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Column Editor: Bonnie Holaday, DNS, RN, FAAN

ParentsT Experiences of Their Children Achieving

Bladder Control
Ulla-Britt Jansson, RN, MSN, PhD
Ella Danielson, RN, PhD
Anna-Lena Hellstrm, RN, PhD

Achieving bladder control is important for children and parents, but there is a shortage of knowledge about experiences from
parents' points of view. The aim of this study was to describe parents' experiences of how their children achieved dryness.
Twenty-two parents of 21 healthy children were interviewed about the process. The transcribed interviews were analyzed using
the qualitative content analysis. How children achieve dryness, as reported mainly by their mothers, seems to be influenced by
knowing the time had come, implementing new daily routines, the child's willingness, and a desire to be like others.
2008 Elsevier Inc. All rights reserved.

Key words: Bladder control; Children; Parent's experiences; Content analysis

B LADDER CONTROL IS an important issue for

both children and parents. Still, not being dry at
an age when they are expected to be has been found
train a child and not only the result. Because the aim
was to get a deeper knowledge and a more
comprehensive picture of the process including
to have a negative impact on children's self-esteem the parents' feelings and thoughts, the terms be-
(Hgglf, Andrn, Bergstrm, Marklund, & Wende- come dry, achieve dryness or achieve bladder
lius, 1998; Moffatt, Kato, & Pless, 1987; Wagner & control were used instead of toilet trained.
Geffken, 1986), causing stress in children (Butler, Developmentally appropriate toilet training is
2001; Foxman, Valdez, & Brook, 1986) and parents well described in the literature, and most recom-
as well as stress between child and parents (Norgaard mendations about toilet training include the impor-
& Andersen, 1994; Zickler & Richardson, 2004). tance of the child's readiness. The general readiness
Many studies on when children are toilet trained have of a child is often described in terms of motor skills
been conducted (Bakker & Wyndaele, 2000; Berk & achievement (sitting, walking), the understanding
Friman, 1990; Bloom, Seeley, Ritchey, & McGuire, of words for elimination, interest in the potty/toilet
1993; Jansson, Hanson, Silln, & Hellstrm, 2005; and in imitating others, and the desire to please the
Largo, Molinari, von Siebenthal, & Wolfensberger,
1996; Schum et al., 2002). In addition, there have
been studies on how physiological characteristics, From the Department of Surgery, Urotherapeutic Unit, Queen
such as sleep, bladder volume, emptying ability Silvia Children's Hospital, Sahlgrenska University Hospital,
(Jansson et al., 2005), and prematurity (Silln, 2001), Gteborg, Sweden; Institute of Health and Care Sciences,
interact in the process, as well as on how changes in Sahlgrenska Academy at Gteborg University, Gteborg,
daily life affect the age at which a child is toilet Corresponding author: Ulla-Britt Jansson, RN, MSN, PhD,
trained (Jansson, Silln, & Hellstrm, 2007). It has Department of Surgery, Urotherapeutic Unit, Queen Silvia
also been suggested that children achieve bladder Children's Hospital, Sahlgrenska University Hospital, Smr-
control at later ages today than in the past (Bakker & slottsgatan 5, 416 85 Gteborg, Sweden.
Wyndaele, 2000; Blum, Taubman, & Nemeth, 2004;,
Jansson et al., 2005; Neff, 1998). 0882-5963/$-see front matter
The term toilet trained is mainly used in Sweden 2008 Elsevier Inc. All rights reserved.
to describe specific activities performed to toilet doi:10.1016/j.pedn.2007.07.011

Journal of Pediatric Nursing, Vol 23, No 6 (December), 2008 471


parents. Specific skills are also important for Table 1. Reported Age When Complete Dryness Was
Achieved, Age When Toilet Training Began, and the
successful toilet training, including being able to
Period of Dryness at Interview
stay dry for a period, being uncomfortable when in
Age When Complete
wet or soiled diapers, and indicating a need to void Dryness (Day and Night) Age When Toilet Period of Dryness at
(American Academy of Pediatrics, 2000; Canadian Was Achieved Training Began Interview

