Nurses working in acute care wards that received patients from Emergency Department or a Paediatric Intensive Care Unit. The implications of new technological interventions preventing death (Melvin, Lacy, & SwaffordTenEyck, 1998) and continued advancement in medical technology has further increased survival rates, increasing the challenges for acute care wards to promote optimum health outcomes for the child and their family. Within paediatric nursing, children and their families are the health care consumers (Lee, 2007). The current study uncovered the significance of a trusting working relationship between nurses, children and their family being essential to optimise the recovery of the child. The study reported in this paper found a universal dearth of literature related to rehabilitative nursing practice in the acute care setting of paediatric hospitals. Literature purports that trust is the necessary foundation for nurses to work with their patient, in this case the child and family (Caron & Bowers,
2000); yet a concept analysis of trust by Johns (1996) and Hupcey, Penrod, and Morse (2001), failed to identify how nurses work with patients to build trust. The research reported here sought to explore how acute care paediatric nurses work with a child and his or her family to promote rehabilitation. The topic was prompted by the first author’s experience of working with children recovering from severe accidental trauma in a small rehabilitation centre. The first author recognised the importance of earlier nursing rehabilitation practice to optimise the recovery of the child and family. The most significant finding was the need to ‘build a trusting working relationship’ with the child and family. The research findings describe how the participating nurses developed this relationship. There is a paucity of contemporary papers explaining how nurses build trust. Background Acute care and rehabilitation nursing are practised in different settings; they are not usually considered the same, yet the promotion of the child’s recovery underpins both. Pryor and Smith (2000, p. 3) stated ‘nurses can and should practice rehabilitation across all settings regardless of the patient’s diagnosis or prognosis’. From the authors’ experience the medical model of care dominates the acute care setting whilst rehabilitation theory governs how nurses work in the rehabilitation setting.
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The reconstruction of life occurs from the moment a child enters the health care system (Edwards, 2001; Melvin et al., 1998). Initially nurses are involved with monitoring the child’s changing signs of altered health status and preventing stress, such as pain, that may hinder the child’s recovery. Nurses collaborating with the family and health care team are integral to working with the child and family to build a trusting relationship. The nurse needs to create an environment which obtains a ‘snapshot’ of the child and family prior to the accident. This snapshot of how the family was prior to the accident provides the goal for the interdisciplinary team when planning and working with the child and family (Pryor, 2002). Thus, acute care nurses work differently with each family depending on the individual family’s journey, which may include: The cause of the injury, their pathway to the ward, characteristics of the individual family, and the developmental age of the child. Nursing practice that reflects the concepts of family centred care and partnership enables the nurse to understand the needs of the child and family. Casey’s (1993) model of partnership supports the implementation of family centred care. Her model is underpinned by the philosophy that care for all children, well or sick, is best carried out by the family with help from health care professionals whenever necessary. The nurse supports the child and family by helping them to cope and function, sharing knowledge and coaching skills to promote their independence. Casey’s interpretation of her exploration of the meaning of family found ‘the paediatric nurse was only concerned for the family as carers of their child’ (p. 185). In the hospital setting, during the 1990s, nurses did not view the family as their patient. Nurses’ contribution to the team is ‘knowing’ the family and assisting with the reconstruction of the family’s life. The tenets of family centred care introduced by Shelton, Jeppson, and Johnson (1987) influenced the delivery of paediatric health care services with the expectation that this philosophy of care underpins all paediatric nursing. However, there is no consensus about the meaning of family centred care (Darbyshire, 1993; Hutchfield, 1999; Nethercott, 1993), although the term seems to be connected with ‘partnership in care’. Nurses work 162
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with families, through ‘involving’ them in care, encouraging their ‘participation’ in care and working in ‘partnership’ (Casey, 1993; Coyne, 1995; Darbyshire, 1994; Hutchfield, 1999). However, this does not necessarily all happen at once. Without the development of a trusting relationship and a strong connection to the concepts of partnership and family centred care, nurses face a challenge to promote the recovery of a child. Harrison’s (2010) report of reviewed literature relating to the state of family centred care in practice confirmed the multifacetedness of the concept and the gap between theory and practice. Shields (2010) has also questioned the reality of family centred care in practice and suggests further exploration to its viability as a model of care in today’s society. To date, studies have identified that family’s desire a relationship of partnership with health professionals (Harrison, 2010; Reis et al., 2010). However, partnership is frequently marred by the difficulties in health professionals’ use of appropriate communication skills to negotiate roles and develop working partnerships (Harrison, 2010). Communicating and negotiating over a considerable period of time were found to be key strategies for partnership between the nurse, child and family (McKelvie, 2001). These strategies supported intentional and meaningful involvement between the nurse, family and other health care professionals. Lee (2007) acknowledged the child and his/her family as consumers of paediatric services, and further noted communication and negotiation as the most essential skills to develop a relationship representing partnership. Thus, fundamental to the effectiveness of partnership and family centred care is the development of communication that has led to a trusting relationship (Bell & Duffy, 2009). Family members need to be with their child in hospital and mutual trust between the nurse and family needs to be developed to enable the family to handover the care of their child to health professionals (Gasquoine, 1996). Nurses perceive that ‘partnership in care’ is reliant on relationships, gaining trust, being there, reassuring, and working together involving the family (Keatinge et al., 2002). The result of partnership in care was found to be positive health outcomes. Whether the development of trust to support partnership is a viable concept within the acute care
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Building trust to work with children after a severe traumatic accident setting, when mothers are in a stressful unknown situation and feel disempowered, has been questioned by Gasquoine (1996) and Gallant, Beaulieu, and Carnevale (2002). These researchers used literature of disciplines that had studied partnerships, including nursing, medicine, the social sciences and psychology, to support their view that partnership does not occur in the acute care setting. Family participation with nurses is important in the acute care setting to enable the family to learn new skills and to promote their ability to care for their child in the future, as well as promoting the family’s ability to function. A relationship that begins with participation in care has the potential to develop into a partnership. It is uncertain whether a child and family have the time in the acute care setting to develop the mutual trust required in a partnership (Cahill, 1996; Casey, 1993; Darbyshire, 1993); and importantly, the process by which nurses actually build the trust needed for partnership – an issue this study sought to address. Methodology and methods Grounded theory methodology was chosen for this study because it fitted the proposed research question ‘What do paediatric acute care nurses do when they care for a child who has had a severe traumatic accident?’ As a qualitative methodology, grounded theory seeks to uncover the processes that underlie societal functioning (Glaser, 1992; Strauss, 1987) and, increasingly, nurse researchers are using this methodology to explain phenomena that relate to nursing (Chamberlain, 1999; Miller & Fredericks, 1999). Data collection Approval for this research was granted from the Auckland University of Technology Ethics Committee, the Auckland Ethics Committees of the Ministry of Health and the Auckland District Health Board. Consent was obtained prior to the one hour recorded interview held in a place designated by the nurse. Purposive sampling was used to recruit seven registered nurses working in acute care wards. Nurses were introduced to this study by their ward managers. They were given information sheets and contacted the primary researcher if they wanted to participate. The participants included two males and five females. Four participants had been registered nurses for © eContent Management Pty Ltd
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1 year, one participant had 3 years experience and two were considered experienced senior nurses. Four participants worked with children admitted with head injuries and two participants worked in an orthopaedic unit. The sampling of two participants from the orthopaedic unit was useful to identify any differences in nursing practice between the two specialities. All participants were interviewed for an hour. The first two interviews began with the open question ‘Tell me what you do when you are caring for a child who has been admitted following a severe traumatic accident’ Thereafter interview questions arose from the constant comparative analysis used for the purpose of conceptualisation (Glaser, 2001). Two of the seven nurse participants, who had the scope and depth of practice to extend and contradict the emerging concepts, rather than merely replicate the existing data, were invited to contribute together in a final interview. Data analysis On completion of each interview and prior to the next interview data was transcribed verbatim and analysed line by line using Schatzman’s (1991) dimensional analyses methods to question the data and develop theoretical questions. Theoretical questioning aids the conceptualisation of the meaning of what is happening. For example, the fourth interview was more focussed using questions that had arisen from data analysis about how effective nursing interactions were in the recovery of the child. Interviewer (I): Can you tell me about the times when you know as a nurse you have worked effectively with children who have had a severe traumatic accident? Participant (P) 4: It helps in nursing if you look after the same child a few times and you can gain their trust.
