International Emergency Nursing xxx (2013) xxx–xxx

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International Emergency Nursing

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Ambulance nurses’ experiences of nursing critically ill and injuredchildren: A difficult aspect of ambulance nursing care

1755-599X/$ - see front matter � 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ienj.2013.04.003

⇑ Corresponding author. Address: Department of Health Science, Luleå Universityof Technology, SE-971 87 Luleå, Sweden. Tel.: +46 920 49 38 75; fax: +46 920 49 3850.

E-mail address: asa.engstrom@ltu.se (Å. Engström).

Please cite this article in press as: Nordén, C., et al. Ambulance nurses’ experiences of nursing critically ill and injured children: A difficult asambulance nursing care. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.04.003

Charlotte Nordén RN, MSc, (Ambulance Nurse) a, Karin Hult RN, MSc, (Ambulance Nurse) b,Åsa Engström RN, CCN, MSc, PhD, (Associate Professor) c,⇑a Falck Ambulans AB, Hässleholm, Swedenb Jokkmokk Ambulace, Jokkmokk, Swedenc Division of Nursing, Department of Health Care Science, Luleå University of Technology, Luleå, Sweden

a r t i c l e i n f o a b s t r a c t

Article history:Received 30 January 2013Received in revised form 15 April 2013Accepted 16 April 2013Available online xxxx

Keywords:Pre-hospital careParamedicAmbulance nurseChildNursingQualitative content analysis

Background: Ambulance nurses work daily in both emergency and non-emergency situations that can bedemanding. One emotionally demanding situation for ambulance nurses is to nurse children who are ill.Aim: The aim of this study was to describe ambulance nurses’ experiences of nursing critically ill orinjured children.Method: Eight specialist ambulance nurses were interviewed and the interviews were analyzed usingqualitative content analysis.Findings: The analysis resulted in one theme, a difficult aspect of ambulance nursing care, with five cat-egories. The security of both child and parents was considered to be paramount. Ambulance nurses feltrelieved when they handed over the responsibility and the child to the receiving unit. The ambulancenurses felt that more training, education and follow-up was desirable in order to increase their securitywhen nursing children.Conclusion: Ambulance nurses are subject to stressful feelings while nursing children. As providing reas-surance to the child and its parents is a cornerstone of the treatment, it is important for the ambulancenurses to take the time to build up a trusting relationship in such an encounter. Skill development in thearea might lead to increased security and reduce the mental burden resulting from negative stress.

� 2013 Elsevier Ltd. All rights reserved.

Introduction

The work of an ambulance nurse requires high levels of knowl-edge and skill in order to be able to care for patients outside thehospital. Ambulance nurses have to meet and identify each indi-vidual patient’s care needs in a variety of environments (Holmbergand Fagerberg, 2010). To carry out treatment and to take action,the ambulance nurse has to establish immediate trust in the rela-tionship with the patient (Bruce et al., 2003b). Working as anambulance nurse means nursing patients of different ages suffer-ing from a variety of diseases or traumas. One of the prerequisitesfor an effective emergency medical service is a unique level of teamcollaboration (Ahl et al., 2005). According to Jewkes (2001) about10% of all pre-hospital emergency alarms involve children, 5% ofwhich represent a real need of urgent help. Pre-hospital emergencycare for children is rare, but when a child falls acutely ill or is

injured rapid and effective response is required. Effective pre-hos-pital emergency care can reduce the number of deaths in children(Jewkes, 2001).

All ambulance emergencies involving children require specificknowledge because children of all ages have special needs. Ambu-lance nurses must have good knowledge of, and ability to antici-pate, possible scenarios and situations that do not necessarilyoccur (Bruce et al., 2003a). Children and adults differ regardinganatomy, physiology and psychology, meaning that they have tobe treated differently (Gaffney and Johnson, 2001). Ambulancenurses who are primarily trained in the care of adult patients must,therefore, reconsider what is normal and abnormal in the case ofchildren. Management guidelines and equipment designed foradults are not suitable for children. In addition to coping with dif-ference in size, training is needed in managing the equipment astechniques used in treating a child can sometimes differ (Atheyet al., 1997).

