Chinese nurses’ perspectives on child-friendly healthcare practice assessment: a qualitative study

Abstract

Background

Nurses play a critical role in the implementation of child-friendly healthcare, ensuring that pediatric patients receive comprehensive and compassionate services. However, there is a global scarcity of research evaluating nurses’ practices in delivering child-friendly healthcare. Therefore, this study focuses on exploring the assessment of child-friendly healthcare practices from the perspective of nurses themselves.

Method

This descriptive qualitative study employed purposive and snowball sampling methods to recruit 14 pediatric nurses from six hospitals in Zhejiang province, Southeast China. Individual semi-structured interviews were conducted face-to-face between January and June 2024. Data were analyzed through the qualitative content analysis approach.

Results

We identified 415 unique meaning units in the interview data, 332 of which were related to child-friendly healthcare practice assessment. These units were classified into 58 codes across 4 categories and 17 subcategories. The four categories were identified: services designed for children’s interests, tailoring the environment adapted for children, facilitating social interactions, and promoting childhood development.

Conclusion

The findings from this study were derived from the perspectives of Chinese nurses on child-friendly healthcare practice assessment, offering a comprehensive and multidimensional view of this field. The results reflect the current state and future direction of child-friendly healthcare in China, which will aid in sustaining the development of a child-friendly healthcare evaluation system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-024-02528-1.

Introduction

Child-friendly healthcare (CFH) stems from the child rights protection movement, particularly the 1989 United Nations Convention on the Rights of the Child (CRC) [1], advocating for equitable healthcare and children’s rights to development, privacy, expression, and participation [2]. In 2000, the “Child-Friendly Healthcare Initiative” (CFHI) was launched by Child-health Advocacy International (CAI), UNICEF, and WHO to operationalize these principles [3]. CFH involves healthcare policies and practices that respect children’s rights, needs, and opinions [4]. In Europe, it emphasizes child protection, family involvement, health promotion, and personalized care [5]. In the US, child life services are integrated into pediatric care to help children and families cope with medical stress through play therapy, education, and psychological support [6]. Recently, China has incorporated CFH into healthcare reforms, focusing on policies, environments, services, and social support for high-quality care [7].

To accurately reflect the results of healthcare reforms and drive continuous improvement, the establishment of a specialized and standardized evaluation system for CFH is essential. While several CFH evaluation tools exist, such as the CFH Toolkit [8] and Iran’s accreditation model for children-friendly hospitals [9], providing valuable insights for institutional evaluation, they primarily focus on structural and management assessments at the macro level. However, CFH is fundamentally implemented through the behaviors and practices of healthcare professionals [8], making it critical to develop evaluation tools that assess CFH at the individual professional level, particularly nurses.

Nurses, as frontline providers, are essential to healthcare delivery due to their close, ongoing interactions with children and families [10]. An evaluation tool from the nurses’ perspective could provide valuable insights into CFH practices, assessing healthcare reform effectiveness and highlighting how nurses support or hinder CFH initiatives. By focusing on nurses’ behaviors and decisions in real settings, this tool would pinpoint improvement areas, fostering a more child-centered approach to healthcare [11].

Despite the evident necessity for developing assessment tools for CFH at the individual professional level, research in this area remains limited. This study aims to address this gap by focusing on the unique perspectives of Chinese nurses in evaluating CFH within their nursing practice. Chinese nurses’ perspectives are valuable globally due to differences in China’s healthcare system, societal culture, and reform [12, 13]. For instance, China’s traditional family structure emphasizes parental authority [14], and the reform in health coverage [15] affects CFH delivery. Additionally, Chinese nurses face unique challenges, including limited resources for a large population, unlike many Western healthcare systems [16]. Their strategies for managing these challenges provide insights into adapting CFH globally.

Given the complexity of CFH delivery, involving nurses’ subjective experiences, work environments, and cultural contexts, a descriptive qualitative research method was employed to gather authentic insights into CFH practices [17]. This approach enhances the understanding and adaptation of CFH within the Chinese cultural context, improving the evaluation system for CFH. By providing deep insights into Chinese nurses’ perspectives on CFH practices, this research contributes significantly to the development of individual professional-level assessment tools. These tools will enable more precise measurement of nursing performance in practice, ultimately fostering further advancements and transformations in pediatric nursing care.

Methods

Study design

A descriptive qualitative study design was employed using semi-structured interviews. This qualitative study was situated within the constructivist paradigm, aiming to understand the implementation and evaluation of child-friendly healthcare practices among Chinese nurses based on their individual experiences and perspectives.

