Nursing Support Perceived by the Mothers of Hospitalized Children in Bangladesh

Background: Having a child in hospital is a stressful experience for most parents, especially for mothers. In Bangladesh, the number of hospital admission of under-5 children is gradually increasing. Support from nurses can assist mothers to maintain their parenting role and promote quality nursing care. Objective: The study was conducted to assess the nursing support perceived by the mothers of hospitalized children in Bangladesh. Methods: A Descriptive cross-sectional study was conducted among 112 mothers whose children were admitted at Dhaka Medical College Hospital. Convenience sampling technique was used to select the study participants. Data was collected by using self-administered structured questionnaires including (1) The Demographic Data Questionnaires and (2) Perception of Nursing Support Questionnaire. Data were analyzed by using descriptive and inferential statistics. Results: The total mean of nursing support was 3.68 (SD=.25). The findings showed that there was a statistically significant difference between mothers’education and nursing support (F=2.73, p=.033). There was a statistically significant positive relationship between child age and nursing support (r=.22, p=.019). There were statistically significant differences between a child’s gender and nursing support of mothers (t=1.99, p=.048) which means mothers who had a male child had more nursing support. Conclusion: The findings of the present study provide information for the nurses ‘that help to increase nursing support among mothers of hospitalized children in Bangladesh. Nurses can promote the quality of care and should be aware of the importance of nursing support. Further study is crucial for identifying factors influencing on nursing support perceived by the mothers of hospitalized children. It is important that nurses continue to develop their knowledge about communication and establishing parent support system. Keyword: mothers; perception; nursing support; children


Introduction
Hospitalization of a child is a stressful experience for parents. About 30% of children are hospitalized at least once during their childhood and, about 5% of them are admitted several times, about 5 million children are admitted annually to hospitals for diagnosis or treatment [1].According to Local Health Bulletin (2020), at Dhaka Medical College Hospital total 13,09463under five children are treated in a year including outpatientdepartment, emergency visits and admission [2].
Children's hospitalization usually leads to disorganization of daily life and family environments, and family members set the child's health and wellbeing as a priority [3].It is shown that this daily life change may be, intensely, considered a hard time for the whole family group and this tends to generate distress [4].Parents experience changes in their parental role when their child is cared for by health care professionals in an unknown environment.The nurse-mothers relationships reach far beyond the stressful experience of hospitalized children and generate more feelings of powerlessness [5]. In order to cope with this stressful experience, parents need information about the child's condition, prognosis, treatment plan, and tests. This information allows them to achieve control over situations that produce uncertainty and anxiety [6].By being provided with the appropriate support and the needed information about their child, parents can successfully overcome these challenges and, in turn, provide appropriate support to their children and fulfil their multiple roles within the family.
Nursing support for parents of hospitalized children includes providing a supportive relationship and ongoing information; helping parents maintain their parental role by encouragement, affirmative comment and appraisal; giving emotional support; and providing competent nursing care to the child [7]. Nurses are in a significant position to support parents as they provide care to their sick child, as they are in regular contact with parents during the child's hospitalization [8]. Mothers' psychosocial functioning is important for children's physical and mental health outcomes, and their attitudes during a child's illness, especially during hospitalization, may deeply influence the child's adherence to the care and impact of the disease [9]. A study found that nurses have an important role in assisting parents in defining their role in the relationship between them and their critically ill child. Mok and Leung (2006) found that the highest source of satisfaction for mothers was the support they received from the healthcare team [10]. Trask et al (2003) also found that nurses have a crucial role in assisting parents in coping with their child's illness both during hospitalization and discharge [11]. Mother's perception of nursing support is defined as the mother's feeling or view of the nursing care they received from nursing staff during a hospital stay and is acknowledged as an outcome indicator of the quality of nursing care [12].
Nursing support is the most important factor indetermining the child's reaction to nursing care, parents who are frequently informed of the health status of their children by nursing personnel are less likely to have stress and can help their children to adapt better to the hospital environment [13]. During hospitalization, mothers have indicated that they are treated as an outsider, a feeling that can heighten their sense of helplessness and powerlessness [14]. Nurses need to be aware of family members' needs and expectations so that effective support strategies can be implemented, and family satisfaction can be maximized [15].
Effective nursing support strategy is necessary for every parent's satisfaction, especially for mothers of hospitalized children. Although the framework has been identified, little work has been done on the impact of providing the support and no previous research has been performed that has examined nursing support perceived by the mothers with hospitalized children in Bangladesh. In addition, most of the studies were conducted with adifferent culture. Moreover, the findings from the study may provide guidelines for the nurses that can help to provide better nursing support for the mothers on hospitalized children in Bangladesh. That is why it was worth to conduct this phenomenon.

