136 Journal of Nursing Scholarship, 2020; 52:2,

136 Journal of Nursing Scholarship, 2020; 52:2, 136-144. © 2020 Sigma Theta Tau International Fever is a cardinal response of the immune system in response to an infection, which is generally viral and self-limiting (Behrman, 1992). Feverish illness is very common in young children, with 20% to 40% of parents reporting such an illness each year (Fields, Chard, Murphy, & Richardson, 2013). Previous studies have demonstrated how parents’ perceptions of fever as an illness in itself, rather than as a symptom or sign of illness, leads to an increase in the number of medical consultations in primary care (PC) and emergency services (Baraff, 2003; Finkelstein, Christiansen, & Platt, 2000). Fever continues to be one of the main reasons for medical consultation in PC, especially in pediatric wards, which is associated with longer waiting lists in ordinary pediatric PC consultations. PC is the first level of professional care for people with health concerns and where most therapeutic and preventive health needs can be satisfied. In addition, PC services can control healthcare expenditures, improve the quality of care, and minimize socioeconomic health inequalities (Kringos, Boerma, van der Zee, & Groenewegen, 2013). The better the gatekeeping function of PC is (meaning that patients can only access secondary care if they are referred by a PC professional), the less the overall cost of medical care (Gerdtham, Jönssen, Macfarlan, & Oxley, 1998). In addition, in hospital emergency services, fever represents the most common reason for consultation, followed by respiratory infections and vomiting/diarrhea (Raso, Fernández, González, Fernández, & Quirante, 2004). This situation, in turn, causes overcrowding and increased health expenditures (e.g., by consuming greater resources, running diagnostic tests, etc.) (Aguado et al., 2012; de Bont et al., 2015; Ertmann, Reventlow, & Söderström, 2011; Walsh & Edwards, 2006). Due to the importance of this phenomenon, this study focuses on issues related to the behavior of parents seeking care for childhood fever. Previous research has shown the generally short timespan between the onset of fever in children and the parents seeking medical care, thus hampering the diagnosis of the origin of fever (Kitt et al., 2012). Behavior of Parents Seeking Care From Emergency Services Due to Fever in Children María Gloria Villarejo-Rodríguez, MSc, RN1,* , & Beatriz Rodríguez-Martín, PhD, MSc, RN2 1 Nurse, Health Center of Bargas, Toledo, Spain and PhD student, University of Castilla-La Mancha. Social and Health Care Center, Cuenca, Spain 2 PhD Professor, University of Castilla-La Mancha. Faculty of Health Sciences. Talavera de la Reina, Toledo, Spain Key words Child, fathers, fever, grounded theory, mothers Correspondence María Gloria Villarejo Rodríguez, Health Center of Bargas C/Real S/N 45593 Spain. E-mail: m..o@alu.uclm.es Accepted December 4, 2019 doi:10.1111/jnu.12538 Abstract Purpose: To explore the behavior of parents, with and without health training, seeking care from emergency services due to their child’s fever. Design and Setting: A qualitative study based on Grounded Theory using a triangulated sample (theoretical sampling and snowball sampling) of parents of children 0 to 12 years old who received care for fever in the emergency primary care services of two Spanish municipalities. Methods: Data saturation was achieved after eight focus groups segmented by gender, place of residence, and education (57 participants). Data analysis followed the constant comparative method and coding process. Findings: The parents attended the emergency department when fever was high or persistent and to determine the cause. The reasons for avoiding the emergency department differed; whereas the health professional parents avoided consulting other colleagues as they felt questioned, for parents who were not healthcare professionals, there was a fear of acquiring an infection. Conclusions: Parents’ search for healthcare differs according to their background and education. Clinical Relevance: These results provide key information for the design of care plans to improve health care and patient satisfaction. Villarejo-Rodríguez et al. Health Care for Childhood Fever Journal of Nursing Scholarship, 2020; 52:2, 136-144. 137 © 2020 Sigma Theta Tau International The parental concern regarding their children’s symptoms or the false beliefs surrounding fever (such as the belief that fever can lead to complications, including fever convulsions, brain damage, mental problems, or even death) (de Bont et al., 2015; Langer et al., 2013; Villarejo-Rodríguez & Rodríguez-Martín, 2019b), the lack of knowledge on the management of fever (Ertmann et al., 2011; Kitt et al., 2012), or the tendency to request antibiotics for the treatment of childhood fever (de Bont et al., 2018; Wun, Lam, Lam, & Sun, 2012), have all been suggested as reasons for the haste parents frequently display in seeking medical assistance for their child. New management models for health services in countries such as Canada, Denmark, and Spain suggest that support for self-care represents one of the most relevant functions of health care (Kitt et al., 2012; Nuño-Solinis, Rodríguez-Pereira, PiñeraElorriaga, Zaballa-González, & Bikandi-Irazabal, 2013). Within this model, nursing professionals must promote self-care and self-management for patients and main caregivers regarding their own health. For self-care to be effective, it