Participants and recruitment

Potential participants were recruited using purposive and snowball.

Sampling methods from the pediatric departments of six tertiary-level hospitals in two cities (Hangzhou and Huzhou) of Zhejiang province, Southeast China. The inclusion criteria were as follows: (1) holding a nurse certificate; (2) bachelor’s degree or above; (3) minimum of three years of pediatric care experience and currently working in a pediatric-relevant department; (4) agreeing to participate in the interview and consent to the recording. The exclusion criteria are as follows: (1) Nurses are not employees of these hospitals, but working there (e.g., intern nurses, trainee nurses); (2) nurses who could not be contacted. To ensure comprehensive data collection, participants were selected based on a range of social demographic factors, including years of experience, professional titles, and departmental affiliations. Trained research team members conducted participant selection. Invitations were sent to nurses via WeChat, face-to-face, or telephone calls. Snowball sampling was employed to recruit additional participants. The researchers informed potential participants about the study’s purpose, precautions, and confidentiality policies through WeChat or face-to-face discussions. Participation was voluntary, and all participants provided written informed consent before joining the study.

Guest et al. [18]asserted that the sample size in qualitative research was not predetermined, however, it was deemed saturated when no new data emerged. They suggested that for most studies aimed at understanding perspectives and experiences, data saturation typically occurred after 12 interviews. Acknowledging that data saturation is a subjective judgment, we opted to recruit additional participants after conducting interviews with the initial 12 to ensure genuine saturation and to strive for the highest levels of comparability and quality. Consequently, we initially invited 15 participants, but one nurse declined to participate, resulting in a total of 14 interviewees who completed the interviews.

Determining the interview outline

An initial interview guide was developed based on the study objectives and a comprehensive literature review. Pre-interviews were conducted with two nurses, followed by a group discussion to refine the guide. Two researchers (WXH and XXL) subsequently conducted separate pilot tests with two other nurses who were not included in the formal study. Feedback from these pilot tests was used to further revise and finalize the interview guide (see Table S1 for the final version).

Data collection

The first author conducted one-on-one, face-to-face, semi-structured interviews with 14 pediatric nurses between January and June 2024. To encourage participants to freely express their personal opinions, a comfortable and supportive setting was established for the interviews. They were given the flexibility to select the interview location based on their preferences, including options such as conference rooms in their workplace, their homes, or other quiet environments. Before conducting the interviews, the researchers introduced themselves and explained the study to the participants to build rapport and address any questions. Each participant was informed about the interview procedure, including audio recording and note-taking. At the beginning of each interview, participants were asked to introduce themselves and then explain their perceptions of child-friendly healthcare practices assessment within the nursing field. The researcher maintained linguistic and nonjudgmental neutrality throughout the interviews to allow for effective observation and recording. At the end of each interview, participants were asked to complete a brief demographic details questionnaire. Each participant was compensated with CNY 200(USD 28) for their time after the interview, acknowledging their contribution to the study.

The duration of the interviews averaged 44.4 min, with individual sessions ranging from 27 to 85 min. Variations in interview length reflected participants’ differing levels of engagement, response depth, and work experience. While shorter interviews offered less detail, they still captured essential insights. To ensure data richness, data saturation was used as a guiding principle, ensuring thorough exploration of all major themes across the dataset. All interviews were conducted singularly, without any repetitions.

Data analysis

Interview data were analyzed using the qualitative content analysis approach proposed by Graneheim & Lundman [19]. All interview transcripts were translated into English using forward and backward translation [20]. WXH, a bilingual doctoral candidate in nursing, handled the forward translation, while MCC, a bilingual nursing professor, performed the backward translation. The research team, including co-authors LYT and XXL, reviewed translations collaboratively to resolve any discrepancies, preserving linguistic and cultural nuances.

Two researchers (WXH and MCC) independently reviewed each transcript, performing line-by-line analyses to identify, condense, and code meaning units [19, 21, 22]. Codes were compared, discrepancies resolved by consensus, and grouped into subcategories, which formed overarching categories for key findings [19, 21]. The team discussed all categories to ensure validity, and analysis was conducted using QSR Nvivo 14.0 software.

Ethical approval

This research was approved by the Medical Ethics Committee of Huzhou University (Reference No. 20231225). All participants voluntarily provided informed consent and were informed that they could withdraw at any time before data analysis.

