Theoretical nursing conceptions in hospitalized child care: scoping review

Objective: Identify the theoretical concepts that have been used in the context of nursing care for hospitalized children. Methods: Scoping review was carried out according to the PRISMA-ScR methodology. The research limitations included: primary studies dealing with the use of theoretical concepts of nursing in the provision of care to hospitalized children, access in full text, in Portuguese or English and published between 2000 and 2019. Research was carried out on grassroots platforms (EBSCOhost, PubMed, SciELO and Web of Science), gray literature and in the bibliography of selected articles. Results: 21 studies were found and 10 theoretical conceptions of nursing were identified, with family-centered care being the most used. Final considerations: The variability of the identified theoretical conceptions is emphasized, with no evidence to support the use of one in detriment of the other. A more integrative theoretical conception, which adds care centered both on the family and the child, emerges as a research trend. Nursing RESUMO Identificar enfermagem criança Realizou-se scoping review


INTRODUCTION
The progression of nursing as a discipline is the result of the contributions of research, practice and theory as cornerstones, in a reciprocal and cyclical relationship (1) . Research guides practice and builds knowledge by developing the theory; clinical practice raises questions of investigation and knowledge for the theory; and this guide investigates and improves practice (2) . Additionally, it is necessary to analyze the theory in order to clarify the nursing intervention domain, guide nursing science and practice. It is also essential to direct and communicate the unique and essential contribution of nursing in the quality of science to health research and health care (3) .
Theoretical conceptions guide care and offer an organized and sustained knowledge approach (4)(5) . The levels of knowledge structure in nursing are presented by Alligood & Tomey (6) and organized into: metaparadigm; philosophy; conceptual model; great theory; theory; and medium-range theory. In this sense, the theoretical conceptions of nursing encompass the view of the discipline and practice based on a key concept and the relationships between two or more nursing concepts developed for their transference in care practice (7)(8) . By using theory in daily care practice, nurses find a sense of purpose and a direction that is consistent with basic nursing values (1) . Additionally, in nursing, as in any other discipline, science is the result of the relationship between the research process and the knowledge product (2) . The primary purpose of theory in the nursing profession is to improve practice by having a positive influence on people's health and quality of life, which is why the relationship between theory and practice is reciprocal (1)(2) . In this sense, when looking at nursing care in a given context, it is crucial to identify how they are supported from the theoretical point of view (9) .
Within the scope of nursing care provided to hospitalized children, the development of theory in the disciplinary area of nursing is still very recent. In fact, until around 1950, hospitals around the world were poorly prepared and adapted to the paediatric population. With the realization of the adverse effects of hospitalization and the impact of separation from the family, the policy of joint accommodation and change in the paradigm of health care began (10) . The conceptualization of care reflects this nursing practice that integrates the family as an active member of the health team. In this sense, it is important to understand the way the nursing team conceives care for children and families, in the context of hospitalization, as it influences the mode of care delivery (11) .
Thus, it was considered pertinent to map, based on the scientific literature associated with the nursing discipline, the available evidence about the use of theoretical concepts of nursing used in the care of hospitalized children. A scoping review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews methodology (PRISMA-ScR) (12) . It is a type of review that allows mapping the relevant literature in a field of useful interest, for broad themes and diversified methodologies, in a less restrictive inclusion format and, therefore, with a greater range of evidence (13) .

OBJECTIVE
Identify which theoretical concepts have been used in the context of nursing care for hospitalized children.
It should be noted that the term "theoretical conceptions" was chosen as the most comprehensive designation and that, in this manuscript, other terms were included (eg, models). The following research question was defined: What are the theoretical concepts used in the context of nursing care for hospitalized children. It should be noted that, in the research question, the acronym PCC was used (Population: child and parents; Concept: theoretical concepts; Context: hospitalization).

METHODS
A Literature review was carried out according to the steps defined by PRISMA-ScR (12) .