Consistency of the individual nurse and trust was seen to be helpful to the child’s recovery by Participant 4, but warranted further exploration before focussing on trust. I: Tell me what your role is and what you have done to promote the recovery of the child?
Participant 4 found it easy to describe her task orientated role, but when faced with the notion of ‘promoting the recovery’ needed time to reflect and think before responding, which then prompted further questioning related to building relationships.
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The relevance of ‘working with’ the family and developing a trusting relationship began to emerge in the first level coding of categories of interview four as the key to the child’s rehabilitation. Constant comparative analysis, the hallmark of the inductive process used in grounded theory research for the purpose of conceptualisation (Glaser, 2001) continued until saturation of the generated codes and categories were complete. These techniques facilitated the unfolding of the social process, building trust. Findings This study found three social processes were integral nurses building a trusting relationship with a child and their family to facilitate the rehabilitation of the child. The social processes found to support the building of trust were ‘developing a working relationship’ and ‘the art of working with to build trust’. These processes are dynamic interactions between nurse, child and family and underpin a third process ‘trusting each other to hand over’, in which the nurse effectively ‘steps out and hands over’ the child’s care to the family and others. Building trust is an important process that enables nurses to step into a family’s physical or emotional space and work with them to promote the rehabilitation of their severely injured child. A family’s previous experience, when interacting with nurses, impacts on the initial level of awarded trust they have with an individual nurse (P3). The nurses in this study perceived that effective nursing of children after a traumatic accident requires a relationship upheld by trust between the nurse, child and family to facilitate the rehabilitation of a child. Developing a working relationship Findings revealed that time to be with a child and family is essential to develop a working relationship supported by trust. Trust is preceded by being able to work with and build rapport. The initial interaction a nurse has with a child and family was described as ‘checking in’, which enabled the nurse to step in and work with the family. Frequently, stepping in was influenced by the awarded trust granted to a nurse, as a health professional, particularly in a critical situation when the parents need to hand over their child (P3). Thus, checking in to effectively step in and build trust is reliant on the nurse spending time with 164
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the child and family to facilitate a rapport and getting to know each other. Although checking in initiates the relationship, ultimately it is the family who gives the nurse permission to step in and work with them. A working relationship is developed by the nurse introducing self, asking the family their needs, and informing the family of the requirements of the health care team. These interactions are eased by ‘chatting’. The importance of remaining focussed on the family but ‘chatting’ about oneself was found to be useful to gain trust and the family’s acceptance. Chatting and getting to know each other protects the awarded but fragile trust granted to a health professional and strengthens rapport and the first building block of trust. The process of ‘stepping in’ is reliant on the nurse engaging the family and reassuring them of what is happening while monitoring the child’s progress and family’s level of coping with the new situation. Different situations alter how the nurse checks in and can challenge the nurse’s ability to secure and further build onto the foundation of awarded trust. The nurse may be required to advance through the barriers that exist. P6: … having to chip away at a wall and have a clean slate to build trust with a family who feels the guilt of the accident. P5: … looks through the windows to gain trust.
Participants described how it is difficult to get to know each other if the nurse is feeling unsure about what is happening at the time. When nurses do not know what is happening they need to inform the family, explain what they are doing, why, and that it is not unusual to be in a position where it is not known what to do. P2: I use a time of silence but I wonder if they think that I don’t know, I usually chat but I can’t if I am scared. P6: All the experience in the world does not prepare the nurse for these situations. The ability to empathize and be with is not easy for the nurse.
Stepping in creates the starting point of getting to know the family, both in the present moment and prior to the traumatic accident to their child. Nurses used chatting to facilitate an open relationship and worked together to orchestrate the care and optimise the rehabilitation process for the child and family. © eContent Management Pty Ltd
Building trust to work with children after a severe traumatic accident The art of ‘working with’ to build trust The nurses felt their ability to build trust provided a stronger base to promote the best working environment for the nurse, child and family. Nurses recognised the importance of using their experience and knowledge to effectively support the development of their art to ‘work with’. While working with, nurses identify the needs of the child and family. They identified that emotional comfort of the family is dependent on a working relationship upheld by trust. From the participants’ view, trusting the nurse is enhanced when the family are informed and reassured about what is happening at the time. Thus, trust is reliant on the nurse’s ability to reassure a child and family. Reassurance is something nurses give; trust is something that needs to be built. Participants identified reassurance as an important element to build trust, and acknowledged that it is not an easy thing to do. P4: The development of trust is nurtured when the family feels reassured. P3: Reassurance is so easy to say but difficult to do. P6: The ability to reassure a family relies on the trusting relationship that has been formed by “getting to know” each other.
The interactions commonly used by the nurses to reassure families related to sharing the knowledge guiding their practice. The nurses p erceived that social processes of informing, educating, and explaining what was happening while working with the child was reassuring to the family. Integral to feeling reassured is the receiving of hope. Hope can be given by nurses through developing family awareness of the small steps of progress in their child’s recovery. P5: A young girl who had a severe head injury was going through the restless waking up phase. I guess with my experience that’s where I got to bringing in the realistic phase as well. Mum was obviously exhausted, shattered, her posture was stooped, she was sighing a lot so I said, “this is a tiring time, it’s a positive time, and this is a stage of recovering from a head injury … this is progress, this is a really good sign.
Nurses’ use of past experiences is an important strategy to reassure the family. However just as
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important is the need to be mindful not to give false hope as this would crumble building blocks of trust. Nurses felt their ability to reassure the family relied on the combination of being honest and realistic with the experiences they shared. The study found that caring and the use of appropriate interventions to ensure a child is comfortable are important to build the family’s trust in the nurse. Participants use ‘doing for’ to develop the trust to initiate a working partnership. The moving of a child in pain, and the management of pain is an example where it is important nurses ‘do for’ the family. P6: Parents first need is to get this pain sorted. P7: If the child is really distressed or traumatized by pain parents are not likely to volunteer to be part of care-giving. P7: Pain is the greatest issue for parents; you cannot have their trust without the control of pain.
When a child is in pain it is difficult for the nurse to maintain a trusting relationship and family to re-establish their role. The importance of pain management was recognised by most participants because a family’s initial concern is that their child is pain free. A serious injury can mean more than physical pain to the child; emotional pain is felt by the family when there is confusion or unknowing of what is happening. Hence, having a trusting relationship facilitated working with the child and family to ease the physical and emotional pain. According to participants, responding to the needs of the child and family is an important component of reassuring the family and building trust. Needs are identified by listening to the family and monitoring the child’s health. In addition to developing a working relationship and the art of working with to build trust, trusting each other to handover was the third social process to emerge in this study. Trusting each other to step out and handover Participants noted that the strength of the trust between a nurse and family is developed by nurses adjusting their practice to work alongside and use the different philosophy and parenting style of the individual family. Knowing these differences is an
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important facet of building trust to uphold the working relationship. The nurses recognised that family, in particular parents, need a substantial foundation of trust to leave their child in a nurse’s care and this trust is dependent on the child’s reaction to the nurse. The nurse develops the child’s trust by ‘using time to just sit down and talk or play rather than just going and doing something to them’ (P4), always mindful of adapting interactions appropriately to the child’s level of understanding and ability to participate at the time. This study found giving support to the family helped reinforce building blocks of trust. The family is supported when the nurse works with and coaches them to parent their child who now has different needs. Importantly a family also needs to be trusted by the nurse that they will promote the rehabilitation of their child by encouraging the child to readapt and learn new skills. The nurse’s skill to let go and have trust in the family’s capability is integral to the rehabilitation of the child. Trust needs to exist between all members of the working relationship to facilitate the interactions to work with. This example demonstrates how nurses come to know when to stand back and not step in. P6: It’s not me that is with them in the future. It’s the family unit that helps the child get well. It’s important to let people grow so they can fly. You can’t keep clipping their wings by doing for them. That’s always challenging as sometimes we think we could have done things better. I wanted to go up and hold his hand to give him a cuddle and that for me would have been a natural thing to do, but I saw all the family there and it was a judgment call to wait for family to do that for him and they did. If I had done it, it would have been wrong. I am only part of a very short time of that child’s life.