Trustworthiness and credibility

To enhance this study’s reliability, participants were recruited with diverse characteristics—varying in age, gender, professional title, position, and department—until data saturation was reached. All interviews were recorded and transcribed verbatim within 48 h to ensure accuracy [23]. To maintain transparency and credibility, a copy of the transcript was sent to each participant for verification, allowing them to review and confirm the content before further analysis [23]. In addition, subcategories and categories from the analyses were independently analyzed by two researchers and validated by all research members to ensure the reliability of the results [19, 21, 22]. Moreover, to enhance the confirmability of the data analysis, representatives from participants were invited to provide feedback on the findings [19, 21, 22]. This process allowed for verification and validation of the results, ensuring that the interpretations and conclusions accurately reflected the participants’ experiences and perspectives. Lastly, this study was reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [24]. Adhering to these guidelines ensured a comprehensive and transparent presentation of the study’s methodology, findings, and processes, enhancing the study’s credibility and reproducibility.

Results

A total of 14 participants were interviewed. The participant’s demographic information was presented in Table 1. The average age of the participants was 37.9 years (range: 29 to 51 years). Among the participants, 78.6% were women, 92.9% were married, and 64.3% had children. The majority of participants had a bachelor’s degree (92.9%), and most (35.7%) had 5–10 years or 11–20 years of working experience. Most of the nurses (57.1%) held the title of nurse in charge, and (64.3%) were nurses without administrative positions. The participants were fairly evenly represented across various pediatric-related departments.

Table 1.

Participant demographic characteristics(N = 14)

Characteristic	Min-Max (Mean, SD)	n (%)
Age	29–51(37.9,7.1)
Gender
Female		11(78.6)
Male		3(21.4)
Marital status
Married		13(92.9)
Single		1(7.1)
Number of children
0		5(35.7)
1		6(42.9)
2		3(21.4)
Education degree
Bachelor		13(92.9)
Master		1(7.1)
Working years
5–10		5(35.7)
11–20		5(35.7)
21–30		2(14.3)
30–40		2(14.3)
Title
Nurse Practitioner		3(21.4)
Nurse in charge		8(57.1)
Associate senior nurse		2(14.3)
Senior nurse		1(7.1)
Position
Nurse		9(64.3)
Head Nurse		3(21.4)
Director of Nursing		2(14.3)
Department
Pediatric Surgery		2(14.3)
Pediatric Medicine		2(14.3)
Pediatric Outpatient Department		1(7.1)
Pediatric Emergency Department		1(7.1)
Pediatric Operating Room		1(7.1)
Neonatal Intensive Care Unit		1(7.1)
Pediatric Intensive Care Unit		1(7.1)
Pediatric Preventive Department		1(7.1)
Pediatric Rehabilitation Department		1(7.1)
General Pediatrics		2(14.3)
Nursing Department		1(7.1)

SD, standard deviation

The data collected from the interviews were analyzed, and 417 unique meaning units were identified. In total, 332 meaning units related to child-friendly healthcare practice assessments in the nursing aspect were identified. These meaning units were then coded, with 58 codes created across 4 categories and 17 subcategories. These categories and subcategories can be found in Table 2.

Table 2.

Categorisation matrix

Main Category	Subcategory
Services designed for children’s interests	Protecting Children’s Rights
	Age-appropriate interventions to reduce distress
	Facilitating companionship and family need
	Effective and efficient nursing
	Internet + nursing services reduce hospital visits
Tailoring the environment adapted for children	Providing a healthy and comfortable physical environment
	Fostering a child-friendly atmosphere
	Ensuring safety
	Enabling recreation and play
	Keeping equipment child-appropriate
Facilitating social interactions	Developing a positive nurse-patient relationship
	Encouraging child participation
	Facilitating social support networks
Promoting childhood development	Supporting academic studies
	Supporting for nutrition
	Delivering comprehensible health education
	Empowering parents with childcare capabilities

Categories are presented in a commentary supported by selected quotes. The quoted material includes relevant Interview ID tags and line numbers to locate the information in the transcript (e.g.,01:10–12). Bracketed information () provides clarity on references mentioned at other points in the conversation. Pseudonyms are used to maintain participant anonymity.

Category 1: services designed for children’s interests

Services designed for children’s interests relate to evaluating whether nurses prioritize and protect children’s rights, needs, and well-being to provide the best possible medical services, reducing fear, anxiety, and suffering for children. It comprises five sub-themes: protecting children’s rights, age-appropriate interventions to reduce distress, facilitating companionship and family needs, effective and efficient nursing, and internet + nursing services reduce hospital visits.

