Hospitalized Children’s Views of

the Good Nurse

Mary Brady
Key words: communication; hospitalized children; professional competence; professional
appearance; safety; virtues

Research relating to patients’ views of the good nurse has mainly focused on the perspec-
tives of adult patients, with little exploring the perceptions of children. This article presents
findings from a qualitative study that explored views of the good nurse from the perspective
of hospitalized children. The aims of the study were threefold: to remedy a gap in the
literature; to identify characteristics of the good nurse from the perspective of children in
hospital; and to inform children’s nursing practice. Twenty-two children were interviewed
using an adapted ‘draw and write’ technique. Five themes relating to children’s views
of the good nurse emerged from the analysis: communication; professional competence;
safety; professional appearance; and virtues. Each of these will be discussed in relation to
good nurse literature and recommendations made for children’s nursing practice.

Introduction
An aspiration to be a ‘good nurse’ is an ethical imperative for those within the pro-
fession. Ethical nursing, it has been argued, occurs when good nurses do the right
thing.1 However, it is not always clear what is meant by a ‘good nurse’. Professional
codes, for example, detail the duties and virtues of the good nurse from the perspective
of professional organizations. Increasingly, there is recognition that patients’ views of
the good nurse are important. Previous research has focused on the perspectives of
adult patients and there has been little exploration of the views of children.
In this article, findings from a qualitative research project using an adapted form of
the ‘draw and write’ technique will be outlined. Twenty-two children, aged between
seven and 12 years, who were inpatients on a paediatric unit in England, participated
in the project. The themes that emerged from the data analysis and implications of the
findings for children’s nursing practice will be discussed.

Address for correspondence: Mary Brady, Faculty of Health and Social Care Sciences, Kingston
University & St George’s University of London, Cranmer Terrace, London SW17 0RE, UK.
Tel: +44 (0)20 8725 0815; Fax: +44 (0)20 8725 2248; E-mail: m.brady@sgul.kingston.ac.uk

Nursing Ethics 2009 16 (5) © The Author(s), 2009. 10.1177/0969733009106648

Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
544 M Brady

Background
The concept of the ‘good nurse’ is dynamic and subject to the influences of society,
culture and political reform.2,3 Views of the good nurse are, therefore, likely to vary
across cultures and may evolve slowly over time. Historical portrayals of the good
nurse emphasizing, for example, virtues and excellences such as devotion, obedience
and meekness,4 seem out of step with contemporary portrayals of the good nurse.
Professional codes provide guidance on the profile of the good nurse, generally in the
form of duties, responsibilities and virtues. The UK’s Nursing and Midwifery Council
code,5 for example, requires nurses to be respectful of the individuality, dignity and
confidentiality of patients and to be trustworthy and to act with integrity. This code also
requires nurses to keep their knowledge and skills up to date and to base their practice
on the best evidence. The International Council of Nurses6 code of ethics emphasizes
nurses’ responsibilities to people, practice, the profession and co-workers. Helpful
as the guidance in codes may be, it is generic and does not and cannot address the
particularities and nuances of children’s nursing practice, nor does it provide insight
into views of the good nurse from the perspective of particular patient groups.
Research exploring patient perspectives on the good nurse has focused on the
views of adult patients.1, 2 Findings from these projects detail a wide range of features
of the good nurse, most commonly in relation to knowledge, skills, characteristics,
attributes or qualities. Rush and Cook’s3 findings highlighted the importance of good
communication, respectful attitudes, attributes and behaviour (e.g. looking smart),
having appropriate clinical skills and knowledge. That study surveyed the views of
patients of all ages and carers; however, the children consulted were schoolchildren
and may not have had hospital experience. The largest study of (adult) cancer patients’
views of the good nurse has been in progress in five countries since 2004 and has
detailed good nurse virtues, good nurse work and the impact of the good nurse.7
To date, there has been little explicit attention to the perspective of children and to
the features of the good children’s nurse. A qualitative study by Carter,8 which did
not focus explicitly on the good nurse, involved interviews with 10 children aged 2–13
years, in their homes, regarding their perceptions of a children’s community nursing
team. She used a variety of imaginative methods (e.g. scrapbooks, photographs, inter-
views, stories and poems) to elicit valuable information. For instance, although the
children (who all had complex needs or siblings with complex needs) valued technical
expertise, they also wanted a nurse who was ‘nice’ and ‘fun’. Listening was another
important issue for these children and this was also highlighted by Forsner et al.,9 who
reported that not being ‘listened to’ made the hospital experience very unpleasant.
Children’s nursing has much in common with other branches of the profession but
there are also differences. Children’s nurses have knowledge of the psychosocial and
biological development of children and, in common with all nurses, they are a com-
munication conduit owing to their contact with members of the multidisciplinary team.
Children and families are an integral part of that team, facilitated by the children’s
nurse, who works in partnership with them to provide care. This focus on working in
partnership underpins the current philosophy of UK children’s nursing and has been
incorporated into much of the current child nursing literature to enhance and advance
nursing care.10–12 In addition, current guidance in England places children at the centre
of care provision, for example, the Children Act13,14 and the National Service Framework
for children, young people and maternity services.15 Furthermore, it is recognized that
children are frequent health service users, accounting for about one third of accident