A sick or injured child elicits many emotions within the familyincluding fear and guilt (Athey et al., 1997). According to Bentley(2005) and Roden (2005) parents want to be involved in the careof their seriously ill child to gain a sense of participation and

pect of

Table 1Interview guide used in the study aimed at describing the experiences of ambulancenurses in nursing critically ill or injured children.

Please:Describe your feelings when you receive a call about a critically ill or injured

child.Describe how you prepare yourself on your way to the child.Describe your experiences of nursing critically ill or injured children within

ambulance care.Describe your experiences of the weaknesses and strengths of different

methods for nursing critically ill children within ambulance care.Describe your experiences of reporting and leaving the sick child at the

emergency department.Describe your experiences of follow-up and reflect after nursing a critically ill

child.Describe your experiences of your education about nursing critically ill

children within ambulance care.Follow-up questions; Explain/describe/develop this more. What do you

mean? How does it feel?

2 C. Nordén et al. / International Emergency Nursing xxx (2013) xxx–xxx

understanding and for communication about the child to be openand honest (Roden, 2005). Noyes (1999) describes how parentsof acutely ill children put their own needs in second place, and to-tally focus on the child and their condition. Most parents think thattheir responsibility is to protect their child by being involved in thecare (Bentley, 2005).

Forsner (2006) describes the fear that ill children experience be-cause they are afraid that the treatment will hurt, that they will getinjured by the examination or treatment, or that their feelings areignored and they are subject to compulsion. Trust in other peoplemay be adversely affected if the child becomes afraid when theyrequire care. According to Athey et al. (1997) children’s reactionsto illness are affected by age; the younger the child, the morestressed it is likely to become in painful situations. Another aspectis the child’s fear of the unknown. Bruce et al. (2003a) show thatwhen communication difficulties with young children occur it isessential that the ambulance nurse cooperate with the child andthe parents to create a feeling of safety. This means that the nursemust adapt the care to the child’s needs and tell both the child andthe parents what is about to happen. According to Houston andPearson (2010) pre-hospital care of children is a great challenge.As children are so rarely in the pre-hospital emergency care thenursing of them will never be a matter of routine.

Aim

The aim of this study was to describe ambulance nurses’ expe-riences of nursing critically ill or injured children.

Method

This study has a qualitative research approach based on semi-structured interviews. Qualitative research aims to develop a richholistic understanding of the phenomenon being studied (Politand Beck, 2012).

Procedure

The heads of one ambulance station in southern Sweden andone in northern Sweden, gave permission for the authors to handout information letters to those ambulance nurses working in theirstations who met the inclusion criteria for participation in thestudy. In total eight ambulance nurses who met the inclusion cri-teria were informed about the study and asked to participate, alleight were interested in participating and answered the letter bysigning a consent form. The first and second authors then con-tacted them by telephone and made appointments for the inter-views in accordance with the participants’ wishes.

Participants

Eight trained ambulance nurses, three men and five womenaged 30–48 years (md = 36) participated in the study. The inclu-sion criteria were: to be specialist ambulance nurses, with at least2 years’ experience of pre hospital emergency care of critically illand/or injured children aged up to15 years. The participants’ expe-rience of pre-hospital emergency nursing care ranged from 3 to9 years (md = 5) and their prehospital experience of nursing criti-cally ill and injured children ranged from approximately 8 to 100children/year (md = 36/year).

Data collection

Data were collected by means of individual semi-structuredinterviews. The first and second authors each interviewed four

Please cite this article in press as: Nordén, C., et al. Ambulance nurses’ expeambulance nursing care. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.i

participants and used an interview guide with open-ended ques-tions that met the study’s aim (Table 1). Each interview was re-corded using a MP3 player; these files were kept secure so thatonly the authors had access to the data. The interviews were tran-scribed verbatim by the author who conducted the interview.

