Journal of Pediatric Nursing xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Research commentary column
Translational Research – Effective Communication and Teaching Strategies for
Improving the Quality of Pediatric Nursing Care for Hospitalized Children and Their
Families
Becky J. Christian, PhD, RN, FNAP ⁎
School of Nursing, The University of Louisville, Louisville, KY
Child hospitalization is inherently stressful for children, their par-
ents, and families from admission through discharge home. The articles
included in this special issue focus on the hospitalized child and provide
strategies to reinforce the quality of patient care and reduce potential
risks and the likelihood of adverse events associated with child hospital-
ization. The quality of pediatric nursing care is strengthened through ef-
fective communication with children and their parents, as well as
communication between pediatric nurses and other healthcare pro-
viders. Effective communication strategies such as the use of standard-
ized handoffs for safe transfer of children within the hospital maintain
continuity of care and prevent communication breakdowns to ensure
the quality of care. Moreover, the importance of effective communica-
tion is highlighted when parents and pediatric nurses communicate
their perceptions to coordinate complex care for hospitalized technolo-
gy dependent children. Strategies to identify potential safety hazards for
hospitalized children reduce risks through assessment of fall risk and
skin injury while improving the quality of care and preventing compli-
cations associated with hospitalization.
Effective communication and teaching best practices to parents,
nurses, and other healthcare providers are fundamental to providing
quality care for children and their families. Combined with creative in-
tervention strategies, the care of children is enhanced in the hospital.
Comprehensive discharge teaching to children and their parents as
well as assessment of discharge readiness prepares parents of hospital-
ized children for the challenges of home care and prevents complica-
tions that lead to hospital readmission. Further, home visits by
pediatric nurses enhance the quality of care for children by reinforcing
discharge teaching, identifying and preventing complications after hos-
pital discharge, thereby improving the quality of life for children and
their families. Effective communication, teaching, and discharge plan-
ning are foundational to pediatric nursing and provide the basis for
high quality of care for children and their families. Therefore, it is imper-
ative that evidence from research and quality improvement projects is
translated into pediatric nursing practice to provide creative strategies
for improving communication, teaching, and discharge planning for
children and their families.
⁎ Corresponding author: Becky J. Christian, PhD, RN, FNAP.
E-mail address: becky.christian@louisville.edu.
http://dx.doi.org/10.1016/j.pedn.2017.04.001
0882-5963/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Christian, B.J., Translational Research – Effective Communication and Teaching Strategies for Improving the Quality of
Pediatric Nursing Care for ..., Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.04.001
When new evidence generated from nursing research is translated
into practice and best practices are affirmed through quality improve-
ment projects (Melnyk & Fineout-Overholt, 2014; Polit & Beck, 2017),
the quality of pediatric nursing care and health outcomes for children
and their families are improved (Hockenberry & Wilson, 2015). Trans-
lating research evidence into pediatric nursing practice yields innova-
tive teaching strategies for parents, as well as identifies the essential
importance of creating partnerships with parents to ultimately improve
the quality of care for children and their families (Christian, 2010,
2011a, 2011b, 2011c, 2014). Further, the importance of effective com-
munication is central to providing high quality of care for children and
their families during hospitalization and through discharge to home.
To that end, translation of research evidence into pediatric nursing prac-
tice is essential for improving care for hospitalized children and their
families.