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 Hospitalized children’s views of the good nurse 545

and emergency department attendances,16 yet they are rarely consulted and their views
are often misinterpreted.17
The study described here, therefore, set out to explore hospitalized children’s views
of the good nurse. The aims were to remedy a gap in the literature, identify the char-
acteristics of a good nurse from the perspective of children in hospital and to inform
children’s nursing practice, thereby facilitating the provision of care that meets the
needs of hospitalized children.

Method
This study used a grounded theory approach, in which theory is discovered by collecting
and analysing data relating to a phenomenon.18 Grounded theory was developed by
Glaser and Strauss.19 Their original methodology was chosen because it focuses on the
description and generation of theory from data by an ongoing process of comparative
analysis using open and theoretical coding that allows codes to emerge. This permits
theory to be generated without the rigidity of other research methods. As an inductive
(bottom-up) process, it is a method that facilitates the identification of the concerns of
the research participants rather than the researcher and these emerging ideas can be
described as grounded in reality. It enables new theory to be discovered and generated
without biasing the process. Thus the rationale for choosing this method was its suit-
ability for assisting children20 to articulate issues that are important to them.
The use of art work can facilitate data collection from children about their lived ex-
perience. Art work is recognized as a powerful communication tool21 that promotes the
building of a rapport between the child and the researcher, thus enabling emotions and
thoughts to be expressed and empowering the child research participant.22,23 In parti-
cular the ‘draw and write’ technique has been gaining popularity with researchers.8,24,25
This is a method whereby the participant draws a picture and the researcher uses that
drawing as a basis for his or her questions. The drawing is not subject to deep ana-
lysis.26 Instead, it is visually analysed and used as the focus for the interview with the
child. In Sartain et al.’s27 study of six children aged 7–12 years, drawing enhanced
the children’s ability to talk about their experiences of chronic illness. However, they
observed that older children did not enjoy the same experience. Furthermore, Nic
Gabhainn and Kelleher28 observed in their study that girls were keener to draw than
boys. Driessnack’s20 meta-analysis of the ‘draw and write’ technique appraised six
fairly small studies (average cohort 40) and demonstrated that this method was useful
for facilitating information retrieval from children’s memories, which further strength-
ened its potential for use in this study.
In the present study, the researcher provided a pencil and some paper and asked
the child participants to draw a picture of a good and a bad nurse. Once the children
had completed their picture, she used a mixture of closed and open-ended questions
to explore the drawings, such as: ‘Tell me what sort of dress the nurse is wearing’,
‘What is the nurse doing?’ and, ‘Why is she doing ... ?’ These interviews were taped
and transcribed afterwards by the researcher. At times during the interviews a child
described characteristics that led the researcher instinctively to reflect back on to
her own practice and she entered these points in her field notes for later use during
the analysis phase. The use of field notes helped to capture the child’s non-verbal
expressions and how the researcher felt at the time.