Data analysis

The data were analyzed using qualitative content analysisaccording to Downe-Wamboldt (1992). Each interview text wasread through several times in order to gain a sense of the contentas a whole. The entire text for all eight interviews was then read inorder to identify meaning units, guided by the aim of the study.The meaning units were condensed and sorted into categories re-lated by content, constituting an expression of the manifest con-tent of the text. All five final categories were then compared anda theme, i.e. threads of meaning that appeared in all categorieswas identified (Graneheim and Lundman, 2004).

Ethical considerations

The University Ethics Committee approved the study and theunit managers in the two ambulance stations gave their permis-sion for it to be carried out. Information about the study was re-peated orally to the participants prior to starting the interviews.Assurances were given that all data would remain confidential,that participation was voluntary and that the participants hadthe right to withdraw at any time without prejudice.

Findings

The theme and categories (Table 2) are presented in the text be-low and are illustrated with quotations from the interview text.

A difficult aspect of ambulance nursing care

Emergencies involving children create stress and strong feelings

Participants described how when they got a call about an illchild they experienced special feelings, such as something like anadrenaline rush. All participants felt stress. A cardiac arrest alarmor an emergency where a child had got something stuck in the tra-chea were considered difficult, while cases involving a small childwith febrile seizures or croup, for example, was considered man-ageable. Participants perceived that it took a long time to reachthe child when what they wanted was to get there quickly. Serious

riences of nursing critically ill and injured children: A difficult aspect ofenj.2013.04.003

Table 2Overview of theme (n = 1) and categories (n = 5).

Theme Category

A difficult aspect ofambulance nursing care

Emergencies involving children create stressand strong feelingsNeeding to feel personally secure in thesituationChildren and parents need securityFeeling relieved to hand over the childRecognize the needs for education andfollow up

C. Nordén et al. / International Emergency Nursing xxx (2013) xxx–xxx 3

alarms involving children were fortunately rare, but at the sametime the low frequency created uncertainty among theparticipants.

Yes that’s one of the worst things you can get, an alarm with achild, when children are involved it’s always difficult. . .

The stress escalated when confronting a critically ill child andthe participants said that they became more focused and had afeeling that nothing was permitted to go wrong. The participantsexperienced frustration in situations where they had been unableto help a child or if a child had received wrong treatment. Nursinga critically ill or injured child was described as one of the most dif-ficult situations participants might face, and this feeling increasedwith the seriousness of the child’s condition.

Then you get performance anxiety, because you really want to dowell, if there is any time you want to do everything absolutely right,it’s when you have a small child . . . Because they are just at thebeginning of their life.

When nursing a child the participants felt a sense of inadequacyas they had at least two people, the child and a parent, to nurture.Participants who had children of their own related to their feelingsas a parent. The parents’ concerns and the rest of the crew’s con-cerns contributed to the stress on the participants. The participantsstated that on these occasions they would liked to have a quiet careenvironment and they therefore moved quickly into the ambulanceto maintain the calm and be able to focus on the child.

And there is a mom next to the child and she is really sad and I donot really know what to do for her, and I have to try to be sufficientfor them both.

Participants assessed what it was really necessary to treat andmostly treated only the child’s most acute symptoms. They de-scribed the stress of failing, for instance, to insert a peripheral veincannula in a child.

I’m always stressed in one way or another, but it is a very uncom-fortable situation because it’s a child and it’s hard because theiranatomy is different, their physiology, they breathe differently, theybehave differently, they have large heads and small bodies . . .

Damn, it’s stressful at times, it’s really tough.