is necessary to empower parents to improve their control over the decisions that affect both their own health and that of their children (Monsma, Richerson, & Sloand, 2015). In this sense, health professionals, especially nurses, have a major role in educating parents on self-care skills (Davison & Cooke, 2015), as involving parents in the care of their children improves their relationship with the medical team and helps support an appropriate use of health resources (De, Tong, Isaacs, & Craig, 2014). The educational level is known to influence a population’s behaviors regarding illness prevention, the identification of pathologies, and the care behaviors adopted (Basu & Stephenson, 2005; Hay, Heron, & Ness, 2005). Regarding the influence of prior training on healthcare-seeking behaviors, previous studies suggest that health professionals usually avoid the standard mode of care as they are embarrassed that colleagues may their professional expertise (Brimstone, Thistlethwaite, & Quirk, 2007; Davidson & Schattner, 2003; Kay, Mitchell, & Del Mar, 2004; Tyssen, 2001). In addition, further studies have described the practice of self-diagnosis and self-medication (Davidson & Schattner, 2003; Forsythe, Calnan, & Wall, 1999; Tyssen, 2001). These findings have been confirmed by the low rates of family doctor consultations found among health professionals when compared with the general population (Rogers, 1998). Another aspect that hampers the access of health professionals to health services is the tendency to perform informal care in corridor consultations (Garelick, 2012; Rosvold & Bjertness, 2002; Tyssen, 2001). It is known that appropriately managing the most common reasons behind attending emergency services can reduce health costs. Nevertheless, the reasons why parents attend emergency services when their child has a fever are little known. Also, to the best of our knowledge, no previous study has analyzed the perceptions of parents both with and without a health background regarding this phenomenon. This study is part of a broader project on childhood fever that addresses very different aspects of the process experienced by parents, ranging from the ideas formed on this symptom to the management of this symptom until its resolution (Villarejo-Rodríguez & RodríguezMartín, 2019a, 2019c). The aims of this study were to explore the behavior of parents in their search for healthcare at PC emergency services in cases of fever in children 0 to 12 years of age and to research the influence of parent’s healthcare training on this behavior. Methods This is a qualitative study designed based on the paradigmatic approach of grounded theory (Strauss & Corbin, 1990). Participants and Sample A triangulated sample was selected (theoretical sample and snowball sampling). The data collection was guided by concepts derived by the theory that is being built (theoretical sample). This sampling process was based on the constant comparative method (Amezcua & Gálvez Toro, 2002; De Andrés Pizarro, 2000), with the aim of reaching out to places or people to enrich the categories and maximize the opportunities of discovering variations amongst the concepts (Glaser, 1978). Thus, the sample included parents of Spanish nationality with children 0 to 12 years of age, who attended for fever consultations over a period of 1 year (November 1, 2016, to October 31, 2017) at the primary care emergency services (PCES) of the health centers of Bargas and Buenavista, and who agreed to participate in this study. The PCES provides health services outside the normal timetable of medical consultations (from Monday to Friday from 3 p.m. to 8 a.m., and throughout the weekend). We included parents with and without a healthcare background. We excluded parents of children with a background of asthma, pneumonia, or heart pathology. Furthermore, we performed “snowball sampling” (a form of nonprobability Health Care for Childhood Fever Villarejo-Rodríguez et al. 138 Journal of Nursing Scholarship, 2020; 52:2, 136-144. © 2020 Sigma Theta Tau International sampling) to select the parents of children who met the previous inclusion criteria and were health professionals. This sampling process is sequential, as informants refer or identify other informants, who are contacted by the researcher and who continue to identify further potential informants, and so on (Noy, 2008). The pediatric nurses of the health centers of the study contacted potential participants by telephone to provide information on this study. This first contact was made within the first 3 weeks after their PCES consultation. An incentive was offered in the form of breakfast or tea, which was offered to participants after the performance of focus groups (FGs). The FGs were held as the means of data collection, considering the criteria of intragroup homogeneity and heterogeneity (Calvente & Rodríguez, 2000). In addition, the segmentation of the FGs was performed according to whether they were parents with or without healthcare training; their area of residence (rural or urban); and gender. This was in order to gather any potential impact of these factors as inhibitory elements (Prieto & Cerdá, 2002). Table 1 describes the main characteristics of the sample. The sampling continued until the criteria of data saturation was achieved, meaning that to continue to expand the sample would not provide any new data (Álvarez-Gayou, 2003). Ethical Considerations Written informed consent for FGs was obtained from all participants. This