Protecting children’s rights

Protecting children’s rights refers to nurses recognizing children as individuals with inherent rights and ensuring these rights are upheld in healthcare settings [2, 4]. These involve privacy protection, providing equitable care, showing respect, and sharing information to keep patients and families fully informed during the medical process [2, 8]. Additionally, all forms of abuse and neglect must be prevented [2, 8].

We should fully respect children’s rights, listen patiently to their thoughts, ensure effective communication, and prioritize their privacy and safety to create an equitable, friendly healthcare environment. (14:20–23)

Medical staff must intervene in child abuse cases, guide parents, and, if necessary, contact the police. (6:208–209)

Age-appropriate interventions to reduce distress

This subcategory relates to tailored healthcare strategies designed to alleviate stress and discomfort in children by considering their developmental stage and individual needs [25]. These interventions should primarily be non-invasive when possible, aiming to minimize unnecessary suffering during the medical process [8]. They typically include pharmacological intervention, psychological support, play therapy and distraction techniques, cognitive and behavioral intervention, comfort nursing care [8, 25, 26], and traditional Chinese nursing techniques [7].

We aim to identify and alleviate children’s pain and discomfort, using oral or nebulized medications to avoid injections whenever possible… Role-playing games help explain procedures, reducing children’s fear. (6:38–39,50–51)

We comfort children with small toys and reward cooperation with cartoon stickers after injections. We also play music, show cartoons, and reason with older children. (11:74–76)

Whenever possible, we use non-pharmacological methods, including traditional Chinese nursing practices like ear acupressure for pain relief and herbal plasters for gastrointestinal discomfort. (4:111–113)

Comfort is illness-related. We assess whether bedridden children need silicone or pressure-relief mattresses. For long-term oxygen therapy or device-induced pressure sores, we use items like artificial membranes or foam dressings to prevent ulcers and injuries. (4:276–280)

Facilitating companionship and family need

It means nurses actively support the presence and involvement of family members to provide emotional support and fulfill both the child’s and the family’s physical and emotional needs [8, 25, 26]. This includes implementing a flexible visitation and caregiver policy, providing facilities and resources for caregivers, ensuring effective communication, encouraging parental involvement and cooperation, and offering psychological support for families [8, 25, 27].

Children often have many caregivers, and these caregivers frequently change. We need to remain flexible in managing this situation. (9:153–154)

The hospital offers free housing for distant parents… and family care rooms for stable patients to ease the transition from NICU to home. (6:80,87–88)

Communication with parents is challenging, as different methods can lead to varied outcomes. Effective communication is therefore essential. (4:284–285)

We prioritize reassuring parents especially anxious mothers, by bringing the child out of NICU during family visits or, if not possible, sharing photos or videos. (7:41–43)

Parental involvement is crucial, so we use a family-centered approach.Parental cooperation is also included as a criterion in the evaluation system. (4:76,300)

Effective and efficient nursing

Effective and efficient nursing emphasizes the timeliness and accuracy of care, key components in CFH [8, 25]. First, professional competence is essential for effective practice, requiring nurses to have advanced knowledge and skills to promptly address children’s illnesses and changes in condition with appropriate interventions [7, 8]. Secondly, adherence to standards and protocols enhances efficiency while reducing variability and errors in care delivery [7]. Thirdly, timely response and handling can effectively meet patients’ medical needs and enhance the overall healthcare experience [25]. Lastly, improved health outcomes reflect nursing effectiveness, while continuous quality improvement (CQI) strengthens both effectiveness and efficiency, contributing to higher-quality service [8].

Service capability is the most important. Professional knowledge and skills of healthcare providers should be the top priority. (11:39–41)

We improve standardized processes to reduce errors and optimize procedures to address family requests… Continuous quality improvement projects are continuously implemented based on patient feedback. (8:138–139, 176–178)

I emphasize the importance of nurses responding promptly, such as swiftly handling milk choking incidents. (3:108–110)

Internet + nursing services reduce hospital visits

Internet + nursing services focus on providing remote access to medical services such as professional consultations, health information, and medical support, thereby minimizing the need for in-person hospital visits [7]. In Chinese pediatric nursing services, this mainly elaborates upon online continuing nursing care, as well as app-based home visit service.