Most of the participants prioritized getting help quickly and de-scribed a desire to get to the hospital as fast as possible but safely.This could be difficult when the child was transported in the par-ent’s lap. Another difficulty was carrying a larger and older child,the child him or herself could lie on the stretcher, but the parenthad to sit in the seat next to the stretcher. This meant that it wasdifficult for participants to gain access to the child. A desire formore secure protection during transport for the child and a betterpassenger seat for the parent was expressed by participants. After-wards participants could dwell on the situations involving care ofchildren.

Please cite this article in press as: Nordén, C., et al. Ambulance nurses’ experienambulance nursing care. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.

It’s the only alarm you cannot forget, otherwise I think some alarmsare okay, that lump in your stomach disappears after a while, but itdoesn’t with children, at least not for me.

Needing to feel personally secure in the situation

Participants felt that they wanted to be better prepared foralarms involving children. They described how they prepared onthe way out by repeating children’s normal values and, based onsymptoms, going through treatment guidelines and drug dosages.Participants felt that the alarm was often worse than the actual sit-uation which was described as relief.

You never know what you will meet, but with the kids I do thinkthat I prepare more thoroughly than for an adult. An adult canalways be treated according to the symptoms, because it’s usualwhat you expect, but a child, you have to be prepared for moreand you prepare more. I do, anyway.

Participants felt that the ambulance was their place of safetywhich meant that they strove to get there quickly. If they couldget help from parents who were knowledgeable about the child’scurrent status, it further increased their feeling of security.

. . .and then there was the mother who was caring for the girl fulltime she was there and sat with us in the back of the ambulanceto help with the ventilator and things like that so I felt secure withit.

However, the participants did not want the parent to sit close tothe child in the ambulance, when the child was very seriously ill orinjured and they wanted to work undisturbed and methodically.

Sometimes you get a sense that you cannot reach the kid . . .

because he or she lies on the stretcher, mother sitting next to himor her and then I sit at the head end. I really have no place to be. . . you are unable to investigate, check things.

The participants thought that the technical equipment had be-come better adapted over the years, which they believed increasedtheir own security. Some participants, however, described feelinguncertainty in relation to children and the equipment when theythought it was disorganized, poorly designed and unreliable. Thismeant that they abandoned the technical equipment and reliedon their clinical gaze to facilitate care.

I feel that the equipment that we have today is substantially betterthan we had in the beginning. Then we had an adult probe for thesaturation measurement and we tried to coax it on one way oranother and hoped that the error in the value would not be toobig. Today we have stuff we can use.

Participants felt, because of the feelings aroused when nursing achild, that they wanted to have someone to share their thoughtsand feelings with, and increasingly used support from colleaguesand physicians. They also felt more secure when there were twoambulance nurses working in the ambulance providing access togreater medical and nursing skill. Having a physician in the ambu-lance when nursing a critically ill child made them feel secure.

Children and parents need security

The child’s safety was considered to be paramount and the par-ticipants felt that a calm and cautious attitude was important inachieving it. The younger the child the more important this was.The participants said that they often used themselves as pedagog-ical tools; they used their personality, their body language andbehavior when communicating with the child. They felt that itwas important to find a balance between telling the child and

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making them part of the care. To achieve this, participants had toadjust the level of information in line with the child’s developmentand age; but despite that small children did not always understandthe purpose of the treatment. The child’s age, physical and psycho-logical maturity was deemed significant for how much he or sheunderstood of what was explained.

I never force myself onto children, because children need security,you may feel a lot with children. Can they handle it if I get close?

Now we have to put in a needle that of course sounds reallystrange. . . To put an oxygen mask over their mouth might seemto be illogical, it should be easier for them to breathe but it maynot be if they have that plastic thing over their mouth and nose.There’s so much stuff that they need to understand and that hasto be explained. An adult can easily understand that this is good,it helps me.

