Research Title: Exploring communication in the care for children with cancer in Palestine: an ethnographic qualitative case study approach

Author: Maha Mohammed Wahbi Atout, Published Year: 2019

The LANCET, 393

Faculty: Nursing

Abstract: Background There has been little research in the Middle East regarding communication in the care for children with cancer. Findings of studies undertaken in diverse cultural settings show that health-care providers report being poorly prepared to communicate with children with cancer and feel inadequately prepared to support families facing loss. The Arab culture differs in numerous ways from western culture (eg, with regard to disclosing prognosis information to children). Therefore, this study explores the experiences of children, families, and health professionals in communication in the care of children with cancer in Palestine. Methods This study used an ethnographic qualitative case study approach. It was conducted in one oncology unit based in the West Bank. Two data collection methods were employed: participant observation and semi-structured interviews. Ethics approval was obtained from the hospital ethical review board. Informed written consent was obtained from all participants (or legal guardians, in the case of children). Findings 70 hours of observation were undertaken and 35 interviews were conducted, involving five physicians, 11 nurses, six children aged 6–18 years, seven mothers, and six grandmothers. Although a few parents completely hid the diagnosis of leukaemia from their children, others tried to relieve the situation by informing their children of different diagnoses, such as a blood infection. The term cancer was avoided in the discussion of the disease by health-care providers and parents to ameliorate the negative effect of this term. The observational data showed that the children were not involved in discussions relating to their disease, and most communication about their illness was between their parents and physicians. Interpretation The findings reveal the challenges that physicians, nurses, grandmothers, and mothers face in communicating with children with cancer. Each group reported a need to improve their communication skills with children with cancer. Strategies are needed to involve children in communication regarding their disease and their prognosis.

Keywords: Communication; cancer; children; Palestine; Physician

Research Title: ‘We try to transmit pseudo strength to our kids; if we are broken, they will be broken as well’: nature of the dialogue between mothers, grandmothers and children with leukaemia in palestine

Author: Maha Mohammed Wahbi Atout, Published Year: 2019

BMJ Palliative & Supportive Care, 9

Faculty: Nursing

Abstract: Background Mothers of children with life-limiting illnesses describe facing challenges such as sometimes finding it difficult to communicate with their children, for example when their children become irritable due to their illnesses. This study explored the experience of communicating regarding the care of children with cancer, from the perspective of physicians, nurses, mothers, grandmothers and children in Palestine. This paper reports on the perceptions of the mothers and the grandmothers. Methods This study employed an ethnographic, collective, qualitative case study approach. It was conducted in one oncology unit in a Palestinian hospital. Two data collection methods were employed: participant observation and semi-structured interviews. Results The study generated 70 hours of observation and 35 interviews; physicians (n=5), nurses (n=11), children aged 6–18 (n=6), mothers (n=7) and grandmothers (n=6). Findings: The mothers and grandmothers stated that they pretended to be strong in front of their children to prevent them from feeling distressed by witnessing their mother’s suffering and grieving. Protecting children from seeing their mothers’ distress was thought to be essential to help children face their illness and their own suffering. Mothers talked to their children about their children’s strengths rather than the deprivations caused by their illnesses. Although they did not feel strong, the mothers tried to transfer their own strength to their children to strengthen them and protect them from being broken. Conclusions Being the mother of a child with cancer is clearly distressing and they suffer along with their child. Their maternal role drives them to conceal their own grief and their conversations with their children are strengths-based. There is clearly a role for nurses caring for families of children with cancer to support mothers and give them the opportunity to express and share their grief and distress.

