The meaning of a “good nurse” in pediatric care: a concept analysis

El significado de la “buena enfermera” en el cuidado pediátrico: un análisis de concepto

ABSTRACT

Objective:

to analyze the attributes, antecedents and consequences of the concept a “good nurse” in the context of Pediatrics.

Method:

concept analysis study based on Rodgers’ evolutionary method. Theoretical stage consisted of searching for articles in the CINAHL, Embase and Pubmed databases and a practical stage of semi-structured interviews with pediatric nurses. The final analysis unified the two stages by categories of antecedents, attributes and consequences of the concept.

Results:

20 articles and 10 interviews were analyzed revealing as antecedents aspects related to education, scientific development and ethical-moral skills and values. Responsibility, compassion, honesty and advocacy stand out as attributes of the “good nurse.” The consequences describe implications for children and families, as well as for professionals.

Final Consideration:

the analysis of the concept of the “good nurse” allowed us to clarify fundamental aspects for the execution of good practices, establishing parameters for investment in professional development programs.

Descriptors:
Pediatric Nursing; Evidence-Based Nursing; Concept Formation; Nursing Theory; Family Nursing

RESUMEN

Objetivo:

analizar los atributos, antecedentes y consecuencias del concepto la “buena enfermera” en el contexto de la Pediatría.

Método:

estudio de análisis de concepto basado en el modelo evolucionista de Rodgers. Se realizó una etapa teórica que consistió en la búsqueda de artículos en las bases CINAHL, Embase y Pubmed y etapa práctica de entrevistas semiestructuradas con enfermeros de pediatría. El análisis final unificó las dos etapas por medio de categorías sobre antecedentes, atributos y consecuencias del concepto.

Resultados:

20 artículos y 10 entrevistas fueron analizadas revelando como antecedentes los aspectos relacionados a la educación, el desarrollo científico y habilidades y valores ético-morales. Responsabilidad, compasión, honestidad y abogacía se destacan como los atributos de la “buena enfermera”. Las consecuencias describen las implicaciones para los niños y las familias, así como para los profesionales.

Consideraciones Finales:

el análisis del concepto de la “buena enfermera” permitió aclarar aspectos fundamentales para la ejecución de buenas prácticas, estableciendo parámetros para la inversión en programas de desarrollo profesional.

Descriptores:
Enfermería Pediátrica; Enfermería Basada en Evidencias; Formación de Concepto; Teoría de Enfermería; Enfermería Familiar

RESUMO

Objetivo:

analisar os atributos, antecedentes e consequências do conceito “boa enfermeira” no contexto da Pediatria.

Método:

estudo de análise de conceito baseado no modelo evolucionista de Rodgers. Realizou-se uma etapa teórica que consistiu na busca de artigos nas bases CINAHL, Embase e Pubmed e etapa prática de entrevistas semiestruturadas com enfermeiros de pediatria. A análise final unificou as duas etapas por meio de categorias sobre antecedentes, atributos e consequências do conceito.

Resultados:

20 artigos e 10 entrevistas foram analisados revelando como antecedentes aspectos relacionados à educação, desenvolvimento científico e habilidades e valores ético-morais. Responsabilidade, compaixão, honestidade e advocacia destacam-se como atributos da “boa enfermeira”. As consequências descrevem implicações para as crianças e famílias, bem como, para os profissionais.

Considerações Finais:

a análise do conceito da “boa enfermeira” permitiu esclarecer aspectos fundamentais para execução de boas práticas, estabelecendo parâmetros para investimento em programas de desenvolvimento profissional.

Descritores:
Enfermagem Pediátrica; Enfermagem Baseada em Evidências; Formação de Conceito; Teoria de Enfermagem; Enfermagem Familiar

INTRODUCTION

Nursing is a social and humanistic discipline of health care practice. It brings together knowledge and skills of prevention, diagnosis and treatment, structured in the science and art of care. The concepts that integrate Nursing mobilize the production of definitions and theories through research to develop, test and apply technologies and instruments that guide the good practices of caring for human beings, families and communities⁽¹⁾.

This science determines, in its metaparadigms, the care of human beings in their experience in a certain space and time. In this sense, understanding and interpreting the meaning of being a nurse requires constant approximation and distancing from the universe of professional performance. Through the approximation it is possible to glimpse the understanding of the process of living of others, their expectations and ways of care. Through the distancing there is the reflection of professional praxis in the way of interpreting, understanding and solving problems, often immersed in qualitative issues arising from the subjective characteristic of care⁽²⁾.

In this context, the study mobilizes reflections about being a pediatric nurse. This cut is justified by the fact that pediatric care consists of a complex phenomenon of multiple interactions with children and their family, which require the valuation of the multidimensionality: emotional, affective and social. Nursing care in Pediatrics, therefore, requires nurse and their team to have differentiated skills while defining action and interaction strategies anchored in the complementarity, reciprocity, intersubjectivity and interdisciplinarity necessary to take care of children and their relatives in their complexity⁽³⁾.

