Introduction

Excellence is a forefront issue for those providing and those in need of healthcare services; however, in the often turbulent and competitive healthcare environment with continuously limited resources and increasing needs, maintaining a balance between quality and cost is challenging. Patient satisfaction has become an established outcome indicator of the quality and the efficacy of the healthcare systems. (1)

There is evidence that satisfaction is an important outcome measure, both because it is related to improvement in health status and because it is useful in assessing patterns of communication. The latter is particularly important in pediatric care, because the quality of care needs to satisfy both children and accompanying parents. (2)

In pediatric care, it is usually the parents and caregivers who are consulted on their children’s experiences. The extent to which parents can appropriately represent their child’s experiences though may be limited. The best way to understand children’s experiences is to ask them. However, collecting data from children involves several ethical and methodological dilemmas, such as questions related to informed contest, privacy, confidentiality, children’s competence, cognitive capacity, and methods of data gathering.

The United Nation Convention on the Rights of the Child says that children have the right to be consulted and to express their views freely in all matters affecting themselves (3).

The American Academy of Pediatrics (AAP) committee on Bioethics acknowledged in their 1995 report that children are intelligent, capable persons, worthy of respect and able to provide assent in pediatric practice. The committee clearly stated pediatric patients should be allowed to participate in health care decision making appropriate to their level of development. (4)

There are only few studies that measure the quality of pediatric care from children’s perspective. The main concern in these studies is with children’s satisfaction with medical care. Sources of dissatisfaction include insufficient information, pain management, problems with communication and a chance to play. (3)

Children want to be heard and consulted and the evidence suggests that the promotion of children’s autonomy leads to enhanced wellness and improved health outcomes. Therefore, health professionals should commit themselves to assessing children’s views in service delivery, which could lead to more focused and relevant services for children. (3)

Drawing is one of marvelous way of children’s presenting knowledge about different phenomenon, people and situations. Drawing is an art expression which clarifies children’s thoughts verbalizing them. Also, it has special relation value and containing particular codes and mixed meanings.

Children’s drawing is among the most versatile tools available to nurses. They can be used for developmental assessment, knowledge assessment, diagnosis of emotional disturbances or abuse, therapeutic intervention, or simply as a developmentally appropriate play activity for children. Drawing requires skills that are refined with age along with opportunities to practice, and it involves the integration of fine motor skills, eye-hand coordination, and cognitive development. (5)

Drawing are popular projective techniques, based on the assumption that drawings reflect a child’s self-concept, attitudes, and conflicts, and represent emotions or thoughts that children are unable or unwilling to verbalize. Indeed, drawing provides important insight into child’s world. (5)

Therefore, due to the appropriateness of drawing as a method of evaluating children’s thoughts and emotions, this study was designed to assess children’s satisfaction of nursing care by use of their drawing.

Material and methods:

This study was done with 20 hospitalized children aged 6-12 years in medical and surgical wards of Dr. Sheikh pediatrics hospital in Mashhad who were hospitalized at least for 2 days. In order to gathering data a blank A4 size paper and 12 color pencils was given to participants and asked them to draw what they’ve been thinking about nursing and their interventions. Parents, if they wish, could assist their children.

Children’s name, sex, age and disease were written on the back of drawing paper. Each drawing was analyzed based on Plander et al scale (2007). This scale was developed in 2007 for assessing hospitalized children’s thoughts about quality of hospital and nursing interventions. It includes two subscale of hospital (hospital building, patient’s room, furniture and accessories, and nursing tools) and peoples (the patient, parents, and nurses). The scale has content validity and reliability of α=0.89. Results:

Most of participants were boys (65%), and hospitalized in medical wards (60%). Children’s sex and hospitalized wards distribution are shown in table 1.

In patient’s room no entertainment tools, toys or even readings were drawn. Most of drawings had bed as furniture and among nursing instruments; Intravenous fluids tube had been painted in most works (90.0%).

In all drawings the child was happy and in most was resting on a bed instead of playing or sitting (80%, 20%, and 0.0%, respectively). None of children had drew their parents; although, in all times during hospitalization they are near children. Three of children hadn’t drawn nurses and some of them drew two nurses of both sexes in their works. All of drawn nurses were happy and color painted. 

Discussion

There is a worldwide trend toward involving patients in health care, but not much is known about children’s expectation of an ideal hospital or nursing care. We set out to assess the children’s satisfaction by asking them to draw their perception of nursing care.

Art is a process by which thoughts, feelings, behaviors, and relationships can be translated into concrete images. Children’s drawings have been used in clinical interviews to provide direction for recollection and memory of events. Drawings encourage the retrieval of experience in the motoric, visual, and auditory recall. The drawing itself gives an expression of motor sensory discharge; the objects in the drawing help with the perceptual cues that are remembered, the cognitive dimensions are represented in the organization, interpersonal patterns, and verbal discussion of the picture.  (10). 

Children drew nurses, environment and themselves in different ways. Although, most of nursing procedures (such as injection, IV- line catheterization and etc.) are painful and expected that children to be unsatisfied; most of them drew themselves and nurses happy and use colorful cloths which indicates their happiness and satisfaction of nursing. Also, most of nurses were drawn during amazing children rather than nursing interventions.

Previous studies (3 and 7, 8) have also highlighted the possibility of assessing children’s satisfaction by asking themselves and drawing is an invaluable source of information. Drawing is a method that yields a specific kind of information that no other method can offer. (6) Slusarka et al found the most of children drawn nurses and themselves smiling like our study; in one of their works a nurse had drawn during giving her heart to the child or in another she painted as a fairy (7). Unlike our study that most of nurses were drawn during treatment interventions including injections, assistance in self-care activities, participating in diagnostic examinations, and preparing drugs and Intra Venous Fluids. This difference may be due to the presence of a therapeutic room in our hospital that most parts of intervention have done in it including preparing drugs or IV fluids.

Plander et al shown almost children mentioned their nurses are kind, honest and funny. Taking care of child was the most activity the nurses were done. Plander et al had used a questionnaire for obtaining children’s perception which has a limit as themselves mentioned that children in different age have different language development level and may answered not appropriately to questions; although, they are good source of information (3).  

The primary limitation of our study is the subjective component involved in the drawing task, which creates a particularly uncontrollable variable, as DiLeo mentioned (9). For improved control, we used identical instructions and asked children to explain their drawing finally. A further limitation of this study is that each child made only one drawing; however, it would be better to draw more than one over time.

Conclusion:

Drawing is a fun, inexpensive, and easy-to-administer method used to provide school-age children a projective means of expressing attitudes and emotions (11). Drawing can be used as a reliable source of obtaining information from children and suggested to use it for assessing their thought about whatever related to them including nursing care quality and satisfaction.

Acknowledgment

We appreciated all children who take part in our study and the kind nurses of Dr. Sheikh’s hospital for their accompanying.