Keywords: Conversation; mothers; children, cancer, Palestine; grandmothers

Research Title: Type, intensity and quality of information given by physicians during the cancer journey of palestinian children with leukaemia: between revelation and concealment

Author: Maha Mohammed Wahbi Atout, Published Year: 2019

BMJ Palliative & Supportive Care, 9

Faculty: Nursing

Abstract: Background Despite the accumulation of evidence that supports the importance of giving parents detailed information, there is less evidence to support the notion that providing ‘negative’ information has a harmful effect on both parents and children. This study explored the communication of information across the cancer journeys taken by children from different perspectives in Palestine. This paper reports on the perceptions of the physicians. Methods This study used an ethnographic qualitative case study approach. It was conducted in one oncology unit in one Palestinian hospital and used two data collection methods: participant observation and semi-structured interviews. Results The study generated 70 hours of observation and 35 interviews; physicians (n=5), nurses (n=11), children aged 6–18 (n=6), mothers (n=7) and grandmothers (n=6). The findings demonstrated that physicians were reasonably open with parents at the diagnosis stage; however, as the child’s condition got worse, they concealed negative information to protect parents from emotional suffering. However, despite their tendency to conceal information, they associated revealing information about the child’s deterioration to parents as an important act to protect themselves legally. Furthermore, they generally concealed negative information from children. There seemed to be a close link between the type, intensity and quality of information revealed and the stage of the cancer journey (diagnosis, treatment and prognosis). Conclusions This study of Arab physicians delivering care to children with cancer and their families are positioned at a point in tension where they are reluctant to reveal information about a child’s deterioration and the knowledge that by concealing this information they place themselves in a difficult position. Although concealing information may be explained by cultural context, it does leave a communication gap for children and their parents at a very sensitive time in the child’s cancer journey.

Keywords: Information; cancer; children; Palestine; Physician

Research Title: A STUDY OF CAPITAL STRUCTURE DECISIONS BY SMES: EMPIRICAL EVIDENCE FROM JORDAN

Author: Mohammad Oqlah Al-Smadi, Published Year: 2019

Academy of Accounting and Financial Studies Journal, 23

Faculty: Business

Abstract: Although of the important role for SMEs in promoting economic growth, as well as in combating poverty and unemployment, the determinants of their capital structure have not been studied sufficiently. Using a panel data of (77) SMEs in Jordan, this study examines factors that affect choices of capital structure. Two models were developed, the long-term debt model and the short-term debt model. The regression results of the long-term model show that assets structure, growth, size, and liquidity have a beneficial impact on the longterm debt ratio, while profitability has a negative effect. The results of the short-term model show that assets structure, size, and profitability have a negative impact, while growth has a positive impact. The results of the study can be used by the management of SMEs and government entities, which develop policies that aim to support and foster the emergence of SMEs in the Jordanian economy.

Keywords: SMEs, Long Term Debt, Short Term Debt, Jordan

Research Title: Corporate governance and risk taking of Jordanian listed corporations: the impact of board of directors

Author: Mohammad Oqlah Al-Smadi, Published Year: 2019

Investment Management and Financial Innovation, 16

Faculty: Business

Abstract: The aim of this study is to evaluate the compliance level of corporate governance rules and examine the impact of this compliance on risk taking of corporations in Jordan. This study used panel data of the listed corporations in Amman Stock Exchange from 2013 to 2017. Corporate governance index was constructed to gauge the compliance level of corporate governance rules. The results show a good level of overall compliance of corporate governance rules. As for the compliance of the categories of corporate governance rules, rules of transparency and disclosure are ranked first, while rules of general meeting assembly are ranked fourth. The regression results report a negative influence of corporate governance and corporate risk taking. In addition, four governance variables concerning the features of the board of directors are used in the study. The results reveal a negative impact of the size of the board of directors, independence of the board, and committees of the board on corporate risk taking. It is expected that the outcomes of the study can be used by management of the corporations in addition to the Jordanian Securities Commission that seek to enhance confidence in the Jordanian capital market.

Keywords: corporate governance, total risk, idiosyncratic risk, Jordanian listed corporations

Research Title: Exploring the communication experience in caring for children with cancer: An ethnographic multiple case study approach from Palestine.

