Activities associated with 20 nurses and 22 mother-child dyads and two unaccompanied children were observed. Six mothers, two registered child nurses and two doctors participated in individual interviews while nine nurses (three registered nurses, five enrolled nurses and one enrolled nursing auxiliary) participated in the focus group. Six sociograms, 40 photographs and one graphic record were obtained.
Explicit nursing practices and policies associated with mothers’ presence
Analysis of data enabled identification of a number of explicit nursing practices and policies associated with mothers’ presence in this setting, involving the following elements:
- An explicit expectation that a mother/grandmother will remain with the child throughout their hospital stay.
- Most mothers co-sleep with their child for the duration of their child’s hospital stay in full-sized beds, except in specific clinical situations, such as children who are receiving orthopaedic traction.
- Provision of meals for mothers at no cost to mothers.
These elements of practice are documented in a variety of ways, offering evidence that they represent formalised practice and organisational policy (see Table 4). A clear narrative account of the rationale for facilitating mothers’ presence was identified. The rural location means mothers often have to make long journeys to bring a child to hospital, expending significant resources. Nurses and mothers recognised that if mothers were not accommodated, they would have no choice but to return home and would then lack the resources to make return visits for follow-up care. This situation is common to many hospitals serving underserved rural communities, where the response is often to allow mothers to stay informally, or to provide a lodge or similar facility on site while permitting mothers’ presence on the ward during specified hours. The practice observed in this facility however adds a different dimension, moving from allowing mothers to stay, to making the continuous presence of mothers an explicit norm.
Table 4 shows how exploration of the explicit rationale for the formalised practices elicited data relating to initial codes of ‘mothers who stay’ and ‘equipment and facilities’. The decision to make formal provision for mothers was presented as a logical response. Nurses described the practical problems mothers encountered making return trips to the hospital, to the detriment of the child’s care, as well as the ‘chaos’ that resulted from accommodating mothers informally in the ward.
While the primary reason given for implementation of co-sleeping in this setting was a practical one, based on the need to accommodate mothers, analysis of data revealed the existence of other implicit practices, rationales and values related to the presence of mothers in this setting.
Six main themes relating to the practice of family involvement were identified (see Table 5). Findings deriving from observational data as well as interviews, field notes and photographs are presented in relation to each of the thematic headings, with an interpretation of the way the findings contribute to the development of the emerging concept of Care Through Family by nurses in African paediatric settings.
Implicit nursing practices and policies associated with mothers’ presence, and underpinning rationales and values
1. Preserving the mother-child pair
Although the majority of practices associated with facilitating mothers’ presence were quite tangible and therefore largely explicit, we also identified implicit rationales and values behind practical arrangements such as the provision of adult-sized beds, bed linen, and meals for mothers. Interviews and focus groups, stimulated by photographic interviewing in particular, revealed nurse participants’ sense of pride in being able to meet the needs of mothers and children during their stay, whilst recognising that not all facilities had access to the resources they had. Mothers are provided with hospital attire (known locally as ‘kitting’). The amenities on offer were clearly appreciated by mothers, as was the organisational culture of generosity.
“We supply toilet paper and hand towels, even the nappies we supply for those babies who wear nappies.” (Nurse, s20)
“If you need anything then you could ask and I think that the nurses would give you. If you want to wash your clothes you can wash them and then take them to the laundry where they are dried and ironed. The laundry gives us clean hospital clothes every day.” (Mother, s13)
Mothers recounted their experiences of accompanying a child for treatment at other hospitals with different policies regarding the presence of mothers:
Mother: “Yes [she slept on the toddler sized bed] for three weeks.
Researcher: You can’t sleep in those little beds… so what did you sleep on then?
Mother: A coffee table [grimaces]. There’s a coffee table there. Because I cannot leave her alone.” (Mother, s16)
This mother reported living more than 100 kilometers from that hospital and lacked the resources to find accommodation in a town where she did not have family:
“We went to [hospital A], we were there for four days. [Hospital A] is different because he sleeps alone in his bed and I sleep on the benches. You join the benches and then you sit next to your child and you sleep on them. They [the nurses] say they are doing you a favour by allowing you to sleep next to your child. You are not allowed to be with your child all the time, you can only come in at certain visiting times to see them. You were told to stay at home, where you normally stay. At [hospital A] there is no accommodation for mothers and that is why we sleep on the bench. They [nurses] say it is only children that are supposed to be here that is why we slept on the benches. Another thing at [hospital A] is that you are told as a mother you will not be given food. Mothers were not given meals, even if your home was far away you were still not given any meals”. (Mother, s15)
2. Enabling continuous presence
We observed nursing care practices and interactions which suggest an implicit expectation that the mother should provide care for the child in the same way that she usually does at home. Mothers and children are essentially regarded by nurses as a single unit:
“We promote a healthy whole for the child. If the child is alone, they cry, they do not eat and so we allow the mothers to stay together with their child. It is easy to heal faster with a mother”. (Nurse, s20)
“We need the mother and baby sharing the same bed like at home, so that the hospital environment cannot differ that much from home environment”. (Nurse Manager, s21)
The policy of continuous maternal presence enables the mother’s role as the child’s primary caregiver to continue uninterrupted. Nurses preserved the mothers’ role as the primary provider of hands-on basic care for their child without interruption. Only in the absence of a mother would a nurse ‘take over’.