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Ethical considerations
The project was scrutinized by a local research ethics committee and it received a
favourable ethical opinion. The hospital Research and Development Committee also
granted approval for the study. The support of the Director of Nursing Services and
the senior nurses in the paediatric department was also sought and obtained.
Issues of consent and confidentiality are cornerstones of ethical research practice.
The researcher was aware that children often have the capacity to consent and make
decisions about participating in research, despite being unable to give legal consent.13
To aid decision making, information leaflets about the study were produced in several
formats (for the parents, children and staff). In addition, an assent form was developed
to obtain proof of the children’s understanding and willingness to participate. Data
from the project was anonymised and the confidentiality of participants respected.

Data collection and analysis

Prior to recruitment and data collection the researcher briefed the senior nurses in the
paediatric department about the study and sent an information sheet with a covering
letter to each member of the ward staff. The researcher visited the paediatric wards
several times each week and asked staff to recommend suitable children to approach.
Nursing staff were asked to identify children because it was important that they had
sufficient cognitive and linguistic skills to understand the study and were able to
communicate with the researcher.29,30
The researcher first introduced herself and the study to potential child participants
and their families. If they were interested she discussed the study further with them
and provided some written information. Any questions were addressed and it was
stressed that the children were not obliged to participate. The researcher arranged
to return when they had had the opportunity to consider taking part. Consent and
assent were obtained at this second meeting. Crucially, the children had to be willing
to participate in the study.

Participants
The children were selected from a large paediatric department in one NHS trust situated
in a multicultural city in Southeast England. With grounded theory it is difficult to pre-
set the amount of data to be sought because the researcher should aim for saturation, a
point where no new data are obtained.31,32 However, since the researcher was limited to
a four-month timeframe, it was this rather than saturation that influenced the amount
of data obtained.
Inclusion and exclusion criteria were developed to focus on a group of children who
possessed the cognitive ability and physical skills to take part in this study and who
were willing to participate.
Twenty-two children (11 boys and 11 girls) were interviewed and five and a half
hours of interview data were obtained over a four-month period during the winter of
2006–2007. The children were from a variety of ethnic backgrounds with an average
age of 9.9 years and had been hospitalized for a variety of reasons (Table 1).
Provided that the timing was convenient for the child, the researcher asked the child
to draw a picture of a good and a bad nurse. Afterwards she used this drawing as a
basis for her questions. The researcher did not provide a definition of ‘good’ or ‘bad’

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 Hospitalized children’s views of the good nurse 547

Table 1 Children’s background information

Name Sex Age (years) Ethnicity Reason for hospitalization

Freya Female 8 White Renal surgery
Bilal Male 9 Asian Asthma
John Male 12 White Unknown
Jamela Female 8 African Sickle cell disease
Jason Male 11 White Cardiac condition
Jane Female 11 White Pyleonephritis
Donna Female 11 Mixed race Afro- Asthma
Caribbean
Richie Male 12 Afro-Caribbean Acute lymphoblastic leukaemia
Martin Male 10 White Unknown
Matthew Male 8 White For removal of coin
Susan Female 9 White Unknown
Rebecca Female 11 South American Weight loss; ?cause
Laura Female 11 White Eye operation
Leo Male 10 White Unclear; on bed rest
Archie Male 7 Mixed race Afro- Asthma
Caribbean
Luke Male 12 White Asthma
Eloise Female 12 African-Chinese Removal of ovarian cyst
Karen Female 8 Afro-Caribbean Facial palsy
Molly Female 10 White Fractured left arm
Dwayne Male 10 Afro-Caribbean Peritonitis following ruptured
appendix
Anna Female 11 White Eye infection
Dean Male 7 Afro-Caribbean Ulcerative colitis, campylobacter
infection

