To our knowledge, this is the first study to provide in-depth, descriptive detail about the experiences and needs of children hospitalised for injury and their families from the perspective of health and support service providers. Strengths of the study included the wide range of key informant providers who willingly participated and the qualitative approach which enabled them to speak freely about their experiences and views. However, the findings must be interpreted in light of several limitations and the scope of this study.
The research was undertaken in the context of two large urban children's hospitals. The information gleaned may not be applicable to all other hospitals, particularly those where resources are even less accessible. Smaller hospitals in provincial or rural settings may, however, have closer engagement with their communities which could overcome some of the challenges identified in this study. Despite some changes to New Zealand's health and hospital services since the collection of these data, feedback from health professionals at presentations of the study findings at several national meetings in 2008 and 2009 suggest that many issues identified by key informants have persisted and are not unique to the hospitals involved in this research, or indeed, trauma services alone. The findings of the present study as well as feedback at presentations since indicate a high level of awareness among service providers regarding the many shortcomings of a busy and overloaded health service and empathy and insight into the innumerable issues faced by children and their families. Most felt they and their health service colleagues were doing the best they could within the constraints of an inadequately resourced system, whose services were stretched, particularly in clinical settings where relatively short-stay admissions are common.
It is possible that given the specific research questions explored in this study, participants were prompted to reflect particularly on service gaps and limitations rather than the areas in which the needs of children and families were adequately met. However, there was considerable agreement between the service issues and concerns identified by the key informants in this study and those mentioned by the whānau/families in the parallel strand of research in the larger study . Both participant groups identified as issues; problems around information and communication needs, difficulties managing the multiple stresses on families when children are injured and hospitalised, the stressful impact of cultural stereotyping and the need for more appropriate resourcing for Māori and Pacific families. This high level of accord adds weight to their significance.
The study findings have direct implications for services that provide care for injured children and their families during and after hospitalisation. In general, the hospital system does not seem to adequately meet the needs of children with mild injuries. Evidences suggest that an injury which may be 'minor' with respect to threat to life, may have a considerable impact on the family involved as well as wider society . Depending on the circumstances surrounding the event, the emotional consequences experienced by these children and their families can be extensive. A high prevalence of post traumatic stress disorder symptoms has been found in children with mild to moderate injury up to 18 months after the event . Other studies, while not exclusively focusing on children, have reported that a considerable proportion of patients with minor traffic injuries had a slow recovery and long-term adverse psychological and social consequences. Psycho-social outcomes were found at times to linger for much longer than physical outcomes and were poorly predicted by the severity of the physical injury [29–31]. Several key informants were aware of this issue and perceived it as a function of time and resource constraints, rather than assuming that these children did not require much attention.
Key informants' concerns about the inadequacies of the hospital system in allaying parental distress appear well founded as one study found that parental distress played a more important role in the persistence of post traumatic stress disorder symptoms in children than the extent of the injury or the course of hospitalisation . A number of factors contribute to parental distress during and after their child's hospitalisation. Important amongst these is inadequate information about the child's condition, care requirements and prognosis. Consistent with concerns expressed by families participating in the complementary arm of this study , key informants highlighted several problematic areas relating to communication, such as parents having to repeat the child's history often, language barriers and the need for better written information. Not alluded to by key informants but considered important by whānau/families was the need for appropriate and effective oral communications. Effective communication through a range of means is the cornerstone of ensuring patient health literacy, particularly where cultural miscommunications can arise . Several studies have found that linguistic and cultural barriers adversely influence family involvement in the care of their children while in hospital and contribute to healthcare disparities for many minority groups [34–37].
The key informant Māori and Pacific support workers in the present study were aware of the significant stresses experienced by families of Māori and Pacific children who are known to experience a disproportionately high rate of unintentional injury [16–18]. However, they were concerned about resource constraints that limited the assistance they could offer these families, and the reality that their service was not accessible to families of most children with 'minor' injuries admitted for short periods This indicates that while the existence of such support services is crucial, these must be well resourced and extend to effective service delivery that is supported by an organisational culture that is responsive to the needs of these populations.
Problems with the coordination of services both within the hospital setting and between the hospital and the community were noted. The movement of patients between services is typically a difficult area to streamline but, in the case of an injury, the involvement of a number of professionals coupled with rapid discharge appears to exacerbate this difficulty. The key informants recognised the first 24 hours at home following discharge as a crucial transition phase. During this period, the 'second crisis of injury' may occur when responsibility shifts from professional care givers to family members . Many informants felt that there was more that could be done of a relatively minor nature that could reduce the stress of this transition for families. For example, a simple follow-up phone call to check on how the child was, how the family was coping and to answer any questions was a frequent recommendation. The communication and coordination between hospital and community or educational services were also recognised as areas that needed more attention. These concerns suggest the need for carefully developed discharge plans that provide continuity of care and effectively work across the boundaries between hospital, home and school, encouraging and reinforcing well developed relations between hospital and community based care services.
For all of the reasons noted above, it is critical that information about hospital processes, issues that would become problematic following discharge to the community, and the resources available to support children and their families to negotiate these transitions, is given in a systematic and proactive manner rather than on an ad hoc basis. This would require the use of a variety of mechanisms to ensure that families under stress understand and retain necessary information. These are likely to include the need for culturally appropriate communication both orally and using written material, informative discharge plans, and where relevant, referrals to primary care and social services. It would be particularly important to ensure that all injured children and families who require further follow up by case managers in New Zealand's Accident Compensation Corporation (ACC), have access to this service. While the resources of this government-funded insurance scheme can serve as a potentially useful safety net for all New Zealanders requiring post-injury health care and rehabilitation, inequities in access to services by some ethnic groups, particularly including Māori, are well documented .
The accord between issues identified by the key informants in this study and those mentioned by the whānau/families in the parallel strand of research  suggests that many staff working with injured children and their families have a keen awareness of what constitutes optimal care but because of structural, time and other constraints are not always able to deliver it. The tension between providers' perceptions of optimum care and their ability to provide it is clearly an area for ongoing exploration and development. Systemic factors can provide significant barriers to effective care, however, health service providers' attitudes and behaviours also remain important influences on families' experience of health services and on the quality of care received [33, 40]. In our study staff members' judgements around the cause of injury were a case in point.
Barriers to quality care for children hospitalised for injury are complex and multi factorial and a clear understanding and analysis of these barriers is needed if service improvements are to occur. Systemic, health provider and patient factors have been identified as key barriers to quality services  and interventions at these three levels have recently been proposed as a means to reduce ethnic disparities in the quality of trauma care . Strategies that would appear to have particular relevance for our suggested improvements to services for children hospitalised for injury and their families include cultural competency training with a focus on patient health literacy, and clinical audits with feedback loops that support continuous quality improvement. Research designed to quantify the importance and predisposing factors that underlie the issues identified in this study could provide useful guidance to prioritise areas of action.