Some patients join a WeChat group post-discharge for health education updates and can ask questions during online consultations. (11:161–163)

To avoid the inconvenience and exposure to germs at hospitals, we offer the “Zheli Nursing” app, allowing parents to order home nursing services. (2:62–64)

Category 2: tailoring the environment adapted for children

This category focuses on evaluating the role of nurses in creating and maintaining CFH environments and spaces. The design and optimization of CFH environments should be based on the “one-meter height” perspective, reflecting the viewpoint of children. The goal is to create a safe, comfortable, warm, and engaging environment that meets the needs of children [7]. The subcategories involve the following five aspects: providing a healthy and comfortable physical environment, fostering a child-friendly atmosphere, ensuring safety, enabling recreation and play, and keeping equipment child-appropriate.

Providing a healthy and comfortable physical environment

A healthy and comfortable physical environment refers to a setting that is harmless to the body, conducive to maintaining health and promoting comfort [28]. Nurses should ensure that the healthcare environment has adequate natural conditions, such as proper lighting and ventilation, while also optimizing physical aspects like adjustable lighting and noise reduction to support children’s recovery [29]. Additionally, they should maintain high standards of cleanliness and hygiene by regularly disinfecting and cleaning the environment, thereby preventing infections and the spread of diseases [8].

A good physical environment for children includes noise control and adjustable lighting…For newborns, a nest-like swaddle can provide support and a sense of security by allowing them to feel cradled. (7: 31,53–54)

First and foremost, the environment should be evaluated for its cleanliness and hygiene standards. (3: 82)

Proper disinfection and isolation are vital, as some children may carry drug-resistant bacteria. Hand sanitizers should be accessible in every room, placed at about one meter high. (8:164–166,172)

Fostering a child-friendly atmosphere

Fostering a child-friendly atmosphere focuses on environmental and aesthetic elements that support the emotional and psychological well-being of young patients [28, 30]. This approach incorporates vibrant decorations, themed designs, and playful visuals, such as bright wall colors, cheerful furnishings, cartoon characters, and artwork [29, 31, 32]. These elements make the hospital setting more inviting and less intimidating, fostering comfort and familiarity.

We aim to create a warm, culturally enriching atmosphere for pediatric patients by decorating wards with cartoon characters and bright artwork. (14:41–42)

In the operating room, staff wear cartoon costumes to escort children, and the radiology department features marine animal images on the ceiling (7:110–1112,13).

Ensuring safety

Safety in CFH is a complex, multidimensional priority encompassing environmental, medical, and social aspects [28]. For environmental safety, nurses are responsible for identifying and mitigating risks associated with unsafe facilities or surroundings, thereby preventing potential injuries [28]. Social safety involves safeguarding patients against crime, violence, and other security threats. Regarding medical safety, nurses are instrumental in preventing medical errors and adverse events by adhering to strict protocols, conducting accurate medication administration, and following evidence-based practices [8].

Key evaluation criteria include providing a safe, appealing environment with child-friendly features like non-slip flooring and rounded furniture edges. (14: 135–137)

We must assess our security system, ensuring surveillance cameras cover key areas to prevent child get lost and stolen. (4:255–256)

The top evaluation criterion is nursing care safety.(2:115)It primarily involves the correct use of medications and equipment. (8:161)

Enabling recreation and play

This standard refers to nurses providing designated areas and materials that support children’s recreational activities and play, which are essential for their psychological well-being and growth [8, 33]. This includes offering libraries and reading areas for relaxation, art and craft rooms for creative expression, and exhibition halls for cultural activities [33]. Additionally, indoor and outdoor play areas equipped with age-appropriate toys and play structures, sensory rooms for therapeutic engagement, and game rooms with board and video games help alleviate anxiety and stress [29].

Our hospital also has recreational areas such as a library and an exhibition hall…(8:70)

Each room has a TV for cartoons, along with play and reading areas stocked with comics… There’s also a block area, and we occasionally organize piano, dance, and game activities for the children. (11:85–86, 117–118)

Keeping equipment child-appropriate

This criterion requires nurses to ensure that both living facilities and medical devices are suitable for children in terms of size, design, and functionality to enhance applicability and service standards during healthcare procedures [28]. This involves selecting and maintaining living essentials, such as beds, chairs, and sanitary facilities, that are appropriately sized and designed to meet the needs of children [7]. Additionally, it includes ensuring that medical equipment and devices are chosen for children of different ages, with the correct specifications, models, and functionalities [28].

Providing child-friendly healthcare involves. having specialized facilities…such as child-specific hospital beds, examination tables. and infusion stations tailored for pediatric use. (14:61–65)

The rehabilitation center is designed for children’s physiology. For example, the sinks are positioned at a height suitable for children.(13:105–106).

