Mothers’ Perception of Nursing Care of Hospitalized Children in Peadiatric Ward in a 3rd Level Facility in South-South Nigeria

Background: Patient perception is an important indicator which gives an idea about the quality of nursing care services. Caregivers or family members who are responsible for the child’s stay in the hospital can play significant role in expressing their perception of the care provided to their relatives. Aim: This study assessed mothers’ perception of nursing care that exists in pediatric department of a teaching hospital in South-south, Nigeria. It also examined the association between mothers’ socio-demographic data and their perception of nursing care their children received. Method: The study utilized the descriptive cross-sectional design. Sample comprised 115 mothers who were conveniently recruited for the study. Data was collected using a validated self-structured questionnaire with reliability of 0.75. Data collected were coded and imputed into Statistical Product and Service Solution (SPSS) version 23.0. The association between mothers’ socio-demographic data and their perception of nursing care their children received was tested at 0.05 level of significance using chi-square test. Result: Findings showed that majority of the respondents were between 35-44 years, 46(40.0%) had tertiary education, 41(35.7%) are civil servants. Majority 83(72.2%) of the mothers had poor perception of nursing care their children received, while only 32(27.8%) had good perception of the care. Educational status (p = 0.01) and number of children (p = 0.02) were significantly associated with mothers’ perception of peadiatric nursing care. Conclusion: This study found that majority of the mothers had poor perception of nursing care their children received. It is recommended that there should be training and retraining of nurses on how best to care for hospitalized children.


Introduction
The health sector is ever evolving and dynamic with the populace expecting high standards of care that is cost effective and offers positive outcomes. According to Adereti, et al. [1], nursing care activities are expected to meet patients' needs in order to conclude that the patient has received quality care. Zhao and Akkadechanunt [2] acknowledged that patients express their requirements in terms of what they need, want, prefer, expect and demand with respect to the nursing service they receive. According to Kyle and Carman [3], children need holistic, constant, organized, and family-focused care along with empathy. However, children admitted to pediatric wards may not be able to express their views about the care they receive. It is believed that when considering what is best for the patient and family, the best people to ask are those who have been a direct recipient of that care. Therefore, caregivers or family members who are responsible for the child's stay in the hospital can play significant role in expressing their perception of the care provided to their relative. While each individual's experience is different, being able to see the hospital experience from a family's perspective is very important [4].
Mothers' perception about nursing care reflects their personal view of services their child received and the result of the treatment and is monitored to determine the delivery and quality of healthcare [5] in Gishu, Weldetsadik and Tekleab [6]. Often times mothers' of children admitted into the pediatric wards express worry, fear and anxiety because of their children's ill-health. However, the quality of care provided can go a long way in reassuring mothers that the child will be restored to a state of wellbeing. How mothers perceive nursing care rendered to their child may be an indication that their expectations in terms of the health and recovery of the child would or would not be met in the period of hospitalization. Without the expectations of the patient being met, quality of care is almost always perceived as poor. This may make them become anxious and express aggressive behaviors in the course of nurse-patient interactions. As such, mothers' perceptions contribute to measure the quality of the delivered care, offering opportunities of improvement [7].
The importance of unraveling patient's perception with nursing care cannot be overemphasized as knowledge and insight from the caregivers of a pediatric patient will allow hospital staff and administrators to see the hospital experience from the purview of the patient and family members [8]. This may provide opportunity for clinicians and nurses to review feedback and suggestions from families of pediatric patients with the goal to improve the quality of nursing care they receive, thus ultimately impacting patient outcomes and nursing practice [9]. Duffy (1992) in Adereti, et al., [10] explains that patients comply better with their medical regimens, meet their health goal sooner and are discharged faster from the hospital when they perceive more caring by nurses.
There are varied reports of mother's perception of nursing care in literature. Afaya, et al., [9] found that the majority (89.5%) of the respondents had positive perception of nursing care. Similarly, Agbele, et al., [11] reported 86.3%. Twayana and Adhikari [12] found that 89(63.6%) had a positive perception while 51(36.4%) had negative perception with general perception mean score of 97.32 ± 13.45. In contrast to this, some authors have reported a rather lower percentage of patients having good perception of nursing care. Kewi, et al., [13] reported that in general only 49.3% had good perception while Shawa [14] reported 40.5%.
Several factors can influence mothers' perception of nursing care and it is necessary that these factors are examined with the view to designing evidence based interventions to address areas of concerns. For example, Shawa [14] reported that there was a significant association between patients' perception and occupation, educational level and history of admission at p < 0.05 while no significant association existed for age, marital status and religion. Agbele, et al., [11] reported that marital status, age, education level, duration/pervious history of hospitalization, health status were significantly associated with perception of nursing care received. Kewi, et al., [13] reported that there was a statistically significant association between patients' level of education, length of hospital stay, companion possession status and type of room admission (p < 0.05) while gender, age and previous hospitalization experiences had no significant association. However, few studies reported a contrary finding. Adereti, et al., [1] found that there were no statistical differences in the perception of nursing care by age, level of education, position in the family and the number of siblings among the paediatric patients. Twayana and Adhikari [12] found that there was no association between demographic characteristics with the levels of perception with the nursing care but a significant association was found between patients' length of stay and perception of nursing care. In a more recent report by Kurniawati, et al., [15] found that patients' perception of nursing was influenced by their level of education while length of hospital stay had no influence. This study assessed mothers' perception with the nursing care given to their children with the view of identifying key aspects of nursing care that requires quality improvement. It also assessed the association between mothers' socio-demographic data and their perception of nursing care their children received.