Thus, the analysis and development of the concept of a “good nurse” in the pediatric context will be the object of study of this work. It is understood the relevance of clarifying the meaning of a concept to promote and update understandings in the direction of care congruent to the chosen study context⁽⁴⁾.

Thus, the proposal for the analysis and development of a concept is closely related to the evolution and expansion of knowledge in Nursing, capable of promoting a continuous and comprehensive refinement of the solid bases of Nursing knowledge. In seeking to define the meanings of a concept, it collaborates for advances in science, since they can be challenged and modified, because they are dynamic, variable and dependent on their use and the context in which they are inserted⁽⁵⁾.

Therefore, the present study aims to contribute to the knowledge about the meaning of being a “good nurse” in the pediatric context, through the development and analysis of this concept in order to contribute to its continuous and refined development.

OBJECTIVE

To analyze the attributes, antecedents and consequences of the concept of a “good nurse” in the context of pediatric care.

METHOD

Ethical aspects

The study received a favorable opinion from the Research Ethics Committee of the Nursing School of Universidade de São Paulo, in accordance with Resolution 466/2012⁽⁶⁾. To those who participated in the field stage codenames of precious stones were assigned, in order to ensure anonymity and allude to the valuable attitudes highlighted in the experience of being a “good pediatrician nurse”.

Theoretical-methodological framework

The study was guided by Rodgers’ evolutionary model for concept analysis, which has an inductive nature⁽⁷⁾. In this model, the main characteristic is the dynamics of the concept, to the detriment of the constant development and evolution of the analyzed phenomena, given the influence of time and context that are used⁽⁷⁾. The analysis of a concept is therefore not intended to provide a final definition but rather to clarify its attributes, antecedents, consequences and related examples.

Type of study

It is a qualitative study of concept analysis, according to the Rodgers’ evolutionary concept analysis model⁽⁷⁾. The hybrid model was used, consisting of a theoretical stage and a field stage for data collection and analysis.

Methodological procedures

The first step proposed by Rodgers is the selection of the concept for analysis. In this stage, it is fundamental to consider the relevance of the concept to the practice and contribution to the problem solving when unveiling the characteristics of the phenomenon⁽⁸⁾. The “good nurse” concept was defined as the need to clarify the roles, beliefs, attitudes and behaviors associated with good nursing practice, which requires complex and comprehensive approaches at the interface with the child and the family⁽⁹⁾.

The second step was carried out between October and December 2017 and involved the selection of material for concept analysis. For that, the criteria for inclusion and exclusion of articles that would be used to collect the information in the CINAHL, Embase and Pubmed databases were defined. Articles published in scientific journals (reviews, editorials or original studies) were included, which had data about being a “good nurse”, carried out in the pediatric context and that were in Portuguese, English and Spanish. There was no restriction on the date or source of information, so the studies could express the experience of pediatric patients, professionals, staff and co-workers or families, as well as Nursing students. Duplicate articles and those that after read in full did not meet the inclusion criteria were excluded. The search strategy was a combination of the following terms: ‘good nurse’ and ‘child’ or similar terms such as infant, teenager, adolescent, toddler, youth, newborn, pediatric.

Titles and abstracts were read out of a total of 153 articles, and 34 were selected for reading in full. After reading, 14 articles were excluded, totaling 20 studies for the final analysis, according to Figure 1.

Figure 1
Flowchart of the selection stage of the material for concept analysis

Preferred Reporting Items for Systematic Reviews and Meta-Analyzes: The PRISMA Statement. PLoS Med 6(7): e1000097. DOI: 10.1371/journal.pmed1000097

Both Rodgers and other authors propose a field stage within the analytical stage of the data, called the hybrid concept analysis model⁽⁷⁾. The purpose of this stage is to identify elements of the concept in practice, as well as the relevance and applicability of the phenomenon. For that, we conducted semi-structured interviews with the purpose of understanding the meaning of being a “good nurse” in the context of Pediatrics.

Research setting

In the field stage, semi-structured interviews were conducted with nurses who worked in pediatric units. These interviews took place in a large tertiary hospital, which has a unit for Pediatrics, considered a Reference Center for Child Health, which deals with high complexity cases referenced in several regions of Brazil, as well as in Latin America.

Data collection and organization

In the theoretical stage, data from the articles selected for reading in full were organized by means of an instrument created for the extraction of data aiming at the systematization of relevant information, such as theoretical and methodological characterization of the studies (type of research, objectives, theoretical reference, population) and aspects related to the concept: antecedents, attributes and consequences. To do so, the following questions were used: What is necessary to achieve the concept of a “good nurse”? What expressions are used to describe a “good nurse” in the context of Pediatrics? What is the purpose of a “good nurse” action?