Protocol and registration
The research protocol was written, reviewed and verified by the authors. Prospectively registered with the Open Science Framework, on April 8, 2020 (http://osf.io/zhjvm/).

Eligibility criteria
The following inclusion criteria were defined: studies dealing with the use of theoretical concepts of nursing in the provision of care to children and families in hospital; context of study in hospitalization services; primary qualitative, quantitative studies with triangulation of methods, including literature reviews in order to maximize the coverage of available evidence; articles available in full text, in Portuguese or English; publication date between 01-01-2001 and 30-09-2019. The option for this time limit aimed to obtain data that would allow the characterization of the theoretical concepts in use in the 21st century.
As exclusion criteria, the following were rejected: articles that addressed very specific contexts (eg, intensive care units and neonatology units), given the particularities of nursing care in these units; articles that did not clearly identify the theoretical concept of nursing; opinion articles; editorials; advertising; and letters to the editor.

Information sources
In the research, the strategy in three stages was used as recommended (14) . Initially, a search was made in two databases (MEDLINE [with full text] and CINAHL [with full text]), followed by an analysis of the words contained in the title and summary of the selected articles, as well as the key terms. The objective was to improve the keywords to include in the research equation, adapting them to the Health Sciences Descriptors (DeCS).
In the second stage, after identifying the descriptors to be used, the research equation was created and the search was carried out, using the electronic platform EBSCOhost, in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) [ The bibliographic reference list of the selected articles was systematically consulted as a way of identifying relevant works for this review.

Search
The applied research equation, using Boolean descriptors and operators, was as follows: ((Model OR theory) AND (child * OR pediat *) AND (hosp *) AND (nurs *)). The database search took place in October 2019 and was carried out by FL and reviewed by ZC. The sample initially oTTained in the different databases was limited according to the inclusion criteria and fields available in the databases, as shown in Chart 1.

Data selection and analysis process
After constituting the corpus of analysis, data extraction was carried out using information systematization tables, taking into account the research question and with a view to comparing scientific evidence. Data extraction was carried out by two authors and reviewed by all authors.

Listing the data
The data were listed in a table format, with the aim of seeking information, namely the following elements (14) : Authors; Year of publication; Parents; Goals; Population and sample; Methodology; Theoretical conception; Results; Main conclusions.

Summary of results
The systematization table gathered all the relative information extracted individually by two authors and approved by consensus by all authors. Data were collected in order to contextualize the use of nursing theories and to relate the objective of the study on screen to the objective of this review.

Selection of sources of evidence
The research strategy allowed the identification of 21 articles, which constitute the corpus of analysis of this review, as shown schematically in Figure 1.

Selection of sources of evidence
The studies were selected by reading the title; and, when it was not clear whether the article answered the research question, the abstracts were read. Repeated articles were removed and the inclusion and exclusion criteria were applied. The process was carried out independently by two reviewers, and consensus was reached for the final list of articles.

Characteristics of evidence sources
This review allowed the identification of a total of ten theoretical concepts applicable to nursing care in the context of child hospitalization and which are summarized in Chart 2. We emphasize that the different theoretical concepts are identified next to the name, with reference to the respective author assuming the its original designation.

Title
Year Country Outline

Main conclusions
Contribution of structured therapeutic play in a nursing care model for hospitalised children (19) 2018

