Exploring Chinese family caregiver vigilance in preventing hospitalized children falls from the attention network theory perspective: a qualitative study

Introduction

Falls are the leading cause of accidental injuries among hospitalized children, and such injuries are largely preventable (1,2). Research has reported that the incidence of falls in in-patient children ranges from 0.77‰ to 1.23‰ (3,4). Other reports indicated that approximately 34% of children who experience fall require Intensive Care Unit (ICU) admission, which increases the length of hospital stay, medical expenses and may even cause death (5,6). Moreover, pediatric falls are also a potential factor in medical disputes, seriously affecting the hospital-patient relationship and patient satisfaction. Jamerson et al. demonstrated that in the majority of pediatric inpatient falls, family caregivers were present at the time of the incident, with an incidence rate of 84% (7). The treatment and nursing of pediatric patients are based on the concept of family-centred care, where the family is the main source of strength and support for children (8,9). Family caregivers play a vital role in preventing children from falling, and their attention and alertness are crucial for fall prevention. However, in the hospital environment, family caregivers’ alertness decreases for various reasons (such as unfamiliarity with the environment, psychological stress, and attention allocation bias) (10,11), thereby increasing the risk of children getting injured.

The attention network theory (ANT) divides attention into three parts: alerting, orienting, and executive control (12-14). These three components constitute the human brain’s attention system, playing a key role when individuals respond to environmental stimuli, especially in preventing accidental injuries (15,16). Brás et al. identified parental presence as a paradoxical risk factor for pediatric inpatient falls, attributable to diminished situational awareness during hospitalization (17). Utilizing ANT, this study defined family caregivers’ attentional allocation patterns in fall prevention under cognitive overload. Through Husserlian phenomenological qualitative research method (18), the research clarified how compromised alerting, orienting, and executive control networks impair hazard detection and response efficacy. These findings inform targeted guidance for clinical staff and also offer references for further reducing the incidence of falls in hospitalized children. We present this article in accordance with the COREQ reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-96/rc).

Methods

Setting

This qualitative study was conducted in the inpatient ward of Shenzhen Children’s Hospital, which treats children and adolescents aged 0-18 years. We employed a semi-structured interview approach to gain an in-depth understanding of family caregivers’ perceptions of falls in hospitalized children and collected detailed information through semi-structured interviews. Typically, the sample size in qualitative studies ranges from 4 to 62 (19). Following the purposeful maximum variation sampling strategy (20), we selected family caregivers ranging from 20 to 68 years old, with varying identities and educational backgrounds. The interviews occurred at both weekdays and weekends, and the participants were from different wards (5 internal medicine wards and 4 surgical wards), taking into account of factors such as the high risk of fall warnings. We intentionally selected participants to ensure information-rich cases within the group. Purposive sampling was used to select family caregivers of hospitalized children from June 2024 to July 2024 as the research subjects. Inclusion criteria: (I) family caregivers of in-patient children; (II) the patient’s Humpty Dumpty Fall Assessment Scale (HDFS) (21) at high risk (>12); (III) age >18 years old; (IV) able to understand and use Mandarin for communication and cooperation to complete the interview; (V) signed the informed consent form and participated voluntarily. Exclusion criteria: those who are unwilling to participate or have communication barriers. The number of interviewees was determined according to the principle of data saturation, and the collection was stopped when the information appeared repeatedly (22). This study complied with the requirements of the Helsinki Declaration and its subsequent amendments. It was approved by the Ethics Committee of Shenzhen Children’s Hospital (No. 202403002).

ANT

We established a research team and adopted the ANT to guide this interview. The ANT was proposed by psychologists Posner & Petersen, aiming to explain the three main components of attention: alerting, orienting, and executive control (23,24). These three sub-networks are relatively independent in terms of brain anatomy but are interconnected and participate together in the attention process (25). The alerting network (sustained attention) maintains individuals in a highly sensitive state of vigilance to respond rapidly and accurately to impending stimuli (26,27). The orienting network, also known as selective attention, is the ability to select specific information to focus on from a vast array of external inputs (28,29). The executive control network inhibits routine response tendencies to flexibly adjust behaviors according to task requirements for goal-directed actions (30). When the central stimulus (target stimulus) is consistent with the surrounding stimuli (distractors), the brain’s reaction time is faster, and the conflict experienced during the processing of consistent stimuli is less (31). Conversely when the brain processes inconsistent target and distractor stimuli, conflicts arise, leading to the ignorance of distractors (32). Figure 1 shows how the ANT model works.