This stage was carried out by two authors independently, with a third reviewer to decide on the disparities that have arisen, which were continuously discussed throughout the analysis process, to refine the methodological steps and to guarantee rigor and consensus in information extracted for the analysis.

In the field stage, performed through semi-structured interviews, the inclusion criteria were to be a nurse and act in Pediatrics. The nurses were invited to participate in the study by signing a Term of Free and Informed Consent. The interviews followed a semi-structured roadmap with the following guiding question: Tell any care that has been marking to you. Tell me about how you can be a “good nurse” for this child. What was the best care for this child? What would you do differently? What do you believe was not good care?

Data analysis

The final stage of analysis progressed as the data of the theoretical and field stages were unified by means of categories elaborated according to the antecedents, attributes and consequences of the concept. Finally, a case-model was constructed as a practical example of the application of the concept⁽⁷⁾.

RESULTS

The theoretical investigation of the literature to develop the concept of a “good nurse” in the pediatric context gathered 215 articles, of which 119 were excluded, because they were not related with being a good nurse and had 62 duplicates. The final sample resulted in 20 publications selected for analysis. Chart 1 summarizes these studies according to author, title, purpose, type of study, place of origin and year of publication.

Chart 1
Synthesis of studies included in the literature review stage (N=20), 2017

N	Author	Title	Objective	Type of study	Place of origin	Year
1	Glasper A, Richardson J, Whiting M(10).	The highs and lows of learning to be a children's nurse.	To investigate the Nursing students' perception related to an educational program for qualification of pediatric nurses.	Qualitative; Empirical study.	England	2006
2	Björkström ME, Johansson IS, Athlin EE(11).	Is the humanistic view of the nurse role still alive - in spite of an academic education?	To explore what being a "good nurse" means to Nursing students.	Qualitative; Empirical study.	Sweden	2006
3	Copnell B(12).	The knowledgeable practice of critical care nurses: a poststructural inquiry.	To explore the critical care nurses' comprehension about educated technique and its relationship with being a "good nurse".	Qualitative; Empirical study.	Melbourne, Australia	2008
4	Randall D; Brook G; Stammers P(13).	How to make good children's nurses: children's view.	To explore the meaning of a "good nurse" and "not so good" to children.	Qualitative; Empirical study.	Birmingham, England	2008
5	Brady M(14).	Hospitalized children's views of the good nurse.	To explore the hospitalized children's perception about a good nurse.	Qualitative; Empirical study.	England	2009
6	Cinar N, Altun I(15).	Good pediatric nurse's characteristics in according to student nurses.	To know the meaning given to by Nursing academics about good pediatric nurse.	Qualitative; Empirical study.	Sakarya, Turkey	2012
7	Clarke S(16).	Informing Pre-Registration Nurse Education: A Proposal Outline on The Value, Methods and Ethical Considerations of Involving Children in Doctoral Research.	To explore how children's point of view about their experience at the hospital and "the good nurse" can contribute to the development of educational programs.	Qualitative; Empirical study.	United Kingdom	2014
8	Shimizu F, Katsuda H(17).	Teachers' perceptions of the role of nurses: Caring for children who are technology-dependent in mainstream schools.	To explore the perceptions of teachers of special education about the role of specialized care nurses for children who are technology-dependent in mainstream schools.	Qualitative; Empirical study.	Osaka, Japan	2015
9	Murakami M, Yokoo K, Ozawa M, Fujimoto S, Funaba Y, Hattori M(18).	Development of a Neonatal End-of-Life Care Education Program for NICU Nurses in Japan.	To describe the evaluation of an educational health care program for NICU nurses.	Qualitative; Theoretical study.	Japan	2015
10	Grahn M, Olsson E, Mansson ME(19).	Interactions Between Children and Pediatric Nurses at the emergency department: a Swedish interview study.	To describe the nurses' methods of interaction with children from three to six years old at a pediatric emergency department.	Qualitative; Empirical study.	Sweden	2016
11	Silva JRS, Pizzoli LML, Amorim ARP, Pinheiros FT, Romanini GC, Silva JG et al(20).	Using Therapeutic Toys to facilitate venipuncture procedure in preschool children.	To study the efficacy of therapeutic toys during venipuncture procedure in children from three to six years old.	Qualitative and quantitative; Empirical study.	São Paulo, Brazil	2016
12	Aydin R, Sehiralti M, Akpinar A(21).	Attributes of a good nurse: the opinions of nursing students.	To determine the opinion of Nursing students from the first and the fourth years about the attributes of a "good nurse", and how it changes over the years.	Qualitative; Empirical study.	Turkey	2017
13	Carter B(22).	"They've got to be as good as mum and dad'': Children with complex health care needs and their siblings' perceptions of a Diana community nursing service	To identify the children with complex health care needs and their siblings' perceptions about specialized nursing care.	Qualitative; Theoretical study.	United Kingdom	2005
14	Erichsen E, Danielsson EH, Friedrichsen M(23).	A phenomenological study of nurses' understanding of honesty in palliative care.	To describe how the nurses experience honesty with home palliative care patients.	Qualitative; Empirical study.	Sweden	2010
15	Janvier A, Barrington K, Farlow B(24).	Communication with parents concerning withholding or withdrawing of life-sustaining interventions in Neonatology.	To address the importance of personalizing conversations about decision making at the end of life.	Qualitative; Theoretical study.	Canada	2014
16	Sugano AS, Sigaud CHS, Rezende MA(25).	The nurse and the nursing staff according to mothers of hospitalized children.	To comprehend how accompanying mothers identify the nurse and other nursing staff members, and to know the perception of these mothers about the care provided.	Qualitative; Empirical study.	São Paulo, Brazil	2003
17	Campbell C, Scott K, Madanhire C, Nyamukapa C, Gregson S(26).	A 'good hospital': nurse and patient perceptions of good clinical care for HIV-positive people on antiretroviral treatment in rural Zimbabwe - a mixed-methods qualitative study.	To comprehend nurse and patient perceptions of good clinical care on antiretroviral therapy.	Qualitative; Empirical study.	Zimbabwe	2011
18	Altun I; Ersoy N(27).	Undertaking the role of patient advocate: A longitudinal study of Nursing students.	To explore tendencies Nursing students follow related to the patient's right to determine changes in these tendencies or attitudes during their education.	Qualitative; Empirical study.	Kocaeli, Turkey	2003
19	Randall D, Hill A(28).	Consulting children and young people on what makes a good nurse.	To know children's perception in a school hospital about a good nurse.	Qualitative; Empirical study.	England	2012
20	Bloomer MJ, O'Connor M, Copnell B, Endacott R(29).	Nursing care for the families of the dying child/infant in Pediatrics.	To explore how NICU/PICU nurses take care of pre-and post-death families and their perspectives on providing family care.	Qualitative; Empirical study.	Australia	2015