Category 3: facilitating social interactions

This category emphasizes evaluating nurses’ role in facilitating interactions with social components within the hospital. The hospital’s social component involves not only peers, family members, and healthcare staff, but also broader social support systems. Key subcategories for assessing child-friendly healthcare practices include developing positive nurse-patient relationships, encouraging child participation, and facilitating social support networks.

Developing positive nurse-patient relationships

Developing positive nurse-patient relationships entails fostering trust, empathy, and effective communication between nurses and pediatric patients to improve their therapeutic alliance and cooperative outcomes [2, 34]. This requires nurses to create an approachable professional image, exhibit friendly attitudes, engage in humanized communication and interaction as well as foster trust through positive experiences [2]. For instance, by wearing colorful and themed uniforms, using a gentle tone, actively listening, and interacting empathetically, nurses can make children feel valued and understood.

We use fruit names like Banana, Strawberry, or Peach on nurses’ badges to help children identify them, making nurses more approachable and recognizable. (4:52–54)

No matter how professional you are, if you don’t have a good attitude, people may not appreciate it. Thus, a good service attitude is the top priority. (1:92–93)

Provide attentive and compassionate care to patients, ensuring a humanistic approach. For instance, delaying procedures for a sleeping child and communicating with them before starting.(3:51–53).

We strive to create a positive experience for patients, which improves communication, builds trust, and fosters a harmonious relationship. (8:25,29–30)

Encouraging child participation

This criterion assesses the ability of nurses to encourage and support children’s engagement in healthcare activities and decision-making, thereby fostering autonomy and involvement in their treatment process [2, 31]. Specific areas of focus include encouraging children to participate in hospital social activities, enabling them to contribute to the design of their environment, empowering them to participate in age-appropriate medical decisions, and incorporating their feedback into service evaluations [2, 35].

The ward hosts themed activities like medical play, games, holiday events, and health education… The “Child Life” program also encourages social interaction, letting children make friends and join group activities in the activity room.(6:107–108,198–199).

Our environment design includes interactive features like a Lego wall and a hand-drawing wall. We showcase children’s artwork and milestone exhibits, creating a warm, familiar atmosphere in the medical area…(4:40–43).

We should respect children’s ideas, involve them in decisions, and communicate to understand their needs for appropriate care. (6:41–42)

We hold a “Most Satisfactory Nurse” vote, where children place a heart sticker under their favorite nurse’s photo upon discharge. (9: 93–95)

Facilitating social support networks

This criterion refers to nurses facilitating connections between pediatric patients, their families, and broader social support systems to ensure comprehensive emotional, informational, financial, and practical support [7]. Social support networks specifically include social assistance and charitable initiatives in China. Social assistance from government and community organizations provides economic and medical aid to low-income families and children with serious illnesses. Charitable initiatives, often led by non-governmental organizations, businesses, and individuals, offer support through donations and volunteer services. Nurses need to inform pediatric patients and their families about these resources to promote children’s social integration [7].

Social support is an indispensable part of child-friendly healthcare.Healthcare providers can collaborate with parents, communities, schools, and others to create comprehensive care for children.(14:73–75).

Our hospital’s social support includes a government disease subsidy program, a rehabilitation program from the Disabled Persons’ Federation, and volunteer services from Dr. Lu’s Children’s Growth Center. We provide this information to patients to ensure they are aware of these available resources.(13: 220–225).

Category 4: promoting childhood development

This category assesses nurses’ ability to address both the immediate and long-term health and developmental needs of pediatric patients. By providing comprehensive support and resources, nurses promote the biopsychosocial health of children during and after their medical treatment. This includes four subcategories: supporting academic studies, supporting nutrition, delivering comprehensible health education for children, and empowering parental childcare capabilities.

Supporting academic studies

This subcategory addresses the role of nurses in supporting hospitalized children’s continued access to school-type education [8]. Nurses conduct thorough physical assessments to ensure children are physically prepared to participate in learning activities. They also facilitate access to educational resources, such as books, digital devices, and suitable study environments within the hospital [8]. Furthermore, nurses maintain communication with school teachers to ensure continuity in the child’s education, coordinating with them to integrate medical and educational needs [36, 37]. Through these efforts, nurses help prevent academic regression and support hospitalized children’s ongoing academic progress.

As exams approach, many parents ask medical staff to assess their children’s physical condition. If a child’s fever subsides and they wish to attend school or take exams, we coordinate with the infusion center to pause treatment, allowing them to return afterward for IV administration (3:196–198).