Figure 1 Attention network theory model.

Research methods

Data collection

All members of our research team underwent qualitative interview training. Based on the literature review and discussion among team members, a preliminary interview outline was developed (3,33-35). Two family caregivers were selected for pre-interviews, and the final interview outline was determined based on the results. The outline included: [1] What do you know about preventing falls? [2] How likely do you think it is for your child to experience a fall during their hospital stay? [3] If you need to leave the bedside briefly, what preventive measures would you take? [4] What are your main concerns during your child’s hospitalization? [5] What sources of information have you used to obtain fall prevention measures for your child? [6] Do you know the assessment score for your child’s fall risk? Has the hospital staff discussed this with you? The interview questions systematically aligned with ANT components: Questions 1,2 assessed alerting through baseline vigilance and risk perception; Questions 3,4 evaluated orienting by probing prioritization conflicts between safety and treatment focus; Questions 5,6 examined executive control via retention of protocols and barriers to seeking assistance. A conversation room was chosen as the interview location to avoid disturbance or interruption. Before the interview, participants were introduced to the research purpose and confidentiality principles, and an informed consent form was signed. The interview was conducted by a Master-degree nurse for questioning and a ward safety officer for follow-up and recording. During the interview, family caregivers were encouraged to express themselves fully, and uncertain meanings were confirmed again. The entire interview was recorded, and participants’ physical and emotional changes were observed and recorded. The interview duration was 20–40 minutes.

Data analysis

Within 24 hours after the interview, one researcher (X.L.) transcribed the recording into text, and another researcher (X.T.) verified the accuracy of the content, using Dedoose software to analyze the data. Two researchers (X.L. and P.H.) independently read and analyzed the text in depth, marked important statements, summarized and encoded repeated viewpoints, sublimated theme concepts, and returned to the interviewees for confirmation when there were ambiguities in the analysis (19). When the opinions of the two researchers were inconsistent, a group discussion was held to confirm and form the final themes.

Quality control

The entire research process was guided by qualitative research experts. To protect participants’ personal information, the encoder replaced recording and text data with a combination of the letter “N” and numbers. All research data were properly stored and visible only to team members, not to be taken out of the hospital. During the research process, interviewees could withdraw at any time and were promised not to be treated unfairly.

Results

Participants and recruitment

Eighteen family caregivers met the inclusion criteria, and 17 were enrolled in the study. One parent was excluded due to language barriers. Table 1 shows the general information about children and family caregivers. The family caregivers included mothers (n=7, 41.2%), fathers (n=6, 35.3%), grandmothers (n=3, 17.6%), and a nanny (n=1, 5.9%).

Theme extraction based on the ANT theoretical model

Four themes were identified: The family caregivers lacked sustained alertness regarding the risk of falls in hospitalized children; failure to prioritize fall prevention; in terms of execution control, insufficient reception of fall prevention information provided by the hospital and inadequate initiative in obtaining fall prevention assistance from medical staff. Table 2 lists the themes extracted according to the ANT structure.

Low alertness

The alerting network of family caregivers demonstrated a significant lack of sustained alertness regarding the risk of falls in pediatric patients. An appreciable proportion of interviewees, 76.5% (13 out of 17), reported that the prevention equipment in the hospital was fully equipped.

“It’s not very likely, it must be better than at home, there’s no..... these,” (pointing to the handrail). “You all are the experts for sure!” (N7)

Furthermore, more than half of family caregivers expressed a belief that constant proximity to their children rendered falls highly unlikely.

“This is not impossible if parents are not attentive. It should be a bit better than at home, (during the hospital stay) I am always watching, but at home, there are household chores to do.” (N13)

During the hospitalization of their children, parents often exhibit excessive confidence in both the hospital and them regarding fall prevention. Additionally, children’s therapeutic interventions or changes in the condition can interrupt participants’ attention to falls.

