Hospitalization is a very sensitive and stressful period for children. The presence of parents close to them is essential and give them a sense of security and reassurance [1]. It was observed that parents require professional conduct from nurses, give them opportunity to participate in their children's care and be informed about everything related to their children [2]. According to United Nations Convention on the Rights of the Child, Guardians are entitled to take part in and have an impact on their children's care [3].   Currently, parental satisfaction is a cornerstone of assessing the quality of nursing care. Over the past two decades, parental satisfaction researches were a main source of information for identifying defect and developing inclusive care plans (4). The quality of healthcare has become a global focus that work for increasing attention directed to in which way parents perceive care from their perspective. Parental satisfaction is an important predictor of the quality of nursing services and most important for healthcare organizations and hospital administrators [5]. Healthcare organizations and hospital administrators prioritize parental satisfaction as it is a significant predictor of the quality of nursing services.   It is a subjective feeling of parental satisfaction with care and multi-faceted concept that based on the alignment with expectation of parents and their perception of the care provided [6].   Parental satisfaction is a crucial component in the evaluation of childcare which reducing child morbidity and mortality, improving parental comprehension of childhood illnesses and increasing treatment plan adherence [7]. In the context of healthcare quality assurance, the assessment of patient satisfaction with nursing care function as a fundamental monitoring role, protecting both patients and their families from potential adverse outcomes associated with care delivery [6]. Patient satisfaction may be impacted by factors such as arrival procedures, wait times, timing of admission, staff productivity, service quality, food standards, interior design and clinical procedures [8].   Nurses play a significant role in shaping patient satisfaction. Studies reported that 44.3% of critical care nurses' working hours throughout the day were spent in or close to a patient's room. This is more than twice as much time as doctors (14.7%) and other vital personnel, such as physical and respiratory therapists (20.5%). In 86.1% of cases, a nurse provided direct patient care [9].   Currently, Family Centered Care (FCC) is the principle used for children who receive care. It recognizes that families are the children's primary caretakers and that it is their duty and responsibility to assist in identifying and satisfying their medical needs [4]. The four core values of FCC are dignity, sharing of information, involvement and collaboration-allowing healthcare teams to fulfill the medical, academic and emotional demands of kids and their parents [10]. Aslan and Esmaeili reported that the family participation in the therapeutic process improves clinical results, decreases the number of deaths, improved levels of satisfaction, enhanced compliance to treatment plans and fewer children being readmitted to hospital [11].   The importance of parental satisfaction is clearly evident through using the results of patient experience evaluations conducted by healthcare companies to support internal quality improvement efforts. Healthcare professionals rely on their patients' experiences and preferences to enhance their practices and demonstrate how they impact patient outcomes [12].   The study aims to assess parental satisfaction with sustained nursing services in pediatric wards at Mosul hospitals and identify sociodemographic factors that affect parental satisfaction.

Study Design and Setting The study participants were selected from the pediatric wards of five teaching hospitals in Mosul city, Iraq. This facility-based cross-sectional study was conducted from November 2025 to February 2026. These hospitals serve an estimated population of more than four million people in the surrounding areas. Two of these facilities are dedicated pediatric hospitals. The other three, however, each have pediatric departments that offer care to children admitted to the hospital. These hospitals also function as major referral centers for numerous primary healthcare centers and hospitals in the region.   The pediatric wards in these hospitals provide comprehensive healthcare services for children and operate 24 hours a day. They provide various medical and nursing services for children admitted with different medical conditions and include facilities equipped to deliver routine pediatric care and monitoring for hospitalized patients.   