Summary of results
Of the articles that make up the corpus of analysis, the majority, more specifically 18 of the 21 articles, were published in the last ten years. With regard to the country of origin, there is variability, in particular articles from the following countries: Australia (1), Brazil (9), United States of America (3), Greece (1), England (1), Iran (1), Ireland (2), Portugal (3) and Turkey (1). As for the methodology, only one of the articles is of a quantitative nature (40) ; also only one is of a theoretical nature (34) ; and three are literature reviews (30,33,41) . In 12 of the articles found, interviews are used, as a method of data collection, in isolation (10,28,35,39) or in conjunction with other forms, such as observation (18)(19)29,32,38) or focus group (36) . Two of the articles report the use of project work as a methodology (25,31) . In the 20 qualitative articles, the sample size varies between 7 (19) and 54 (10) . Regarding the subjects, one of the studies has a sample composed of parents of hospitalized children (37) ; one of them presents as sample parents and nurses (38) ; two others have samples composed exclusively of children (18)(19) ; and two works use the perspectives of children, parents and nurses (10,32) . Most studies, specifically 11 of the 21 studies, have nurses as subjects (24)(25)(26)(27)(28)(29)31,(35)(36)(39)(40) .

Summary of the evidence
The review made it possible to find several theoretical concepts used in the context of nursing care for hospitalized children. The variability of designations is evident, without unanimity in the nomenclature used. Chinn & Kramer (1) point out that, in its origin, the initial theoretical works of authors such as Callista Roy, Betty Neuman or Imogene King have sparked debate around the term to be used: "models", "theories" or "philosophies". They emphasize that it remains a topic still under debate, with varied terminology found in contemporary literature. Although there is a generalized understanding regarding the nursing metaparadigm, described by four concepts (person, environment, health and nursing), the same thing does not occur in other levels of knowledge structure (6) . For example, family-centered care (FCCs) emerges predominantly in the quality of a philosophy, despite being commonly referred to as a paradigm, a theory or a concept (32) .

Individual results from evidence sources
The results extracted from each study are summarized in Chart 3.
of Theoretical nursing conceptions in hospitalized child care: scoping review Loureiro FM, Antunes AVRA, Charepe ZB.

Title
Year Country Outline

Main conclusions
The practice of nurses caring for families of pediatric inpatients in light of Jean Watson (24) 2014 Brazil Objective: to know the facilities and difficulties of nurses in the practice of caring for the families of hospitalized children; Population and sample: nurses from paediatric services; 12 nurses; Methodology: qualitative; semistructured interviews, submitted to inductive thematic analysis; Theory of human care, by Jean Watson; Three themes were identified: recognizing a reference for care; considering the institutional context; and challenges in the relationship with the family; The theory favored reflections on the self, on institutions and on the relationship with the child's family; Implementation of a nursing professional practice model of care in a pediatric hospital (25) 2007 United States of America Objective: to describe the implementation of the synergy model in a pediatric hospital; Population and sample: nursing staff at a pediatric hospital; Methodology: project work; Synergy Model; The team was divided into two groups that implemented the model across the hospital; The use of a professional nursing practice model is important because it facilitates describing, unravelling, guiding and evaluating nursing practice; Validation of nursing diagnoses, interventions and outcomes in a pediatric clinic (26)  There was effectiveness in using the nomenclature in this context; There was effectiveness in using the nomenclature in this context; Hospitalized school children: proposition of a data collection instrument in light of Horta's theory (27)  The instrument has both contributed to the data collection of hospitalized students and guided the phases of the nursing process, considering the specific needs of school-age children; Unveiling humanized care: nurses' perceptions in pediatric oncology (28) 2013 Brazil Objective: to know the elements of humanized care present in the meeting between nurses, family and children with cancer; identify the perception of these nurses regarding the humanization of assistance and verify in which situations the nurse perceives that humanization is anchored to care; Population and sample: nursing staff at a hospital; 9 nurses; Methodology: exploratory-descriptive study; semi structured interview; Theory of human care, by Jean Watson; The theoretical elements emerged from the descriptions of clinical events or situations presented by nurses; The data allowed reflections on possibilities of building the interpersonal humanistic process in the care environment in paediatric oncology and advances and limitations regarding the applicability of this framework in practice; Partnership in paediatric nursing care: from discourse to nurses' action (29) 2012 Portugal Objective: to know in paediatric nurses how they perceive the process of building the partnership in the practice of caring for parents and to identify in the context the actions taken; Population and sample: nursing staff from a paediatric service; 12 nurses. Methodology: qualitative study supported by grounded theory, supported by the theoretical framework of symbolic interactionism; interview and observation;

FCCs;
Working in partnership with parents is present in the nurses' "thinking". However, the observations made showed gaps in the contemplation of dimensions that are fundamental to the development of an effective partnership with parents; Nurses contemplate the partnership in thinking, but not in acting; Chart 3 To be continued of Theoretical nursing conceptions in hospitalized child care: scoping review Loureiro FM, Antunes AVRA, Charepe ZB.