Paediatric Society, 2000; Chordas, 2005; Fox, M 32 months 21 months 20 months

2002; Hockenberry, Wilson, Winkelstein, & (2.75 years) (1.75 years) (1.75 years)
Kline, 2003; Polaha, Warzak, & Dittmer-Mcmahon, Mdn 30 months 30 months 17 months
(2.5 years) (2.5 years) (1.75 years)
2002; Schmitt, 2004; Schum et al., 2002; Stein,
Range 1651 months 245 months 636 months
2000). The readiness of the parents is also described (1.54.25 years) (0.253.75 years) (0.53 years)
in most recommendations of today, including
willingness to invest time in toilet training and to
recognize the child's level of readiness and the study with this focus is that by Rundahl Hauck
absence of changes in the family (American (1991). In this study, components of the toilet-
Academy of Pediatrics, 2000; Chordas, 2005; training process were identified from the mother's
Dixon & Stein, 2000; Hockenberry et al., 2003). perspective. Learning more about parents' every-
The most commonly recommended toilet-train- day experiences of their children's acquisition of
ing methods are the child-oriented approach of bladder control may contribute to our knowledge of
Brazelton (1962) and the structured behavioral a better understanding of the process.
method of Azrin and Foxx (1974). In an evaluation
study of their effectiveness, both methods were
found to result in quick successful toilet training, AIM
although no information about the sustainability of The aim of this study was to describe parents'
the training was available (Klassen et al., 2006). experience of how their children achieved blad-
Achieving bladder control is a process that der control.
usually takes place at home and in which parents,
historically mostly mothers, have played a domi-
nant role. Factors that may contribute to the METHOD
postponement of dryness include access to high- This study is part of a larger project about the
quality superabsorbent diapers, people's lifestyles achievement of bladder control in healthy children,
today, and their level of economic welfare. Owing in which only quantitative methods were used
to all these factors, neither parents nor health (Jansson, Hanson, Hanson, Hellstrm, & Sillen,
professionals actively encourage starting the toilet- 2000; Jansson et al., 2005, 2007). The present study
training process at any given time or consider it focuses on parents' experiences of how their
essential to discuss the matter. Parents' experiences children achieved bladder control. A qualitative
of the transition period from diaper use to bladder approach was chosen to gain deeper knowledge
control have not been sufficiently studied. about the process of becoming dry as well as to
Qualitative research goes to the source for achieve a comprehensive picture of bladder func-
information; here, the source would be the children. tion development in children.
There are methodological problems associated with
interviewing children of toilet-training age about Participants
bladder control. However, observation as a research This study was conducted at one child health care
method has been used, for example, in an center (CHC) in an urban area in Sweden. Mothers or
ethnographic study by de Vries and de Vries fathers of children reported to have been completely
(1977). The toilet-training process in 16 children toilet trained, day and night, for a period of at least
from the Digo population of East Africa was 6 months were included in the study (Table 1). The
followed by observation from the ages of 34 participants had to be Swedish speaking. They were
weeks until the child was toilet trained at informed and invited to join the study consecutively
approximately 46 months of age. This method is by the nurse at appointments at the CHC. Twenty
time consuming, and for the purposes of obtaining mothers and one couple participated in the present
more knowledge about the transition period in the study. Altogether, there were 16 girls and 5 boys, all
daily life of the family, the parents' experience is reported by their parents to have been completely
also of importance. To our knowledge, the only toilet trained for a period of between 6 and 36 months

(3 years; Table 1). Eighteen children were their Table 2. Overview of Categories and Subcategories
parents' first child, 2 the second child, and 1 the third Categories Subcategories

