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

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    Article history:Received 30 January 2013Received in revised form 15 April 2013

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    for 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

    differ regardingthat they have to001). Ambult patient

    therefore, reconsider what is normal and abnormal in thechildren. Management guidelines and equipment designadults 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

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

    International Emergency Nursing xxx (2013) xxxxxx

    Contents lists available at

    International Eme

    .eE-mail address: (. Engstrm).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 prerequisites

    occur (Bruce et al., 2003a). Children and adultsanatomy, physiology and psychology, meaningbe treated differently (Gaffney and Johnson, 2nurses who are primarily trained in the care of ad1755-599X/$ - see front matter 2013 Elsevier Ltd. All rights reserved.

    Please cite this article in press as: Nordn, C., et al. Ambulance nurses experiences of nursing critically ill and injured children: A difcult asambulance nursing care. Int. Emerg. Nurs. (2013), must,case ofed forIntroduction

    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 patients care needs in a variety of environments (Holmbergand Fagerberg, 2010). To carry out treatment and to take action,

    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 specicknowledge 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 necessarilyAccepted 16 April 2013Available online xxxx

    Keywords:Pre-hospital careParamedicAmbulance nurseChildNursingQualitative content analysisBackground: 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 difcult aspect of ambulance nursing care, with ve 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.Ambulance nurses experiences of nursinchildren: A difcult aspect of ambulance

    Charlotte Nordn RN, MSc, (Ambulance Nurse) a, Kasa Engstrm RN, CCN, MSc, PhD, (Associate Professa Falck Ambulans AB, Hssleholm, Swedenb Jokkmokk Ambulace, Jokkmokk, SwedencDivision of Nursing, Department of Health Care Science, Lule University of Technology

    journal homepage: wwwcritically ill and injuredursing care

    Hult RN, MSc, (Ambulance Nurse) b,) c,

    le, Sweden

    SciVerse ScienceDirect

    rgency Nursing

    l sevier .com/locate /aaenpect of

  • Assurances were given that all data would remain condential,that participation was voluntary and that the participants hadthe right to withdraw at any time without prejudice.


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

    A difcult 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 difcult, while cases involving a small child

    Describe your experiences of reporting and leaving the sick child at the

    Follow-up questions; Explain/describe/develop this more. What do you

    ergeunderstanding 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) childrens reactionsto illness are affected by age; the younger the child, the morestressed it is likely to become in painful situations. Another aspectis the childs fear of the unknown. Bruce et al. (2003a) show thatwhen communication difculties 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 childs 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.


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


    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).


    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 rst and second authors then con-tacted them by telephone and made appointments for the inter-views in accordance with the participants wishes.


    Eight trained ambulance nurses, three men and ve womenaged 3048 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

    2 C. Nordn et al. / International EmData were collected by means of individual semi-structuredinterviews. The rst and second authors each interviewed four

    Please cite this article in press as: Nordn, C., et al. Ambulance nurses expeambulance nursing care. Int. Emerg. Nurs. (2013), and used an interview guide with open-ended ques-tions that met the studys aim (Table 1). Each interview was re-corded using a MP3 player; these les 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 ve nal categories were then compared anda theme, i.e. threads of meaning that appeared in all categorieswas identied (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.

    mean? How does it feel?emergency department.Describe your experiences of follow-up and reect after nursing a critically ill

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

    children within ambulance care.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.

    ncy Nursing xxx (2013) xxxxxxwith 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 difcult aspect ofenj.2013.04.003

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

    Yes thats one of the worst things you can get, an alarm with achild, when children are involved its always difcult. . .

    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-cult situations participants might face, and this feeling increasedwith the seriousness of the childs condition.

    Then you get performance anxiety, because you really want to dowell, if there is any time you want to do everything absolutely right,its 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 crews 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 sufcientfor them both.

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

    Im always stressed in one way or another, but it is a very uncom-fortable situation because its a child and its hard because their

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

    Theme Category

    A difcult 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. Nordn et al. / International Emanatomy is different, their physiology, they breathe differently, theybehave differently, they have large heads and small bodies . . .Damn, its stressful at times, its 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 difcult when the child was transported in the par-ents lap. Another difculty 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 wasdifcult 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.

    The childs safety was considered to be paramount and the par-ticachThicabewa

    Please cite this article in press as: Nordn, C., et al. Ambulance nurses experienambulance nursing care. Int. Emerg. Nurs. (2013), felt that a calm and cautious attitude was important inieving it. The younger the child the more importan...


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