In this special issue of the Journal of Pediatric Nursing focused on the
hospitalized child, 13 articles present research and quality improve-
ment projects designed to improve the quality of pediatric nursing
care for hospitalized children and their families from admission through
discharge home. Several articles address the importance of using effec-
tive communication strategies to improve the quality of care for hospi-
talized children, by: (a) using standardized handoffs for safe transfer of
children within the hospital to maintain continuity and quality of care;
(b) comparing nurse-reported missed care in neonatal intensive care
units (NICUs) between Magnet®-designated and non-Magnet®-desig-
nated hospitals; (c) exploring communication processes between par-
ents and pediatric nurses to coordinate complex care for hospitalized
technology dependent children resulting in improved quality of care;
(d) understanding family and healthcare team communication and in-
teraction patterns during child hospitalization course for traumatic
brain injury; and (e) identifying parental psychological stress and deci-
sional conflict associated with child hospitalization in the pediatric in-
tensive care unit (PICU). Five articles focus on the identifying creative
intervention strategies to improve the quality of care for hospitalized
children, as well as the importance of risk assessment and risk reduction
for preventing complications associated with hospitalization, through:
(a) evaluating the effectiveness of pain management strategies during
gastric tube insertion for infants; (b) reviewing and identifying the
best pediatric fall risk assessment tool for assessing fall risk in hospital-
ized children; (c) evaluating a newly developed skin injury risk
2 B.J. Christian / Journal of Pediatric Nursing xxx (2017) xxx–xxx
assessment scale (SIRA + P); (d) comparing the use of essential oils
with standard care for children with traumatic burn injury; and
(e) identifying pediatric inpatient nurses' perceptions of and knowledge
about child maltreatment and legal reporting requirements. Another
three articles highlight the critical importance of teaching and discharge
planning with parents of hospitalized children to prevent complications
and readmission, through: (a) evaluating the effectiveness of an Asthma
Action Plan educational program taught by pediatric nurse practitioners
(PNPs) to resident physicians to improve their knowledge and confi-
dence in teaching families prior to discharge from children's hospital;
(b) assessing parent perceptions about the quality of discharge teaching
and readiness with respect to caring for their children hospitalized for
respiratory conditions or neurologic disorders, as well as parental cop-
ing difficulties post-discharge; and (c) evaluating the feasibility and
utility of a pediatric nurse home visit program for parents of children
with medical complexity (CMC) at high-risk for hospital readmission
to improve the quality of home care post-hospital discharge to prevent
potential complications and readmission.
The articles in this special issue of the Journal of Pediatric Nursing fo-
cused on hospitalized children highlight the critical importance of effec-
tive communication, creative intervention strategies, teaching and
discharge planning for improving the quality of pediatric nursing care,
thereby providing evidence for translation into pediatric nursing prac-
tice, as follows:
• An intradepartmental quality improvement (QI) project was designed
to standardize handoff communication during hospitalization to pro-
mote safe transfer of pediatric patients across multiple departments
within a large Magnet®-designated pediatric medical center (Patton
et al., 2017). Forty bedside nurses from different units participated
in the evidence-based practice (EBP) QI project to assess and evaluate
the safe transfer of pediatric patients, timing and handoff communica-
tion. The standardized patient and family-centered ISHAPED (Intro-
duction, Story, History, Assessment, Plan Error prevention, Dialogue)
handoff tool for clinical staff was selected for system-wide implemen-
tation. Clinical nurse specialists provided educational in-service ses-
sions to clinical staff. The clinical nurse specialist group led a subset
of bedside nurses to address improving handoff communication for
transfers between emergency department (ED) and acute care ser-
vices (ACS) using Lean Six Sigma methods. Pre- and post-
implementation surveys focused on medical emergency team re-
sponses, unplanned ICU admissions, and medication errors within
six hours of transfer from ED to ACS. Outcomes of the QI project result-
ed in the implementation of system-wide handoff communication
tool with improvements in quality metrics including reduced number
of medication errors related to handoff between ED and ACS, no
change in time of transfers to PICU from ACS, and improved time in
medical emergency team responses within six hours of admission
from ED. The overwhelming majority (94%) of bedside nurses noted
their improved knowledge and comfort levels in conducting an EBP
project, as well as satisfaction with use of handoff tool.