child. Eighteen children (13 girls and 5 boys) had The time had come Making a decision
worn disposable diapers, and 3 girls had used both Having time
cloth and disposable diapers. New daily routines Creating a positive atmosphere
Doing activities
Interviews Child's willingness Cognitive skills
Personality traits
Qualitative interviews were conducted and were Being like others Unspoken rules
of a narrative nature, implying that the interviewer Comparing and fitting in
and the interviewee participated in a conversation
about the current topic, and the interviewee was
allowed to speak freely without interruption (Kvale, describing the content, efforts were made to stay
1996). All interviews were performed by the first close to the interview text. From the codes and
author and began with an open question: Would preliminary categories, eight subcategories and four
you please tell me about how your child achieved categories were identified by going back and forth
bladder control? Supportive questions (What do among the preliminary categories, the codes, and
you think? What do you mean? Could you the meaning units. The text was independently
explain?) were added during the interview. The analyzed with regard to agreement among all the
interviews lasted between 29 and 55 minutes, with authors to increase the credibility of the analysis. If
an average of 39 minutes. All interviews were tape agreement could not be achieved, further analysis
recorded and transcribed verbatim. was performed until consensus among the authors
was reached.
When a parent agreed to participate, he or she
was contacted by the first author (U.B.J.) by FINDINGS
telephone to make an appointment for the interview. The findings are classified into four categories,
Both written and verbal information about the study with two subcategories under each category. An
were given, and informed consent was obtained. overview of subcategories and categories is pre-
The parents' participation was voluntary, and sented in Table 2.
confidentiality was guaranteed. All the interviews
were individual except for the one couple, who The Time Had Come
were interviewed together. The interviews were The parents' experiences that the time had
carried out over an 8-month period between come included descriptions of making a decision
September 2004 and May 2005. The interviews and having time.
took place during the evening at the CHC, which
was a familiar place to the parents because they had Making a Decision
been there many times for checkups. Approval was The parents described the process of becoming
obtained from the Child Health Care Authorities of dry as something that has to be done (the sooner the
Gteborg, Sweden, and the Research Ethics Com- better) because all children need this skill in the end.
mittee at Sahlgrenska University Hospital, Gte- It was seen as a private matter and something the
borg University, Sweden (Study Code 584-02). parents are responsible for. They did not expect day
care staff to have time to train the children.
Analysis According to the parents' narratives, becoming dry
A qualitative content analysis method was used. is a process usually initiated by the parents, who
According to Krippendorff (2004), content analysis have the feeling that the time to start had come.
is a technique for analyzing the content of a text in There is a point when they decide that the diaper
various steps. The interviews with the 22 parents period is coming to an end, that it is the right time to
were combined into one text, which was read and try to stop using diapers. They set a goal; that is,
reread. The analysis was performed inductively; before the child goes back to day care again after the
that is, the content was structured into meaning summer vacation, the parents will try to get him or
units according to the aim of the study. The her dry. The decision is made for practical reasons
meaning units were extracted and sorted into and is not seen as negotiable. Once the decision is
codes. During the analysis, when identifying and made, they have to complete the procedure.

I took the diapers away, right away, when I had made Doing Activities
up my mind there was no turning back (No. 21).
The parents believed that different activities
might create new habits and help the child stop
Having Time
wearing diapers. The parents found that there were a
All the parents talked about the possibility of lot of possible activities, and as a starting point, they
starting to stop using diapers for their children bought a potty or a toilet ring, showed it to the child,
during the summer because they will then have the and talked about how to use it. It was important to
time, it will be warm outside, and, hence, the child have the door to the bathroom open so that the child
does not have to wear clothes. As the child runs could observe what his or her parents, brothers, and
around naked outside, it will be easier to put up sisters did there. Some parents used cloth diapers for
with puddles of pee or poo. In the summer, at their child or let their child wear underwear instead
least one parent would have been on vacation and, of diapers whereas some parents observed signs
thus, could spend a lot of time with the child. from their child that he or she needs to go (to the
Spending a lot of time with their children to be able bathroom) to avoid their child wetting his or her
to figure out what is happening and parents' pants. They also paid attention to other children who
participation have been described as important. were dry. They reminded and encouraged their child
While on parental leave or having had a longer to void regularlybefore and after sleep and after
holiday together with their child, the parents eating. The child was also encouraged not to drink
experienced that they had the time they needed to before bedtime. During this time, the children were
get their child dry. not using diapers as much as possible during the
day, in the beginning and only at home. The parents
You have to have time with the child; you can't do
it over the weekend or in the afternoons after picking
experienced this as taking a chancea small chance
up the child at daycare It doesn't work that way in the beginning. When going out, the parents
(No. 5). described the situation as taking chances and not
knowing for how long, or if, the child could manage
New Daily Routines not to wet his or her pants. As time passed by and
depending on the number of accidents, the time of
The parents' experiences of new daily routines
being without diapers was prolonged.
involved descriptions of creating a positive atmo-
sphere and doing activities. Child's Willingness
The parents' experiences of their child's will-
Creating a Positive Atmosphere
ingness included descriptions of cognitive skills
To get the child to use the potty the parents tried and personality traits.
to make the toilet visits fun; they kept the child
company, read to the child, spent time talking, Cognitive Skills
were in no hurry, and had cozy moments together. The parents said that certain prerequisites had to
The thing was to involve the children by tempting be fulfilled in their children before they could
or enticing them and letting them participate while become dry. The parents interpreted their child to be
having different choices: potty or toilet, the color mature enough to begin training if he or she paid
of the potty, emptying the potty afterward, and attention, cared, showed an interest, or expressed an
flushing the toilet. The children were also given a understanding of what it was all about. The child's
lot of attention. If they succeeded, they were responses also gave the parents a hint as to how
praised and rewarded. The parents believed that successful the training would be or if there was any
their attitudes could influence their child to point in trying at all. Another indication was when
become dry. They tried to be cool, to let it be a the child's diaper was dry for longer periods during
natural part of daily life, and to not react the day or after the afternoon nap or when the diaper
negatively to accidents, and they also modified was dry in the morning. The ages of the children
potty training into a special event or a game to when the parents found their child mature enough
make it fun. to begin varied (Table 1).
if she urinated a little in the potty it was fantastic, Then I know she was without a diaper and then
we showed it to the whole family, took a picture, and she peed on the floor, she really noticed I peed
made it a fun thing (No. 5). (No. 3).