Main conclusions
The evolution of models of nursing care for children hospitalized in the last 30 years: from the diseasecentered model to the child and family-centered model (30) 2015 Brazil Objective: to identify the evolution of nursing models for children hospitalized in the last 30  Families are available to help with child-care, but they need information, support and clear guidance from nurses. These must be trained and have the appropriate resources to respond to the needs of the family: Family-centered care for hospitalized children aged 0-12 years: a systematic review of qualitative studies (33) 2014 Austrália Objective: to investigate the effects of FCC models in hospitalized children aged 0-12 years; Population and sample: not applicable; Methodology: systematic literature review; FCCs; There is still little evidence of the use of family-centered care and its relationship with the results of nursing care; The use of family-centered care appears to have positive effects on increasing parental satisfaction; Comfort Theory and its application to pediatric nursing (34) 2015 United States of America Objective: to present the theory of comfort and its application to the practice of pediatric care; Population and sample: not applicable; Methodology: theoretical article; Comfort Theory; The comfort theory was presented; demonstrated its application in a practical case; described the premises about comfort; exposed how care focused on comfort can be organized; described how comfort can be measured with instruments applicable in pediatrics; guidelines for practice are provided; The comfort theory can be easily applied to the context of pediatric nursing care; To be continued

Main conclusions
Nursing Care for the Families of Hospitalized Children and Adolescents (35) 2019 Brazil Objective: to describe strategies adopted by nurses to care for families of hospitalized children and adolescents; Population: nurses working in paediatrics; sample: 12 nurses; Methodology: semi-structured interviews analyzed using a computer program; Systems theory, by Neuman; The following strategies were identified: bonding, communication, health education; looking for support in the multiprofessional team; listening; quiet professional posture; The use of systems theory frames the care provided to families of hospitalized children and adolescents; is a facilitator, as it aims to reduce system responses (family) to environmental stressors (hospitalization); Nursing care through the perception of hospitalized children (36) 2016 Brazil Objective: to develop a proposal for a nursing process to implement the systematization of nursing care in a pediatric hospital; Theory of basic human needs, by Wanda Horta; Two categories were identified: nurses' knowledge about the systematization of nursing care; the strengths and weaknesses that nurses face in the construction of the nursing process; Theoretical knowledge, associated with practical care experiences, is fundamental for the construction of all phases of the nursing process; Partnership opportunities in caring for children with special health needs: the parents' perspective (37) 2015 Portugal Objective: to understand how the care partnership is experienced by parents of children with special health needs; Population: parents of hospitalized children with special health needs; sample: 10 parents; Methodology: qualitative, descriptive and exploratory study with narrative method; ethno-biographical orientation interview; Care partnership model; There were two partnership opportunities: parent training; and decisionmaking in partnership; The partnership in caring for children with special health needs, from the parents' perspective, is understood as a relational and development process, dynamic, unique and continuous established between parents and nurses, centered on training opportunities for child care and taking shared decision: Parental exercise during the child's hospitalization (38) 2012 Portugal Objective: to identify the therapeutic intentions of nurses when they promote the partnership of care with parents during the child's hospitalization; Population: parents of hospitalized children and nurses working in pediatric services; sample: 103 parents (phase 1 -questionnaires); 5 nurses and 22 mothers (phase 1 -interviews) 444 fathers (phase 1); Methodology: action-research study with application of observation, interviews and questionnaires; Care partnership model; The child's hospitalization is an event in personal life related to the parental role. The experiences can be seen in two perspectives: hospitalization generates an interruption in the usual pattern of performance of the maternal role; the self-awareness about the changes and differences that need to be introduced in the exercise of the maternal role usually performed until now, due to the child's health status; Seven objectives were identified: promoting parental participation in developmental care (usual care); promoting parenting skills to provide complex care; promoting parental participation in complex care when parental skills were assessed as effective; improvement in the performance of parents to perform complex care when a potential for enhancing the skills of parents to perform complex care was identified; reduction of the stress level associated with the parental role in parents of children with permanent special needs, facilitating, during hospitalization, rest in the role; preparing parents to provide complex care; preparing parents to promote the child's autonomy; Communication between children and health professionals in a child hospital setting: a Child Transitional Communication Model (18) of Theoretical nursing conceptions in hospitalized child care: scoping review Loureiro FM, Antunes AVRA, Charepe ZB.