Population Inclusion Criteria: Parents of children in pediatric wards must meet specific criteria for participation in the study: The child's hospital stay should exceed 24 hours and the parent must be present with the child for at least 12 hours. Obtaining informed consent is essential and parents must be able to understand and respond to the questions in the questionnaire. Also, the child must be under nursing care during the data collection period, with the parent present in the hospital at that time.   Exclusion Criteria Parents who refuse to participate in the study. Parents who cannot understand or answer the questionnaire questions. Children whose hospital stay was less than 24 hours. Parents who were not present with the child during the hospital stay. Parents who have communication difficulties due to a severe illness or mental health disorder. Children with very critical or emergency conditions that may prevent parents from participating in the study.   Sampling Size and Sampling Procedure The sample size was calculated using the single population proportion formula with a 95% confidence level and a 5% margin of error. As there was no previous local study, a proportion of 50% was used. The calculated sample size was 384 and after adding a 20% non- response rate, the final sample size became 460 participants.   Data Collection Method Data were collected using the EMPATHIC questionnaire (Empowerment of Parents in The Intensive Care) developed by Jos M. Latour and colleagues to measure parental satisfaction with nursing care and healthcare services provided to hospitalized children [13].   The EMPATHIC questionnaire is a validated and widely used instrument designed to assess parents’ perceptions and satisfaction with healthcare services in pediatric settings. The questionnaire consists of several items covering different domains related to nursing care, including information, care and treatment, organization, parental participation and professional attitude of healthcare staff.   This tool evaluates several aspects of nursing services for parents of hospitalized children, including: The clarity and adequacy of information provided about the child's condition, perceptions of the quality and appropriateness of nursing care; coordination and organization of healthcare services; the level of parental involvement in decision-making; and the professional attitudes of healthcare providers towards both parents and children. Participants were asked to rate each item using a five- point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).   To classify satisfaction levels on the five-point Likert scale, the "Equal Interval Length" method was applied through Interval Length = (Upper limit of the scale-Lower limit of the scale)/Number of required levels, resulting in an interval of 1.33. Accordingly, mean scores from 1.00-2.33 indicate Low Satisfaction, 2.34-3.67 indicate Moderate Satisfaction and 3.68-5.00 indicate High Satisfaction. This approach is widely accepted in social sciences for converting arithmetic means into descriptive levels to facilitate interpretation.   Statistical Data Analysis The obtained study data were analyzed using Windows 10 platform: Microsoft Office Excel 2019, the Statistical Package for the Social Sciences (SPSS) version 26, The Shapiro-Wilk test revealed that parental satisfaction scores were not normally distributed (p<0.05), prompting the use of non-parametric tests. The Mann-Whitney U test and the Kruskal-Wallis test. A significance level of p<0.05 was established also, Cronbach’s alpha was calculated to assess the internal consistency of the measurement scales used to evaluate parental satisfaction with nursing care.

The study included 460 parents, 57.4% of whom were female (264) and 42.6% male (196). The most common age group was under 25 years old (28.7%, 132), while those with primary education constituted 44.8% (206) and the unemployed (including housewife/student/no job) made up 70% (326).   Regarding the characteristics of the children, 37% (170) were under one years old and 62.6% (288) had emergency hospital admissions most of the children (36%, 172) had been hospitalized for the first time and the most common length of stay was 1-3 days (43.9%, 216). The details are presented in Table 1-6.   One of the foremost challenges facing modern healthcare systems is the delivery of outstanding medical services, evidenced by the satisfaction expressed by patients and their families [14]. Evaluating satisfaction with medical and nursing care helps establish the direction for improvement within contemporary healthcare institutions, as part of integrated quality management [6].   