Author: Maha Mohammed Wahbi Atout, Published Year: 2018

The Lancet Palestinian Health Alliance 9th conference, American University of Beirut, Lebanon

Faculty: Nursing

Abstract: Background: There has been little research in the Middle East regarding the experience of communicating with children with cancer from the perspectives of physicians, family carers and nurses. A preliminary systematic review of research about health care providers shows that they report being poorly prepared to communicate with children with cancer and their families, feeling inadequately prepared to support families facing loss and lacking confidence to deal with difficult questions and conflict. However, the Arab culture significantly differs from the previously mentioned studies’ culture in numerous respects, specifically Western culture with regard to disclosing prognosis information to children. Consequently, this study explores the experience of communicating regarding the care of children with cancer, from the perspective of physicians, nurses, mothers and children in Palestine. Material and Methods: This study employed an ethnographic collective qualitative case study approach. It was conducted in one oncology unit in a Palestinian hospital. Two data collection methods were employed: participant observation and semi-structured interviews. Findings: The number of interviews collected to date is (10) ten interviews. We conducted interviews with physicians (n=2), nurses (n=2), children aged 6–18 (n=2), mothers (n=2) and grandmothers (n=2) with 30 observational hours. The initial findings reveal that, while a few parents completely hid the diagnoses of leukaemia from their children, others tried to relieve the situation by informing their children of their having different diagnoses, such as a blood infection. The term cancer was avoided in the discussion of the disease by health care providers and parents to ameliorate the negative effect of this term, which is considered taboo in the studied culture. Generally, children were not involved in discussions related to their diseases. Instead, the majority of communications about their illnesses were with their parents and physicians. Although a few physicians and nurses agreed on the importance of involving children in the discussion regarding their prognosis and illness, they reported a lack of skills on the appropriate manner of providing them with sensitive information. Physicians reported facing challenges to communication, such as disclosing the bad news at the time of the initial diagnosis and the bad prognosis having an extreme effect on parents. Additionally, nurses experienced emotional suffering because of their long-term treatment of children with cancer, which affected their personal life. Conclusion: The study findings reveal that physicians, nurses and mothers demonstrated the challenges they face when they communicate with children with cancer. They also reported their need for improving their communication skills with children with cancer. The lack of communication skills education with children with cancer is quite clear and requires specialised communication skills education for both health care providers and parents. Finally, strategies are needed to involve children in the communication regarding their disease and their prognosis on the hospital level.

Keywords: Cancer, communication, ethnography, family carers, children, Palestine

Research Title: Guideline Model for Nurses to Prevent the Medication Errors and Adverse Drug Events in Pediatric Inpatients

Author: Maha Mohammed Wahbi Atout, Published Year: 2012

Journal of American Science, 8(8)

Faculty: Nursing

Abstract: Abstract: Medication errors were defined as errors in medication ordering, transcribing, dispensing, administering, or monitoring. Quasi experimental design was conducted for this study, The study aimed to identifying nurses needs of knowledge, practice, and attitude, developing guideline model for prevention of medication errors according to nurses needs and evaluating the effect of guideline model for prevention of medication error on nurses knowledge, practice, and attitude. The study was conducted in the pediatric medical, surgical and neonatal intensive care units in Al – Basher hospital in Amman city Jordan. This is a convenient sample of 85 registered nurses who's worked in the mentioned above setting. For data collection an interview questionnaire (pre/ posttest format) was used to assess nurses knowledge and practices as regard to definition, causes, contributing factorsand complication of medication errors also medication calculations, correct reading order, review patient six rights and double check of medication. The result of the study showed the effectiveness of guideline model on nurses who caring with children for medication administration. The implementation of guideline model showed significant improvement in nurses knowledge regarding all tested items , also concluded that the highest statistical significant improvement in nursing practices were noticed in most of the tested area which lead to prevent of medication errors . According to this study it is recommended that using the guideline model by all pediatric nurses which are dealing with children to prevent the medication errors, encourage continuous education program for pediatric nurses by using the different educational strategies to achieve high level of care for children and develop other standardized guideline model relevant to different aspect in pediatric nursing in order to cover most of the nurses educational needs.