“I was in a rush to get my kid to the CT scan... and when I got back, the nurse told me that I should have called them to come with me, and my son wasn’t strapped in safely... I was just so worried about finding out what was going on with his lung...” (N9)

Orientation deviation

The orienting network of family caregivers exhibited a failure to prioritize fall prevention. A considerable majority of 94.1% (16 out of 17) interviewees did not consider fall prevention as a primary concern. Moreover, one-third of them emphasized the primacy of disease treatment and focused on their kids’ recovery over safety.

“Treating the disease is the priority, safety is also considered, but not to such a high degree, right? The most important thing is to cure the disease. I came here just to get my son cured, not to an amusement park, so I don’t care about safety.” (N5)

“For example, during ward rounds, when doctors conduct examinations, I don’t think about whether the child might have a safety hazard.” (N6)

“Just hope my son gets better and goes home quickly.” (N8)

“I’m mainly concerned about the surgery of my son and hygiene. As for fall safety (pause), you (the hospital staff) have the capability, so I’m not worried about it.” (N12)

Notably, only family caregiver N3, the nanny, identified safety prevention as the top priority.

“He’s much better now, and the tube (drainage tube), you know...doctor took out his tube, he’s getting better and eating well. So, his papa and mama go to work. Boys are naughty, and he’s super active, and I’m always on the lookout to keep him safe... Avoid accidents, safety should be noted.” (N3)

This divergence in prioritization underscores a critical gap in the family caregivers’ alerting networks regarding fall prevention in the hospital setting.

Insufficient information reception

In terms of the execution control, the family caregivers were insufficiently receptive to fall prevention information provided by the hospital. The hospital implements a multifaceted approach to prevent falls, including infrastructural measures such as bedrails and handrails, as well as informational resources like leaflets, posters, educational films and videos, risk assessment forms, and verbal health education sessions conducted by medical staff. Despite these efforts, the preventive information does not seem to resonate sufficiently with the family caregivers. A significant proportion of family caregivers, 76.5% (13 out of 17), acknowledged that nurses had verbally informed them about fall prevention, yet they were unable to recall the specific measures.

“When we were admitted, there were videos, but I couldn’t remember the details.” (N6)

“You know when my kid was little, she fell once. The nurses here told us to pull up the bedrails, they told me a lot, but I forgot.” (N10)

“...Oh, it just hit me, the hospital’s public account mentioned it, and there are ‘Watch Your Step’ stickers in the bathroom! And there must be other things, nurses mentioned to me, but I am sorry...I think some are common senescence” (N16)

When queried about their awareness of the child’s HDFS, 15 (88.2%) interviewees unequivocally stated that they were unaware of it.

“You had this assessment? I didn’t know, just told us to pay more attention.” (N6)

Two participants believed an assessment had been conducted but could not provide the specific score.

“There might be. Yeah, there were just too many things when we first came, I can’t remember clearly.” (N1)

“I know, we are very scared...” Upon being asked to state the score, she shook her head, smiled embarrassedly, and then raised her voice, saying, “Oh, I’m old and can’t remember.” (N9)

Insufficient execution ability

Family caregivers also demonstrated inadequate initiative in obtaining fall prevention assistance from medical staff. When posed with the question, “If you need to leave the bedside briefly, would you ask someone else to look after your child?”, a mere 17.6% (3 out of 17) of the interviewees indicated a willingness to consider enlisting the help of a nurse.

“Ask the nurse to take care of my kid.” (N3)

A more significant 41.2% (7 out of 17) reported that they would request the accompanying person in the neighboring bed to assist with supervising their child.

“When I gotta the restroom or the doctor calls me for a chat, I’ll ask the mom next bed to keep an eye on him for a bit, just not for too long. Every time my kid is in the hospital, it’s like this, you know... I’ve never been refused, and I’m always down to help other parents too.” (N4)

“This morning, the father from the next bed sought help from me. Maybe if I can’t find anyone, I might turn to your nurses…what I mean is, your staff are very busy...” (N5)

Another 41.2% (7 out of 17) expressed a reluctance to bother others.