The analysis of these studies, along with that of the interviews, enabled the identification of the elements of the concept of a “good nurse” in the context of pediatric care, based on the identification of their antecedents, defining attributes and consequences, presented respectively in Charts 2, 3 and 4.

Chart 2
Distribution of the antecedents of the pediatric "good nurse" identified in both reference studies and interviews

Identified antecedents	Convergent speech	Reference article
Emphasis on attributes during training/ Specific knowledge in Pediatrics/ Permanent education.	I finished my undergraduate studies in 2006, [...] I joined the hospital's clinic improvement, I studied Neurology and Intensive Care [...] in 2011 I entered the Master's Degree [...]. (Topaz) I think here in Pediatrics everything is very different, right? Because the child you need to be friends with, you have to talk, you have to know how to approach her/him, right? (Amethyst)	( 10 - 21 )
Excellence in skills: Communication/ Ability to create a good meeting.	Support means words of comfort, friendship, be available if the person needs to talk. Ask if she/he wants to talk, if she/he wants a glass of water [...] if she/he wants to leave the room a little, to breathe... (Sapphire)	( 14 - 15 , 20 , 22 - 24 )
Experience/ Technical managerial and relational skills with the team.	You have to reduce that stress of pain to the maximum, if you can reduce it with medication [...] 'Ah, I have a bandage to take away that I know it hurts,' I'm going to put on some oil, (Amethyst)	( 11 , 13 , 15 , 19 , 21 - 23 , 25 - 26 )
Ethical and moral values.	The most we can give is some moral support. (Sapphira) I think the question of professional ethics is involved here [...] how far will we decide what the patient needs [...] (Topaz)	( 11 , 14 - 16 , 18 , 21 , 23 , 27 - 29 )
Scientific curiosity (research)/ Evidence-based practice.	There was no reference in the interviews.	( 11 - 13 , 21 )
Alignment in care goals among professionals.	Because every decision to continue or not to invest in the prognosis of the patient is always discussed with the family and the physician, all the teams involved in the care. (Topaz) I am, thank God in a very competent team, very responsible, very capable, as for the conduct I had no questions.(Grenade)	( 24 , 26 )
Advocate for the profession/ Be proud of the profession.	[...] It is not about doing it just for doing it, it is about enjoying what you do. [...] then it is doing it out of love [...] (Rubi) If we work mechanically, then things do not work, right? You have to work with your heart too. (Tourmaline)	( 10 - 12 )

