Family-centred care (FCC) is identified as “best practice” in paediatrics. However, its implementation in paediatric settings in the developing world is low. This paper presents the paediatric nurses’ experiences in implementing family centred care in the management of hospitalised children in Kenya. Data were obtained from thirteen trained paediatric nurses through focus group discussions. Content analysis is used in analysing the data and the results are discussed in themes. The study established that the paediatric nurses are zealous of applying FCC in their paediatric nursing. However, patient population, parental ignorance, low level of awareness among their colleagues and hospital policies were cited as pose a great challenge to the implementation. The study concluded that FCC can be applied in the management of hospitalised children if all those concerned with care of children are trained or sensitized on the same.

Keywords: family centered care, child health nursing, paediatric nurses, experiences, focus group discussions

The philosophy and principles of FCC have made it to be identified as “best practice” in paediatric hospitals in the developed world.¹ The approach was born out of the recognition that the emotional needs of hospitalised children were in most cases unmet, parents were not involved in the direct care of their children, children were often unprepared for procedures and tests and that visiting was severely controlled.² According to O’Malley³ in the practice of FCC care is provided to a person not a condition, the patient is best understood in the context of his or her family, culture, values, and goals, and showing of honouring results in better healthcare, safety, and patient satisfaction.

In the developing world, there is scarce documentation on the approaches used in the management of hospitalised children. A study by Richter et al.⁴ in South Africa observed that the ward atmosphere and care context was emotionally stressful to both the hospitalised children and their parents as the nursing staff were reluctant to become involved with parents and children. In Kenya, a study by Orinda⁵ found that little thought is given to the role of the mother when her sick child is admitted to the paediatric ward and planning for the ward does not include the mother. Further, parents are mainly involved in giving information about their sick child and preparing the child for procedures but not in planning and implementing care.⁶ The National Co-ordinating Agency for Population and Development (NCAPD), most healthcare providers in Kenya do not take care of sick children holistically, but rather treat them only for the presenting illness (NCAPD and ORC Marco, 2005)

Prior to the commencement of paediatric nurse training programme in Kenya in 2004, FCC had not been included in the paediatric component of all the nurse training programmes. Further, despite its emphasis during the training of the paediatric nurses, their practice of the same after qualifying has not been evaluated. This study therefore set to answer the questions:

1. How do the paediatric nurses apply family centred care in the management of hospitalised children in Kenya?
2. What challenges do the paediatric nurses face in the implementation of family centered care in managing hospitalised children in Kenya?

A qualitative study was conducted among paediatric nurses working in a public hospital and a private hospital in Nairobi, Kenya. Data were collected through focus group discussions (FGD). Two FGDs, one from each institution were constituted. The FGD from the public institution had six participants whereas the one from the private institution had seven participants. A structured FGD guide was used for data collection. Further, discussion was guided by the responses from the participants. During the FGD session, each participant was given a chance to respond to the item under discussion before progressing to the subsequent question. Data were recorded using a voice recorder and taking of field notes. At the end of the discussion the participants built consensus on the key emerging issues from the discussion under the guidance of the moderator. The data were transcribed, content analysis was done by reading through the transcripts, and emerging codes were derived and merged. The results are presented in themes.

A total of 13 paediatric nurses participated in the discussions. Majority (84.6%, n=11) were females with each group comprising one male participant. The majority (76.9%, n=10) were married, aged below 40years (61.5%, n=8) and had worked as paediatric nurses for more than 2 years (53.8%, n=7).

Practice of FCC

The participants were asked to narrate their experiences in the practice of FCC. Their discussions brought forth two themes; FCC practice strategies and benefits experienced.