The study demonstrated that parental satisfaction with nursing services was moderate, with a mean score 3.57 (71%) with a standard deviation (0.57). This result is consistent with the study [15], which found that 71.8% of the parents under investigation had a neutral satisfaction rating. This outcome is consistent with study [4], which found that 72% of parents expressed moderate satisfaction. Consistent with study [16], which found that moderate satisfaction was expressed by parents.   The finding assessment revealed a moderate score for the major criterion "information.", with a mean score of 3.17 (63.4%). These results align with those of study [17], which found that moderate satisfaction was expressed by parents regarding the information domains.   In the "information" domain, about 49% of parents reported being satisfied with the statement (in the event of a child's condition deteriorating, we are always alerted immediately). These results correspond with study [15], which found that more than half of the studied parents expressed satisfaction with it.   In the “care and treatment” domains, parents expressed the highest level of satisfaction, with a mean score of 3.99 (80%) and a standard deviation of (0.70). As previously reported by [6], the mean satisfaction score for “care and treatment” was 4.11, which is consistent with the current findings.   In the domain of "care and treatment," roughly 80% of the parents studied were in strong agreement that nurses consistently administered accurate medications promptly. Consistent with study [15], which found that (81%) of parent were Expressed satisfaction with nurses providing correct drugs promptly.   In the “parental participation” domains, parents reported a moderate level of satisfaction, with a mean score of 3.25 (65%) and a standard deviation of (0.77). Consistent with study [4], which found that 75% of parents expressed moderate satisfaction across “parental participation” domains. The statement (Our child's care was reviewed with us by the nurse once again before we left the ward) got a lower score among the participation domain, which was 2.78 and a standard deviation of 1.27. This is inconsistent with study [13], which found the score for the same item was 9.06 from 10 and a standard deviation of 1.25. This may be attributed to its reliance on strict protocols before patient discharge and its family-centered care model.   In the “organization” domains, parents expressed a moderate level of satisfaction, with a mean score of 3.5 (70%) and a standard deviation of 0.80.These results contrast with study in Spain [18] and study in the United States [19]. This may be attributed to the widespread harm that the recent conflict caused to Mosul's medical facilities. Three of the hospitals under study were totally destroyed and children are now receiving care at alternative facilities. Regarding the statement (Maximum efforts were made to reduce noise) 20% of the parents in the study were in strong agreement, with a mean score of 3.76 (75%). This is in agreement with the study conducted by (13), who found that the mean score for the same item was 7.30 out of 10 (73%).   In the “professional attitude” domains, parents expressed a high level of satisfaction, with a mean score of 3.94 (79%) with a standard deviation of 0.66. Similarly, like study [19]. Regarding the statement (The nurses always began by introducing themselves, including both their name and designation) 49% of the parents in the study were in strong disagreement, with a mean score of 2.00 (40%). Regarding the statement (All child received high-quality care from the nurses, irrespective of their race, religion, gender, or level of education) 71% of the parents in the study were in strong disagreement, with a mean score of 4.52 (90%). Similarly, in line with [6].   The tool (EMPATHIC) had strong internal validity, Spearman's score correlations ranging from 0.56 to 0.79, p<0.001. Several studies support this finding [16,18,19].   The finding prove that mother had higher satisfaction than father in the following domains: information, parental participation and organization. In agreement with study [20], which stated that mothers did report four times as much satisfaction as fathers.   It was proved that older parents had higher satisfaction with nursing services. Consistently with study [16]. Which stated that older parents had a better opinion of the aid provided by nurses.   It was proved that Parents with higher levels of education reported lower satisfaction compared to those with less education. Similarity, like study [21], which stated that Parents who had attained higher education levels gave lower ratings to daycare facilities than their less-educated counterparts.   