• A secondary analysis of data from a cross-sectional, web-based survey
of neonatal intensive care unit (NICU) nurses (N = 230) from seven
states was conducted to explore the relationship between nurse-
reported missed care in Magnet®-designated hospitals and non-
Magnet®-designated hospitals (Tubbs-Cooley et al., 2017). Logistic
regression analyses were used to explore relationships between
Magnet® designation, occurrence of missed care, and nurse and
shift characteristics. Results indicated that no significant relationship
was found between Magnet® designation status and missed care oc-
currence for 34 of 35 types of care in NICUs. However, nurses in
Magnet®-designated hospitals were 75% less likely to miss teaching
and preparing parents and caregivers for discharge from NICU. Nurses
in Magnet®-designated hospitals were significantly less likely to re-
port communication breakdown with other nurses, tension or com-
munication breakdown with medical staff, lack of familiarity with
Please cite this article as: Christian, B.J., Translational Research – Effective Communication and Teaching Strategies for Improving the Quality of
Pediatric Nursing Care for ..., Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.04.001
equipment/procedure/policy, and lack of backup support from team
members with respect to missed care.
• A qualitative grounded theory approach was used to explore commu-
nication processes between parents and nurses of hospitalized tech-
nology dependent children (4 to 15 years) (Giambra, Broome,
Sabourin, Buelow, & Stiffler, 2017). Perspectives of parents (n = 5; 3
mothers, 2 fathers) of hospitalized technology dependent children
and nurses (n = 9) caring for their children were obtained through
semi-structured interviews to validate the authors' theory of shared
communication. Parents also recorded their thoughts and observa-
tions of communication with nurses in a journal. Results validated
the major concepts of the theory of shared communication and the in-
terrelationships among the concepts that were reflected in mutual re-
spect for parents' and nurses' expertise. The communication process
was described as: (a) asking, (b) listening, (c) explaining,
(d) advocating, (e) verifying understanding, and (f) negotiating
roles to achieve mutual understanding of the child's plan of care.
The nurses' perceptions of the communication process reflected the
same concepts identified by the parents of hospitalized technology
dependent children, thereby providing additional support and valida-
tion to the theory of shared communication.
• A prospective observational approach was used to understand family
and healthcare team interaction patterns along the illness trajectory
during the first eight days of child hospitalization for traumatic
brain injury (Reuter-Rice, Doser, Eads, & Berndt, 2017). Data from
the electronic health records of pediatric patients (N = 35, ages
5 days to 15 years) were used to assess traumatic brain injury sever-
ity, mechanism of injury, and length of stay. Characteristics of family
and healthcare team interactions were categorized by illness severity
group to identify patterns of illness course and were graphically
displayed. Three distinct categories of traumatic brain injury severity
were classified as: mild (n = 24), moderate (n = 3), and severe (n =
8). Family and healthcare team interactions were characterized by
information-seeking, watchful waiting, and decision-making. Howev-
er, the pattern of interactions differed by severity category and these
trajectories changed throughout the course of illness as the child's
condition stabilized, improved, or worsened during hospitalization.
• A descriptive exploratory, cross-sectional design study was conducted
to identify the prevalence of psychological outcomes of anxiety, depres-
sive symptoms, and decisional conflict among parents (N = 118; n =
74 mothers, n = 44 fathers) of children (n = 91) during their hospital-
ization in the pediatric intensive care unit (PICU) (Stremler, Haddad,
Pullenayegum, & Parshuram, 2017). The majority of children (59%)
were less than one year of age. Children were admitted to PICU for ei-
ther planned surgery (40%), acute illness or trauma (32%), or exacerba-
tion of chronic illness (28%). Findings indicated that 24% of parents (14
mothers, 9 fathers) demonstrated severe anxiety, 51% of parents (34
mothers, 17 fathers) exhibited major depressive symptoms, and 26%
of parents (16 mothers, 9 fathers) had decisional conflict with respect
to hospitalization in PICU. No significant relationship was found be-
tween psychological outcomes and parents' sleep duration and number
of nocturnal awakenings. Parents with moderately variable sleep (1–2
variable nights) evidenced fewer depressive symptoms and lower deci-
sional conflict. Greater social support was found to be protective against
poor psychological outcomes. Thus, the findings confirm that hospitali-
zation of children in the PICU is stressful to parents contributing to poor
psychological outcomes.