Chart 3
Distribution of pediatric "good nurse" attributes identified in both reference studies and interviews

Attributes identified	Convergent speech	Reference article
Responsibility/ Self-confidence	You also have to look at reason, it's not just the heart, it's not just the emotional side, no, let's do his will, regardless of the risks? No! When he's here with us, we're here for this [...] to make him happy, but also safe.(Ruby)	( 11 , 29 )
Good relationship/ Good listener/ Bond/ Playful interaction	[...] I had a closer bond, I gained her confidence to the point that every trouble she had, she'd talk to me [...] I was always trying even to snuggle her, literally. She came, hugged me, sometimes she cried, I could hear it. (Emerald) [...] provide a moment of leisure, with a movie, a game, something, you know? Talk to her, try to get her out of here, from that moment of stress.(Amethyst)	( 11 , 13 , 19 , 21 - 22 , 24 - 26 , 29 )
Compassion/ Understanding/ Empathy/ Humanity	[...] I have always put myself in the family's shoes, understanding that it adds value to it [...] (Jade) [...] we have that empathy for parents because we put ourselves in their shoes, you know? Like what their suffering is. (Ruby)	( 11 , 14 - 15 , 20 - 22 , 24 )
Kindness/ Availability/ Patience/ Tolerance/ Calmness	The way I have to take good care is by having patience, and waiting for the time: 'Lady, do not punch me now' [...] 'No, I'll wait, I'll be back soon', I'll be back in ten times in the room [...] as much as I can I try to be patient... to be a little more sensitive. (Amethyst)	( 11 , 15 , 21 , 22 , 25 , 27 - 28 )
Honesty/ Justice/ Confidentiality/ Respect	My role is educational with the family, trying to explain what is happening to the patient, what efforts are being made, what conducts we are having. (Topaz)	( 11 , 13 , 15 , 19 , 21 - 23 , 27 )
Advocate for the patient/ Make beneficial decisions for the patient and the family	[...] we begged the doctors because they had no intention of passing a central catheter in it, except they couldn't wait longer. He was suffering, they made an exception. (Ruby) [...] I think I helped in the decision-making process, in the activation of the team and in encouraging the family to join this support, to listen, to share the problems [...] (Topaz)	( 11 , 16 , 18 , 24 , 27 )

Chart 4
Distribution of consequences of the "good nurse" pediatric identified both in the reference studies and interviews

Consequences identified	Convergent speeches	Reference article
Less frightening hospital experience/ Humanized care	We took him on the gurney and we set up his bed with oxygen on the third floor, we left him there, and there was literally a party for him, over fifty people. (Ruby)	( 14 , 20 , 24 )
Comprehensive care for the child in partnership with the family - safety and autonomy	The role of nurses [...] is to participate more actively in decisions, care and have a closer look at the family. (Agate) Whenever she had a chance, sometimes in the shower, she would involve her [the mother]. (Emerald)	( 11 - 14 , 17 - 20 , 22 , 24 - 25 , 27 - 29 )
Fulfillment and professional recognition of the nurse	[...] our profession teaches this, we have this greater contact with the patient and his/her relative, different from other areas. (Diamond) [...] the mother came to me and thanked us, the support we gave her family. (Sapphira)	( 10 , 20 - 21 , 26 )
Autonomy and empowerment of the nurse	[...] I try to do as much as I can to my knowledge and the standards that have been set that I think are right [...]. So, to do the most is to go beyond nursing care, a little care, talk to the child [...] sometimes sing a little bit [...] (Sapphire)	( 12 , 18 , 23 - 24 )
Self-preservation of the nurse	[...] I try not to bring it to me, I end up bringing some, but I have tried to improve it. I try not to remember what happened, but I know the subconscious is there, but you try not to think about it, you try to move on with your life. (Grenade)	( 10 , 18 , 23 , 27 )
Risk of censorship and judgment	There was no reference in the interviews.	( 11 - 12 )

Case-model of a “good nurse” in the context of pediatric care

When identifying the antecedents, attributes and consequences of being a “good nurse” in the context of pediatric care, the aim is to clarify the definition of the concept so that it is better explored in practice, education and future research. According to Rodgers’s proposition on the temporary definition of the concept, given its dynamic and evolutionary characteristic, instead of a literal definition as final product, a case-model is used as a reflexive resource to portray in an exemplary way how the phenomenon expressed in real life, highlighting its attributes⁽⁷⁾. Thus, the following is a case study that portrays the “good nurse” in the context of pediatric care:

V.M.G, 11 years old, male, diagnosis of Relapsed Acute Lymphoblastic Leukemia and Refractory to Chemotherapy. He was in follow-up of exclusive palliative care and hospitalized for three months in ward for pain control and urinary tract infection. Nurse Turquoise has been following the child and family since his admission and has developed close ties with both. Due to the distance of the family’s residence city, the mother is always keeping up with the minor. Turquoise realized the difficulties faced by the binomial from the attentive listening and availability always demonstrated to both. She is a differentiated professional who maintains a good relationship with the team and exercises empathy with patients and their families. As his mother was very confident in Turquoise, the nurse led the communication of bad news at the end of V.M.G.’s life, in the meeting with the health team and the family. It was a difficult time but conducted with honesty and ethics in ensuring the family’s awareness about prognosis. After that the child began to decline psychologically, he no longer wanted to play with Turquoise as he did before, when she offered him the music accepted by him. The pain increased, and tracking for relief increasingly bothered him, so Turquoise talked to the medical staff and interceded for the passage of the delay tracking for the better comfort of her esteemed patient. On the day of his death, V. M. G was quite restless and demanding, but Turquoise kept being patient and sensitive, seeking to make him feel better. After he died, his mother hugged Turquoise and said crying, “Thank God that you were this “good nurse” during his hospitalization, we admire your care and responsibility with us. Thank you!

DISCUSSION

The discussion about the antecedents, attributes, and consequences of being a “good nurse” in the context of pediatric care, even it is old, continues to be a source of concern and active investment in dealing with subjective human care for children. Thus, the professional identity of nurses, in this context, is faced with the constant challenge of analyzing and rediscovering, that is, of conceptualizing, which is discussed below.

Antecedents of the concept of a “good nurse” in the context of pediatric care

The findings about the antecedents of pediatric “good nurse” praxis relate to different and convergent views of each study and each nurse, which outline an interpretative identity profile of their professional experiences.

This process of building a professional identity aspired permeates dreams, an ideal and the romantic vision of the profession, which exalts humanistic skills and love for the profession. Elements influenced by the literature and reinforced as valuable in the daily professional exercise, making possible a differential when dominating the labor market⁽³⁰⁾.

Thus, the antecedents identified in this study concerning the concept of a “good nurse”, in the context of pediatric care, are consistent with the recovery of the fundamental values of Nursing, in the direction of establishing an identity committed to the profession and averse to the culture of individualism and the empty speeches that are filled with ethical, moral and practical dilemmas in the life of workers of this class. It is a remodeling in which, first, nurses need to strengthen their human convictions and then refresh their self-confidence for the courageous exercise of the skills that involve the act of surrendering to patients to form bonds with them⁽³¹⁾.

However, it is not an easy task to develop antecedents such as communication skills, interaction/ability to create a good meeting, and technical and managerial skills expected in an ethical-moral context of love and loyalty to Nursing. This improvement certainly counts on the contributions of the Nursing Continuing Education.

A study in the area affirms that it is possible to develop managerial competencies of nurses in the logic of Continuing Education, but emphasizes that it is necessary to understand these competences not only as an individual attribute that can be acquired and constructed by the nurses’ expertise, but also of developed competences in a contextualized way, based on real demands of the labor practice⁽³²⁾.

In reference to academic training, the National Curricular Guidelines of the Undergraduate Nursing Course define the objective of training nurses to provide professionals with the knowledge required for the exercise of specific skills and abilities. Among them, the following stand out: to develop technical-scientific training qualifying the professional practice; to act professionally, understanding human nature in its evolutionary phases; to act in the programs of integral assistance to the health of children; assume the ethical, humanistic and social commitment to work in health; respect the ethical, legal and humanistic principles of the profession; and, to incorporate into science the art of caring as an instrument of professional interpretation⁽³³⁾.

In line with what has been advocated in Brazil, foreign studies affirm that an adequate ethics training and good professional models can allow Nursing students to obtain, during undergraduation, the attributes necessary to develop the skills expected in the actual practice of Nursing⁽²¹⁾.

Some examples of successful educational practices in the direction of developing humanistic skills in Nursing involve the use of role-play and evidence-based practice. The first was based on the evaluation of the educational intervention according to the role-playing methodology, which means a behavioral test before a staged hypothetical situation. Student performance measures, specific to the exercise of empathy, were collected before and after the intervention. The training proved to be effective in improving the empathy of university students in the study and was interpreted as promising for the retention of skills that can be acquired through experiential training⁽³⁴⁾.

The second emphasized the importance of incorporating evidence-based practice in the Nursing curriculum, especially in baccalaureate programs. It showed as essential in a first step preparing students for their professional role as nurses. In this sense, it encourages the use of creative and pleasant teaching strategies for the promotion and engagement of students in the learning of evidence-based practices, while developing relational and technical skills necessary for the proper exercise of their profession⁽³⁵⁾.