for the child because she wanted to gather the child’s interpretation without influenc-
ing the child’s ideas. The interview was taped and transcribed by the author, who then
analysed the data with the help of an experienced researcher. The initial interview acted
as a pilot and, since no changes were subsequently made to the interview process, this
was included in the data.
Seventeen participants drew pictures. The remaining five (Table 2) were also keen to
contribute: one wrote and the others were interviewed and asked to imagine what they
would have drawn and describe that. Although drawing may have helped to build
rapport with these children, the interviews contained valuable data.
There is no single recommended method for analysing qualitative data, thus ensur-
ing the accuracy of such data is vital if they are to be of value.33 Ideally the chosen
method should produce reliably similar data if repeated in similar circumstances. In
addition, researchers need to be aware of their own preconceptions and, if possible,
review the transcripts of the interviews with the participants to ensure clarity, rigour
and accuracy.18,34 Unfortunately, the researcher was not able to do this, which is a
limitation of this study but, when she interviewed the children about their drawings,
she was also facilitating clarification of their interpretations of the good nurse, while
checking for accuracy. In addition the researcher kept field notes detailing her own
interpretations, the non-verbal behaviour of the children and any events that occurred
during the interviews, such as visits by staff to the children.

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Table 2 Reasons for refusal to draw

Name Sex Age (years) Reason given by child

John Male 12 Did not like drawing
Susan Female 9 Wrote instead
Rebecca Female 11 No good at drawing
Dwayne Male 10 Did not want to draw
Anna Female 11 Soreness from cannula recently removed from hand

Results and discussion

The interview data and drawings were analysed for emerging ideas using a constant
comparative approach to compare and group together the data under common head-
ings. This resulted in five themes that highlighted important characteristics of the good
nurse: communication, professional competence, safety, professional appearance and
virtues. Each of these themes will be discussed in turn using some of the children’s
drawings and quotes for illustration. To protect each child’s identity pseudonyms have
been used.

Communication
Communication has been identified as a vital component of the good nurse’s attributes.3
The children in this study reported that the good nurse used ‘terms of endearment’
when communicating with them, for example:

... she calls me sweetie pie. (John age 12)

Hiya, alright darling, let’s get you better. (Richie age 12)

This made them feel special and is in contrast to research relating to older participants
as described in Woolhead et al.’s35 qualitative study (n = 72), where being overfamiliar
with a patient was seen as disrespectful.
The children appreciated being praised by the nurse for their bravery during un-
pleasant procedures or when having to take distasteful medicines, which perhaps
demonstrates the nurse’s empathy with the child.

... maybe, sometimes just to like tell ‘em well done for being a good person because they’ve
just had an injection or something and it really hurt. (Anna age 11)

The children were sensitive to the nurse’s tone of voice and body language. Many
stated that good nurses did not shout and used a ‘nice’, ‘calm’, ‘relaxed’, ‘cheerful’,
‘kind’ tone of voice to speak to them. The bad nurse was ‘bad tempered’, ‘bossy’,
‘angry’, ‘grumpy’, ‘moaning’, ‘shouted’, and did not listen to them, whereas the good
nurse was willing to listen and spend time with them. For instance, Laura (age 11)
observed that nurses should sit down and meet children at their eye level; this is in
support of current literature.36 Comments about being listened to have previously
been highlighted by Carter8 and by Forsner et al.9 Forsner et al.’s9 participants were

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 Hospitalized children’s views of the good nurse 549

previously well children who described ‘feeling lost in their bodies’. It is suggested
that hospitalization disempowers children, rendering them helpless.
It was evident that the children formed opinions about nurses by integrating appear-
ance and body language with the spoken word, such as their demeanour (face and
body), hand position, body posture and gait. Smiling and ‘smiling eyes’, in particular
were frequently mentioned and the children appeared to be able to differentiate
between types of smiles and nurses’ sincerity. Leo (age 10) thought that if nurses had
their thumbs in their pockets they would appear ‘stroppy’ and this would imply that
they were not listening and did not care. Donna (age 11) described the bad nurse as
‘louching’, by which she meant hands on hips. Her drawing depicted a nurse who was
smiling but not listening to her patient (Figure 1).
In eight-year-old Matthew’s drawing of the bad nurse, the nurse was absent because
no one came to deal with his empty intravenous fluid bag, whereas the good nurse was
the person who came and replaced the bag (Figure 2).
The children observed that sometimes nurses walked promptly to deal with a
patient, but this could evoke fear or make a child worse (Donna age 11), while others
walked quickly to avoid the patient or without paying much attention to their work.