Theme 1: FCC practice strategies The FCC practice strategies are the ways in which the paediatric nurses ensure they apply the principles and elements of FCC in the care of the hospitalised child. These include:

1. Encouraging the parents to be with the child in the process of examination and treatment. In explaining this point one of the respondents from the public hospital explained that though the hospital has not adapted the approach in its child care policies, in her unit she has embraced it. She explained as follows:
2. “FCC has been embraced; it starts immediately when the child has been brought to the unit. We encourage both parents to be there and we find it             being applicable because they assist one another when the child is sick in caring. We encourage them to be with the child at every point”. (KPN01).
3. Being zealous about the application of the concept whether adapted in policy or not. This is by ensuring they orientate and encourage their colleagues on the benefits of the approach “It is self initiative but it is not documented”. (KPN01, 2).
4. Sharing information with the sick child’s family and explaining to them the child’s condition and management process.
5. Allowing the children to be accompanied by their parents throughout the period of hospitalization.
6. Teaching and allowing some parents to perform or assist in the performance of some procedures.
7. Not restricting children to the hospital food. This is upheld in the public hospital whereas it is not upheld in the private hospital.
8. Allowing the accompanying parent to participate in the ward round when the child is being reviewed “They are allowed to participate even during the ward round”(KPN 05).

Theme 2: benefits of practicing FCC
The paediatric nurses, expressions on the practice of FCC brought forth the benefits that they have realised. The benefits extracted from their expressions include:

1. When the parents are involved in the care of the hospitalised child, coping is easier.
2. The healthcare providers find it easier to care for the child when they involve the parents “When you involve them, caring is easy”. (KPN02).
3. The parents get empowered to care for the child even after discharge. This is particularly so if they are involved from the first day of admission. “Most of the time when we involve the parents, they feel empowered and confident to manage the children even on discharge, especially those with chronic illnesses”. (KPN 08).
4. The child’s home routines and practises are not adversely disrupted as they used to be before the adoption of FCC particularly in the children’s hospital. One of the respondents narrated her experience as follows: “I remember when I came here in 2002, I was in an open ward, at 2’oclock, the children were given a cup of milk, the curtains were closed and they were all told to sleep so as to wake up at 4.00 but now we are not doing that, the child will sleep as they sleep at home”.(GPN04).

During the focus group discussions, the paediatric nurses were asked to narrate the challenges they face in their practice of FCC while providing healthcare to children and their families. The challenges derived from their discussion included the following

Disparity in handling the children’s parents

Due to differences in awareness about FCC among the nurses, a disparity exists on how they handle the parents. This makes it difficult to work with the parents because they are made to have a negative attitude toward the nurses as the majority have not been trained on the concept. One of the respondents gave the following explanation: “Nurses imagine that parents are know-it-all due to their access to information from the internet. So the challenge to the health personnel is, why is the parent doing my work? Like I remember a nurse asking a mother why she had a thermometer and yet they have been educated and they have them at home. So fear of the nurses on mothers taking over their work, you find a mother bathing the baby and you ask, ‘kwa nini unafanya kazi yangu’ (why are you doing my work)”? (KPN01).

Parental behaviour due to cultural influences

They cited cultural influence on the approach parents take in the presentation of their sick child to the hospital. One of the respondents gave the following scenario: “Parents due to culture like fathers staying a distance away and yet when the mother leaves the doctor’s room they start questioning them, did you explain about this properly”? (KPN01).

Space, staffing and time limitation

Participants from the public hospital cited space constraints and the overwhelming number of patients which makes it difficult to practice FCC properly. Lack of essential facilities, like beds for the parents, makes some of them opt to go home leaving the child alone in the hospital. “Facility-environment, the parents have no space to sleep or even a blanket to use so the parents feel that since the child sleeps alone at home, she can as well leave her”. (KPN 05) Another respondent, in emphasizing the same point, explained that they handle a large number of patients which makes them experience time constraints in individualizing patient care. For instance, instead of conducting individualized patient education, they opt for group education.

Parental fear of witnessing some of the procedures

Some parents fear accompanying their children during some procedures especially if they are traumatic. Thus they opt to stay away leaving the child alone with the nurse. In this instance, it becomes difficult to practise a traumatic care. One of the respondents explained as follows: “Some parents not wanting to be with the children during some of the procedures like resuscitation, lumbar puncture because they find them to be rather traumatic, so they will want to be away and trying to pull them back sometimes is hard”. (KPN03).