study was approved by the Clinical Research Ethics Committee (no. 29, dated February 29, 2016). Data Collection The FGs were held between January and October 2017 in a quiet and private setting. Each FG consisted of a maximum of 10 participants, with an average duration of 50 min per session. Sessions were audio recorded after the participants had provided their written consent. The FGs were conducted and monitored by a moderator (MGVR) and an observer (collaborator). Data Analysis The recordings were transcribed line by line using F4 software (a software program for transcription; audiotransktiption GmbH, Marburg, Germany) and thereafter anonymized (each participant was identified with a capital or lowercase letter). The transcript of each participant was sent by email for participant verification. During data analysis, the themes were identified and classified, and the discourse content was coded. To review the point of data saturation, each transcript was analyzed before the next FG was held. We performed a process of open, axial, and selective coding. During open coding, separately categorized concepts are clustered around a related theme to structure more abstract categories. In axial coding, we reassembled data that were fractured during open coding and related subcategories to a category. Lastly using selective coding procedures, the categories were Table 1. Main Characteristics of the Parents Participating in the Focus Groups Sex Men Women Age <30 years 0 4 30-40 years 15 14 >40 years 12 12 Number of children 1 11 12 2 7 13 3-4 7 5 >4 2 0 Place of residence (environment) Rural environment 13 16 Urban environment 14 14 Level of studies No studies 0 0 Primary studies 4 2 Secondary studies 6 9 University studies: diploma, Bachelor’s degree 16 18 Master’s/PhD 1 1 Profession Non-health professional 14 15 Health professional Medical degree 7 7 Nursing diploma or degree 4 8 Nurse aide/health technician 2 0 Villarejo-Rodríguez et al. Health Care for Childhood Fever Journal of Nursing Scholarship, 2020; 52:2, 136-144. 139 © 2020 Sigma Theta Tau International integrated and developed into the theory (Strauss & Corbin, 1998). Two researchers conducted the coding process (MGVR & BRM), assisted by the use of Atlas.ti version 7.0 software (Atlas.ti Scientific Software Development GmbH, Berlin, Germany). During the analysis, a circular and flexible method was kept, conducting a constant comparison of the research findings (Salgado Lévano, 2007). Results Data saturation was achieved after eight FGs (57 participants). Four groups of parents with health training participated, of whom half included participants from a rural environment, while the other half were from an urban environment. Separate groups were established comprising fathers and mothers. In addition, we performed four FGs of fathers and mothers who were unrelated to the healthcare sector (fathers and mothers, separately), two per each health center, rural and urban. After the data analysis, six main categories explained the behavior regarding the search for care for episodes of childhood fever, observing differences among healthcare parents and non-healthcare parents. No differences were found between the urban and rural environments: criteria for going to the emergency room, emergency services avoidance, emergency consultation modality, consultation expectations, requests at the emergency service, and therapeutic relationship with the professionals consulted. For a greater understanding of the results, Table S1 displays the categories, subcategories, and codes that emerged, together with the main verbatim quotations from participants. Figure S1 is a summary of these findings. Parents, both with a medical background or not, verbalized the following reasons for attending emergency services in the case of childhood fever: the presence of fever lasting 3 consecutive days; having a temperature of over 38ºC; the age of the child, (infants younger than 6 months); the appearance of symptoms, such as a sore throat; vomiting or not eating; for the performance of diagnostic tests; due to family pressure from another parent, or the grandmothers; and to obtain a diagnosis for peace of mind. The impossibility of obtaining an ordinary medical appointment with the pediatrician or, if this was obtained, medical referral to the PCES, or the absence or resistance to the prescribed treatment were all reasons exclusively given by parents who had no healthcare training. In contrast, we found that a minority of parents avoided going to the PCES due to the fear of contracting an infection. In these cases, the parents believed that a telephone consultation was a good alternative to going to the PCES. In addition, the parents who were healthcare professionals avoided going to the PCES for fear of being criticized by their peers as they perceived that, due to their training or profession, they should be the ones to perform the diagnosis and treatment of their children. Other reasons disclosed by the non-healthcare participants for avoiding consulting the PCES were dissatisfaction with previous consultations for fever at the same service and the discomfort associated with emergency services, such as extended waiting periods. We have to go incognito, we can’t say anything about being health professionals. (father p; group of health professional fathers, rural environment) I am the one who decides in health issues. (mother R; group of health professional mothers, urban environment) Here [in emergency services] we