Personality Traits failure. The parents were not in favor of such

The parents believed that it would be easier for methods but wanted their efforts to get their child
them to toilet train their child if he or she was calm dry to be a natural part of the day and not to be
and patient, as compared with other children, and if associated with any compulsion.
he or she took his or her time or was curious about Certain things you just do not talk about (No. 5).
new things. If the child liked to do things
Somewhere there is a limit. How old is it
independently, this also contributed to success in acceptable for children to wear diapers? (No. 6).
the child becoming dry. However, other parents
described their child as being preoccupied by Comparing and Fitting in
learning other things and not being interested in According to the parents, both parents and
the potty or toilet. Some children liked their children compared and tried to live up to the
routines and doing things the easy way; they were unspoken norms: It was important to be more or
not interested in changes. They found their diapers less like one's age group and not to deviate too
comfortable, and, according to their parents, this much. Parents felt the pressure to toilet train their
prolonged the time of achieving dryness. children when other children are already dry; it
since she is calm she had the patience to sit still a
would be embarrassing or shameful for the child
lot which also makes it easier to get dry (No. 13). who still wears diapers. When they talk with other
parents, parents automatically compare their chil-
Being Like Others dren and their different skills. The parents
The parents' experiences of being like others expressed a strong desire for their children to be
involved descriptions of unspoken rules and com- like other children, to be good enough, to be
paring and fitting in. attractive to others, and not to deviate. There were
also worries about day care staff feeling uncomfor-
Unspoken Rules table or disgusted when changing their child's
How children stop wearing diapers was viewed diapers. The parents did not want to expose their
as a sensitive subject and was not commonly children to these reactions from others.
brought up either with or by day care staff or CHC In the end it's shameful it's embarrassing that no
staff and not even by friends of the family. The one else wears diapers there is a kind of group
parents had not talked much with others about how pressure (No. 1).
to get their children dry, as the subject was
experienced as private and a little taboo. There
are certain things one should not talk about; toilet DISCUSSION
training is one of them. If a child became dry early, Achieving bladder control is a complex process,
the parents were more likely to bring it up than if which, like other developmental processes, takes
being dry occurred late. Some parents said that a time and is challenging even to a family where the
child's being dry early was a sensitive subject to child is developing normally. There are not many
discuss; others said the same thing if dryness previous studies, from parents' perspectives and
occurred late in a child. When a child succeeded, from using a qualitative approach, on how children
there was a great deal of positive feedback from the achieve dryness. The interviews in this study gave
people around him or her. Success was being the parents the opportunity to speak freely about
good. According to all the parents, there was an and describe their experiences of how their children
understood age limit, like an unspoken rule, when it became dry.
was no longer acceptable not to be dry. Once this In this study, the parents stated very clearly that
age limit had been passed, wearing diapers was they did not find getting dry a very important
considered negative, and group pressure arose from question. They felt that it would come naturally to
others. Although the limit seemed to be higher now the child: Sooner or later, all children would stop
than in the past, no parent stated it precisely. The wearing diapers. Contradictorily, however, they
children also ranked themselves as to whether or stated that it was important to seize the opportunity
not they were dry. The expression toilet training when the time to help their child had come.
had negative connotations for some of the parents, All parents felt responsible and ready to take
such as forcing the child to sit on the potty or toilet command of the work that had to be done after
with a time schedule and punishing the child for making the decision to start the toilet-training