Teachers conducting educational activities in the hospital is very beneficial. It ensures that children keep up with their studies and can ease anxiety for motivated learners.(6:193–195).

Supporting nutrition

This standard emphasizes nurses provide nutritional care for children to meet their specific nutritional needs during treatment, recovery, and growth [3, 8]. Nurses provide essential breastfeeding guidance to new mothers, ensuring proper techniques and overcoming common challenges to optimize infant nutrition [3, 38]. Additionally, They conduct thorough nutritional assessments to identify deficiencies and special dietary needs, enabling the creation of individualized nutrition plans [4, 8]. Besides, nurses provide tailored dietary recommendations, often collaborating with dietitians to support children with specific medical conditions [4, 8]. This integrated approach ensures that children receive balanced and adequate nutrition, significantly enhancing their overall health outcomes.

After the birth of a newborn, our focus shifts to their feeding needs. Breastfeeding has become our primary concern in nursing care.(1:27–28).

Since children are in a critical growth stage, we prioritize their nutrition through assessments, risk screenings, and personalized guidance. (14:16–18)

For postoperative diets, we collaborate with nutritionists to provide guidance, using visuals like check-marked pictures for suitable foods and crosses for unsuitable ones. (8:181–182)

Delivering comprehensible health education

This subcategory focuses on whether nurses can use simple, vivid language and interactive educational tools, to help children grasp the importance of disease, treatment processes, and health management [39]. Techniques include picture books and illustrated brochures to convey concepts, story-based education to make health education enjoyable and memorable, and animated videos to simplify complex topics. Role-playing and simulations help children understand medical procedures and build confidence, while educational games make learning interactive and reinforce key health information [40]. Online resources further support flexible access to health education.

We use cartoons to explain how the surgery will be performed…(4:62–63).

We use picture books and role-play to help children easily understand disease. (6:154–155)

We have an app called “317 nurses”, through which we send educational content to the patients. (3:133)

Empowering parents with childcare capabilities

This criterion primarily assesses the extent to which nurses can empower parents with childcare capabilities by equipping them with essential knowledge and skills to effectively care for and support their children [7]. By using one-on-one guidance, specialized training sessions, and distributing educational materials, nurses can empower parents to improve the quality of home care.

We offer a monthly early childhood education program with specialized teachers, covering topics like growth, development, and nutrition (1:143–145).

Before discharge, we provide a transition period for families to practice kangaroo care, diaper changing, and bathing, helping them gain confidence in caring for their child at home. (7:43–45)

Discussion

This study gathered insights from Chinese pediatric nurses on evaluating child-friendly healthcare (CFH) practices, focusing on their hands-on roles rather than macro-level factors like policy and management [8, 9]. The analysis identified four key CFH evaluation areas: services designed for children’s interests, tailoring the environment adapted for children, facilitating social interactions, promoting childhood development, forming a framework for improving pediatric care.

These results can be interpreted through the lens of the Development Contextualism Theory [41], which emphasizes that individual development is shaped by interactions within their contexts, including personal, physical environment, social components, and temporal aspects [42]. Each identified category fits into these dimensions: “services designed for children’s interests” correspond to “personal”, emphasizing the specific needs and rights of children [2, 4]. “tailoring the environment adapted for children” aligns with “physical environment”, highlighting the supportive and stress-free healthcare environment [30, 43]. “facilitating social interactions” is linked to “social components”, underscoring the positive interactions with social networks to enhance cooperation, resilience, and overall well-being [27, 44]. Lastly, “promoting childhood development” corresponds to “temporal aspects”, considering changing developmental needs over time [7, 8, 45]. Moreover, The theory emphasizes that optimal development depends on the alignment between the child and their contexts, known as the “goodness of fit”, rather than on any single characteristic [42]. This means nurses should continually assess and adjust this fit, creating an adaptive and responsive healthcare context where children feel understood, secure, and engaged [33]. This approach fosters children’s positive development, viewing CFH as a dynamic, individualized process rather than a static set of practices [46].

This study highlights the evaluation of providing CFH services. Nurses prioritize children’s interests through child protection, age-appropriate interventions, family support, and effective care delivery [8, 25]. These findings align with previous research and also emphasize unique practices in China, such as integrating traditional Chinese nursing (e.g., Tuina, cupping, herbal steam, moxibustion, herbal patches, and auricular acupressure) as culturally significant [47–50], non-invasive methods that alleviate symptoms and discomfort [51]. Additionally, using information technology—such as Internet + nursing services for remote health education, consultations, follow-ups, and home visit services—reduces hospital visits [52, 53] and aligns with the CFHI standard “keeping children out of hospital” [8]. Therefore, these evaluations reflect the integration of local medical culture and modern advances into CFH.