“If my husband is not here, I will take her (the patient) with me. I have never called a nurse in the hospital.” (N13)

“Hold my daughter and walk or use the stroller. If it’s just a few minutes away, I won’t like to trouble others. I’m not familiar with others, it’s not safe.” (N17)

In response to whether they would seek help from doctors, all family caregivers unanimously indicated that they would not.

“If there is someone, I will ask the person next bed. I can consider asking the nurse, but not the doctor, as they have more important medical matters to attend to.” (N11)

“Definitely won’t trouble them (the doctor), they are so busy here!” (N12)

This lack of initiative and execution control ability in seeking assistance from medical staff highlights a significant gap in the family caregivers’ approach to fall prevention, underscoring the need for enhanced communication and support systems within the hospital environment to ensure the safety of pediatric patients.

Discussion

In accordance with the ANT, the uneven allocation of family caregivers’ alerting, orienting, and executive control networks during hospitalization, with most attention focused on disease-related information rather than safety, impairs environmental monitoring, reduces hazard detection, and delays intervention when children face risks, thereby increasing pediatric fall incidence via weakened situational awareness and response efficacy. Therefore, bolstering the alertness, orientation attention, and execution control capabilities of family caregivers is pivotal to fall prevention. Medical staff can enhance the attention allocation of family caregivers through the following avenues: augment alertness by educating and training family caregivers to heighten their awareness of potential risks within the hospital environment, thereby enabling them to respond more swiftly to potential fall hazards. Appropriately allocating orientation attention, family caregivers should acquire the skills to effectively direct their focus towards the child’s behavior and the surrounding milieu, particularly when the child is active or approaching perilous zones. Furthermore, family caregivers need to cultivate superior execution control abilities to make accurate decisions when confronted with conflicting information. For instance, when a child is playing near the bedside, the family caregiver should be able to suppress distractions and concentrate on supervising the child’s safety. Additionally, hospitals can mitigate the risk of falls by optimizing the design (e.g., attaching high-visibility cartoon stickers to bedrails, broadcasting rhythmic auditory fall-prevention reminders, utilizing anti-slip flooring, and ensuring ample lighting in the wards). These interventions enhance caregivers’ executive network functionality during cognitive overload.

Owing to trust in hospital personnel and facilities, coupled with confidence in their caregiving capabilities, most family caregivers exhibit inadequate alertness to potential accidental injuries. Risk alertness represents an individual’s non-rational experiential comprehension derived from a subjective analysis of current environmental risks, with both overestimation and underestimation of risks constituting alertness deviations. This deviation in risk alertness diminishes their attention to potential risks and underestimates the likelihood of falls. This cognition, in turn, results in family caregivers not taking sufficient measures to prevent safety accidents. During hospitalization, the primary focus of family caregivers is concentrated on the treatment of the disease itself, with safety considerations being overlooked. This finding resonates with the results of AlSowailmi et al. (35) family caregivers are more inclined to seek information related to the disease that aligns with their current focus while disregarding safety knowledge related to it. When family caregivers are required to process a substantial amount of disease-related information and make decisions, their cognitive capacity becomes excessively occupied, leading to insufficient attention allocation to safety prevention. The cultural background and psychological state of family caregivers may also impact their perception of hospital safety. We also found that when the family caregivers were grandparents or nanny, rather than the parents of the children, their focus tended to be more on safety than on treatment. This may be related to the different roles they play and the different responsibilities they bear. Non-parental family caregivers may be concerned that if the child falls or has other safety issues, they will be considered careless in their duty. Therefore, their attention network may be more inclined towards safety rather than the treatment of the disease.

Moreover, negative emotions experienced during hospitalization, such as anxiety, tension, and anger, are also significant contributors to the attention bias of family caregivers. Therefore, alleviating the negative emotions of family caregivers, selecting appropriate educational timing, such as after therapy and treatment, enhancing family caregivers’ safety awareness in preventing falls, and allocating a portion of their attention to risk prevention are keys. The hospital nursing staff conducted HDFS assessments for all children upon admission and emphasized the necessity of providing safety-related health education to each family caregiver. However, these measures did not garner adequate attention from family caregivers. This finding may be attributed to several factors: the hospital provided an overwhelming amount of information and educational materials in a short span, leading to information overload for family caregivers and making it challenging for them to assimilate and retain all the information; the educational methods employed were not engaging or targeted enough, failing to effectively capture the family caregivers’ attention; the educational content was disconnected from reality, failing to elicit a positive response from family caregivers; the hospital environment was excessively busy and noisy, making it difficult for family caregivers to concentrate on the educational content. To enhance education, the following measures can be implemented: reduce the volume of information, highlight key points, and avoid information overload; utilize interactive educational methods, such as role-playing and simulation exercises, to increase family caregivers’ participation and interest; encourage family caregivers to provide feedback, follow up on their understanding and implementation of the educational content, and ensure the effectiveness of the education. Through these measures, the hospital may be able to increase family caregivers’ attention to fall prevention measures, thereby more effectively safeguarding the well-being of pediatric patients.