The nurse in this situation was supporting an injured child who was visiting his father and family in an Intensive Care Unit. His father was to be removed from artificial ventilation later that day. Both were victims of the same motor vehicle accident. This nurse relied on her trust that the family would attend to the needs of this child. The trust between a nurse, child and family is only a stepping stone towards the family’s need to work with the greater team of health professionals guiding the child’s rehabilitation. 166
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Building trust emerged as the basic social process to facilitate the rehabilitation of a child after a severe traumatic accident. The social interactions identified in this study are important to build trust. Trust is necessary to enable the child, family and nurses to work together and gain a confidence in each other that will optimise a child’s recovery from a severe traumatic accident. Discussion This study identified the social interactions identified by nurses to build trust to promote the rehabilitation of a child following a severe traumatic accident. The social interactions are referred to as elements to support the three social processes found to be essential to build trust with a child and his/her family. The three processes: ‘developing a working relationship’, ‘the art of working with’, and ‘trusting each other to step out and handover’ are dynamic processes found to be necessary to promote optimal rehabilitation of the child and support the family to adapt to different ways of functioning. Developing a working relationship was the most significant social process identified in this study. These processes support the development of a working relationship based on trust between an individual nurse and family that reflects a partnership. This is reliant on a nurse caring for a child and family on a regular basis. The nurses discussed the importance of having the time to use informal chat and communication to get to know families. Informal communication makes the learning of a family’s values, beliefs and ways of doing things possible to then enable working with each other to build trust. Chatting or informal communication has been uncovered in the literature as an important social interaction that nurses have used to get to know the family and enable the family to get to know them (Espezel & Canam, 2003; Fenwick, 2001; Stucki, Stier-Jarmer, Grill, & Melvin, 2005; Thompson, Hupcey, & Clark, 2003). The nurses emphasised the importance of family knowledge to optimise the nurse’s ability to advocate for and protect an individual family’s patterns of living. Conversing in an informal manner, therefore, has been a key finding in this study and needs to be recognised and valued as a significant part of nurses’ day to
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Building trust to work with children after a severe traumatic accident day practice. This social process creates a more intimate working relationship, is integral to the development of trust and provides less formal updates for families on their child’s progress. The most complex social process revealed in this study was the art of working with. A working relationship founded on trust assists family’s to re-establish their individual roles while learning to take care of their injured child when working with the nurse. Working together is dynamic, and fluctuates between stepping in, working with, and stepping out of the working relationship for the overall purpose of optimising the child and family’s health. This study has shown that the nurse’s ability to effectively step in and out of the working relationship is eased when honesty and provision of timely information are significant when working together to develop a purposeful trusting relationship. This study revealed anticipating the future, providing reasons for change and giving hope to the child and family integral to developing the art to work with. In the current study, the nurses used their experience to guide the realistic hope they gave to the children and families. The nurses’ previous experiences enhanced their ability to recognise steps of progress or acknowledge when progress was slow or deteriorating. Previous experiences guided the nurses ability to give realistic hope to sustain the development of trust This process has been similarly described by Ramritu and Croft (1999) who found using ‘anticipatory guidance’ to inform families of the future was a useful strategy to give hope and build trust. Similarly, Turner and Stokes (2006) agreed that giving hope is integral to building trust; but they acknowledge that changes occur over time and the short stay in acute care and lack of consistent care by individual nurses can impede the process. This finding was also revealed in the current study where the structure of acute care services, prohibited the consistency of time for nurses to work with the child and family to develop the optimal trusting relationship. Trusting each other to step out and hand over is the third process revealed in this study. The nurse is a central member the health care team, all working together to optimise the outcomes for the child and family. The nurses recognised the family as integral to the health care team. The family are the constant
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and therefore most significant in enhancing their child’s rehabilitation when they are aware of how they can do this, a finding also supported by Thompson et al. (2003) who studied the development of trust in parents of hospitalised children. This study has described how the nurse’s ability to effectively promote comfort for the child is the most important skill to support family to have a trusting relationship to handover the care of the child to the nurse. The challenge of handing over responsibilities deemed to be parents or nurses between both parties in the working relationship was found to be a dynamic process that relied on the ability to have a depth of knowing and trusting each other, only achieved by the art of working with. Implications for practice This study has important implications to the management and staffing of acute care units. The ability of nurses to build trust and promote the rehabilitation of a child and family is influenced by the working environment. Trust is built between the individual nurse and family and demands reliance on continuity of care, also supported by Thompson et al. (2003). This is not easily managed in acute care wards for multiple reasons. Nurses’ ability to spend the time necessary to incorporate the important social processes identified to build trust with a child and their family is challenged in the acute care ward because of the demand to monitor, maintain, and promote the stability of more than one child at this stage of their rehabilitation process. Barriers to having the time to build trust are imposed by the demands of the changing nursing workforce in New Zealand. From the first author’s clinical experience, increases in casual staff (Richardson & Allen, 2001), the lessening number of experienced nurses, the introduction of 12-hour shifts, and early discharge, all inhibit the constancy of care and time needed to develop effective trusting working relationships with children and families. Checking in, chatting, informing to reassure, giving hope, working with and supporting family’s rely on the nurse having the continuity of time to be with and recognise the family’s needs during the entirety of the child and family’s presence in the acute care ward, is also supported by Turner
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and Stokes (2006). Nurses’ presence, by being with, enhances the development of the social processes to build trust. However it takes time and a continuity of care between the individual nurse and child and family to ‘be with to build trust’ and thereby promote the rehabilitation of the child. Findings of this study and research by Stucki et al. (2005) recommend the need to have a rehabilitation nurse as part of the mobile multidisciplinary teams in acute care to co-ordinate programmes, constantly work with the child and family, and optimise health outcomes. Study limitations The small group of nurses who have contributed to the identification of social processes to build trust with a child and family following a traumatic accident work within an environment with its own culture and philosophy of care. Therefore the study findings may not be relevant in other settings of care. The question and intent of this study was limited to exploring the work of the nurse in the acute care setting. It did not expand to the transitioning to another health care provider or community care. The child and families’ perspectives were not explored, and their view would be most relevant in a study encompassing the extended care required to support the rehabilitation of children and families. The experience of the participants varied, using more experienced nurses may have resulted in a greater exploration of the concept of trust as the less experienced nurses focussed on the medical model of care. Conclusion Trust is critical to survival yet often taken for granted because it is part of everyday life. It is the foundation of all working and personal relationships and the scarcity of research in building trust may be due to the ‘difficulty to identify, describe and analyse what we take for granted’ (Caron & Bowers, 2000, p. 294). Social processes nurses need to embed in nursing practice to build trust have been identified in this study. It is clear that from the perspective of the participants in this study the development of a trusting working relationship between the nurse and family with a child in an acute care ward, following a severe 168
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traumatic accident, has the potential to improve the outcomes of the rehabilitation of the child. Ultimately, family are the constant who work with their child; thus successful rehabilitation is reliant on the family’s knowledge and skills. Their learning is embodied in the trust they have built and shared with acute care nurses. The social processes, described in this study, are a significant and important part of nursing practice. Although this study has found the importance of these processes in a specific situation; it is suggested that the processes to build trust are significant to nurses’ working relationships in any area of practice. Wider exploration of the importance of these concepts and the view of all participants in a working relationship is warranted to further enrich nurses’ knowledge of how to work with others to build trust within health care services. References Bell, L., & Duffy, A. (2009). A concept analysis of nursepatient trust. British Journal of Nursing, 18(1), 46–51. Cahill, J. (1996). Patient participation: A concept analysis. Journal of Advanced Nursing, 24(3), 561–571. doi:10.1046/j.1365-2648.1996.22517.x Caron, C. D., & Bowers, B. J. (2000). Methods and application of dimensional analysis: A contribution to concepts and knowledge development in nursing. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 285–319). Philadelphia, PA: Saunders. Casey, A. (1993). Development and use of the partnership model of nursing care. In E. A. Glasper & A. Tucker (Eds.), Advances in child health nursing (pp. 183–193). Middlesex, England: Scutari Press. Chamberlain, K. (1999). Using grounded theory in health psychology: Practices, premises and potential. In M. Murray & K. Chamberlain (Eds.), Qualitative health psychology: Theories and methods (pp. 183–201). Thousand Oaks, CA: Sage. Coyne, I. T. (1995). Parental participation in care: A critical review of the literature. Journal of Advanced Nursing, 21(4), 716–722. doi:10.1046/j.1365-2648. 1995.21040716.x Darbyshire, P. (1993). Parents, nurses and p ediatric nursing: A critical review. Journal of Advanced Nursing, 18(11), 1670–1680. doi:10.1046/j.1365-2648. 1993.18111670.x Darbyshire, P. (1994). Living with a sick child in hospital. London, England: Chapman Hall.