In addition to the undergraduate space, scientific evidences follow as a relevant instrument in the education of nurses from the interrelation between theory, research and professional practice, which, ideally, must be based on theories validated by research. That is, the interaction between practice and research is necessary for the continuity of the development of Nursing as a profession and as a science, affecting each other in a continuous and reciprocal process of professional improvement⁽⁵⁾.

Attributes of the concept of a “good nurse” in the context of pediatric care

The attributes identified in the literature and interviews involve the active attitude of care based on responsibility, honesty, justice, empathy and communication between the “good nurse” and patients with their family in the context of pediatric care.

In this sense, responsibility for care is understood as an attitude of attention to sick children in its contextual totality, which occurs through the interaction between Nursing professionals, the hospital institution and, above all, patients and their families. Dialogue is, therefore, an essential instrument to exchange knowledge and a co-responsibility on the health-disease process, which must be built on the ethical conduct of nurses. For that, professionals must overcome possible difficulties in reflecting on ethical-professional values in their behaviors, which they can do from continuing education, involving ethical competence and comprehension of the subject’s completeness^(36-37).

Thus, communication mediated by the nursing team is an important care instrument and provides an interactive and effective interpersonal relationship capable of maximizing care. Its practice is estimated by patients and families, especially when based on honesty, providing information on the child’s clinical situation and treatment, as well as on the possibility of this family sharing child care in a context of individuality and uniqueness in care. A good interpersonal relationship between the family and the nurse enhances patient’s safety, especially when messages are transmitted completely, without barriers and noise⁽³⁸⁾.

This process of interaction between nurses and children/families promotes the bond between them, enabling more autonomous and confident nursing actions with the health team and/or institution. One study confirms that when experiencing greater openness to dialogue, nurses seem to be encouraged to advocate for their patients’ interests, even in times of difficult coping, using parrhesia. This is understood as an honest and courageous dialogue capable of breaking with seemingly perceived situations as unquestionable in nurses’ daily routines. This attribute is based on nurses’ knowledge and contributes to patients and families being sufficiently informed to exercise their autonomy and to avoid inappropriate practices performed by other health professionals⁽³⁹⁾.

In this direction, nursing care is consolidated as an attitude of excellence of the profession through the interpersonal relationships ruled by empathy, as well as the professional’s solidarity with the hospitalized individual, in which Nursing develops from host actions to technical assistance and management in leading the nursing team towards good professional practices. Thus, the attentive look at care practices, when associated with reflection, converges with a constant improvement of nursing care, allowing more complete attention to the needs of others, through the humanistic precepts necessary to build a context of care that values others^(37,40).

In Paediatrics, the specific context of this analysis, there is a differentiated demand of childhood, such as the need to play. The “good nurse”, aiming to guarantee integral assistance to children, through the empathic encounter uses creativity, seeking playful strategies contrasting with the restricted and stressful hospital environment. This attribute turns assistance into something less authoritarian and more humanistic, with closer ties and minimization of traumas⁽⁴¹⁾.

Therefore, the attributes of a “good nurse” in the context of pediatric care envisage an expanded approach that requires, according to the literature: differentiated knowledge, instruments and skills, which can be more easily developed from experiences based on respect for others in their individuality; and autonomous relationships of care and the competent organization of therapeutic actions consistent with the expectations and health needs of children and their family⁽⁴²⁾.

Consequences of the concept of a “good nurse” in the context of pediatric care

The discussion involving the consequences of the concept of “good nurse” in the pediatric context refers to the aspects that patients and their family expect from a good care of the nursing team and reaches the faculties that the professional aims to deliver a satisfactory performance, resulting in the figure of a complete nurse.

In the context of Pediatrics, the family transposes the barrier of supporting action and becomes a direct agent in the care of hospitalized children. Studies show that family involvement in child care is considered an important practice by both the caregiver and the staff and should be encouraged^(43-45). For this reason, establishing a partnership with the family, involving it in the care provided, is an intrinsic unit of the consequences of the concept of a “good nurse” in the pediatric context.

Additionally, a sensitive and humanized care is translated by the practice of the good nurse, in view of the well-being and satisfaction of his/her patient. Literature contributes to this reflection and endorses the basic virtues of love, humor and sweetness as essential elements in the caring process. It reinforces the perspective of ethical humanization, developed with a view to contributing to a more comprehensive training and assistance capable of healing, releasing and transforming sadness into joy, especially in the pediatric context, in which it has the ability to minimize the “white coat syndrome” and to collaborate for a less stressful and frightening hospitalization⁽⁴⁶⁾.

In this sense, the integral care to children perspectives an environment beyond the clinic, that can provide contact with nature and spaces that explore playful activities. In order to provide this freedom for patients to be children, in addition to their illness, it is necessary to be involved in a differentiated care that adds moments of living the fantasy. Good pediatric nurses transcend the biomedical model, since they are sensitive enough to look more broadly at the context of their action, undertaking a more holistic approach to humanizing care to sick children⁽⁴⁷⁾.