• A systematic review of research was conducted to evaluate the effec-
tiveness of pain management strategies during gastric tube (nasal or
oral) insertion for infants (0–12 months of age) (Chen, Zhang, Xie,
Wen, & Harrison, 2017). Research studies employing either randomized
controlled trial (RCT) or quasi-experimental designs published from
1946 to April 2016 were retrieved through electronic searches of multi-
ple databases, including MEDLINE, Embase, CINAHL, all EBM review,
Cochrane library, and Web of Science, as well as Chinese databases,
China National Knowledge Infrastructure (CNKI), WanFang database,
 B.J. Christian / Journal of Pediatric Nursing xxx (2017) xxx–xxx
and VIP journal integration. Of the 1236 articles (518 Chinese and 718
English articles) retrieved, six studies (5 English, 1 with English abstract
and Arabic full-text) met the inclusion criteria. All of the studies (N = 6)
evaluated the use of oral sweet solutions (24–20% sucrose or 25% glu-
cose) compared to water (placebo) or no treatment during gastric
tube (GT) insertion in newborn infants. Four studies measured pain
with the same instrument and demonstrated significant reductions in
pain scores in newborns during or immediately after GT insertion
when oral sweet solutions were employed as compared to placebo or
no intervention. The findings support the use of oral sweet solutions
as effective in reducing pain in newborn infants during GT insertion.
• An integrative review of pediatric fall risk assessment tools was
employed to synthesize the literature and provide recommendations
about the best tool for assessment of fall risk in hospitalized children
(DiGerolamo & Davis, 2017). A search of pediatric fall risk assessment
tools (ages 0–21 years of age) published between 2006 and 2015 was
conducted using two electronic databases, MEDLINE and CINAHL. Of
the 22 articles, 12 articles met the inclusion criteria and were evaluated
for evidence quality using the Johns Hopkins Nursing evidence apprais-
al method. Findings indicated that the majority of the available pediatric
fall risk assessment tools had poor reliability and validity, across institu-
tions and diverse populations of children. Additionally, few reports pro-
vided information about sensitivity and specificity. Thus, the evidence
suggests that further validation of the pediatric fall risk assessment
tools is warranted. To determine which pediatric fall risk assessment
tool is most appropriate, it is important to match the identified risk fac-
tors with the appropriate assessment tool and then validate the tool
with the specific pediatric patient population in the institution.
• A retrospective chart review using the electronic health record (EHR)
was conducted to evaluate the psychometric properties (reliability
and validity) of a new skin injury risk assessment scale (SIRA +
P) with patients from birth to adulthood regardless of acuity of illness
who were hospitalized in a free-standing, children's hospital, including
NICU, PICU, acute care pediatrics, hematology/oncology/stem cell trans-
plant, and fetal health center obstetric patients (Foster et al., 2017). The
SIRA + P scale was designed to be used within the EHR to facilitate skin
injury risk assessment. Sample participants (N = 385) were obtained
from the children's hospital and were stratified by age group: birth to
30 days (n = 150), 31 days to 17 years (n = 150), and 18 years and
older (n = 85). In comparison with other skin injury risk assessment
scales, internal consistency reliability for the newly developed SIRA +
P scale was reported as 0.556 (Cronbach's alpha), which was lower
than the Neonatal Skin Risk Assessment Scale (alpha 0.661), Braden Q
Scale (alpha 0.730), and Braden Scale (alpha 0.817). Interrater reliability
between the two nurse raters was high (ICC = 0.878). Concurrent va-
lidity for the SIRA + P scale indicated moderate to high correlations
with the three existing age-appropriate skin assessment scales: Neona-
tal Skin Risk Assessment Scale (r = 0.725), Braden Q Scale (r = −
0.634), and Braden Scale (r = −0.778), establishing concurrent validity.
Thus, the initial psychometric testing indicated that the newly devel-
oped SIRA + P scale was valid for all age groups regardless of acuity
of illness with greater sensitivity than the other three scales, although
the internal consistency reliability was low.