Main conclusions
Nurses perceptions of barriers to implementing family-centered care in a pediatric setting: A qualitative study (39) 2017 Turkey Objective: to explore nurses' view of their practice with FCCs; Population: nurses at a pediatric hospital; sample: 18 nurses; Methodology: qualitative study with application of interviews; FCCs; Two themes emerged: nurses' opinions and views on parental participation; Nurses have a positive view of FCCs and recognize the need for the family to remain present in the child's life; the cultural characteristics of families are an obstacle; the application of the model implies not only their conceptual knowledge, but also an understanding of the rights, roles and responsibilities of parents; Evaluating how paediatric nurses perceive the family-centred model of care and its use in daily practice (40) 2018 Greece Objective: to understand nurses' perceptions about FCCs and how they apply it in daily practice; Population: nurses at a paediatric hospital; sample: 183 nurses; Methodology: quantitative study using questionnaires; FCCs; FCCs were considered important for the sample; their implementation was correlated with: experience, age, marital status and having children; The importance of FCCs is well established, however nurses do not understand that it is essential to apply them in all aspects of daily care practice; Family-centred care for children in hospital (41) 2007 England Objective: to investigate the effects of FCC models on hospitalized children when compared to other models of care focused on the child, family and results of the use of health services; Population and sample: not applicable; Methodology: systematic literature review;

FCCs;
No studies were found that met the inclusion criteria; The lack of quantitative studies on the use of this model is highlighted.