Operational Definition Nursing Support
Nursing support is defined as providing a supportive communication and provision of information related to the the child's illness, treatments, care; enhancing, and supporting the parental role; emotional support to help the parents cope with their own needs related to the childs illness; and caregiving support invoving the quality of care provided to the child [16,17].
In the present study, the perception of nursing support is defined as the perception of mothers regarding to assist mothers by nurse in providing information related to the childs illness, treatment, and care; facilitate safe and consistent care, and provide emotional support to help mothers cope with their own needs to the childs illness. It was measured by the Perception of Nursing Support Questionnaire.

Study Design
This is a descriptive cross-sectional study. It was conducted at Dhaka Medical College Hospital, Dhaka, Bangladesh. The data was collected from December 2019 to February 2020.

Study Participants
The sample of the study was the mothers of children admitted at Dhaka Medical College Hospital Dhaka, Bangladesh. The study was conducted at the paediatric wards, Dhaka Medical College Hospital (DMCH). This is the biggest tertiary hospital in Bangladesh. This hospital is equipped with 2700 beds, there are 07 pediatric wards/units, including both inpatient and outpatient departments. Therefore, the subjects drawn from this setting was considered to be an appropriate setting. The sample size was estimated by using G-power analysis with the accepted significant level (α) 0.05, medium effect size 0.03, and power 0.80 produced 84 participants. By considering a 20% attrition rate, the final sample size was 112. A convenience sampling method was used to select the participants. The sample size of the study was 112 with the following inclusion, exclusion criteria. TheInclusion criteria: (1) mothers whose children admitted with chronic illness at Dhaka Medical College Hospital, (2) only mothers, whose children age 3-8 years, (3) understand and speak the Bengali language. The Exclusion criteria:the exclusion criteria were mothers unable to communicate with others.

Instruments
A self-report structured questionnaire was developed by the researcher based on the literature review. It consists of 2 parts: 1.The Demographic Data Questionnaires, and 2. Perception of Nursing Support Questionnaires.
The Demographic Data Questionnaire: It consists of socio-demographic questionnaires including age, sex, religion, and mother's education, monthly family income, mother's occupation to identify the sociodemographic characteristic of the study participants etc.
Perception of Nursing Support Questionnaire:It was developed by the researcher based on the literature reviewed. This questionnaire consists of 35 items, including three subscales:regarding nursing care (14-items), Nurses behavior (13-items) and communication (8-items). It was a 5point Likert scale; 1=strongly disagree to 5=strongly agree. A higher score indicated to be better nursing support.
The questionnaire was validated by the three experts: one expert (PhD Faculty) from NIANER, one assistant professor (nursing) Universal Nursing College, Dhaka, and a paediatrician, Dhaka Medical College Hospital. The original instruments of this study were developed in theEnglish version and translated into a Bengali version and then the back-translated into English based on the back-translation process.