The participants thought that immobilization reduced the feel-ings of safety in children when they were afraid and did not wantto lie still. The child might be afraid of the ambulance nurse be-cause he or she was a stranger. One participant said that childrencould experience the ambulance clothes and environment as bothscary and exciting. When children were stressed participants feltthat the situation and the child’s own status deteriorated. They alsofelt that the greatest source of security for the children was theirparents and argued that the parent should always accompanythe child in the ambulance, as calm and secure parents facilitatednursing care. A confident parent was considered a resource in com-municating with the child. One participant said that a teddy couldhelp build up trust in the child.

The participants described how the parents were often insecureand scared when the child was acutely ill and the worse the childwas the stronger these feelings were. Participants felt that the par-ents transferred their stress to the child which could adversely af-fect the child’s status. A calm attitude and informing them aboutthe child’s status was a way of providing reassurance for the par-ents. Another way was to allow them to be involved in care andprovide them with tasks to focus on so that they felt needed.

It’s different with different parents, some may be very quiet, butsome are really stressed. You may perhaps remind parents thattheir concerns rub off on the child, you might have to give thema task so that they can help a little instead, then they have some-thing else to focus on and they feel that they are needed.

The participants said that they felt satisfied with the care whenthey managed to create security for the child and parent, and whenthey gained the child’s trust so that it accepted the necessarytreatment.

Feeling relieved to hand over the child

Participants described feeling relieved when they got to thehospital and handed over the responsibility for the child’s care tosomeone else. The participants said that when they warned thehospital reception about the child’s arrival it usually worked welland the handing over of children in the emergency room and thecooperation generally worked smoothly. They said that the staffin the receiving unit felt more focused when receiving children.Participants felt that the staff spoke less often over the heads ofchildren compared to adults. A child had higher priority than anadult when arriving at hospital and participants felt that every-thing possible was always done for the critically ill children andthat, for instance, to save their lives resuscitation attempts lastedlonger, compared to old adults.

Please cite this article in press as: Nordén, C., et al. Ambulance nurses’ experienambulance nursing care. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.

Thus, it is often a relief to see this little man settled inside the hos-pital and they have, like, made it there, you’re really happy.

Recognize the need for education and follow up

Participants felt that they had inadequate training in emergencycare for children and it felt strange and frustrating not to receivefurther training in the subject. They expressed a desire for moreeducation concerning children e.g. emergency care, trauma care,pediatrics and how to handle equipment suitable for children. Par-ticipants said that learning more about nursing care of childrencould also be archived by visiting children wards and learning fromthe nurses working there. Another proposal for improving mutualunderstanding was education given by pediatricians.

I would have felt safer. . . I think absolutely, and I think most peoplethink this is important in our work; we can never have too mucheducation.

Participants were interested in following up after nursing achild to ensure that they had acted lawfully at the time, but thiswas limited by privacy rules and organizational factors.

Discussion

The result shows that emergencies involving children provokedfeelings of stress. According to Svensson and Fridlund (2008)ambulance nurses develop internal stress when they are exposedto situations they are unaccustomed to. For paramedics the situa-tions that induce worst anxiety are those involving children, par-ticularly the seriously ill ones (Alexander and Klein, 2001).Participants described feeling a sense of injustice based on theirperception of children as being in the beginning of their lives.According to Lipton and Everly (2002) paramedics experience feel-ings of inadequacy when nursing children as they consider them tobe innocent and with their entire lives ahead of them. Participantswere afraid to make mistakes when caring for children. Jonssonand Segesten (2004a) show that ambulance nurses feel guilt whenthey fail to help the patient. They also feel pressured to do theirabsolute utmost when caring for children and this creates stress(Gunnarsson and Stromberg, 2009).

Jonsson and Segesten (2004b) claim that emotionally exhaustedambulance nurses are more stressed and are therefore less proneto give the patient optimal cares and more likely to show symp-toms of post-traumatic stress disorder. Bruce et al. (2003b) statethat the nurses must familiarize themselves and understand thepatient’s suffering to the extent that allows them to meet the pa-tient’s need for care.