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Building trust to work with children after a severe traumatic accident Edwards, P. A. (2001). Pediatric rehabilitation nursing. In J. B. Derstine & S. D. Hargrove (Eds.), Comprehensive rehabilitation nursing (pp. 545–570). Philadelphia, PA: WB Saunders. Espezel, H. J., & Canam, C. J. (2003). Parent-nurse interactions: Care of hospitalized children. Journal of Advanced Nursing, 44(1), 34–41. Fenwick, J. (2001). ‘Chatting’: An important clinical tool in facilitating mothering in neonatal nurseries. Journal of Advanced Nursing, 33(5), 583–593. Gallant, M. H., Beaulieu, M. C., & Carnevale, F. A. (2002). Partnership: An analysis of the concept within the nurse–client relationship. Journal of Advanced Nursing, 40(2), 149–157. Gasquoine, S. (1996). Constant vigilance: The lived experience of mothering a hospitalized child (Unpublished Master’s Thesis). Massey University, Palmerston North, New Zealand. Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press. Glaser, B. (2001). The grounded theory perspective: Conceptualization contrasted with description. California, CA: Sociology Press. Harrison, T. M. (2010). Family centred paediatric nursing care: State of the science. Journal of Pediatric Nursing, 25(5), 335–343. doi:10.1016/j. pedn.2009.01.006 Hupcey, J. E., Penrod, J., & Morse, J. M. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282–293. Hutchfield, K. (1999). Family-centered care: A concept analysis. Journal of Advanced Nursing, 29(5), 1178–1187. Johns, J. L. (1996). A concept analysis of trust. Journal of Advanced Nursing, 24(1), 73–83. Keatinge, D., Bellchambers, H., Bujack, E., Cholowski, K., Conway, J., & Neal, P. (2002). Communication: Principal barrier to nurse– consumer partnerships. International Journal of Nursing Practice, 8(1), 16–22. Lee, P. (2007). What does partnership in care mean to children’s nurses? Journal of Clinical Nursing, 16(3), 518–526. doi:10.1111/j.1365-2702.2006.01591.x McKelvie, R. (2001). Partnership in paediatric nursing: A descriptive exploration of the concept and its practice (Unpublished Master’s Thesis). Massey University, Auckland, New Zealand. Melvin, C. L., Lacy, M. L., & Swafford-TenEyck, L. E. (1998). Pediatric rehabilitation. In P. A. Chin, D. Finocchiaro, & A. Rosebrough (Eds.), Rehabilitation nursing practice (pp. 681–704). New York, NY: McGraw-Hill.
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Miller, S. I., & Fredericks, M. (1999). How does grounded theory explain? Qualitative Health Research, 9(4), 538–552. Nethercott, S. (1993). A concept for all the family. Family-centred care: A concept analysis. Professional Nurse, 8(12), 794–797. Pryor, J. (2002). Creating a rehabilitation milieu. Rehabilitation Nursing, 25(4), 141–147. Pryor, J., & Smith, C. (2000). A framework for the speciality practice of rehabilitation nursing (Vol. 4). Sydney, NSW: Rehabilitation Nursing Research and Development Unit. Ramritu, P. L., & Croft, G. (1999). Needs of parents of the child hospitalized with acquired brain damage. International Journal of Nursing Studies, 36(3), 209–216. Reis, M. D., Rempel, G. R., Shannon, D., Scott, B. A., Brady-Fryer, B. A., & Van Aerde, J. (2010). Developing nurse/parent relationships in the NICU through negotiated partnership. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 39(6), 675–683. doi:10.1111/j.1552-6909.219.01189.x Richardson, S., & Allen, J. (2001). Casualization of the nursing workforce: A New Zealand perspective on an international phenomenon. International Journal of Nursing Practice, 7(2), 104–108. Schatzman, L. (1991). Dimensional analysis: Notes on an alternative approach to the grounding of theory in qualitative research. In D. R. Maines (Ed.), Social organizations and social process: Essays in honour of Anselm Strauss (pp. 303–314). New York, NY: Aldine De Gruyter. Shelton, T. L., Jeppson, E. S., & Johnson, B. H. (1987). Family-centred care for children with special health care needs. Washington, DC: Association for the Care of Children’s Health. Shields, L. (2010). Questioning family-centred care. Journal of Clinical Nursing, 19, 2629–2638. Strauss, A. L. (1987). Qualitative analysis for social scientists. Cambridge, England: Cambridge University Press. Stucki, G., Stier-Jarmer, M., Grill, E., & Melvin, J. (2005). Rationale and principles of early rehabilitation care after an acute injury or illness. Disability and Rehabilitation, 27(7/8), 353–359. Thompson, V. L., Hupcey, J. E., & Clark, M. B. (2003). The development of trust in parents of hospitalized children. Journal of Specialists in Pediatric Nursing, 8(4), 137–147. doi:10.1111/j.1088-145X.2003.00137.x Turner, D. S., & Stokes, L. (2006). Hope p romoting strategies of registered nurses. Journal of Advanced Nursing, 56(4), 363–372. doi:10.1111/j.1365-2648. 2006.04017.x Received 26 May 2011
Accepted 19 September 2013
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Building trust to work with children after a severe traumatic accident Julianne Hall and Shoba Nayar* Faculty of Health & Environmental Science, Department of Nursing, School of Health Care Practice, Auckland University of Technology, Auckland, New Zealand; *Faculty of Health & Environmental Science, Department of Occupational Science and Therapy, School of Rehabilitation & Occupation Studies, Auckland University of Technology, Auckland, New Zealand
Abstract: Trust is integral to nursing; yet little is known about how nurses establish trust when working with patients. This grounded theory study explored nurses’ perspectives of how to build trust with a child and family in the context of paediatric acute health care. Seven paediatric acute care nurses were asked what they did when they cared for a child admitted to an acute care ward from emergency department or intensive care unit following a severe traumatic accident. Building trust emerged as the basic social process for an effective working relationship between a nurse and family to promote the rehabilitation of the child. This paper argues that building trust is critical to nurses developing a working relationship with both child and family to promote optimal health, and enables nurses to effectively step out and handover the care of the child to the family.