It was proved that parents who had children admitted for the first time did report higher satisfaction as much as other parents. This finding does not align with study [22], which found that parental dissatisfaction with the quality of medical care significantly decreases with each subsequent visit to Ukrainian hospitals. This may be attributed to that in the first admission parents did not have past experiences to compare, any service received will be assessed optimistically and parents did not have any expectation regarding the service provided.   The findings proved that parents who did not work and housewives reported a higher satisfaction than employees. This may be attributed that employees have a high level of education and skill in evaluating the quality of services. This makes them evaluate more critically.   The current study proved that parents of children were 12 years old and older reported high satisfaction compared to the parent of children under 12 years old. Consistently with study [6], which stated that parents of children over 6 years old had higher satisfaction than parent of children under 6 years old.   The study proved that parents of child were hospitalized (1-3) day had higher satisfaction than those who hospitalized for longer time. This finds support in studies conducted in Poland and Ethiopia [6,17]. One could assume that a newborn's outcome is correlated with how long they stay. The longest hospitalized children are those who are really ill or preterm and their parents will undergo a great deal of mental anguish, this makes them more negative in their evaluation of services [17].   The results proved that parents whose children were planned hospital admission reported a higher score of satisfaction than those who emergency admitted their children. This finds support in studies conducted in Poland [23], which state that parents of children admitted to the hospital electively scored higher on satisfaction with care.   The results showed that parents of children admitted to Ibn-Al-Atheer Hospital demonstrated a higher score of satisfaction in all domains of nursing services. This may be attributed to hospital not being damaged during previous conflicts, as it is the only specialized pediatric’ hospital in Mosul and the hospital was completely rehabilitated by the UNDP organization.   Table 1: Distribution of Study Participants according to Parents’ Sociodemographic Characteristics and Children’s Demographic and Hospitalization-Related Characteristics Variable Category Frequency Percentage Parent’s age Less than 25 years 132 28.7 25-34 years 100 21.7 35-44 years 80 17.4 45-55 years 114 24.8 More than 55 years 34 7.4 Relationship to child Father 196 42.6 Mother 264 57.4 Educational level Illiterate 50 10.9 Primary school 206 44.8 Secondary school 130 28.3 Diploma 26 5.7 Bachelor’s degree 40 8.7 Postgraduate studies 8 1.7 Occupation Unemployed (housewife/student/no job) 326 70.9 Government employee 71 14.8 Self-employed 63 15.2 Child’s age Less than 1 year 170 37.0 1-<3 years 130 28.3 3-<6 years 42 9.1 6-<12 years 60 13.0 12 years and above 58 12.6 Type of admission Emergency 288 62.6 Planned 172 35.7 Number of hospital admissions First admission 168 36.5 Two admissions 80 17.4 3-5 admissions 86 18.7 More than 5 admissions 126 27.4 Length of hospital stay 1-3 days 216 43.9 4-7 days 148 32.2 More than 7 days 96 20.9 Hospital name Ibn Sina Hospital 40 8.7 Ibn Al-Atheer Hospital 154 33.5 Al-Khansa Hospital 82 17.8 Al-Salam Hospital 108 23.5 Mosul General Hospital 76 16.5   Table 2: Distribution of Parents’ Satisfaction with Nursing Services Satisfaction Dimensions Poor (No.) % Moderate (No.) % High (No.) % Mean SD Assessment Information provided by nurse 102 22.2 180 39.1 178 38.7 3.17 0.96 Moderate Nursing Care (treatment and Care) 18 4 109 24 332 72 3.99 0.70 High Parent participation 54 11.7 252 54.8 154 33.5 3.25 0.77 Moderate Organization 20 4.3 224 48.7 216 47 3.50 0.80 Moderate Nursing professionalism 12 2.6 44 9.6 404 87.8 3.94 0.66 High Overall satisfaction 12 2.6 256 55.7 192 41.7 3.57 0.54 Moderate   Table 3: Correlation between Parents’ Satisfaction and Nursing Service Dimensions First Variable Direction relationship Second Variable Correlation (rho) p-value 95% confidence interval N Interpretation Lower Upper Parents satisfaction <--> Information provided by nurses 0.739 <0.05 0.682 0.786 460 Strong positive correlation parents’ satisfaction <--> Nursing care 0.600 <0.05 0.514 0.674 460 Moderate to strong positive correlation Parents’ satisfaction <--> Parent Participation 0.794 <0.05 0.740 0.842 460 Strong positive correlation Parents’ satisfaction <--> Organization 0.725 <0.05 0.677 0.765 460 Strong positive correlation Parents’ satisfaction <--> Nursing professionalism 0.564 <0.05 0.486 0.638 460 Moderate to strong positive correlation P = p-value, the symbol <-> a two-way correlation (without cause and effect)   Tables 4: Differences in Parental Satisfaction