Parental commitments

The respondents indicated that the parents have a number of commitments and other social responsibilities to attend to. These limit their availability to be with the hospitalised children. This is expressed in the following scenario: “Single parents – this parent has some other children at home and one has been admitted so she finds it difficult to coordinate between home and here. So, as much as we would want to practise FCC, as a hospital we cannot cater for the children who are at home and here. Parents might go, there is fear and anxiety in the parent on what is going to happen to the other children and what is happening to this one”. (KPN04).

The impact of the history of hospital care in the country

One major challenge was in the way hospital care for children have been carried out in the past. The parents have been en cultured that once the child is in the hospital, it is the responsibility of the healthcare providers to decide and implement care. This makes them to be bystanders rather than active participants in the planning and implementation of care for their hospitalised child. This is reflected in the comment below: “We have lived in the old time that the healthcare provider is the one who knows it all; so long as the child is in the hospital, we should take care. We have not erased it from the parents”. (KPN05).

Influence of parents on one another

Parents share experiences in the ward and in the process they sometimes influence each other wrongly. This challenge is reflected in the following remark: “They influence one another and children may not be having the same problem but they interact and influence one another-pick wrong concepts regarding care”. (GPN01) This challenge was further explained by another participant as follows: “You want to involve the family in the care; sometimes especially relatives get too involved or are problematic. Those who think they know sometimes come with their own ideas making the parent to follow their idea more than the one from the healthcare providers. Sometimes you find what they want for the child is not what the parents or healthcare providers want”. (GPN03)

The paediatric nurses cited a number of challenges that they experience in their endeavour to practise FCC. These challenges included: lack of support from the institutional managers and other healthcare providers; parental behaviours due to cultural influences; space constraints due to congestion of patients; understaffing; limited time to be with each patient; and parental fear to witness some of the procedures performed to their children. These challenges are similar to those established by Espezel & Canam⁷ in their study on parent-nurse interactions in the care of hospitalised children. They also concur with those of Paliadelis et al.⁸ in their exploration of paediatric nurses’ beliefs and practices of FCC.⁹

1. Paediatric nurses apply the principles and elements of family centered care in the management of hospitalised children
2. According to the paediatric nurses low level of awareness of FCC among other healthcare providers and policy makers is a key contributor of the challenges they experience in implementing FCC.

1. FCC should be included in all the basic and post-basic training curricula of all healthcare providers, in the in-service training programmes and continuing medical education programmes.
2. Child healthcare policies need to be reviewed to include FCC.

This research was [partially] funded by the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC), and Jomo Kenyatta University of Agriculture and Technology (JKUAT).

The author declares no conflict of interest.

1. Eichner MJ. American academy on pediatrics, Committee on hospital care, Policy statement; Family centered care and the pediatrician’s Role; 2003.
2. Neff M, Spray M. Introduction to maternal and child health nursing. USA: Lippincott; 1996.
3. O’Malley P, Brown K, Krug S. The committee on pediatric emergency medicine. Patient and family-centered care of children in the emergency department. Pediatrics. 2008;122:511–521.
4. Richter LC. Improving Hospital Care for young children in the context of HIV/AIDS and Poverty. Journal of Child healthcare. 2009;13(3):198–211.
5. Orinda V. The mother of a sick child in a pediatric ward: Her role in ward management. UoN: MMed dissertation; 1982.
6. Makworo D, Laving A. Caring for children with acute, Treatable and preventable medical conditions. African Journal of Midwifery. 2010;4:33–37.
7. Espezel H, Canam C. Parent nurse interactions: Care of hospitalized children. Journal of Advanced Nursing. 2003;44(1):34–41.
8. Paliadelis PC, Wainohu D, Winskill R, et al. Implementing family centred care: An exploration of the beliefs and practices of pediatric nurses. Australian Journal of Advanced Nursing. 2005;23(1):31–36.
9. National coordinating agency for population and development (NCAPD) and ORC marco. Kenya Servise Provision Assessment Survey (KSPA). Kenya, Nairobi: Springer; 2005.