Tailoring the environment adapted for children is the most impactful manifestation of CFH in Chinese medical institutions. Such environments should be meticulously designed and managed to address physical, emotional, safety, recreational, and equipment needs [28], reducing anxiety and fear, and improving the overall experience for pediatric patients [28, 30, 33]. This study underscores the importance of designing environments from a child’s perspective, such as a “one-meter height” view [29], and highlights the vital role nurses play in maintaining and optimizing these environments [30, 33]. Future developments in child-friendly environments will place greater emphasis on mobility, adaptability, accessibility, connectivity, affordability, and participation, necessitating the integration of these features into healthcare settings [43]. Consequently, the awareness and competencies in cultivating and sustaining CFH environments are essential components of assessing CFH practice.

Facilitating social interactions emerges as an important issue in evaluating CFH practices, as social connections inside and outside the hospital are indispensable for a positive hospital experience [27]. Firstly, a positive nurse-patient relationship is foundational, as it builds trust and comfort, allowing children to express fears and preferences, thereby reducing anxiety and encouraging active participation in their care [54]. Secondly, supporting children’s participation in healthcare processes further enhances their sense of control and cooperation, helping to reduce the helplessness often felt during hospitalization [31, 35]. Lastly, fostering social networks provides comprehensive support such as informational, emotional, and financial needs that promote resilience and coping ability [7]. Nurses can facilitate these connections by coordinating family and friends visits and integrating social resources, thereby enabling children to navigate the challenges of illness and recovery [7, 8].

Finally, under the framework of sustainable child development [45], evaluating nurses’ ability to support child growth holistically—through school-type learning, nutrition, health education, and parenting—is a critical component of assessing CFH practices [7, 8]. Illness and hospitalization disrupt schooling [37], which poses a psychological burden, especially in China, where high familial educational expectations add significant pressure [55, 56]. Assessing nurses’ capacity to facilitate educational continuity can help mitigate this impact, yet current educational support for hospitalized children remains limited, highlighting a need for further investment [36]. This study also underscores the importance of health education tailored to children’s cognitive levels to improve health literacy [39]. In China, however, health education largely relies on traditional formats like picture books and pamphlets. Integrating advanced technologies such as augmented reality (AR) [57] and virtual reality (VR) [40] into these efforts still requires significant development and promotion. Furthermore, With growing expectations for evidence-based parenting, empowering parents to participate in their child’s health management is essential [7, 58]. Providing parents with knowledge and skills fosters a collaborative environment, making them active partners in care [59, 60]. This improves care quality, as parents can better follow treatment plans, advocate for their child, and manage health at home [5, 59].

Limitations

This study has limitations. First, participants were mainly hospital-based, excluding nurses from primary healthcare institution, which may limit generalizability. Second, data were only collected from nurses, without patient or family perspectives, possibly overlooking the full care experience. Third, the study was confined to two cities in Zhejiang Province, where similar healthcare policies and culture may reduce diversity in CFH practices. Future research should include various healthcare levels and regions while incorporating the perspectives of patients and their families.

Conclusion

This study identified four core areas for assessing CFH from Chinese pediatric nurses’ perspectives. Nurses’ efforts in these areas reduce pediatric distress and enhance patient engagement, emphasizing the need for evaluating CFH practices to maintain high-quality child healthcare. These findings offer a framework for CFH assessment, supporting the ongoing development of CFH evaluation systems.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

WXH: collected data, analyzed, and drafted the manuscript. MCC: analyzed, revised the manuscript, and supervised the study. LYT: analyzed, designed the study, and revised the manuscript. XXL: collected data, analyzed, and added some ideas to the manuscript. MF, YYS, XLG: collected data and analyzed.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The original data, including participants’ voice recordings and interview transcripts, will be kept confidential and not be disclosed publicly. Nonetheless, the analytical codes derived from this study can be provided by the corresponding author upon a reasonable request.

Declarations

Ethics approval and consent to participate

This research was approved by the Medical Ethics Committee of Huzhou University (Reference No. 20231225). Informed consent was obtained from all participants before the study. Additionally, to protect participants’ confidentiality, all data were anonymized.

Consent for publication

Not applicable.

Clinical trial number

Not applicable.

Competing interests

The authors declare no competing interests.