Data Collection Methods
The study was approved from the Institutional Review Board (IRB) at the National Institute of Advanced Nursing Education and Research (NIANER) and Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. After obtaining permission from the authority of Dhaka Medical College Hospital and signing written informed consents forms by the participants. Distributed questionnaire to an individual participant. Participants were informed aboutho wto fill up the questionnaires without consulting and sharing others. Participants were taken approximately 40 minutes to complete the questionnaires. The primary researcher has checked all return questionnaires for completeness. Anonymity and confidentiality of the respondent were strictly maintained.

Data Analysis
Descriptive analysis such as frequency, percentage, mean and standard deviation was used to describe the demographic characteristics of the participants. Inferential analysis including t-test, one way ANOVA and Pearson correlation coefficient were used to describe the relationship between socio-demographic characteristics and perceived nursing support by the participants.

Results
This chapter represents the findings of the study regarding participant's demographic characteristic and mother's perception of nursing support on hospitalized children. The results of the study are presented under following headlines: (1) Socio-demographic characteristics of mothers and theirchildren, (2) Nursing support perceived by the mothers, (3) Relationship between socio-demographic characteristic of nursing support perceived by the mothers of hospitalized children.   Table 3 shows that relationship between socio-demographic characteristic of nursing support perceived by the mothers of hospitalized children. The results showed that there was a statistically significant relationship between maternal education with nursing support (F=2.73, p=.033). It means a mother who has higher education had good perception regarding nursing support. It was also revealed that there was a positive relationship between child age and nursing support perceived by the mothers of hospitalized children (r=.22, p=.019). It indicates mothers of comparatively elder children reported significantly higher perceived nursing support than the mother of younger children. There was statistically significant difference between a child's gender and nursing support of mothers (t=1.99, p=.048). Considering the gender, it was found that mothers of male children perceived significantly higher nursing support than mothers of female child which means, mothers who had male child had more nursing support than those of female child.

Discussion
The present study was conducted withdescriptive cross-sectional study design among mothers whose child was admitted at Dhaka Medical College Hospital, Dhaka and the child aged was 3-8 years. The study aimed is to examine the socio-demographic characteristics and nursing support perceived by the mothers of hospitalized children.

Mothers and Childs Characteristics
The study has been completed over 112 mothers of hospitalized children. Based on the results, it was found that the mothers received a high level of support (3.68±.25) from the nurses. The result was similar to that of Mok and Leung (2006), who reported an overall mean for received support from nurses of 3.8, and , who reported overall, score 4.1 [10].
The findings of this study showed that the participants mean age was 29.12 (SD=5.88) years. Consistent with other study found that the mothers mean was 28 years [18]. In the context of Bangladesh, the mothers mean age 18.5 years [19]. In the present study, most of the participants were Muslims. According to the Bangladesh Demographics Profile (2020), 89.1% of people are Muslims [20].
The present study showed above half of the mothers completed primary education. This finding is similar to another study found that the majority of the mothers were completed primary education [21,22]. This result inconsistent with the study of Sanjari et al. (2009) [22].The monthly family income of the participants was 14723.21(SD=7802.99) Taka which was similar to the national standard in Bangladesh, According to Trading Economics global macro models and analysts expectations in Bangladesh is expected to reach 15100.00 BDT/Month by the end of 2020. The result was incongruent with the study conducted in other countries, found that most of the participants family income was insufficient [21,23].
The present study showed that the mean age of child was 5.97 (SD=1.68) years. A study Al-Nouri (2005) found that child mean 5years [24]. Incongruent with other studies showed that the mean of a child was 7 years [21,22,23]. The present study showed that the majority of the children was a boy, which is similar to the study conducted [25,22].