• A comparative, matched case control design was used to explore the
hospital course, treatment, and recovery of two toddlers hospitalized
with traumatic burn injuries comparing standard care (case A, Kesha)
with standard care augmented with essential oils (case B, Maria)
(Jopke, Sanders, & White-Trout, 2017). Data were obtained from the
children's electronic health records (EHR) comparing burn site descrip-
tion and treatment, number of days on ventilator, length of stay in PICU
and hospital, white blood cell count, blood stream infection, and pain.
On day 7, one girl's grandmother (case B, Maria) supplemented her
care by applying essential oils on the soles of her feet, as well as diffusing
essential oils into the air. There were notable differences with respect to
clinical outcomes along the course of treatment and recovery. The girl
(case A, Kesha) who received standard care alone was diagnosed with
Please cite this article as: Christian, B.J., Translational Research – Effective Communication and Teaching Strategies for Improving the Quality of
Pediatric Nursing Care for ..., Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.04.001
3
two blood stream infections and four hospital acquired infections. In
comparison, the other girl (case B, Maria) who received standard care
augmented with supplemental use of essential oils did not have any
blood stream infections and was diagnosed with one hospital acquired
infections, spent one day less in the PICU, and had length of stay of four
days less. Findings from the case study have implications for further re-
search into the role of essential oils in promoting wound healing, de-
creasing infection rates, and facilitating recovery following burn injury.
• An online, cross-sectional survey was used to explore pediatric inpa-
tient nurses' perceptions of child maltreatment using a standardized
questionnaire (Lavigne, Portwood, Warren-Findlow, & Brunner Huber,
2017). Pediatric inpatient nurses (N = 80) who participated in the sur-
vey were employed at a children's hospital in a large metropolitan area.
The overwhelming majority (78.75%) of the pediatric nurses had pro-
vided care for a substantiated case of child maltreatment and one-
third (33.75%) of the nurses had observed child maltreatment outside
of their work environment. The majority (87.5%) of these pediatric
nurses reported that they were confident in their ability to identify
child abuse and neglect, while 58.75% noted that they had received ad-
equate education about child maltreatment. An overwhelming majority
(98.75%) of the pediatric nurses reported that nurses are responsible for
identifying and reporting child maltreatment, although 40% revealed
that they did not know the applicable state reporting laws. Pediatric
nurses were grouped on the basis of whether or not they had encoun-
tered substantiated cases of child maltreatment and then their re-
sponses to 40 vignettes of child abuse and neglect were compared.
Findings indicated that there were significant differences between
groups for 7 of 40 vignettes with pediatric nurses who had encountered
substantiated cases of child maltreatment at work rating the vignettes
as more abusive. However, nurses who reported having adequate edu-
cation about child maltreatment rated all of the vignettes as less abu-
sive. Thus, findings suggest the lack of knowledge and need for
continuing education for pediatric inpatient nurses about the identifica-
tion of child maltreatment and legal reporting requirements.
• A quasi-experimental pretest–posttest design was employed to deter-
mine the effectiveness of an Asthma Action Plan educational program
using simulation that was taught by pediatric nurse practitioners
(PNPs) at a children's hospital to resident physicians (N = 26 partici-
pants, 24 resident physicians, 2 fourth-year medical students) to im-
prove their knowledge and confidence in teaching families
(Borgmeyer, Gyr, Ahmad, Ercole, & Balakas, 2017). PNPs who special-
ized in inpatient management of children with asthma and were certi-
fied as asthma educators developed the program that was comprised of
didactic content about the Asthma Action Plan, PNP-developed simula-
tion scenarios, knowledge test, and simulation evaluation using a stan-
dardized patient/parent actor with debriefing. It is noteworthy that his
asthma education program was previously implemented with more
than 100 nurses over six years. Findings comparing resident physician
knowledge pre- and post-simulation class demonstrated significant im-
provement in asthma knowledge on composite scores from 44.8% to
80.4% (p b 0.001). After taking the class, all participants identified the
perceived benefit of the class and 80.8% of the participants strongly
agreed that they felt more confident in teaching the AAP to hospitalized
children and their families. Thus, the PNP-led asthma education pro-
gram with simulation evaluation using a standardized patient/parent
actor was effective in improving resident physician knowledge and con-
fidence in teaching hospitalized children and their families about the
Asthma Action Plan in preparation for discharge.