Keywords: acute care, child, family, rehabilitation, trust
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his article reports the findings of a grounded theory study that explored what acute care nurses do to promote the recovery of children who had severe injuries caused by a traumatic accident. For the purpose of this study a traumatic accident is defined as an unintentional accident that results in severe injury requiring hospitalisation and ongoing rehabilitation. The participants in this study were Registered Nurses working in acute care wards that received patients from Emergency Department or a Paediatric Intensive Care Unit. The implications of new technological interventions preventing death (Melvin, Lacy, & SwaffordTenEyck, 1998) and continued advancement in medical technology has further increased survival rates, increasing the challenges for acute care wards to promote optimum health outcomes for the child and their family. Within paediatric nursing, children and their families are the health care consumers (Lee, 2007). The current study uncovered the significance of a trusting working relationship between nurses, children and their family being essential to optimise the recovery of the child. The study reported in this paper found a universal dearth of literature related to rehabilitative nursing practice in the acute care setting of paediatric hospitals. Literature purports that trust is the necessary foundation for nurses to work with their patient, in this case the child and family (Caron & Bowers,
2000); yet a concept analysis of trust by Johns (1996) and Hupcey, Penrod, and Morse (2001), failed to identify how nurses work with patients to build trust. The research reported here sought to explore how acute care paediatric nurses work with a child and his or her family to promote rehabilitation. The topic was prompted by the first author’s experience of working with children recovering from severe accidental trauma in a small rehabilitation centre. The first author recognised the importance of earlier nursing rehabilitation practice to optimise the recovery of the child and family. The most significant finding was the need to ‘build a trusting working relationship’ with the child and family. The research findings describe how the participating nurses developed this relationship. There is a paucity of contemporary papers explaining how nurses build trust. Background Acute care and rehabilitation nursing are practised in different settings; they are not usually considered the same, yet the promotion of the child’s recovery underpins both. Pryor and Smith (2000, p. 3) stated ‘nurses can and should practice rehabilitation across all settings regardless of the patient’s diagnosis or prognosis’. From the authors’ experience the medical model of care dominates the acute care setting whilst rehabilitation theory governs how nurses work in the rehabilitation setting.
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The reconstruction of life occurs from the moment a child enters the health care system (Edwards, 2001; Melvin et al., 1998). Initially nurses are involved with monitoring the child’s changing signs of altered health status and preventing stress, such as pain, that may hinder the child’s recovery. Nurses collaborating with the family and health care team are integral to working with the child and family to build a trusting relationship. The nurse needs to create an environment which obtains a ‘snapshot’ of the child and family prior to the accident. This snapshot of how the family was prior to the accident provides the goal for the interdisciplinary team when planning and working with the child and family (Pryor, 2002). Thus, acute care nurses work differently with each family depending on the individual family’s journey, which may include: The cause of the injury, their pathway to the ward, characteristics of the individual family, and the developmental age of the child. Nursing practice that reflects the concepts of family centred care and partnership enables the nurse to understand the needs of the child and family. Casey’s (1993) model of partnership supports the implementation of family centred care. Her model is underpinned by the philosophy that care for all children, well or sick, is best carried out by the family with help from health care professionals whenever necessary. The nurse supports the child and family by helping them to cope and function, sharing knowledge and coaching skills to promote their independence. Casey’s interpretation of her exploration of the meaning of family found ‘the paediatric nurse was only concerned for the family as carers of their child’ (p. 185). In the hospital setting, during the 1990s, nurses did not view the family as their patient. Nurses’ contribution to the team is ‘knowing’ the family and assisting with the reconstruction of the family’s life. The tenets of family centred care introduced by Shelton, Jeppson, and Johnson (1987) influenced the delivery of paediatric health care services with the expectation that this philosophy of care underpins all paediatric nursing. However, there is no consensus about the meaning of family centred care (Darbyshire, 1993; Hutchfield, 1999; Nethercott, 1993), although the term seems to be connected with ‘partnership in care’. Nurses work 162
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with families, through ‘involving’ them in care, encouraging their ‘participation’ in care and working in ‘partnership’ (Casey, 1993; Coyne, 1995; Darbyshire, 1994; Hutchfield, 1999). However, this does not necessarily all happen at once. Without the development of a trusting relationship and a strong connection to the concepts of partnership and family centred care, nurses face a challenge to promote the recovery of a child. Harrison’s (2010) report of reviewed literature relating to the state of family centred care in practice confirmed the multifacetedness of the concept and the gap between theory and practice. Shields (2010) has also questioned the reality of family centred care in practice and suggests further exploration to its viability as a model of care in today’s society. To date, studies have identified that family’s desire a relationship of partnership with health professionals (Harrison, 2010; Reis et al., 2010). However, partnership is frequently marred by the difficulties in health professionals’ use of appropriate communication skills to negotiate roles and develop working partnerships (Harrison, 2010). Communicating and negotiating over a considerable period of time were found to be key strategies for partnership between the nurse, child and family (McKelvie, 2001). These strategies supported intentional and meaningful involvement between the nurse, family and other health care professionals. Lee (2007) acknowledged the child and his/her family as consumers of paediatric services, and further noted communication and negotiation as the most essential skills to develop a relationship representing partnership. Thus, fundamental to the effectiveness of partnership and family centred care is the development of communication that has led to a trusting relationship (Bell & Duffy, 2009). Family members need to be with their child in hospital and mutual trust between the nurse and family needs to be developed to enable the family to handover the care of their child to health professionals (Gasquoine, 1996). Nurses perceive that ‘partnership in care’ is reliant on relationships, gaining trust, being there, reassuring, and working together involving the family (Keatinge et al., 2002). The result of partnership in care was found to be positive health outcomes. Whether the development of trust to support partnership is a viable concept within the acute care
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Building trust to work with children after a severe traumatic accident setting, when mothers are in a stressful unknown situation and feel disempowered, has been questioned by Gasquoine (1996) and Gallant, Beaulieu, and Carnevale (2002). These researchers used literature of disciplines that had studied partnerships, including nursing, medicine, the social sciences and psychology, to support their view that partnership does not occur in the acute care setting. Family participation with nurses is important in the acute care setting to enable the family to learn new skills and to promote their ability to care for their child in the future, as well as promoting the family’s ability to function. A relationship that begins with participation in care has the potential to develop into a partnership. It is uncertain whether a child and family have the time in the acute care setting to develop the mutual trust required in a partnership (Cahill, 1996; Casey, 1993; Darbyshire, 1993); and importantly, the process by which nurses actually build the trust needed for partnership – an issue this study sought to address. Methodology and methods Grounded theory methodology was chosen for this study because it fitted the proposed research question ‘What do paediatric acute care nurses do when they care for a child who has had a severe traumatic accident?’ As a qualitative methodology, grounded theory seeks to uncover the processes that underlie societal functioning (Glaser, 1992; Strauss, 1987) and, increasingly, nurse researchers are using this methodology to explain phenomena that relate to nursing (Chamberlain, 1999; Miller & Fredericks, 1999). Data collection Approval for this research was granted from the Auckland University of Technology Ethics Committee, the Auckland Ethics Committees of the Ministry of Health and the Auckland District Health Board. Consent was obtained prior to the one hour recorded interview held in a place designated by the nurse. Purposive sampling was used to recruit seven registered nurses working in acute care wards. Nurses were introduced to this study by their ward managers. They were given information sheets and contacted the primary researcher if they wanted to participate. The participants included two males and five females. Four participants had been registered nurses for © eContent Management Pty Ltd
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1 year, one participant had 3 years experience and two were considered experienced senior nurses. Four participants worked with children admitted with head injuries and two participants worked in an orthopaedic unit. The sampling of two participants from the orthopaedic unit was useful to identify any differences in nursing practice between the two specialities. All participants were interviewed for an hour. The first two interviews began with the open question ‘Tell me what you do when you are caring for a child who has been admitted following a severe traumatic accident’ Thereafter interview questions arose from the constant comparative analysis used for the purpose of conceptualisation (Glaser, 2001). Two of the seven nurse participants, who had the scope and depth of practice to extend and contradict the emerging concepts, rather than merely replicate the existing data, were invited to contribute together in a final interview. Data analysis On completion of each interview and prior to the next interview data was transcribed verbatim and analysed line by line using Schatzman’s (1991) dimensional analyses methods to question the data and develop theoretical questions. Theoretical questioning aids the conceptualisation of the meaning of what is happening. For example, the fourth interview was more focussed using questions that had arisen from data analysis about how effective nursing interactions were in the recovery of the child. Interviewer (I): Can you tell me about the times when you know as a nurse you have worked effectively with children who have had a severe traumatic accident? Participant (P) 4: It helps in nursing if you look after the same child a few times and you can gain their trust.