process. The process was experienced as time parents about the potty-training process they used.
consuming and usually started when the family was The parents in this study started potty training their
on vacation and the parents had enough time and children mainly by intuition (Seim, 1989).
longer periods of free time. This need for time is in The children in the present study were reported to
agreement with the findings of de Vries and de be dry at a median age of 2.5 years (M = 2.75 years),
Vries (1977), describing the training process as which is quite early when compared with the children
watching for and catching the child's need for in the study of Jansson et al. (2005), where healthy
elimination. This study was performed in the Digo children were found to be dry at a median age of
population of East Africa, where the training 4 years (M = 3.5 years). This might indicate that the
responsibility initially fell on the mother and was parents in the present study were more concerned,
later passed on to the older siblings. more sensitive, and eager to get their child dry for
In a study by Rundahl Hauck (1991), the mothers their child to be like others. However, the aim of the
described a reward-and-punishment system in present study was to describe the parents' experiences
detail, but in our study, the punishment aspect of how their children had become dry, regardless of
was quite absent: No parents mentioned yelling, age. Although the children in the present study were
spanking, or restricting privileges. The mothers in completely dry early, the parents were still concerned
our study had spontaneous negative connotations to that their children would not live up to the implicit
the words potty or toilet training, such as forcing acceptable age limit for wearing diapers.
the child to sit on the potty at fixed time intervals
and punishing the child if he or she failed. All the Limitations
parents said that instead of traditional toilet training, The inclusion criterion was to have been toilet
they had tried to create a positive atmosphere by trained for at least 6 months, but some of the children
encouraging their children, reminding them, prais- had been dry for as long as 3 years. Some details
ing them, and rewarding them. New daily routines might therefore have been forgotten. The average age
were implemented at home to support the child and for being toilet trained found in this study was quite
the process of achieving bladder control. early, as compared with findings from other studies
The process of achieving bladder control was (Jansson et al., 2005). This indicates that the parents
considered to develop successively, that is, with the were successful in their training, which resulted in
child's cooperation. The child's willingness, positive experience. If the children had become dry
including cognitive skills and personality traits, later, the parents might have felt less successful and
was of importance in guiding the parents on how to more negative. One possible source of bias in our
proceed and is a confirmation of earlier findings study was that all the children studied lived with both
(Brazelton, 1962; Brazelton et al., 1999; Klacken- their biological parents.
berg, 1971; Largo & Stulze, 1977; Polaha et al.,
2002; Schmitt, 1988). The parents expressed a
strong desire to help and support their children in CONCLUSIONS
achieving bladder control. It felt important to the How children are toilet trained, as reported
parents for their children to be like others and to mainly by their mothers, seems to start when
protect them from deviating from other children of parents realize that the time had come. New daily
the same ages. By watching and comparing other routines to support children in achieving bladder
children and their parents, they were guided on how control were implemented. Achieving dryness was
to help their own children. The parents also experienced as an important and time-consuming
expressed concern about unspoken rules governing process. The right time to achieve dryness
when or if to start any potty training. As a depended not only on the parents' having time
consequence, the parents experienced toilet training and the child's willingness but also on an under-
as a sensitive subject to talk about at the CHC, at the lying desire of the parent for their child to be good
day care center, or with friends. The parents were enough, to be like others, to fit in, and not to deviate
frustrated that neither the CHC nor the day care from other children.
staff brought up the question or guided the parents
in the process. There seems to be a need for up-to-
date guidelines advising parents, as a service when IMPLICATIONS FOR CLINICAL PRACTICE
parents ask. This confirms the results from a Health professionals working in health care
questionnaire study in the United States of 266 settings have good opportunities to bring up toilet-

training issues when parents bring their children al. (1999) for parents, clinicians, and day care
for checkups or to talk about other developmental providers are concrete and simple and could be
issues. Nurses and other health professionals need implemented in health professionals' routines.
strategies to support and advise parents on potty Based on new knowledge, there is now a need for
training and on having realistic expectations of intervention studies regarding the toilet-training
their children. Nurses can make significant con- process in children of various ages. There will also
tributions to reducing the uncertainty and frustra- be an increased interest to further study the toilet-
tion of parents who are about to start training their training process in different sociocultural settings
children by providing information on when to because differences in methods used as well as
train, how to train, and what to do while training outcomes have been identified (Horn et al., 2006;
their child. Guidelines with concrete and simple Schum et al., 2001).
advice about potty training must be a subject that
should be brought up just as naturally as other
developmental stages and discussed regularly at ACKNOWLEDGMENTS
appointments with parents of healthy children. This study was supported by Swedish government
According to the toilet-training guidelines of the grants through the ALF agreement, Sahlgrenska
American Academy of Pediatrics (2000) and the University Hospital (Gteborg, Sweden), the Wil-
Canadian Paediatric Society (2000), both based on helm and Martina Lundgren foundation (Gteborg,
Brazelton's recommendation from 1999, the potty- Sweden), and the Solstickan Foundation (Stock-
training procedure can be brought up from the age holm, Sweden). We would also like to thank Lena
of 1.5 years. The recommendations by Stadtler et Olsson for her help in transcribing the interviews.

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