If I was really ill, really ill as I am now, the nurse, just like, if she like, just rushed me
around and then she just leaves me or rushes to do whatever she has to do ... make it
[asthma] worse. (Donna age 11)

There was also an acknowledgement of the role of reciprocity in children’s

relationship with nurses. Bilal (age 9) stated:

A good nurse I think probably like ... if you treat her with like good stuff, if you maybe
smile ... if you like, do something for her or smile and take it she might like smile back to
you and say that ‘Oh I really like you, you are a really nice boy or girl’.

Figure 1 Donna (age 11)

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550 M Brady

Figure 2 Matthew (age 8)

In discussing her drawing, Jane (age 11), whose mother was a health care profes-
sional, talked of the importance of patience and politeness. She also revealed an
awareness of reciprocity, albeit in negative terms:

They’re manners at the end of the day and you don’t want to be rude to them otherwise
they are gonna be rude to you and it causes violence and that’s what the hospital doesn’t
want.

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 Hospitalized children’s views of the good nurse 551

Professional competence
Previous good nurse research had highlighted the importance of professional com-
petence to patients12 and demonstrating professional knowledge and skills was, it
seems, as important to children as to adult patients. The good nurse was expected to be
knowledgeable, although the children were often unclear where this knowledge had
been acquired:

... ’qualified’ or ‘educated’ ... (Leo age 10)

... or see it on the television in a ‘Doctor film.’ (Archie age 7)

The participants also expected a good nurse to be organized and able to perform cer-
tain skills competently and promptly, and do them no harm, as illustrated in Figure 3,
with the good nurse celebrating her competency at venepuncture with a raised syringe,
in contrast to the bad nurse who was unable to take blood. Some of the children had
very specific knowledge about how their care should be administered and were critical
of nurses who deviated from this, for instance, by not washing their hands, or not
wearing gloves and aprons.
Some children described the good nurse as someone who administered intravenous
drugs slowly and knew which drugs were particularly painful for them to receive, and
made efforts to reduce the unpleasantness. In contrast, the bad nurse gave intravenous
drugs too quickly. Other children thought that a good nurse would try to give more
pleasant tasting medicine where possible and make an effort to take the unpleasant
taste away afterwards. Jason and Rebecca (both age 11) expected the nurses to give
medication on time and to come promptly when called. Eloise (age 12) believed that if a
nurse did something in a careless way it would imply that the nurse did not like her.

Figure 3 Archie (age 7)

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552 M Brady

Safety
Safety was a strong theme in the data and related to children’s concern about cross-
infection, unsafe behaviour and safeguards to ensure that nurses and others were
not fraudulent or fake. The latter point was supported by the many references to the
importance of name badges and identity verification, as expressed by Martin (age 10):

‘Cos like, I don’t know them ... I would say show me your pass and stuff.