Consistency of the individual nurse and trust was seen to be helpful to the child’s recovery by Participant 4, but warranted further exploration before focussing on trust. I: Tell me what your role is and what you have done to promote the recovery of the child?
Participant 4 found it easy to describe her task orientated role, but when faced with the notion of ‘promoting the recovery’ needed time to reflect and think before responding, which then prompted further questioning related to building relationships.
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The relevance of ‘working with’ the family and developing a trusting relationship began to emerge in the first level coding of categories of interview four as the key to the child’s rehabilitation. Constant comparative analysis, the hallmark of the inductive process used in grounded theory research for the purpose of conceptualisation (Glaser, 2001) continued until saturation of the generated codes and categories were complete. These techniques facilitated the unfolding of the social process, building trust. Findings This study found three social processes were integral nurses building a trusting relationship with a child and their family to facilitate the rehabilitation of the child. The social processes found to support the building of trust were ‘developing a working relationship’ and ‘the art of working with to build trust’. These processes are dynamic interactions between nurse, child and family and underpin a third process ‘trusting each other to hand over’, in which the nurse effectively ‘steps out and hands over’ the child’s care to the family and others. Building trust is an important process that enables nurses to step into a family’s physical or emotional space and work with them to promote the rehabilitation of their severely injured child. A family’s previous experience, when interacting with nurses, impacts on the initial level of awarded trust they have with an individual nurse (P3). The nurses in this study perceived that effective nursing of children after a traumatic accident requires a relationship upheld by trust between the nurse, child and family to facilitate the rehabilitation of a child. Developing a working relationship Findings revealed that time to be with a child and family is essential to develop a working relationship supported by trust. Trust is preceded by being able to work with and build rapport. The initial interaction a nurse has with a child and family was described as ‘checking in’, which enabled the nurse to step in and work with the family. Frequently, stepping in was influenced by the awarded trust granted to a nurse, as a health professional, particularly in a critical situation when the parents need to hand over their child (P3). Thus, checking in to effectively step in and build trust is reliant on the nurse spending time with 164
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the child and family to facilitate a rapport and getting to know each other. Although checking in initiates the relationship, ultimately it is the family who gives the nurse permission to step in and work with them. A working relationship is developed by the nurse introducing self, asking the family their needs, and informing the family of the requirements of the health care team. These interactions are eased by ‘chatting’. The importance of remaining focussed on the family but ‘chatting’ about oneself was found to be useful to gain trust and the family’s acceptance. Chatting and getting to know each other protects the awarded but fragile trust granted to a health professional and strengthens rapport and the first building block of trust. The process of ‘stepping in’ is reliant on the nurse engaging the family and reassuring them of what is happening while monitoring the child’s progress and family’s level of coping with the new situation. Different situations alter how the nurse checks in and can challenge the nurse’s ability to secure and further build onto the foundation of awarded trust. The nurse may be required to advance through the barriers that exist. P6: … having to chip away at a wall and have a clean slate to build trust with a family who feels the guilt of the accident. P5: … looks through the windows to gain trust.
Participants described how it is difficult to get to know each other if the nurse is feeling unsure about what is happening at the time. When nurses do not know what is happening they need to inform the family, explain what they are doing, why, and that it is not unusual to be in a position where it is not known what to do. P2: I use a time of silence but I wonder if they think that I don’t know, I usually chat but I can’t if I am scared. P6: All the experience in the world does not prepare the nurse for these situations. The ability to empathize and be with is not easy for the nurse.
Stepping in creates the starting point of getting to know the family, both in the present moment and prior to the traumatic accident to their child. Nurses used chatting to facilitate an open relationship and worked together to orchestrate the care and optimise the rehabilitation process for the child and family. © eContent Management Pty Ltd
Building trust to work with children after a severe traumatic accident The art of ‘working with’ to build trust The nurses felt their ability to build trust provided a stronger base to promote the best working environment for the nurse, child and family. Nurses recognised the importance of using their experience and knowledge to effectively support the development of their art to ‘work with’. While working with, nurses identify the needs of the child and family. They identified that emotional comfort of the family is dependent on a working relationship upheld by trust. From the participants’ view, trusting the nurse is enhanced when the family are informed and reassured about what is happening at the time. Thus, trust is reliant on the nurse’s ability to reassure a child and family. Reassurance is something nurses give; trust is something that needs to be built. Participants identified reassurance as an important element to build trust, and acknowledged that it is not an easy thing to do. P4: The development of trust is nurtured when the family feels reassured. P3: Reassurance is so easy to say but difficult to do. P6: The ability to reassure a family relies on the trusting relationship that has been formed by “getting to know” each other.
The interactions commonly used by the nurses to reassure families related to sharing the knowledge guiding their practice. The nurses p erceived that social processes of informing, educating, and explaining what was happening while working with the child was reassuring to the family. Integral to feeling reassured is the receiving of hope. Hope can be given by nurses through developing family awareness of the small steps of progress in their child’s recovery. P5: A young girl who had a severe head injury was going through the restless waking up phase. I guess with my experience that’s where I got to bringing in the realistic phase as well. Mum was obviously exhausted, shattered, her posture was stooped, she was sighing a lot so I said, “this is a tiring time, it’s a positive time, and this is a stage of recovering from a head injury … this is progress, this is a really good sign.
Nurses’ use of past experiences is an important strategy to reassure the family. However just as
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important is the need to be mindful not to give false hope as this would crumble building blocks of trust. Nurses felt their ability to reassure the family relied on the combination of being honest and realistic with the experiences they shared. The study found that caring and the use of appropriate interventions to ensure a child is comfortable are important to build the family’s trust in the nurse. Participants use ‘doing for’ to develop the trust to initiate a working partnership. The moving of a child in pain, and the management of pain is an example where it is important nurses ‘do for’ the family. P6: Parents first need is to get this pain sorted. P7: If the child is really distressed or traumatized by pain parents are not likely to volunteer to be part of care-giving. P7: Pain is the greatest issue for parents; you cannot have their trust without the control of pain.