Nursing Care Protocol of the Setting
Caring for children is a very important and challenging field of nursing. Upon admission, nursing care activities are essential in contributing to restoring the health of children. Every child who is ill comes into the hospital through either the Children Emergency Ward (CHEW), or the Children Out-patient Clinic. At the point of entry in the CHEW, the child and relatives are received by a nurse who triage and determines the severity of the illness. The nurse observes the child and provides care in collaboration with the medical team with the aim of stabilizing the child. If the condition of the child is severe, the child is admitted into the children emergency ward while prompt medical and nursing care is provided until child is stable. However, if the child becomes stable and needs further care, the child is transferred to children medical wards depending on the child's diagnosis. In the out-patient clinic, children are seen and treated by the medical team but if further medical management is needed, the child is admitted in the children medical ward for expert care. For neonate (0-28 days), those not given birth to in the hospital (out-born), are seen in children emergency ward and immediately transferred to special Babies Care Unit (SCBU) for admission. In-born neonates who have complications after birth are however transferred to special babies care unit immediately after delivery. However, when they are discharged from the SCBU and are taken home by the mother, if the child gets ill and he/she is readmitted again, they are admitted in out-born section. assess mothers perception of nursing care, responses of the mothers were score as follows strongly agree 4 points, Agree 3 points, disagree 2 points and strongly disagree 1 point with scores ranging from 18-72 and expressed in percentage. A score of 0-49% was termed poor perception while a score of 50-100% was termed good perception. The association between mothers' socio-demographic data and their perception of nursing care their children received was tested at 0.05 level of significance using chi-square test. Approval to conduct the research was obtained from the office of the Assistant Director of Nursing Services, after due consideration of the research proposal. Written informed consent was obtained from study respondents. Respondents were informed of their right to voluntary participation and withdrawal from the study at any time without coercion, manipulation or undue inducement. All information that was obtained from the participants was confidentially handled and anonymity of respondents was ensured. Respondents were not required to write their names or phone numbers so that any information supplied will not be linked to them. All the respondents were treated equally and the researcher avoided all forms of bias.

Socio-demographic data of respondents
Result showed that majority of the respondents 55(47.8%) had 3-4 children with most mothers aged 35 and above accounting for 33.9% while mothers between 16-34 years had majorly 1-2 children and accounted for 18.3%. In addition, majority of the respondents 46(40.0%) had tertiary education with mothers aged 16-34 representing 24.4% in this category. 28(24.3%) had secondary education with most mothers aged 35 years and above representing 19.1%. However, less than one-fifth of the respondents had primary education, no formal education and vocational training respectively. Furthermore, majority of the respondents 41(35.7%) are civil servants which was followed closely by traders with a difference of about 0.9%. Approximately half of the respondents stayed in the hospital with their child within 1-7 days (Table 1). Table 2 shows the responses of the respondents' to questions on perception of nursing care, majority of the respondents agreed to positive statement about the nurse, few respondents agreed to positive statement on some salient issues about the nurses attitude. The most remarkable of them is that 50(43.4%) agreed that nurses are not concerned about patients' feelings, 55(47.8%) agreed that nurses are hostile and harsh, 57(49.6%) agreed that nurses are rude, 43(37.4%) agreed that nurses are unkempt, 46(40%) neglect their duties while 52(45.2%) agreed that nurses are not organized. In sum-To achieve its highest and best possible clinical outcome, care provided must be of high quality. Nurses have an essential role in the assurance of the quality of care [16]. According to Øvretveit [17], quality care is the 'provision of care that exceeds patients' expectations and achieves the highest possible clinical outcomes with the resources available. Nursing care ranges from history taking using the nursing process approach, and physical examination, observation and admitting patient into a comfortable bed. Also, the child's relatives, for example, the mother are supported and encouraged so as to allay anxiety, open communication is encouraged and they are oriented to the ward and environment. Therefore, providing high quality paediatric-focused care, with which the child and his/her mother is satisfied, is important to ensure that their needs are being met [18].