Keywords: Guideline model, Medication error, Pediatric nurses

Research Title: Exploring the experience of communication in the care of children with palliative care needs:Adopting different stances : mothers' communication experiences

Author: Maha Mohammed Wahbi Atout, Published Year: 2018

The General Pediatrics, Adolescent Medicine and Neonatology Congress: Addressing the challenges in the health care of children , Abu Dhabi, UAE

Faculty: Nursing

Abstract: Background: despite having limited access to specialist palliative care, countries can successfully satisfy palliative care needs by ensuring all health professionals are properly trained and educated in their respective roles. To ensure that adequate care is provided for children with palliative needs in all healthcare settings, adequate training and support for care professionals is essential, even in cases where minimal specialist services are offered. Effective communication is a fundamental element in ensuring the quality of care provided to children with palliative care needs and has a considerable effect on the well-being of children as well as their relatives and care professionals. Nonetheless, a broad overview of the existing literature reveals that nurses often feel inadequately trained or prepared in terms of the communication skills needed to deal with the difficult situations. They often lack the confidence to communicate properly with parents or to deal with difficult questions or issues of conflict. Whilst this seems to echo studies previously conducted across a range of countries worldwide, research shows that countries with an Arab culture face slightly different issues in terms of disclosing serious prognoses to families. The current study is the first to examine communication between children, parents, and health professionals, in the care of children with non-malignant life-threatening and life-limiting illnesses in Jordan, and in particular the cultural and spiritual context that affects this communication. Purpose and objectives: The purpose of the current study is to explore the experience of communication in the care of children with palliative care needs, from the perspective of physicians, nurses, and mothers in Jordan. In this paper, the findings concerning mothers’ experiences will be presented. Methods: This study employed a collective qualitative case study approach. It was conducted in three paediatric units in a Jordanian hospital. Each case comprised a child aged 1-12 years, their most involved family carer (mothers), physician(s) and nurse(s). Two data collection methods were employed: participant observation and semi-structured interviews with three categories of participants: mothers, physicians, and the nurses who cared for the children that participated in this study. Within-case and cross-case analysis was undertaken in accordance with Stake’s (2006) recommendations. The within-case analysis focused on establishing the contextual background for every case. This was significant to protect the uniqueness of each case within its context and to be consistent with the case-study approach. The within-case analysis was presented narratively for every case. Then, cross-case analysis was undertaken to systematically extract the themes and subthemes of each case to identify similarities, differences, and contradictions. Findings: the study was based on 15 cases, with a total of 197 observational hours and 60 interviews (conducted with 15 mothers, 12 physicians and 21 nurses). The findings indicate that, in their experiences of communication with their children and healthcare professionals, mothers cited their adoption of different stances based on the specific care circumstances of the child. Thus, the role of the mother was determined by context as they adopted whatever stance they perceived as most appropriate in any given circumstances. For example, mothers were very empathetic and supportive when their child had to undergo invasive or painful procedures. On the other hand, other situations required mothers to convey strength in order to overcome emotional distress and motivate children to maintain strength as well. Furthermore, while some mothers allowed the doctor to determine the best course of action in their child’s treatment, others played a more active role in endorsing the rights of their child to be given the best health care available and safeguarding them from any unnecessary harm. Mothers controlled their style of interaction with both health care professionals and their children based on specific situations at various stages of the care process. Conclusion: These findings have several implications. In the first instance, the parents’ experiences should be taken into consideration when the medical teams establish the children’s treatment plans. Additionally, the continuous education and specialised training for professionals, which provides staff with specialised communication skills and emotional support for children and parents are imperative in improving the clinical practice in the healthcare settings with limited access to specialist palliative care.

Keywords: Children with life-threatening or life- limiting illnesses, End of life, Experience of communication, Healthcare care providers, Paediatric palliative care.