• A secondary analysis of data from a longitudinal correlational study on
family self-management discharge preparation of hospitalized children
was used to explore the sequential relationships of parent perceptions
of the quality of discharge teaching, as well as nurse and parent percep-
tions of discharge readiness, as related to post-discharge outcomes of
coping difficulty at discharge and at 3-weeks post-discharge, and from
electronic health records for readmission and emergency department
visits at 30-days post-discharge (Weiss et al., 2017). Parents (N =
4 B.J. Christian / Journal of Pediatric Nursing xxx (2017) xxx–xxx
194) of children hospitalized for respiratory conditions or neurologic
disorders at a pediatric academic medical center were assessed for
their perceptions of the quality of discharge teaching and readiness, as
well as coping difficulties post-discharge. Simultaneous regression anal-
ysis indicated that higher quality of discharge teaching was significantly
associated with greater perceived readiness for discharge by parents
and nurses. However, the amount of discharge teaching content was
not significantly associated with discharge readiness. Parent perception
of higher discharge readiness was significantly associated with fewer
coping difficulties post-discharge. However, neither the quality of dis-
charge teaching to parents nor readiness for hospital discharge was as-
sociated with emergency department visits post-discharge. Thus,
higher quality of discharge teaching to parents was related to greater
readiness of parents for the child's hospital discharge and fewer coping
difficulties post-discharge.
• A prospective pilot study was used to determine the feasibility and
utility of a post-discharge home visit program for children with med-
ical complexity (CMC) who were at high-risk for readmission and
were discharged from an urban children's hospital (Wells et al.,
2017). Home visits were conducted by pediatric nurses within 72-h
of discharge from hospital with the goals of reinforcing education
and discharge planning, assessing the child's home environment, as
well as identifying and addressing any problems post-discharge to
prevent readmission. These children with medical complexity (N =
36) were all diagnosed with multiple chronic conditions and 89% (n
= 32) required medical technology assistance. During every home
visit, the nurse identified and addressed post-discharge problems
for all children (n = 36). Of the 147 post-discharge problems identi-
fied by the nurse during home visits, problems were categorized as
social/family issues (26.5%), medication problems (23.8%), durable
medical equipment (20.4%), unsafe conditions in the child's home en-
vironment (20.4%), and unresolved child health problems (8.8%). The
overwhelming majority (n = 31, 86.1%) of home visits required a
follow-up either by phone (93.5%) or with a second home visit
(6.5%). Further, for 88.9% (n = 31) of the home visits, the nurse
followed up with the healthcare team to triage problems identified
during the home visits. At completion of the home visits, families (n
= 18, 50%) were surveyed by phone to determine their level of satis-
faction with the home visit. Families were highly satisfied with the
home visit experience and with the nurse's ability to address identi-
fied problems. Thus, the post-discharge home visit program for chil-
dren with medical complexity delivered by pediatric nurses was
found to be feasible and successful in addressing problems at home.
As highlighted by these articles in this special issue on hospitalized
children, translation of research evidence into pediatric nursing practice
improves communication processes between parents, nurses and
healthcare providers, identifies new strategies to reduce risk and im-
prove care of hospitalized children, and enhances teaching about care
and coordination of care with discharge planning. To that end, this evi-
Please cite this article as: Christian, B.J., Translational Research – Effective Communication and Teaching Strategies for Improving the Quality of
Pediatric Nursing Care for ..., Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.04.001
dence about the essential need for effective communication, teaching
best practices of care, and new intervention strategies leads to im-
proved hospitalization experiences for children and their families, as
well as improved quality of care for children, ultimately advancing pe-
diatric nursing practice.
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