Relationship between Socio-Demographic Characteristics of the Participants and Nursing Support Perceived by the Mothers of Hospitalized Children
There was a statistically significant relationship between demographic characteristics (the mother's education, children age and gender) and nursing support perceived by the mothers of hospitalized children. These results are consistent with other studies [25,22]. The findings of the present study showed that mothers who had higher education level had greater support than those of mothers had low education level(F=2.73,P=.033). This finding is similar to the study of Al-Akou, Gharaibeh, and Al-Sallal (2012) found that education influenced mother's perception of nursing support [26]. The finding is also inconsistent with the previous studies showed that mothers' lower education had greater nursing support [22,27]. This suggests that theeducational level of mothers may be an important predictor affecting their understanding of and concerns related to their children's illness.
In the current study, it was found that there was a significant positive relationship between the child's age and nursing support (r=.22, p=.019) which is congruent study conducted in Turkey showed there was a significant relationship between children age and nursing support [28]. That means mothers who had older child had greater nursing support than those of had younger child. This result is inconsistent with another study found in Iran that there was no significant relationship between children age and nursing support [25].
The present study found that there was a significant relationship between child sex and nursing support (t=1.99, p=.048). It means mothers those who had male child have more nursing support. This result suggests that mothers reported more nursing support when their child was a boy. These findings implied that, based on Eastern culture, the gender of the offspring stillmay be important for mothers [22].

Nursing Care
In terms of sub-dimension of nursing support like nursing care, it was found that there was a statistically significant relationship between demographic characteristic and nursing care. The results found that there was a significant positive relationship between child age and nursing care (r=.19, p=.042) which is congruent with the previous study conducted in Turkey [29] ,which means mothers who had older child had greater nursing care those who had younger child. This result in dissimilar to another study found in Iran [25]. There was a significant differences between child gender and nursing care (t=2.42, p=.017). It means mothers those who had male child had better nursing care.This result suggests that mothers reported better nursing care when they have male child. These findings implied that based on Asian culture, the gender of the offspring still may be important for mothers [22,25].

Behavior
In terms of behavior of nursing support, there was a statistically significant relationship between demographic characteristics and behavior.It was showed that mothers who had ahigher education had better behavior of nurses than those of mothers had alower education level (F=3.29, P=.014). This finding is similar to the other study found that education influenced mother's behavior [26,30]. The finding is inconsistent with the previous studies showed that mothers' lower education had better behavior [22,27]. The present study found that there was a significant relationship between child sex and nurses behavior (t=2.42, p=.017). It means mothers who had male child have better behavior of nurses.

Communication
In the present study, there was a significant positive relationship between child age and nurses communication (r=.19, p=.42) which is congruent with the study conducted in Turkey showed that there was a significant relationship between nurses and child age [29].This result is dissimilar to another study conducted in Iran [25].
On the other hand, the present study did not find any significant differences between mothers' age, marital status, religion, residence, monthly income, occupation, number of child and admission ward.

Limitations
The instrument of the present study was developed based on the existing literature reviewed and Bangladesh culture and context. In terms of generalizability, the subjects were limited to those mothers admitted to a national hospital in Bangladesh. Therefore, the results may not be generalized to district or rural hospital population.

Conclusion
The study was adescriptive cross-sectional design carried out from July 2019 to February 2020 at Dhaka Medical College Hospital, Dhaka, Bangladesh. The aim of the study was to the assess nursing support perceived by the mothers of hospitalized children in Bangladesh. The total sample included 112 mothers of children who admitted at Dhaka Medical College Hospital, Dhaka.
The findings of the study showed that the perception of nursing support among mothers of hospitalized children was high (M=3.68). In terms of relationship, there was a statistically significant relationship between mothers' education, child age, sex, and nursing support perceived by the mothers of hospitalized children. At the same time, other characteristics did not show any significant results. Therefore, it is suggested that nurses may actively participate in facilitating mothers who have ill children in the hospital. Providing support may alleviate mothers' stresses and help to increase their satisfaction regarding pediatric nursing care. Thus, mothers need information about their children situation when they are admitted in hospital.

Recommendations
Based on the study results and limitations of the present study, the findings of the study can be used in factors identifying nursing support perceived by the mothers of hospitalized children. Further intervention research is also needed to increase better nursing support for mothers of hospitalized children in Bangladesh.