Chart 3 (concluded)
Regardless of the term used, theoretical conceptions of nursing are taught in educational institutions, integrated in the practice of care and used to guide research, thus promoting the advancement of nursing as a discipline.
Within the scope of nursing care in child and paediatric health, the context in which this review focuses, references to different theoretical concepts were found, and the family-centered care philosophy emerges in 8 of the 21 articles selected for this review, that is, it is the most mentioned theoretical conception. In the last decades, FCCs have been followed, in the area of paediatrics, by several disciplines in which nursing is included (42) as the dominant theoretical framework assumed by many health organizations, professionals and institutions (43) . It is a perspective of care that sees the child integrated into the family, which is why hospitalization should not interrupt this connection. They are defined as an approach in the scope of care where there is a partnership between the family and health professionals (44) . They adopt nine central principles: recognition of the family as a constant in the child's life; facilitating collaboration between parents and health professionals at all levels of health care; respect for the racial, ethnic, cultural and socio-economic diversity of families; recognition of the strengths and individuality of each family, respecting the different coping methods; continuous sharing with the family of complete and unbiased information; encouragement and facilitation of family and network support; responding to the developmental needs of the child and family as an integral part of health care practices; adoption of policies and practices that give families emotional and financial support; and flexible health care planning, culturally competent and responsive to family needs (41) .
FCCs are seen as a challenging care approach for nurses, but with benefits described, namely: increased satisfaction with health care and improvement in the comfort and welcome of the child and family (35) . It is understood as an important instrument, however, it is not clearly defined, being addressed in different countries with different designations (32) . There seem to be gaps in its applicability, especially in the effective action of nurses, as highlighted by Mendes & Martins in a study developed in the Portuguese context (29) ; in the absence of support, reported by Khajeh et al. in a study carried out in Iran (32) ; and guidance to parents, pointed out by Coyne in a study that took place in Ireland (10) . The works found emphasize that the applicability of FCCs implies conceptual knowledge on the part of nurses (39) and correlates with factors such as professional experience, age, having/not having children and marital status (40) . Therefore, the difficulty of its operationalization in practice is recognized, being identified as an abstract concept (42) . It is concluded that, although it is referred to as the most adequate theoretical conception for the context of the child's hospitalization, there is still little research that proves its greater effectiveness in comparison to other theoretical perspectives.
It should be noted that the basic principles of FCCs support other theoretical concepts, such as the Duffy & Hoskins qualitycare model (20) , and also integrate the theory of human care (17) . They appear as particularly appropriate to the context of the child's hospitalization (31) , because they are based on central concepts such as relationships and caring (45) .
Two of the theoretical concepts identified were developed specifically for the paediatric population and focus on aspects that of Theoretical nursing conceptions in hospitalized child care: scoping review Loureiro FM, Antunes AVRA, Charepe ZB.
are characteristic of paediatric care, namely the use of therapeutic toys (19) and the nature of communication between professionals and children (18) . There is also the adaptation to the child population of theoretical concepts commonly used in the adult population, such as the quality-care model (20) ; the synergy model (21) ; the comfort theory (22) ; the theory of human care (17) ; the theory of basic human needs (15) and the model of Neuman systems (23) . These mirror the breadth of these concepts and their suitability for different care contexts in which child health is included. The care partnership, presented by Anne Casey (16) , is also identified in this literature review (37)(38) . It is based on the principle that parents are capable and want to take care of their children in a disease situation, placing the emphasis on the care provided by the family, and this implies that this should be the focus of nursing care (46) . In this sense, he stresses that the role of nurses is one of support and support, replacing the care usually provided by parents only when they are not able to do it (16) . In this way, the care partnership is aligned with the FCCs and, in fact, Arabiat et al. (47) refer that they derive from such a theoretical perspective, having evolved from their key ideas.
Miranda et al. (30) conducted an analysis of the evolution of nursing theorization in the care of hospitalized children in Brazil, identifying three types: centered on pathology; child-centered; and child-centered and family. Recent literature brings arguments about the need for more integrative models, which consider not only the family, but also the child as the target of care and an effective member of the health team (48)(49) . Child-centered care has been referred to as a perspective that considers the realization of children's rights, advocating the need to collect information directly from them, involving them in all stages of the care process (50) .

Study limitations
A limitation of this work refers to the evaluation of the quality of the articles. Since it is optional according to the PRISMA-ScR methodology, it was not carried out on this route by the authors' decision. However, it could have provided a different look at the discussion of the results.

Contributions to the Nursing Area
The contribution to the identification of theoretical references in use for the provision of nursing care is highlighted, in line with the most recent scientific research. The literature review process allowed the verification of the variability of theoretical conceptions in use and the lack of studies that show their reasoned use.

FINAL CONSIDERATIONS
The scoping review allowed the identification of several theoretical concepts, used in the context of nursing care in children's hospitalization. The lack of consensus in the adopted terminology is highlighted, as well as the scarcity of scientific evidence to support the use of the theoretical concepts found. Although FCCs are assumed to be the dominant and most accepted theoretical conception, the applicability of other theoretical currents is verified in specific contexts that meet the needs of the child and his family during hospitalization.
Finally, the need for more integrative theoretical conceptions that put care in perspective -considering all the actors involved -and focus them both on the child and the family.