Research Title: Changing priorities in the care of children with cancer: The experience of Jordanian Parents

Author: Maha Mohammed Wahbi Atout, Published Year: 2018

The General Pediatrics, Adolescent Medicine and Neonatology Congress 'Addressing the challenges in the health care of children', Abu Dhabi, UAE

Faculty: Nursing

Abstract: Background: when a child has a terminal illness, parents reach a stage of acceptance of their forthcoming bereavement, refocusing their efforts on providing the best end-of-life (EOL) care that is possible. This comes when all treatment options have been explored, and there is no cure found for the illness. Cancer is the most common illness that requires EOL care in Western countries, with life-prolonging treatments explored. It is more and more becoming the norm in Western countries for EOL care to take place out of hospitals and in the patients’ homes which is in response to the wishes of the patients and their families, as well as the medical professionals involved in their care. However, the Arab culture significantly differs in numerous ways from Western culture. There have been no prior studies in Palestine on different issue related to parenting for children with cancer, but is something that requires attention. Purpose: the purpose of the current study is to explore the experience of parenting among parents who care for children with cancer. Methods: a Phenomenological hermeneutic approach was conducted informed by the philosophy of Martin Heidegger. The study was conducted in one oncology unit a Jordanian hospital. Parents of children aged (6-18) years old or with all types of cancer were considered eligible. A purposeful sampling strategy was adopted to recruit the participants. Maximum variation sampling will be employed. Data was collected using semi-structured interviews. Findings: thirty-two interviews were collected involving mothers (n=29), fathers (n=3). The parents changed their focus during the care of their children from an initial emphasis on normalising their children’s lives, to relieving their physical and psychological discomfort. This change of focus accompanied changes in the parents’ understanding of their children’s disease over time. They became more realistic regarding the future of their children, and therefore attempted to make their lives as enjoyable and comfortable as possible. Moreover, they evaluated any activity their children performed according to how much it affected their levels of comfort. When these activities resulted in further physical or psychological effort, the parents prioritised the comfort of their children over the benefits of the activities. Conclusion: the parents’ experiences should be taken into consideration when the medical teams establish the children’s treatment plans. Additionally, the continuous education and specialised training for professionals, which provides staff with specialised communication skills and emotional support for children and parents are imperative in improving the clinical practice in the healthcare settings with limited access to specialist palliative care.

Keywords: Cancer, experience, parents, children, Jordan

Research Title: The practice of mutual protection in the care of children with palliative care needs: multiple case study approach from Jordan

Author: Maha Mohammed Wahbi Atout, Published Year: 2018

Journal of Pediatric Nursing (Elsevier) ,

Faculty: Nursing

Abstract: Abstract Purpose This study explores the experience of disclosing critical information in the care of children with palliative care needs, from the perspective of physicians, nurses, and mothers in Jordan. Design and methods This study employed a qualitative case study approach. It was conducted in three paediatric units in a Jordanian hospital. Each case comprised a child aged 1–12 years with a condition eligible for palliative care who received health care in one of these units, and their most involved carers (e.g. mother, physician and nurse). Two data collection methods were employed: participant observation and semi-structured interviews with three categories of participants: mothers, physicians, and nurses. Ethical approval was obtained from the hospital ethical review board. Written consent was obtained from all participants. Results Qualitative case studies were developed around 15 children (aged 1–12 years, nine were boys and six were girls, with varying diagnoses: renal disease, neurological conditions, and congenital heart defects). A total of 197 observational hours and 60 interviews were completed (15 mothers, 12 physicians and 21 nurses). The findings demonstrate that the practice of ‘mutual protection’ dominated communication between children, parents and clinical staff. Parents protected their children by disclosing only partial information about their disease, and by avoiding any information they thought would cause the child distress or loss of hope. Similarly, children avoided expression to their parents of their anxieties or fears, in order to protect them. In turn, nurses attempted to ensure observance of professional boundaries with children and mothers to avoid a sense of loss when a child died. Conclusion The findings of the current study indicate that while open and honest communication between parents and children is generally recommended by literature, not all mothers agree with adopting open communication with their children concerning their illnesses. Therefore, any future intervention planned for them should respect parents' autonomy and decisions in addition to their cultural backgrounds. Practical implications The provision of ongoing education and specialised training for professionals to provide them with culturally sensitive skills in communication and provision of emotional support for children and parents is needed to improve clinical practice in healthcare settings with limited access to specialist palliative care such as Jordan.

Keywords: Child, Life- limiting, Communication, Mutual protection, Palliative care, Jordan, Qualitative