When a child is in pain it is difficult for the nurse to maintain a trusting relationship and family to re-establish their role. The importance of pain management was recognised by most participants because a family’s initial concern is that their child is pain free. A serious injury can mean more than physical pain to the child; emotional pain is felt by the family when there is confusion or unknowing of what is happening. Hence, having a trusting relationship facilitated working with the child and family to ease the physical and emotional pain. According to participants, responding to the needs of the child and family is an important component of reassuring the family and building trust. Needs are identified by listening to the family and monitoring the child’s health. In addition to developing a working relationship and the art of working with to build trust, trusting each other to handover was the third social process to emerge in this study. Trusting each other to step out and handover Participants noted that the strength of the trust between a nurse and family is developed by nurses adjusting their practice to work alongside and use the different philosophy and parenting style of the individual family. Knowing these differences is an
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important facet of building trust to uphold the working relationship. The nurses recognised that family, in particular parents, need a substantial foundation of trust to leave their child in a nurse’s care and this trust is dependent on the child’s reaction to the nurse. The nurse develops the child’s trust by ‘using time to just sit down and talk or play rather than just going and doing something to them’ (P4), always mindful of adapting interactions appropriately to the child’s level of understanding and ability to participate at the time. This study found giving support to the family helped reinforce building blocks of trust. The family is supported when the nurse works with and coaches them to parent their child who now has different needs. Importantly a family also needs to be trusted by the nurse that they will promote the rehabilitation of their child by encouraging the child to readapt and learn new skills. The nurse’s skill to let go and have trust in the family’s capability is integral to the rehabilitation of the child. Trust needs to exist between all members of the working relationship to facilitate the interactions to work with. This example demonstrates how nurses come to know when to stand back and not step in. P6: It’s not me that is with them in the future. It’s the family unit that helps the child get well. It’s important to let people grow so they can fly. You can’t keep clipping their wings by doing for them. That’s always challenging as sometimes we think we could have done things better. I wanted to go up and hold his hand to give him a cuddle and that for me would have been a natural thing to do, but I saw all the family there and it was a judgment call to wait for family to do that for him and they did. If I had done it, it would have been wrong. I am only part of a very short time of that child’s life.
The nurse in this situation was supporting an injured child who was visiting his father and family in an Intensive Care Unit. His father was to be removed from artificial ventilation later that day. Both were victims of the same motor vehicle accident. This nurse relied on her trust that the family would attend to the needs of this child. The trust between a nurse, child and family is only a stepping stone towards the family’s need to work with the greater team of health professionals guiding the child’s rehabilitation. 166
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Building trust emerged as the basic social process to facilitate the rehabilitation of a child after a severe traumatic accident. The social interactions identified in this study are important to build trust. Trust is necessary to enable the child, family and nurses to work together and gain a confidence in each other that will optimise a child’s recovery from a severe traumatic accident. Discussion This study identified the social interactions identified by nurses to build trust to promote the rehabilitation of a child following a severe traumatic accident. The social interactions are referred to as elements to support the three social processes found to be essential to build trust with a child and his/her family. The three processes: ‘developing a working relationship’, ‘the art of working with’, and ‘trusting each other to step out and handover’ are dynamic processes found to be necessary to promote optimal rehabilitation of the child and support the family to adapt to different ways of functioning. Developing a working relationship was the most significant social process identified in this study. These processes support the development of a working relationship based on trust between an individual nurse and family that reflects a partnership. This is reliant on a nurse caring for a child and family on a regular basis. The nurses discussed the importance of having the time to use informal chat and communication to get to know families. Informal communication makes the learning of a family’s values, beliefs and ways of doing things possible to then enable working with each other to build trust. Chatting or informal communication has been uncovered in the literature as an important social interaction that nurses have used to get to know the family and enable the family to get to know them (Espezel & Canam, 2003; Fenwick, 2001; Stucki, Stier-Jarmer, Grill, & Melvin, 2005; Thompson, Hupcey, & Clark, 2003). The nurses emphasised the importance of family knowledge to optimise the nurse’s ability to advocate for and protect an individual family’s patterns of living. Conversing in an informal manner, therefore, has been a key finding in this study and needs to be recognised and valued as a significant part of nurses’ day to
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Building trust to work with children after a severe traumatic accident day practice. This social process creates a more intimate working relationship, is integral to the development of trust and provides less formal updates for families on their child’s progress. The most complex social process revealed in this study was the art of working with. A working relationship founded on trust assists family’s to re-establish their individual roles while learning to take care of their injured child when working with the nurse. Working together is dynamic, and fluctuates between stepping in, working with, and stepping out of the working relationship for the overall purpose of optimising the child and family’s health. This study has shown that the nurse’s ability to effectively step in and out of the working relationship is eased when honesty and provision of timely information are significant when working together to develop a purposeful trusting relationship. This study revealed anticipating the future, providing reasons for change and giving hope to the child and family integral to developing the art to work with. In the current study, the nurses used their experience to guide the realistic hope they gave to the children and families. The nurses’ previous experiences enhanced their ability to recognise steps of progress or acknowledge when progress was slow or deteriorating. Previous experiences guided the nurses ability to give realistic hope to sustain the development of trust This process has been similarly described by Ramritu and Croft (1999) who found using ‘anticipatory guidance’ to inform families of the future was a useful strategy to give hope and build trust. Similarly, Turner and Stokes (2006) agreed that giving hope is integral to building trust; but they acknowledge that changes occur over time and the short stay in acute care and lack of consistent care by individual nurses can impede the process. This finding was also revealed in the current study where the structure of acute care services, prohibited the consistency of time for nurses to work with the child and family to develop the optimal trusting relationship. Trusting each other to step out and hand over is the third process revealed in this study. The nurse is a central member the health care team, all working together to optimise the outcomes for the child and family. The nurses recognised the family as integral to the health care team. The family are the constant
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and therefore most significant in enhancing their child’s rehabilitation when they are aware of how they can do this, a finding also supported by Thompson et al. (2003) who studied the development of trust in parents of hospitalised children. This study has described how the nurse’s ability to effectively promote comfort for the child is the most important skill to support family to have a trusting relationship to handover the care of the child to the nurse. The challenge of handing over responsibilities deemed to be parents or nurses between both parties in the working relationship was found to be a dynamic process that relied on the ability to have a depth of knowing and trusting each other, only achieved by the art of working with. Implications for practice This study has important implications to the management and staffing of acute care units. The ability of nurses to build trust and promote the rehabilitation of a child and family is influenced by the working environment. Trust is built between the individual nurse and family and demands reliance on continuity of care, also supported by Thompson et al. (2003). This is not easily managed in acute care wards for multiple reasons. Nurses’ ability to spend the time necessary to incorporate the important social processes identified to build trust with a child and their family is challenged in the acute care ward because of the demand to monitor, maintain, and promote the stability of more than one child at this stage of their rehabilitation process. Barriers to having the time to build trust are imposed by the demands of the changing nursing workforce in New Zealand. From the first author’s clinical experience, increases in casual staff (Richardson & Allen, 2001), the lessening number of experienced nurses, the introduction of 12-hour shifts, and early discharge, all inhibit the constancy of care and time needed to develop effective trusting working relationships with children and families. Checking in, chatting, informing to reassure, giving hope, working with and supporting family’s rely on the nurse having the continuity of time to be with and recognise the family’s needs during the entirety of the child and family’s presence in the acute care ward, is also supported by Turner