Anna (age 11) thought that good nurses were safety conscious and concentrated on
their work. Good organizational skills were described by Susan (age 9), who observed
that the good nurse came prepared with the appropriate equipment.
Being clean and having clean hair appeared to be a common concern for many
children, who thought that a nurse with dirty hair might have head lice that would
spread to the children and staff. This could relate to their school life where head lice are
often prevalent, with various inaccuracies circulating regarding the preference of lice
for dirty hair and their association with children from more deprived backgrounds.37
The children were also aware that hair could drop into food or wounds and that this
would be unpleasant and perhaps harm them. Furthermore, Anna (age 11) thought
that it depended on the type of patients the nurse was caring for, because small babies
might pull loose hair.
Many of the participants, such as Jason (age 11), were aware of their vulnerable
status as sick children in hospital, highlighting handwashing and general cleanliness
to avoid the spread of infection (Figure 4).
Some of the children believed that the good nurse should be a role model for good
health, as illustrated by Eloise (age 12), who questioned nurses’ ability to care for others
if they were unhealthy. They were concerned about the nurse having a very spotty
face, implying that she was unhealthy and could make them unwell, whereas an overly

Figure 4 Jason (age 11)

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 Hospitalized children’s views of the good nurse 553

made-up nurse was viewed as having an ‘inappropriate appearance’. Jane (age 11)
stated that, as hospital representatives, they needed to reflect this in their clothing. For
her, the bad nurse was depicted wearing too much make-up and unhygienic clothing
that was torn (Figure 5).
Types of footwear were often discussed by the children, with the good nurse wear-
ing ‘sensible’, ‘black’, ‘laced up’ or ‘wrap over’, ‘low-heeled’ shoes that were ‘non-slip’,
similar to school shoes.

... slip-on shoes ... which aren’t very good to walk about in because they could just come
off and when you are a nurse you have to do a lot of walking about to get to the patient, so
it wouldn’t be very good if they kept on coming off. (Susan age 9)

Anna (age 11) was also concerned about safety issues relating to younger children
when nurses carried scissors around in their pockets.

... carry around scissors ... I don’t think that’s very good because some children might ...
just take them out and do stuff, cut the wires ... (Anna age 11)

The emphasis on safety was integral to competence and, it seems, more pronounced
in relation to an awareness of the possibility of infection and fear of contamination.
Certainly, at least three of the children (Jason, Richie and Susan) had a high level of
awareness of infection control and of their own vulnerability to infection and could be
described as ‘expert patients’.38 Hygiene was a topic also raised in Rush and Cook’s3

Figure 5 Jane (age 11)

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study, which suggests that children are acutely aware of the risk of infection, despite
lacking an in-depth knowledge of micro-organisms.

Appearance
Several of the children had conservative opinions about nurses’ appearance, for
example, Anna (age 11), who described the good nurse as ‘graceful’, and Dean (age 7)
who spoke of the good nurse as looking ‘decent’. The majority expected the nurse to
wear a uniform that was neat, clean and identified him or her as a hospital employee.
A few children drew or described nurses wearing dresses or skirts with socks, which
perhaps reflects aspects of their own clothing rather than that of an adult.
‘Sensible’ and ‘professional’ hairstyles were frequently mentioned and two children
drew nurses with hairstyles that reflected a style currently popular with young ado-
lescents. Others referred to sensible school-type shoes and were opinionated about
fashionable clothing. This may suggest that children are accommodating to certain as-
pects of fashionable attire for nurses as long as they remain, in their opinion, ‘sensible’
or ‘professional’. The researcher suggests that the children were comparing current
fashion trends with their appropriateness for the nurse at work and making value
judgements using their own life experiences.
Crosses were often drawn on the nurse’s hat or uniform. When questioned, the
children stated that a cross identified the nurse as belonging to the hospital; thus it ap-
peared to provide corporate identity. It is also interesting to note that, although nurses’
uniforms have changed over recent years, dressing-up clothes and children’s books
still depict nurses in traditional attire. The researcher suggests that this may have
influenced the children’s opinions.
There appeared to be some confusion about the roles of nurses and doctors, as
reported by Rossiter et al.,39 who investigated nursing as a possible career option. This
confusion is contrary to findings in McDonald and Rushforth’s40 study (n = 63), which,
however, addressed the allocation of tasks by doctors and nurses. In the present study,
some children linked gender and profession, believing that all doctors were men and
all nurses were women. This was illustrated by Martin (age 10) who clearly thought
that doctors were men and would therefore not wear dresses:

What kind of doctor would come in in a dress? (Martin age 10)