come to catch a virus [sarcastic remark]. (father a; group of non-health professional fathers, rural environment) I am going to go and they are going to tell me that it is a virus and give me paracetamol, for that, it’s best I do it myself here at home. (mother M; group of non-health professional mothers, urban environment) Those parents who had no healthcare background had the following expectations when they went to the PCES: being treated appropriately, meaning that their children were treated with kindness and delicacy; adapting to the patient’s characteristics; receiving a complete physical examination; achieving a diagnosis for the cause of the fever; and receiving a treatment prescription for antibiotics. In some cases, the parents stated that they had specifically requested that the doctor provide them with a certain treatment and diagnosis and “a quick solution” for their child’s fever. I prefer that one of the doctors there attends us . . . he is Latin American, charming, the girls prefer him because of the way he treats us, his delicacy, the way he speaks to them. (father a; group of non-health professional fathers, rural environment) Health Care for Childhood Fever Villarejo-Rodríguez et al. 140 Journal of Nursing Scholarship, 2020; 52:2, 136-144. © 2020 Sigma Theta Tau International They didn’t listen to me [in the emergency room], they gave him the antibiotic on the 7th day. . . . (mother K; group of non-health professional mothers, urban environment) These non-healthcare parents also demanded an increase in the number of pediatric specialists, both in PC consultations and in emergency services, and shorter waiting periods, and requested that doctors spend less time on the computer and give them instructions in writing: He spent 10 minutes typing . . . it made me feel upset because we had been in the emergency room ages in order to have someone look at our girl. . . . I didn’t understand what took them so long. (father e; group of non-health professional fathers, rural environment) And the instructions the doctor gives you, would it be possible to get them in writing? Because I leave with a good feeling, but as soon as I go out the door I ask myself: what did they say? (father a; group of non-health professional fathers, rural environment) Concerning the elements necessary for establishing a good therapeutic relationship, the non-healthcare participants highlighted the feeling of trust associated with being cared for by their usual pediatrician and their distrust towards the care provided by an unknown doctor. Besides, the parents perceived that going to the PCES could “be a nuisance” for the professionals, which, in some cases, was a cause of fear and a more defensive attitude of the parents towards the health professional who attended them. I trust the professional [usual pediatrician]. (mother C; group of non-health professional mothers, rural environment) When I come and she isn’t here [her pediatrician], sometimes I feel like going back home. (mother I; group of non-health professional mothers, urban environment) It seemed like you had to apologize for taking your girl, as if it bothered them. You feel a bit conditioned, more defensive. (father b; Group of non-health professional fathers, rural environment) I am afraid of taking him, you don’t take them for any little thing. (father x; group of non-health professional fathers, urban environment) Discussion To our knowledge, this is the first study to jointly analyze the perceptions of parents, both with and without a healthcare background, regarding the search for health care in the case of childhood fever. The results of this study follow the line of previous studies, which suggest the following reasons for parents attending emergency services in episodes of childhood fever: when the fever lasts several days; when the child has a temperature above 38ºC; in infants below the age of 6 months; in the presence of other symptoms; to obtain a diagnosis of the cause of fever; or to obtain reassurance (de Bont et al., 2015; Maguire et al., 2011; Walsh, Edwards, & Fraser, 2007; Winskill, Keatinge, & Hancock, 2011). Among parents without healthcare training, other reasons cited were not being able to book an ordinary appointment with their pediatrician, and demanding more specialists. These results suggest the need to improve the management of human resources and the organization of pediatric consultations to facilitate accessibility and reduce the waiting period. In addition, this study provides another previously unreported reason for parents to attend the PCES, namely, pressure from a partner or other family members, such as the grandmothers. For this reason, we consider that healthcare education strategies should be directed not only at the parents, but also to the secondary guardians. Previous studies that have analyzed fever in children have not reported findings regarding the misgivings felt by certain parents for attending emergency services (de Bont et al., 2015; Maguire et al., 2011); however, this study analyzed the behavior of parents with healthcare training and found that they may avoid attending emergency services or consulting with their pediatrician in the event of a fever episode for fear of being criticized by their peers, as they perceived that, due to their training and profession, they should be the ones to perform the diagnosis and treatment of their children. These parents may perceive an extra responsibility towards the care of the child, feeling that their professional competency may be called into should they seek professional care. For this reason, when they need to consult another health professional, they tend to hide their healthcare training. Future studies need to analyze this phenomenon in other cultural contexts to determine Villarejo-Rodríguez et al. Health Care for Childhood Fever Journal of Nursing Scholarship, 2020; 52:2, 136-144. 