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and Stokes (2006). Nurses’ presence, by being with, enhances the development of the social processes to build trust. However it takes time and a continuity of care between the individual nurse and child and family to ‘be with to build trust’ and thereby promote the rehabilitation of the child. Findings of this study and research by Stucki et al. (2005) recommend the need to have a rehabilitation nurse as part of the mobile multidisciplinary teams in acute care to co-ordinate programmes, constantly work with the child and family, and optimise health outcomes. Study limitations The small group of nurses who have contributed to the identification of social processes to build trust with a child and family following a traumatic accident work within an environment with its own culture and philosophy of care. Therefore the study findings may not be relevant in other settings of care. The question and intent of this study was limited to exploring the work of the nurse in the acute care setting. It did not expand to the transitioning to another health care provider or community care. The child and families’ perspectives were not explored, and their view would be most relevant in a study encompassing the extended care required to support the rehabilitation of children and families. The experience of the participants varied, using more experienced nurses may have resulted in a greater exploration of the concept of trust as the less experienced nurses focussed on the medical model of care. Conclusion Trust is critical to survival yet often taken for granted because it is part of everyday life. It is the foundation of all working and personal relationships and the scarcity of research in building trust may be due to the ‘difficulty to identify, describe and analyse what we take for granted’ (Caron & Bowers, 2000, p. 294). Social processes nurses need to embed in nursing practice to build trust have been identified in this study. It is clear that from the perspective of the participants in this study the development of a trusting working relationship between the nurse and family with a child in an acute care ward, following a severe 168
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traumatic accident, has the potential to improve the outcomes of the rehabilitation of the child. Ultimately, family are the constant who work with their child; thus successful rehabilitation is reliant on the family’s knowledge and skills. Their learning is embodied in the trust they have built and shared with acute care nurses. The social processes, described in this study, are a significant and important part of nursing practice. Although this study has found the importance of these processes in a specific situation; it is suggested that the processes to build trust are significant to nurses’ working relationships in any area of practice. Wider exploration of the importance of these concepts and the view of all participants in a working relationship is warranted to further enrich nurses’ knowledge of how to work with others to build trust within health care services. References Bell, L., & Duffy, A. (2009). A concept analysis of nursepatient trust. British Journal of Nursing, 18(1), 46–51. Cahill, J. (1996). Patient participation: A concept analysis. Journal of Advanced Nursing, 24(3), 561–571. doi:10.1046/j.1365-2648.1996.22517.x Caron, C. D., & Bowers, B. J. (2000). Methods and application of dimensional analysis: A contribution to concepts and knowledge development in nursing. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 285–319). Philadelphia, PA: Saunders. Casey, A. (1993). Development and use of the partnership model of nursing care. In E. A. Glasper & A. Tucker (Eds.), Advances in child health nursing (pp. 183–193). Middlesex, England: Scutari Press. Chamberlain, K. (1999). Using grounded theory in health psychology: Practices, premises and potential. In M. Murray & K. Chamberlain (Eds.), Qualitative health psychology: Theories and methods (pp. 183–201). Thousand Oaks, CA: Sage. Coyne, I. T. (1995). Parental participation in care: A critical review of the literature. Journal of Advanced Nursing, 21(4), 716–722. doi:10.1046/j.1365-2648. 1995.21040716.x Darbyshire, P. (1993). Parents, nurses and p ediatric nursing: A critical review. Journal of Advanced Nursing, 18(11), 1670–1680. doi:10.1046/j.1365-2648. 1993.18111670.x Darbyshire, P. (1994). Living with a sick child in hospital. London, England: Chapman Hall.
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Building trust to work with children after a severe traumatic accident Edwards, P. A. (2001). Pediatric rehabilitation nursing. In J. B. Derstine & S. D. Hargrove (Eds.), Comprehensive rehabilitation nursing (pp. 545–570). Philadelphia, PA: WB Saunders. Espezel, H. J., & Canam, C. J. (2003). Parent-nurse interactions: Care of hospitalized children. Journal of Advanced Nursing, 44(1), 34–41. Fenwick, J. (2001). ‘Chatting’: An important clinical tool in facilitating mothering in neonatal nurseries. Journal of Advanced Nursing, 33(5), 583–593. Gallant, M. H., Beaulieu, M. C., & Carnevale, F. A. (2002). Partnership: An analysis of the concept within the nurse–client relationship. Journal of Advanced Nursing, 40(2), 149–157. Gasquoine, S. (1996). Constant vigilance: The lived experience of mothering a hospitalized child (Unpublished Master’s Thesis). Massey University, Palmerston North, New Zealand. Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press. Glaser, B. (2001). The grounded theory perspective: Conceptualization contrasted with description. California, CA: Sociology Press. Harrison, T. M. (2010). Family centred paediatric nursing care: State of the science. Journal of Pediatric Nursing, 25(5), 335–343. doi:10.1016/j. pedn.2009.01.006 Hupcey, J. E., Penrod, J., & Morse, J. M. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282–293. Hutchfield, K. (1999). Family-centered care: A concept analysis. Journal of Advanced Nursing, 29(5), 1178–1187. Johns, J. L. (1996). A concept analysis of trust. Journal of Advanced Nursing, 24(1), 73–83. Keatinge, D., Bellchambers, H., Bujack, E., Cholowski, K., Conway, J., & Neal, P. (2002). Communication: Principal barrier to nurse– consumer partnerships. International Journal of Nursing Practice, 8(1), 16–22. Lee, P. (2007). What does partnership in care mean to children’s nurses? Journal of Clinical Nursing, 16(3), 518–526. doi:10.1111/j.1365-2702.2006.01591.x McKelvie, R. (2001). Partnership in paediatric nursing: A descriptive exploration of the concept and its practice (Unpublished Master’s Thesis). Massey University, Auckland, New Zealand. Melvin, C. L., Lacy, M. L., & Swafford-TenEyck, L. E. (1998). Pediatric rehabilitation. In P. A. Chin, D. Finocchiaro, & A. Rosebrough (Eds.), Rehabilitation nursing practice (pp. 681–704). New York, NY: McGraw-Hill.
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Miller, S. I., & Fredericks, M. (1999). How does grounded theory explain? Qualitative Health Research, 9(4), 538–552. Nethercott, S. (1993). A concept for all the family. Family-centred care: A concept analysis. Professional Nurse, 8(12), 794–797. Pryor, J. (2002). Creating a rehabilitation milieu. Rehabilitation Nursing, 25(4), 141–147. Pryor, J., & Smith, C. (2000). A framework for the speciality practice of rehabilitation nursing (Vol. 4). Sydney, NSW: Rehabilitation Nursing Research and Development Unit. Ramritu, P. L., & Croft, G. (1999). Needs of parents of the child hospitalized with acquired brain damage. International Journal of Nursing Studies, 36(3), 209–216. Reis, M. D., Rempel, G. R., Shannon, D., Scott, B. A., Brady-Fryer, B. A., & Van Aerde, J. (2010). Developing nurse/parent relationships in the NICU through negotiated partnership. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 39(6), 675–683. doi:10.1111/j.1552-6909.219.01189.x Richardson, S., & Allen, J. (2001). Casualization of the nursing workforce: A New Zealand perspective on an international phenomenon. International Journal of Nursing Practice, 7(2), 104–108. Schatzman, L. (1991). Dimensional analysis: Notes on an alternative approach to the grounding of theory in qualitative research. In D. R. Maines (Ed.), Social organizations and social process: Essays in honour of Anselm Strauss (pp. 303–314). New York, NY: Aldine De Gruyter. Shelton, T. L., Jeppson, E. S., & Johnson, B. H. (1987). Family-centred care for children with special health care needs. Washington, DC: Association for the Care of Children’s Health. Shields, L. (2010). Questioning family-centred care. Journal of Clinical Nursing, 19, 2629–2638. Strauss, A. L. (1987). Qualitative analysis for social scientists. Cambridge, England: Cambridge University Press. Stucki, G., Stier-Jarmer, M., Grill, E., & Melvin, J. (2005). Rationale and principles of early rehabilitation care after an acute injury or illness. Disability and Rehabilitation, 27(7/8), 353–359. Thompson, V. L., Hupcey, J. E., & Clark, M. B. (2003). The development of trust in parents of hospitalized children. Journal of Specialists in Pediatric Nursing, 8(4), 137–147. doi:10.1111/j.1088-145X.2003.00137.x Turner, D. S., & Stokes, L. (2006). Hope p romoting strategies of registered nurses. Journal of Advanced Nursing, 56(4), 363–372. doi:10.1111/j.1365-2648. 2006.04017.x Received 26 May 2011
Accepted 19 September 2013
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