Anna (age 11) clarified that, although in her opinion, women might make more careful
surgeons, she would prefer a man surgeon. The wearing of a stethoscope appeared to
suggest a role distinction for some children: for instance Luke (age 12) suggested that
the difference between nurses and doctors was that nurses did not wear stethoscopes,
in contrast to seven-year-old Dean (Figure 6), whose drawings of the good and bad
nurses were identical except for the stethoscope worn by the good nurse.
The researcher suggests that the children were relying on their limited life experience
(access to media images, dressing-up clothes, previous hospital experiences and books)
to distinguish between these roles. Additionally, although young, the majority of the
children expressed traditional and conservative views about appearance. For instance,
often the choice of footwear was in keeping with guidance on school uniform (Anna,
age 11) and the nurse was expected to wear a traditional uniform and be ‘neat’, ‘tidy’,
‘decent’ and ‘graceful’.

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 Hospitalized children’s views of the good nurse 555

Figure 6 Stethoscope by Dean (age 7)

Virtues
The children who participated in the project referred to many ethical and social
qualities, character traits and virtues of nurses. Virtues can be defined as networks of
dispositions to feel, think and act in particular ways, for example, justly, respectfully or
courageously.41 Some of the virtues identified in this study have appeared previously in
the literature.3,42–44 Characteristics such as ‘honest’, ‘listening’, ‘trusting’, ‘nice’, ‘helpful’,
‘gentle’, ‘kind’, ‘reassuring’, ‘polite’, ‘cheerful’ and ‘friendly’ were highlighted by the
children. They appreciated honesty, especially about procedures that would be painful,
and afterwards being praised for their bravery. The children particularly valued the
friendship and courtesy that was extended to their parents and other visitors. This
has not appeared in previous literature but supports some of the work of Smith et al.45
regarding family-centred care. In addition, the children also referred to social virtues
such as humour and politeness. They highlighted the importance of nurses being able
to joke and have fun with them and of laughing together. Being polite was also an
important characteristic of the good nurse. As parents and teachers frequently expect
children to be well behaved, it is possible that they looked for this in others such as the
nurses who care for them.
Some children observed that good nurses could be both good and bad when they
had to encourage the children to take unpleasant medicine or do something that would
be painful. Others, such as Luke (age 12) mentioned the evil nurse (Figure 7). They
drew and described extreme examples of badness, perhaps owing to their stage of
moral development, imaginations or poor linguistic ability.
It is suggested that some children appeared to balance the good and bad characteristics
of an individual nurse when making an overall value judgement. This seems to reflect
Kohlberg’s46 work on moral development, in which he proposed that, at about 10 years
of age (the average age of the children in this study), children begin to make higher level
moral judgements (conventional morality). At this stage children begin to consider
how actions may be viewed by others rather than whether they are punishable or merit
a reward. However, this is a gradual process that appears to depend on children’s life
experiences, gender and parental influence.47

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556 M Brady

Figure 7 Luke (age 12)

Trustworthiness is an important virtue.41,48 As a vulnerable child in hospital, trust