In addition, this study also revealed that family caregivers in China have a low willingness to proactively seek assistance from healthcare professionals, which is inconsistent with the findings of international scholars. Children’s family caregivers in other countries and regions are more inclined to involve professionals in their health and safety management (36,37). This discrepancy may be related to the traditional Chinese cultural values that advocate self-reliance and hierarchical order. These values may cause family caregivers to feel uneasy when communicating with healthcare professionals, thereby discouraging them from actively raising questions or seeking support. The complexity of the healthcare system further complicates the situation for family caregivers, making it difficult for them to know how to seek help. Additionally, factors such as unequal resource distribution, economic pressure, and social status may influence family caregivers’ behaviors and decision-making, leading them to prefer solving problems on their own. Healthcare professionals should pay attention to the psychological state of family caregivers, practice empathy during communication, and provide emotional support to encourage them to seek help proactively.

Limitations and strengths

There are several limitations in this study. Firstly, the research was confined to a single hospital’s inpatient department, which may restrict the generalizability of the findings to other healthcare settings. The hospital’s unique characteristics, including its patient population and caregiving practices, could influence the outcomes and may not represent broader contexts. Secondly, recruitment through a research registry may have introduced selection bias. Although the demographic characteristics of the interviewees align with the general family caregiver population, unmeasured variables could differ between registry participants and non-participants. For example, the absence of grandfathers among the interviewees may have skewed the results, as their perspectives and experiences may significantly differ from other family caregiver groups. Methodologically, exclusive reliance on self-reported data without observational validation risks response bias, compromising triangulation’s robustness in this study. Furthermore, the sampling method was limited to Mandarin-speaking family caregivers, potentially excluding valuable insights from those who speak other languages, leading to an under representation of diverse cultural perspectives related to pediatric fall prevention. Future research should include family caregivers from various linguistic backgrounds to enrich the understanding across different cultural contexts. Additionally, the sample was entirely Chinese, which may limit the cultural and ethnic diversity of the findings. A more heterogeneous sample could provide deeper insights into the multifaceted needs and experiences of family caregivers, revealing additional themes relevant to fall prevention in hospitalized children. Lastly, the research team consisted of nurses from the participating medical institution, which may have introduced bias or limited the breadth of professional expertise. Future studies could benefit from a multidisciplinary research team to offer a more comprehensive perspective on family caregiver vigilance and fall prevention.

Despite these limitations, the study contributes valuable insights into the attention allocation and vigilance of family caregivers in the context of pediatric fall prevention. The findings highlight areas for targeted interventions and suggest avenues for future research to further explore and address the complex interplay of factors influencing family caregiver behavior and hospital safety practices.

Conclusions

In summary, through the application of ANT, we can better understand the cognitive mechanisms of family caregivers in preventing falls in hospitalized children. Unlike adult patients, children are curious and have limited cognitive and comprehension abilities, and they cannot fully understand the importance of preventing accidents. Therefore, hospitalized children are almost entirely dependent on adult care, and improving and enhancing the alertness of adult family caregivers to fall is of great significance. The limitation of this study is that it was conducted in only one children’s hospital in China, and future research could consider multi-center studies and further exploration.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-96/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-96/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-96/prf

Funding: This study was supported by Shenzhen Science and Technology Innovation Commission (No. JCYJ20230807093803007).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-96/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study complied with the requirements of the Helsinki Declaration and its subsequent amendments, and was approved by the Ethics Committee of Shenzhen Children’s Hospital (No. 202403002). Informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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