according to Parents’ Gender Variables Samples Categorize Mean STD. p-U Mann-Whitney Mean rank Rank Overall Parental satisfaction Sex Male 3.34 0.44 0.00 165.31 2 Female 3.74 0.53 278.90 1 Information provided by nurse Male 2.66 0.84 0.00 155.58 2 Female 3.55 0.87 286.12 1 Nursing Care (treatment and Care) Male 3.98 0.63 0.133 Female 4.00 0.76 Parent in Participation care Male 2.91 0.76 0.000 169.35 2 Female 3.50 0.69 275.90 1 Organization and coordination Male 3.20 0.69 0.00 172.49 2 Female 3.72 0.81 273.57 1 Nursing professionalism Male 3.95 0.40 0.061 Female 3.94 0.80 Note: p-U Mann-Whitney (p-value from Mann-Whitney U test)   Table 5: Differences in Parental Satisfaction according to Demographic Variables Variables Sample Categorize Frequency Mean (PS) STD. Kruskal-Wallis H df p-value RII Rank Parental satisfaction Parent’s age Less than 25 years 132 3.5644 0.611 15.724 4 0.003 0.712 3 25-34 years 100 3.6477 0.44 0.729 2 35-44 years 80 3.4525 0.556 0.69 4 45-55 years 114 3.6541 0.497 0.73 1 More than 55 years 34 3.4273 0.562 0.685 5 Parental satisfaction Educational level Illiterate 50 3.69 0.34 56.29 5 0 0.73 1 Primary school 206 3.58 0.61 0.71 4 Secondary school 130 3.65 0.46 0.73 2 Diploma 26 3.6 0.48 0.74 3 Bachelor’s degree 40 3.16 0.28 0.63 5 Postgraduate studies 8 2.9 0.16 0.58 6 Parental satisfaction Parental Occupation Unemployed (housewife/student/no job) 328 3.61 0.524 9.27 2 0.01 0.72 1 Government employee 68 3.45 0.561 0.69 3 Self-employed 64 3.52 0.587 0.7 2 Parental satisfaction Child’s Age Less than 1 year 170 3.3945 0.611 55.1 4 0 0.67 5 1-less than3 years 130 3.74 0.44 0.74 2 3-less than 6 years 42 3.3949 0.556 0.68 4 6-less than 12 years 60 3.66 0.497 0.73 3 12 years and above 58 3.75 0.562 0.75 1 Parental satisfaction Number of hospital admissions First admission 168 3.8584 0.44653 95.71 3 0 0.77 1 Two admissions 80 3.5625 0.59042 0.71 2 3-5 admissions 86 3.4646 0.46806 0.69 3 More than 5 admissions 126 3.2809 0.48521 0.65 4 Parental satisfaction Length of stay 1-3 day 216 3.76 0.3 72.8 2 0 0.75 1 4-7 day 148 3.52 0.44 0.7 2 I more than 7 96 I 3.26 0.56 0.65 3   Table 6: Differences in Parental Satisfaction according to Hospitals Hospital name No. General mean Mean of information Mean of care and treatment Mean of parental participation Mean of organization Mean of professionalism Ibn-Sina Hospital 40 3.32 2.66 4.29 2.66 3.03 3.98 Ibn-Al-Atheer Hospital 154 3.82 3.65 3.97 3.51 3.93 4.05 Al-Khansa Hospital 82 3.70 3.60 4.01 3.46 3.46 3.96 Al-Salam Hospital 108 3.18 2.21 3.93 2.64 3.30 3.82 Mosul General Hospital 76 3.61 3.37 3.94 3.68 3.21 3.87 Kruskal-wallis H 135.05 186.372 22.011 156.753 86.050 39.449 p-value 0.00 0.00 0.00 0.00 0.00 0.00

These findings conclusively show how crucial parent satisfaction is to elevating the standard of nurse care in pediatric wards. The general quality of healthcare services and the importance of services that satisfy the requirements and expectations of families are both positively impacted when parents express satisfaction with the care provided by nurses. One important pointer of nursing effectiveness, roles and the efficiency of hospital departments in providing care is parental satisfaction.   The study showed moderate parental satisfaction with nursing care in Mosul teaching hospitals. (Care and treatment) and (nursing professionalism) were the main domains with the highest average scores, whereas (information) and (parental participation) had the lowest mean scores. Nursing care must be optimized, particularly in the domains of parental participation and information.   Parental satisfaction with nursing services was profoundly affected by age, occupation, educational attainment and parental gender. In the same direction, the child's age, length of hospital stay, types of admission and hospital of admission all had an important impact.   Limitations This study was descriptive and is unable to be used to make broad judgments about parental satisfaction with nursing, causal relationship correlations cannot be established. Parental satisfaction in a private hospital was not included in the study, which was exclusively conducted in a government hospital.   Acknowledgement For both the Iraq's University of Mosul's College of Nursing and general pediatric units in Mosul Hospitals. We sincerely thank all of the participants in this study as well as our experienced colleagues for their assistance.   Ethical Statement Ethical approval for this study was legally obtained by the Collegiate Committee for Medical Research Ethics at the University of Mosul (Code: CCMRE-nur-26-1). Additional institutional permissions were secured from the Ethics Committee of the Nineveh Health Directorate and from the administrative authorities of all participating hospitals across Mosul City.