According to Swor et al. (2005) children in prehospital care of-ten receive little or no treatment at all before arriving at the hospi-tal, which seems to be consistent with the findings in this studyand might pose a risk for the child. Participants in this study wouldlike to be more prepared when facing an alarm involving a child.Jonsson and Segesten (2004a) describe preparation as an internaldialog which helps to increase awareness. The dialog is a way ofhandling the insecurity by mentally preparing for what will comeas well as drawing on previous knowledge and experience. Bruceet al. (2003a) claim that the need of preparation is based on theambulance nurses’ competence and experience. This means thatacquired experience provides basic security and thereby reducingthe need for preparation. Suserud and Haljamäe (1997) show thatexperience is the most important factor in achieving security; anexperienced nurse tends to work longer at the scene of the incidentwhile the more inexperienced tend to move to the ambulancemore quickly to their security, in order to start the transport.

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The desire to have someone to share one’s feelings with whencaring for a child was revealed among the participants. Accordingto Suserud (2002) ambulance nurses’ experience of support fromcolleagues during major accidents is important, especially fromtheir closest colleagues, and a trusting relationship contributes tofeelings of security. Svensson and Fridlund (2008) suggest thatthe anxiety subsides when ambulance staff work with more expe-rienced colleagues as they then feel secure and can discuss prob-lems together. Jonsson and Segesten (2004a) show that supportcan be found in an interlocutor who is present and a good listener.The absence of this support can provoke post-traumatic stressdisorder.

In this study the child’s safety was considered paramount forthe interaction and the information level was based on the child’scognitive development. According to Gimbler-Berglund et al.(2008) the nurse must take the time to establish a relationshipand collaborate with the child. This is confirmed by Björk et al.(2006); children should be treated empathetically and the care-giver should speak directly to the child. The information levelshould be adjusted to the child’s age as to make it comprehensiblefor the child (Pölkki et al., 2001).

The participants described difficulties in informing childrenabout certain treatments, confirming findings by Forsner et al.(2005) that children easily misunderstand information so thatsomething becomes frightening rather than reassuring. Accordingto Coyne (2005) children need to be involved in decisions relatingto their care in order to feel secure and Schmidt et al. (2007) statethat nurses can reduce children’s fear by explaining their role.

The parents were considered to be the greatest source of secu-rity for the children and participants argued in favor of the parentsaccompanying them. Pelander et al. (2007) and Pelander and Lei-no-Kilpi (2004) confirmed that the parents’ presence contributesto the child’s feeling of safety as well as making treatments moreeasily accepted. Gimbler-Berglund et al. (2008) emphasize that itis the parents who have the greatest knowledge about the child.However, the participants in this study considered that this wasonly possible if the parent was calm as an insecure parent trans-ferred anxiety to the child. Participants believed it was importantto also create a safe environment for the parents. Nugent et al.(2007) state that parents can develop negative stress when theirchild becomes acutely ill. Hopia et al. (2005) emphasize the impor-tance of creating a sense of security for the parents when thechild’s health is impaired by keeping the parents informed andinvolving them in the care. According to Aldridge (2005) parentswant what is the best for their child, and often wish to be closeand involved in the care. Participants in this study believed thata calm approach, and information regarding the treatments andthe status of the child increased the parents’ level of security. Ald-ridge (2005) claims that parents need truthful information in orderto feel safe and involved. Information should be given in easy, com-prehensive language easy to understand in order to reduce the pos-sibilities of misinterpretations. Power and Franck (2008) state thatit is valuable to offer the parents the chance to participate in thecare of their child.

Participants in this study said that the handover usually workedwell especially if the receiving staff were informed about the arri-val of the child. According to Bruce and Suserud (2003) good team-work is a requirement between the ambulance nurses and the staffin the receiving unit. This allows the patient and their relatives thepossibility to see the care chain functions and that the staff is therefor them. Owen et al. (2009) show that ambulance nurses experi-ence frustration when the receiving nurse is more occupied withthe patient than with listening to the report. According to Thakoreand Morrison (2001), as well as Talbott and Bleetman (2007), thereceiving nurses often make their own assessment of the patientinstead of paying attention to the report given by the paramedics.