141 © 2020 Sigma Theta Tau International whether this tendency of going incognito found in a sample of Spanish parents with healthcare training appears in other cultural realities. This study also reveals certain misgivings found among parents without healthcare training for going to emergency services due to the risk of acquiring an infection, the long waiting times, or because of a negative experience in the past. In addition, there are some parents who feel that they are a “nuisance” to the professionals when attending the PCES. This, in some cases, led to fear and a more defensive attitude of those parents towards the healthcare staff who attended them. A previous study showed that making a telephone call to the emergency services is a common strategy used among parents seeking health care (Winskill et al., 2011). The results of this study support these findings, showing that a telephone consultation is considered by parents as being an alternative to attending the PCES in order to avoid catching infections and long waiting times. Nevertheless, parents considered that this type of consultation is limited due to the impossibility of the child receiving a physical examination and complementary tests as already reported in previous studies (de Bont et al., 2015; Winskill et al., 2011). Furthermore, our results reinforce previous findings suggesting that some parents attend emergency services to receive treatment with antibiotics to quickly resolve the fever episode (de Bont et al., 2018; Wun et al., 2012). Other expectations of parents regarding their consultations with the PCES, and which have not appeared in previous studies, are that their child receive the appropriate treatment, adapted to the patient’s characteristics and with less time spent on the computer. Fulfilling these expectations would increase satisfaction with the service and the perception of the quality of the care offered, thus improving the therapeutic relationship between the healthcare professionals and the parents. Strengths of This Study This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ), using verification techniques to ensure rigor (Tong, Sainsbury & Craig, 2007). The methods used for guaranteeing validity and reliability were data triangulation, including participants with different sociodemographic characteristics, triangulation of data analysis via different researchers (Morse et al., 2002), and constant comparative methods (De Andrés Pizarro, 2000). The veracity and credibility of data and the principal criteria for the assessment of the study’s scientific rigor were ensured by asking participants to review and approve the FG transcripts. Furthermore, the participants of the FGs were unknown to each other to reduce the bias of participants feeling self-conscious or inhibited in expressing their experience and opinion on the subject. Limitations One of the possible study limitations is recall bias, which occurs when participants fail to remember previous events due to the time passed between the fever consultation and the performance of the FG. To avoid this, the established time period between these events was limited to 3 months. Conclusions Parents attend the PCES to obtain a diagnosis on the cause of their child’s fever. Among the parents with a healthcare background, there is a sense of extra responsibility in the care of the child and misgivings towards consulting other healthcare colleagues due to the fear that they may be questioned regarding their professional capacity. In addition, the findings regarding telephone consultations, used as an alternative by certain parents to avoid infections or undergoing prolonged waiting times, suggest that it would be interesting to support these types of consultations in order to reduce emergency department crowding. In addition, the nonavailability of ordinary consultations reflects the need to increase the number of healthcare professionals. Implications for Nursing Management This study provides key information for the design of care plans directed at improving the care and satisfaction of parents in the management of childhood fever. The reasons parents attend emergency services should be incorporated into health education programs directed at increasing the knowledge of the parents and guardians in the management of childhood fever. This could help decrease the numbers of early or repeated consultations to the PCES and more efficiently manage the available resources. Acknowledgement This study was funded via the Research Training Startup Project of the Provincial Council of Cuenca (Record VA50618000035). Health Care for Childhood Fever Villarejo-Rodríguez et al. 142 Journal of Nursing Scholarship, 2020; 52:2, 136-144. © 2020 Sigma Theta Tau International Clinical Resource • Qualitative studies analysis. https://core.ac.uk/ download/pdf/82822372.pdf References Aguado, A., Rodríguez, D., Flor, F., Sicras, A., Ruiz, A., & Prados-Torres, A. (2012). Distribution of primary care expenditure according to sex and age group: A retrospective analysis. 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