Consequences of having an attitude that contemplates the attributes of a “good nurse” involve individualized, attentive and efficient care – nurses receive professional recognition. Studies show feelings of fulfillment among nurses, associated to the possibility of assisting in the recovery of patients and being recognized, by patients and their relatives, for the work developed. It is proven that the more empowered nurses feel, the more professional satisfaction they will have and the more apt they will feel to perform their functions efficiently^(48-49).

In general, the concept of a “good nurse” in the pediatric context has proved to be a complex and ambiguous phenomenon, when to the detriment of their actions, nurses are subject to censorship and judgment of co-workers. In addition, one of the consequences of being a “good nurse” is the constant review of caregiving actions in self-awareness exercises. Both the judgment of colleagues and self-assessment can lead nurses to develop moral suffering by realizing that they cannot act according to their understanding about the correct course of action⁽⁵⁰⁾.

Study limitations

The limitations of this study are related to the fact that the concept was analyzed from studies in databases that do not represent the entire literature, as well as the interviews were done in the context of the Brazilian southeast in a hospital setting, which points to gaps that can be explored in further research. Nevertheless, although the field stage was carried out with the objective of obtaining new evidence about the “good nurse” in the pediatric context and validating the theoretical stage, the subjectivity and complexity of the phenomenon remain a challenge. This limitation can be minimized by choosing the method that establishes the constant reflexivity about the phenomenon analyzed to address its dynamicity and evolution of contextual and temporal characteristics.

Different realities may contribute to the expansion of the concept developed here, especially in the direction of other spaces of action of pediatric nurses, and in the discovery of this concept referring to other health professionals of this specialty. It is necessary to deepen in the investigation of the analysis the concept of the interdisciplinary team, which assists children and their families to ensure cohesion in the planning and execution of care actions, as well as the well-being of health professionals. Moreover, the definition of a “good nurse” should be analyzed in other concepts at different levels of attention beyond the hospital space.

Contributions to the Nursing, Health or Public Policy fields

The results of the present study contribute to support the multidimensional praxis of pediatric care based on up-to-date evidence and validated by a rigorous theoretical-empirical study capable of reflecting on a transforming Nursing practice. Data include the perception of a good nurse by children, family members, nursing professionals and students; in addition, studies carried out in countries whose diverse historical and cultural roots allow us to consider a broad context for understanding the phenomenon involved in this concept. Therefore, it is expected that the referred findings will be the guiding principles for assisting professionals in the area, as well as for managers and legislators of this science, using such evidence to promote a better preservation of professionals who still have to take the risk of suffering censorship and judgment of colleagues when choosing to make the difference and to be just like a “good nurse” is.

FINAL CONSIDERATIONS

The analysis of the concept of a “good nurse” in pediatric care through the method proposed by Rodgers provided greater technical-scientific consistency in clarifying essential qualities to achieve good practices as an episteme of nursing care. The identification of the antecedents, attributes and consequences of the concept has determined elements that deserve the attention of physicians, managers and educators in the efforts to guarantee meetings among children, families and nurses that can transcend time and space, adapting the practice to the theoretical and humanistic conceptions of care.

The “good nurse” is expected to play an active role in developing and improving the actions of professionals, seeking quality research to tailor an evidence-based care practice. However, the commitment of nurses to research results for the practice of care was not common in the studies and absent in the speeches of professionals.

Considering the evolutionary perspective, it was seen that aspects related to the ethical and moral values of human beings and the practice of the good were frequent in data and stable over time. Markers related to technical-scientific expertise, competence and skills were less frequent, appearing more in more recent studies. Interestingly, data show that to be a “good nurse” one must be creative and daring, which consequently induces the risk of censorship and judgment by colleagues, alerting to a negative component that, with time, can stray professionals from the ideal that brought them closer to the profession.

The need to continuously analyze the concept is clear, as proposed by Rodgers, to investigate changes intrinsic to the dynamics of relationships in the development of new generations and the globalization of health care practices.

• FUNDING
  National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPQ).
• ERRATUM
  Article “The meaning of a “good nurse” in pediatric care: a concept analysis”, with number of DOI: http://dx.doi.org/10.1590/0034-7167-2018-0497, published in the journal Revista Brasileira de Enfermagem, v72(2): 494-504, on page 502:
  Include after Final Considerations the information:
  FUNDING
  National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPQ).
  ACKNOWLEDGMENTS
  Dr. Pamela Hinds and her staff at Children’s National Medical Center for their contribution to the study.

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Publication Dates

• Publication in this collection
  18 Apr 2019
• Date of issue
  Mar-Apr 2019

History

• Received
  25 June 2018
• Accepted
  10 Aug 2018