in the good character and competence of nurses is important. However, in contrast,
children are also encouraged to be wary of strangers in an effort to maintain their own
safety. Several of the children thought that a good nurse would be wearing an identity
badge or sign that denoted they were legitimately working at the hospital. Karen (age 8)
supported this by voicing her concerns that the bad nurse might be pretending to be a
nurse and have evil intentions, manifested, for example, by giving incorrect amounts
of medicine. Leo (age 10) suggested that the bad nurse might be dishonest and lack
the ability to perform skills appropriately. For Jane (age 11) it was important to see
the person’s hands to convey trust; she disliked seeing men with their hands in their
pockets and felt it was a bit ‘suspicious’. Two children (Matthew, age 8, and Anna,
age 11) discussed the importance of the nurse taking her job seriously, concentrating
and ‘not mucking about’. One could postulate that, in the light of the malpractice and
negligence claims against hospital staff that have featured in the media, children may
have a heightened awareness of such issues.
Carter’s8 study of children involved in a community nursing scheme demonstrated
the importance of the nurse being ‘fun’ and ‘nice’. This was repeated in this study,
where the children described how the good nurse watched television with them or
made them laugh. As hospital inpatients, children lose some of their normal freedoms
and live in an often unfamiliar environment. Having fun helps them to cope with this
reality. Sometimes the children implied that the good nurse did not ‘stick to the rules’
and therefore made their hospital stay ‘fun’. This has resonance with Cooke’s49 literature
review about scapegoating, where sometimes an unpopular nurse is unpopular with
colleagues but not with patients. Popularity with the patients may be because the nurse
is patient centred and gives the impression of breaking a few rules in patients’ best
interests.
The importance of play was highlighted by most of the participants who saw the
good nurse as ‘fun’ and someone who played or spent time with them, distracting
them from what was happening on the ward. However, there was an appropriateness
to the humour, as denoted by Anna (age 11), who stated that the good nurse could
have a few laughs with the patient but also had to concentrate and ‘not muck about’.

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 Hospitalized children’s views of the good nurse 557

For Susan (age 9), the nurse who lacked imagination was deemed ‘boring’ and ‘not fun’
to be with. Jason (age 11) had experienced care in several hospitals and was critical of
some wards where the nurses were too serious and not enough fun.

Study limitations
The data collection was conducted over a relatively short period. More time would
have yielded more data from a wider range of children, although often certain themes
reappeared and the amount of new data was beginning to shrink. This suggests that
the breadth of the data was approaching its maximum.
Ideally, the researcher should have included a review of the interview transcript
with each child participant to ensure validity and reliability.32 However, by reviewing
the drawings with the children she was clarifying the meanings behind them.
The study excluded a number of children whose inclusion may have provided new
data, for example, those who were critically unwell, mentally or physically disabled, or
had a limited ability to speak English. This suggests areas for future research.

Conclusion
This study achieved its broad aims of identifying those characteristics that are per-
ceived by hospitalized children as belonging to the good nurse, remedying a gap in
the literature as well as identifying implications for practice. Some of the findings are
supported by previous research and highlight the importance of having nursing staff
that are role models for good health, are competent and knowledgeable, and have an
understanding of the needs of children. A fundamental need for hospitalized children
is that their family is included in their care provision.45,50 Children’s nurses also need
to be able to combine technical skills with the characteristics that are appreciated by
children, such as being fun and being able to incorporate fun into care activities. This is
integral to children’s nurse training, where child development is linked with the practical
use of age-appropriate toys and activities, plus distraction techniques. However, in
the practice area this can be a forgotten aspect of nurses’ scope of knowledge as they
address the more technical aspects of their role.
Although children may not have fully developed the linguistic skills necessary
to state their opinions, this study demonstrates that they have an understanding of
meaningful care by good nurses and are capable of communicating this to others. In
addition, despite their limited life experiences, the children in this study were able to
demonstrate insights into possible reasons for poor nursing behaviour. Indeed, some
of them had begun to exhibit a developing sense of moral judgement regarding the
complexities of ‘good’ and ‘bad’. Although trustworthiness of the nurse was valued,
the older children were more discerning. Trustworthiness included the ability to be
truthful about future unpleasant procedures and treatments, and also to be prompt
and competent in dealing with the children. The children in this study were sensitive
to whether or not the nurse liked them. They appeared to appreciate being valued
positively, as demonstrated by the nurse being attentive, spending time with them,
and using praise and endearing terms when communicating with them.

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558 M Brady

Further research concerning the perceptions of the good nurse could include more
in-depth studies using a broader sample of children, including those with chronic dis-
abilities who experience frequent nursing care. It would also be of interest to address
which characteristics are ascribed greater importance by children when using a quanti-
tative method and to research whether this hierarchy of characteristics changes with
age and maturity.

Conflict of interest statement

The author declares that there is no conflict of interest.

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