Children in the pediatric intensive care unit are indisputably in a vulnerable position, dependent on nurses to acknowledge their needs. It is assumed that children should be approached from a holistic perspective in the caring situation to meet their caring needs. The aim of the study was to unfold the meaning of nursing care through nurses' concerns when caring for children in the pediatric intensive care unit. To investigate the qualitative aspects of practice embedded in the caring situation, the interpretive phenomenological approach was adopted for the study. The findings revealed three patterns: medically oriented nursing--here, the nurses attend to just the medical needs, and nursing care is at its minimum, leaving the children's needs unmet; parent-oriented nursing care--here, the nursing care emphasizes the parents' needs in the situation, and the children are viewed as a part of the parent and not as an individual child with specific caring needs; and smooth operating nursing care orientation--here, the nursing care is focused on the child as a whole human being, adding value to the nursing care. The conclusion drawn suggests that nursing care does not always respond to the needs of the child, jeopardizing the well-being of the child and leaving them at risk for experiencing pain and suffering. The concerns present in nursing care has been shown to be the divider of the meaning of nursing care and need to become elucidated in order to improve the cultural influence of what can be seen as good nursing care within the pediatric intensive care unit.

Background: The thesis has a standpoint in a synthesis of caring science and education science from a clinical perspective. Children in a Pediatric Intensive Care Unit (PICU) are in an exposed position, dependent on nurses to acknowledge their needs. The alleviation of children's pain has been investigated from various perspectives, but undertreated pain remains a problem in the PICU. There is a preponderance of empirical evidence pointing toward the role of nurses in uncovering children's pain and suffering. How nurses interpret the child's expressions and judge the clinical situation influences their actions in the clinical care. In a PICU, the basis for nurses' concerns and interpretation of what is meaningful in the nursing care situation are formed by professional concern, workplace culture, traditions, habits, and workplace structures. This influences how parents interpret the meaning of care as well. Patricia Benner's theory on clinical judgment forms a reference framework for this thesis. The assumption is that children need to be approached from a holistic perspective in the caring situation in order to acknowledge their caring needs. A nurse's clinical education and insights allow for the possibility to enhance the quality of care for children and parents in the PICU. Aim: To uncover clinical concerns, from caring and learning perspectives, in caring for children in the Pediatric Intensive Care Unit (PICU) from nurses and parents perspective. Methods: Qualitative methods were used in all studies to unfold and explore the phenomena in the nurses' and parents' everyday clinical life world. In Papers I and II, a phenomenographic method was adopted. In Papers III and IV, an interpretive phenomenological approach was adopted. Findings: Nurses that have a holistic view of the child and approach the child from a multidimensional perspective, with a focus on the individual child and his/hers caring needs, develop a clinical "connoisseurship" and meet the parents' expectations of the meaning of care. The nurses express that it is only when they focus on the child that subtle signs of pain are revealed. The meaning of nursing care, in the ideal case, is a holistic care where all aspects are integrated and the child as a person has first priority. Conclusion: The meaning of caring and children's needs must become elucidated to improve the cultural influence of what can be seen as good nursing care within the PICU.

Background and aims:An effective handover is crucial to the delivery of high quality, safe and effective care in a large and expanding PICU. Lean methodology was used to identify the number, duration and content of handover episodes and change manage inefficiencies. Aims: To improve the safety and quality of handover. Methods: 1. A time and motion study of handover episodes and length 2. A survey of multi professional PIC staff to determine quality and reliability of handover information. Results: In a 24 hours time period there were a total of 68 handover episodes for 24 patients. There were multiple handovers, with bedside nurses, middle grade medical staff, consultants and nurse coordinators having independent handover's. The main medical morning handover took place in a conference room, thereby excluding the bedside nurse. The reliability of information and the ability to manage a single conference handover for 24 patients in the allotted time was increasingly difficult. The staff survey found that information handed over was repetitive and unless at the bedside, information was sometimes unreliable and therefore not of the expected quality. Conclusions: Handover timelines, team briefs and a multi professional bedside handover have been implemented and are now scheduled into each shift. There are now 55 handovers per 24 hours for 26-28 patients. Content and length are currently being evaluated. A multi professional collaborative approach has ensured that all staff involved with handover were represented and involved with this process change, maximising patient safety and information handover quality.

No abstract