“If the mum is not here, nurses take over, look after the patient. We are feeding them, bathing, because there is no mum”. (Nurse, s6)
Mothers provide almost all the hands-on care for their child, adapting ordinary caring practices in response to the hospital environment or the child’s altered medical needs (e.g. tube feeding or mobilising after orthopaedic surgery) as an extension of their usual role:
“I bath him, and I make sure that where he is playing is safe and that he's not going to hurt himself. I wake him up to give him his medications. Even if he doesn't want to eat, I am able to encourage him, and I feed him patiently”. (Mother, s13)
“I must help her. I just carry her and put her down and help her to walk.” (Mother, s16)
Data from two direct observations emphasise the degree to which the presence of the mother comforts the child and the ease with which care continues:
Child is sat against grandmother in bed, appears entirely relaxed throughout and does not object to presence of the doctor, medical student, nurse and observer. (Direct Observation)
[On completion of the dressing change] The mother immediately put the baby to the breast while she was still standing, and quickly moved to lay on the bed and continue breastfeeding. The baby settled instantly, mid cry. (Direct Observation)
3. Belief and trust
Nurses in this setting trusted mothers to be responsible for aspects of their child’s care. While the child was in hospital nurses expected mothers to participate in care such as observing the child’s condition and reporting changes and concerns, assisting with prescribed physiotherapy exercises, providing a reassuring presence for the child during procedures and dressing changes, and assisting with giving medication.
Observation of nursing care practices in this setting suggested that both nurses and mothers have innate confidence in mothers’ abilities to learn and to cope, and high expectations about the speed at which they will become competent. Practices such as tube feeding were regarded by nurses as straightforward tasks that mothers could quickly become familiar with following minimal instruction, and observations of mothers who were tube feeding babies suggested that mothers were comfortable and exhibited no anxiety.
I [researcher] asked the nurse in charge if this was normal practice [mothers to tube feed their child] and she said ‘yes’. If a child needs to be tube fed, the mother is taught to tube feed her own baby. (Direct Observation)
Nurses’ accounts suggested that they regarded the presence of mothers as supporting the smooth running of the ward, reducing demands on nurses and contributing to faster healing and recovery for the child. Nurses were observed coming alongside mothers to provide information and feedback in a way that upheld the mother’s position as the child’s main carer. This was seen as having benefits during the period of hospitalisation and beyond, for both the child and the nursing staff.
“...with mum around it is so easy because the mother knows how to make their child to take medication, so it is working for us”. (Nurse Manager, s21)
“[Mothers chose to stay] Because they love their child. And the babies also understand more of their mothers than with other people. Even with the medication, the babies will take it more easily with the mothers than with us.” (Nurse, s6)
“So, it is positive, so the mothers have jobs to do [breastfeeding] and even the changing of the nappies”. (Nurse, s2)
Mothers indicated that they were aware that nurses continued to supervise some aspects of care, and nurses articulated their rationale for maintaining oversight in specific situations:
“But, you know mothers, they sometimes cheat when they want to go home and say that the stools are normal but we [nurses] need to check. The reality is that we need to witness the stools… especially in the babies with gastroenteritis”. (Nurse Manager, s21)
4. Psychological support and empathy
Nurses described an authentic intention to provide care aimed at promoting the physical, social, emotional and psychological well-being of the mother and child. The rationale for the carefully considered ward policies and processes already described extends beyond making practical provision for mothers’ presence in the ward. The descriptions of practice stimulated by graphic facilitation suggested an emphasis on ‘welcoming’ mothers to the ward (see Figure one).
Nurses’ accounts of practices revealed that they are designed to enable the mother to be physically close to and emotionally and mentally present for her sick child. Amenities ensure that all her physical needs are taken care of, while a relaxed ward atmosphere with minimal routines reduces anxiety and frees her to focus on her child.
Mothers are asleep in their beds in the middle of the day, there is no specific routines for mothers, other than having a bath or shower early in the morning. (Direct Observation)
Observation data describes mothers being served courteously by domestic staff and treated with dignity and respect in all interactions with staff. There was a sense that mothers were cared for in ways that went far beyond simply tolerating their presence. Nurses are interested in and actively responsive to a mother’s social and emotional wellbeing and health needs. Nurses ensure that, where possible, these needs are addressed appropriately. It is as though, in viewing the mother and child as a single unit, nurses accept that caring for the mother is part of their responsibility.