Materials and Methods
This was a descriptive cross sectional study conducted in paediatric department of the hospital, which includes the wards and clinics. The hospital is a federal government owned hospital founded in the year 1988 with a mission to provide excellent health care services made possible by well-trained and well-motivated workforce. A convenience sampling technique was adopted in recruiting one hundred and fifteen (115) mothers who met the inclusion criteria, out of 145 using the Taro Yamene formula for sample size. A pretested, interviewer administered questionnaire was proportionately distributed to the mothers in the different units of the paediatric department to collect data and retrieved after they were duly completed. The questionnaire consisted of two (2) sections; section A: Consisted of five (5) items on socio-demographic data and section B: Contained 18 items on mothers' perception of nursing care presented on a 4-point likert scale of strongly agree, agree, disagree and strongly disagree. Face and content validity of the instrument was established by presenting the instrument to experts to assess and certify that the items are relevant to the area of research. The questionnaire was administered to 20 mothers of patients in pediatric wards of Braithwaite Memorial Specialist Hospital (BMSH), Rivers state now known as Rivers State University Teaching Hospital in order to ascertain its reliability. A reliability coefficient of 0.75 was calculated using Cronbach alpha and as such the instrument was considered reliable [19]. Data collection lasted for four (4) weeks as mothers were given the questionnaires to complete themselves after going through the questionnaire with them while those not comfortable with English language were assisted to complete the questionnaire using Pidgin English. Data collected were coded, entered and analyzed using Statistical Produce and Service Solution, SPSS version 23.0. Descriptive statistics such as mean, frequencies and simple percentage was used to describe and summarize the data while data presentation was done on tables and pie chart. To

Discussion
Mothers' play a vital role in determining where and when to access care for their wards. As they access this care, they experience a variety of caring behaviours that might build or destroy their trust in nursing care and profession [20] resulting in perception and projection of nursing image to the outside world. The findings of this study revealed that the overall perception of the mothers about nursing care was poor as reported by 72.2% of them with only 37.3% having good perception. Literatures have documented varying findings. While mary, vast majority 83(72.2%) of the respondents had poor perception of nursing care while only 32(27.8%) had a clear cut good perception of nursing care (Figure 1).

Association between mother's socio-demographic data and perception of the nursing care
From the result presented in Table 3 below, educational status (p = 0.02) and number of children (p = 0.01) were associated with respondents' perception with nursing care. However, age (p = 0.66), occupation (0.40) and length of hospital stay (0.12) were not associated factors for respondents' perception with nursing care.   [11][12][13][14][15]. In contrast, some other studies reported that age, marital status, level of education, position in the family, number of siblings, previous hospitalization experiences, length of hospital stay and religion were not associated factors [1,[12][13][14]. The significant association reported for level of education and number of children in this study may be explained by high level of mothers' enlightenment depicted by the respondents' educational status. Majority of our respondents had a minimum of secondary education therefore may know the minimum expectations of care from the nursing staff. The higher the level of education, the poorer the perception of nursing care as such they may expect a higher standard of care than lower education status respondents. Nurses are great, caring and an epitome of humility in service and as such should remember that nurses' professional duty is a call to serve God and man. Nurses as care coordinators and patient's advocate should strive to promote and maintain good work relationship with other health professionals. They are encouraged to provide information and education about care processes and other salient aspects of hospital through pamphlets, audio-visual, posters and pictorials.

Conclusion
This study found that majority of the respondents had poor perception of nursing care with emphasis that nurses were rude, did not involve them in the care of their children and did not provide information or education to them. Educational status and number of children were significantly associated with perception of nursing care. It is recommended that nurses working in pediatric unit go for specialization so as to be equipped with the right knowledge, attitude and skill to care for patients and their relatives. Nurse leaders should also support nurses and approve for study leave when nurses gain the report of Shawa [14] and Kewi, et al., [13] that only 40.5-49.3% had good perception of nursing care received supports our low figure finding. This study report is contrary to the results reported by Twayana and Adhikari [12], Afaya, et al., [9] and Agbele, et al., [11] in which a significant proportion; 63.6%, 89.5% and 86.3% of the respondents have positive perception regarding nursing care respectively. The discrepancy observed in the current study when compared with other literature may be due to variation in nurse staffing, socio-demographic features of the respondents and the level of health facility studied. The nurses may have prioritized completion of nursing task than spending time to educate the patient. They may have also lacked knowledge on the concept of patient centered care, coupled with work overload. This assumption is buttressed by our study finding as mothers reported that the nurses were rude, did not involve them in the care of their children and did not provide information or education to them. These reports are rather not too good for the image of the profession as well as unprofessional. Furthermore, the poor perception level reported in the study may likely be linked to the level of education of the respondent. Majority of the mothers had secondary education ( Table 1) and as such may know their rights and the minimum expectations of care from the nursing staff. Such a poor perception where several factors including perception of care influence' the health seeking behaviours of the populace. It is important that nurses demonstrate care and caring behaviours to patients and their relatives at all times. Nurses should communicate all rules and minimum expectations binding the day to day operations/activities in the wards/hospital. Nurse leaders should emphasize that nurses are role models to their patients and as such should provide ethically sound and patient/family focused care.
Identification and modification of factors associated with patient's perception of nursing care will enhance satisfaction with nursing care services which will in turn project a positive image for the nursing profession. Our study findings implied that educational status and number of children were found to be associated with