Please cite this article in press as: Nordén, C., et al. Ambulance nurses’ expeambulance nursing care. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.i

Talbott and Bleetman (2007) explain that if the receiving staff arestressed important information passed on by the paramedics getslost.

Participants thought that knowledge and education regardingchildren was inadequate. Poljak et al. (2006) show that ambulancenurses need more knowledge and education in the care of children.Gentil et al. (2008) claim that knowledge as well as scenario train-ing is needed in order for ambulance nurses to be able to makequick and correct decisions during stressful situations. Accordingto Jewkes (2006) paramedics have too little training and routineregarding care for children, which can lead to loss of pain reliefsince the paramedics may have difficulties establishing vein access.Choen et al. (2008) believe it is necessary to be able to treat acutepain in children as untreated pain may cause to long-term adversenegative effects. Suserud (2005) states that all patients have theright to be treated by competent personnel regardless of wherethey are treated. The Social Board decided in 2005 that all Swedishambulances should be staffed with at least one registered nurse forskill enhancement purposes. There is a 1-year postgraduate coursewithin prehospital emergency care aimed at further increasing thecompetence further in this field (Suserud, 2005). The participantsin this study all had followed this postgraduate education and,while they thought it was very good, they still wanted more edu-cation about critically ill children.

The participants described it as difficult to follow up the chil-dren they had cared for due to rules of confidentiality. Accordingto Harrahill and Gunnels (1999) ambulance nurses never becomecompletely fully trained, therefore following up their patientscould help the nurses to develop their knowledge. This is con-firmed by Sadosty et al. (2004), who values monitoring patientsas an important part for personal development. Harrahill and Gun-nels (1999) explain that follow up should be easily accessible andoccur close to the actual time of caring to be of use in awareness-raising. The participants in this study also made this request.

Methodological considerations

This study has limitations; for example eight ambulance nurseswere interviewed, which is a rather small group. The interviewswere rich in content and described similar experiences, which cre-ated a pattern that we found adequate to serve as a basis for thefindings. The interviews were conducted in different places; thefirst author interviewed four ambulance nurses in southern Swe-den and the second author four ambulance nurses in northernSweden. Comparison of the interview material from the two loca-tions showed that experiences among the participants are similarreinforcing the views that nursing acutely ill children gives riseto shared experiences. The validity of this study has been ensuredby reviewing the analysis in a seminar setting and by continualsupervision by third author who has wide experience of this kindof research.

Conclusion

The theme of this study is a difficult aspect of ambulance nurs-ing care. It describes ambulance nurses’ experiences of nursingacutely ill and injured children. Emergency care of children createsuncertainty, stress and insecurity among ambulance nurses, and itseems to be based on limited experience and knowledge concern-ing the care of acutely ill and injured children. This limitationmakes it difficult for ambulance nurses to encounter the childrenand their families in a quiet and secure manner. Throughout thisstudy security has been described as the most important founda-tion for care for both the child and the parents, and ambulancenurses want more preparation and training in the subject. Skills

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can be developed by increasing the acquisition of knowledgethrough hospital training in emergency care for children, regularscenario training, lectures by experts in the field and ambulancenurses’ own studies. There is a desire that more practical and the-ory training in the care of the acutely ill or injured child should beincluded in the specialized education needed to become an ambu-lance nurse. This is supported by studies showing that, for instance,increased simulation training in this field is important (Eppichet al., 2006, 2008). Following up and reflecting on the child are alsoways in which to increase competence. Studies show that psycho-logical stress in the form of negative stress in the care of acutely illor injured children can lead to the development of post-traumaticstress disorder. To counteract this, after such emotionally demand-ing events the possibility of debriefing should be offered.

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