“Sometimes the mother comes here without their own treatment…then we ask the doctor to write a new prescription and order the treatment for them. We ask the mother about social problems…so we can pick up social problems, we then tell the doctor and they refer to the social worker”. (Nurse, s2)
5. Mothers as a capable resource
In this setting it was striking to observe the way that mothers exhibited a relaxed sense of ‘belonging’ within the communal ward environment. Direct observations suggested there was a sense of community among the mothers who ‘room-in’ for the duration of their child’s hospitalisation. Overall, mothers appeared comfortable and at ease in the ward environment, with nurses unobtrusively facilitating this through the ward routine and their interactions with mothers, rather than formalised arrangements such as ‘support groups’.
Mothers were spontaneously described by nurses in ways that suggested nurses regarded their continuous presence as an important resource:
“Mothers can do the feeding while we are busy with the doctors in the ward and doing procedures. Working together with mothers assists us in speedy recovery of patients”. (Nurse, s6)
“If the child is alone they cry, they do not eat and so we allow mothers to stay together with their child. It is easier to heal faster with a mother”. (Nurse, s20)
Mothers indicated awareness of the extent to which nurses regarded them as a resource, and appeared to accept the responsibility without question and indeed to regard it positively:
“I am in hospital so that I can be close to her and look after her, because nurses cannot always be with my child. Also, so that I can see if there is something not going well with my child and tell the nurses”. (Mother, s14)
It was rare to hear a child crying or exhibiting signs of distress. During the period of observation, a variety of procedures were observed. In these cases, the mother was central to providing reassurance and comfort and was given a prominent role in the procedure by nurses:
The mother was holding the child while the nurse cut off part of the burns dressing. The mother lay the child down on the bed, which was her normal bed in the ward, while the dressing was cleaned, and the mother consoled the child by rubbing the child’s arm and head. When the dressing had been changed, the mother picked the child up immediately and the child was consoled. (Direct Observation)
Mothers appeared to give and receive both practical and emotional support to one another, and to one another’s children. Mothers were observed participating in caring activities for children other than their own, for example pouring juice and responding to requests for help, such as to pass a set of crutches.
Beyond the provision of practical support, nurses indicated that they regarded mothers providing psychological support to one another as a valued resource and indicated that they regarded interaction between mothers and the sharing of experiences and stories as beneficial. Providing psychological support was not the sole preserve of nurses:
“We give them [mothers] psychological support and let them talk to other mums, sometimes other mums have the solutions to each other’s problems”. (Nurse, s4)
6. Sharing knowledge
The data extract presented in Table 2 shows that the ability to teach mothers is a part of the explicit rationale for their presence in this setting. However, nurses’ accounts also pointed towards implicit ways in which the continuous presence of mothers was integral to the way nurses in this setting work to share knowledge. Mothers were expected by nurses to become competent at managing the child’s health needs through a dynamic two-way process of knowledge sharing and nurses exhibited a belief that mothers had deep understanding of their own children.
The mothers’ continuous presence was seen as making it possible for learning to take place more effectively than would otherwise have been the case, working towards the goal of the child and mother returning home with enhanced health capacity. Vicarious learning in this setting is facilitated by nurses ‘there and then’ in a responsive and opportunistic fashion, driven by the needs of the mother and child, and the opportunities afforded by daily events:
“We give education about the child’s diagnosis on admission, we check in the file what the doctor wrote as the diagnosis...we tell the mother about the sugar salt solution. We do that there and then. We give education according to the child’s diagnosis”. (Nurse, s11)
Opportunities to share knowledge written in the local language were integral to the fabric of the ward.
“Here are the teachings on the wall written in isiZulu. It is the oral rehydration method with pictures to reinforce the message to mothers. It is to remind mothers about the oral rehydration solution”. (Nurse, s20).
Nurses were also observed employing formal instruction one to one with mothers or gathering small groups of mothers in the ward setting to provide health education sessions. Topics and practices included provision of basic health education advice regarding infection prevention and control, including hand hygiene, practical steps within the home to reduce the risk of accidents such as burns, and the correct management of acute gastrointestinal illness, including preparation of oral rehydration solution, at home.
“All categories of staff can teach tube feeding to mothers. Teaching and training is an allocated task, one nurse a day is allocated to teaching and training. However, all other staff are encouraged to encourage mothers and train as required”. (Nurse, s20)
In the case of a young child recovering from acute gastrointestinal disease, a mother and a nurse were able to explain to researchers how knowledge sharing in this setting works as a two-way process, enabling the transmission of information about the condition of a young child using the mother as a mediator:
“I'm feeding the child and changing the nappy, they [nurses] are asking me has my child eaten and how was my child's nappy”. (Mother, s19)
“Mothers must show us [nurses] the contents of the nappy before being given another nappy. This is to keep a check on the condition of the child, especially those in the gastro ward”. (Nurse, s20)