Being in care situations with young children presents ambiguous challenges

Abstract

The importance of consulting children in health care situations is acknowledged but not always put into action. Health care professionals have difficulties with facilitating children’s participation and children are not pleased with their amount of involvement. The aim of this study was to explore health care professionals’ reflections on being in care situations with children. A qualitative design with workshops and content analysis was used. The participants (n = 29) represented various health care professions. The findings show that health care professionals understand being in care situations with children as an ambiguous challenge since each situation depends on the participants involved: the child, the parents and the professionals. The findings can be used for integrating theory and practice to broaden professionals’ awareness of the child’s perspective in care situations. This will encourage professionals to question procedures which are taken for granted and facilitate children’s participation.

Introduction

If and how children participate in a health care situation and have their voices heard is dependent on belief in the children’s competence among the health care professionals present.^1,2 Studies show that the importance of consulting children is acknowledged but not always put into action.^3–15 Thus, there are remaining questions concerning knowledge acquisition, reflections and skills development among health care professionals working with children. This study focuses on analysing and describing reflections made by health care professionals concerning caring situations with younger children. The knowledge gained can be used for direct reflection with the intention of integrating theory and practice to broaden professionals’ awareness of the child’s perspective in care situations. ¹⁶

Background

The Swedish Health and Medical Act ¹⁷ emphasizes patients’ right of participation. Further, the United Nations Convention on the Rights of the Child ¹⁸ states that children (0–18 years old) have the right to protection, promotion and participation.

According to Sommer, Pramling Samuelsson and Hundeide ¹⁹ the meaning of protection, promotion and participation should be viewed as a product of a society’s ideology in the health care setting. This paper adopts a Scandinavian welfare service perspective. This service is based on the ideology that children have the right to equality and equity regarding their health and early childhood education, and also the right to participate in matters that concern them. Children are not viewed as recipients in need of protection, but rather as subjects who can be empowered by the promotion of their capacities. They should be given ‘a voice’ as participators. Article 12 in the Convention on the Rights of the Child ¹⁸ emphasizes children’s right to make their voices heard on matters that concern them, and for their voices to be given due weight. To be able to exercise these rights children need information appropriate to their maturity and experience. ²⁰

Children act in a situation according to how they perceive it. Perceptions and feelings are expressed and presented by children’s voices and actions. Swedish Government policy ²¹ actually underlines that what is in children’s best interests and their right to participate should form the foundation for all professionals working with children. However, Coyne ³ found that health professionals have difficulties with supporting and facilitating children’s participation.

Other studies suggest that children are not happy with the amount of involvement allowed when interacting with professionals in the health care sector.^4–11 These studies describe situations where children have felt they have not been given the desired amount of information and have not been listened to. Further, they have felt a lack of support and have not been given the opportunity to participate in their own care; when expressed, their perspective has not been taken seriously.^4–10 When asked, children said that they would like to be more involved in planning their own treatment.^11,12 Even though health care professionals agree that the child’s own view is important, and that they should be given respect as individuals in their own right, they tend to place children in one of two positions. Either they place the child as a passive onlooker or as an active participant. In the case of treating children as passive onlookers, information is given to the parents instead of the child.⁹ If children’s rights are to be realized in the health care system, professionals’ child perspectives need to be expanded to include children’s views.^13–15

Aim

The aim of this study was to explore health care professionals’ reflections on being in care situations with young children.

Methodology

To examine health care professionals’ reflections on being in care situations with young children, a qualitative design with content analysis was chosen. Such design presupposes an understanding that the reality is complex, constructed and subjective. Accordingly, the researchers need an unprejudiced approach to obtain an understanding of individuals’ experiences. A given experience can always be interpreted in varying ways. ²⁰

Sample and data collection

The sample in this study was made up of health care professionals (N = 29) from one health care centre (n = 18) and one child and youth hospital clinic (n = 11) in a middle-sized Swedish community. The professionals in this study included: heads of clinics, general practitioners, paediatricians, child nurses, public health nurses, assistant nurses, welfare officers, play therapists and physiotherapists. The health care settings are part of research based improvement work to enable young children’s participation in care situations. The professionals from the two health care providers were invited to take part in a workshop for this study.

To explore the professionals’ reflections on being in care situations with young children the various professionals were mixed in groups (n = 7). Each group was provided with a written case, describing a child undergoing a bodily examination. They were requested to be attentive to and reflect on their experiences of being in health care situations with young children. The intention was to capture the professionals’ undirected verbal reflections, which were audio-recorded and transcribed verbatim for analysis.

Analysis

Qualitative content analysis following Elo and Kyngäs ²¹ was used to explore the professionals’ reflections on being in health care situations with young children. The analysis began with reading through the recorded and transcribed reflections to obtain a sense of the content in its entirety. This was conducted independently by the authors and made it possible to identify essential features of those reflections. The features identified concerned the professionals’ perspectives of the child, the parents and themselves. In the second step the first and third author independently coded the reflections regarding the content of each identified perspective. The first and third author compared and discussed their codes to reach agreement. In the third step the codes were scrutinized and grouped into sub-categories with regard to their similarities and differences. By going back and forth among the transcribed reflections, the codes and the sub-categories, the professionals’ reflections were abstracted into three generic categories describing the various perspectives identified. The second author verified the analysis during this process. The three categories were abstracted into the main category: being in care situations with young children – an ambiguous challenge (Table 1).

Table 1.

Sub-categories, generic categories and main category emerged from the analysis.

Sub-categories	Generic categories	Main category
Competence	Reflections on the child	Being in health care situations with young children – an ambiguous challenge
Vulnerable
Responsible for the child	Reflections on the parents
Responsible in the situation
Pliable	Reflections on the health care professional
Challenges and restrains

Ethical considerations

The study was performed in accordance with the guidelines of the World Medical Association. ²² Written and oral information about the study was given prior to data collection. The information included that data was to be treated confidentially in accordance with the Swedish Personal Data Act ²³ and that participants had the right to withdraw from the study at any time. All participants gave their written informed consent to take part in the study. According to Swedish law, ²⁴ the approval of an official research ethics committee is not required for this kind of research.

Findings

The professionals’ reflections led to an understanding that being in a care situation with young children presents an ambiguous challenge. This was understandable because a care situation needs to involve an essential respect for human beings independent of age, and an acceptance that every situation is unique depending on its actors and its purpose. The challenge also arises from the fact that a care situation with children is viewed as an integrated experience involving at least three various perspectives: those of the child, the parents and the professionals themselves. Furthermore a care situation is always asymmetric depending on the various experiences of and understandings among the actors. The professionals and parents are in a power relationship as regards the child.

Reflections on the child

The professionals’ reflections concerning the child in care situations are that children are competent and at the same time vulnerable: ‘It depends on how old the children are – if they can converse and reason – it can be difficult for them to explain exactly what the problem is’.

The child’s competence is described as something that varies depending on the child’s age, maturity, experiences, and the specific care situation. Substantially this is expressed thus: children are clever, capable and have the ability to capture an atmosphere and interpret their parents. That children are viewed as competent is manifested in the children’s desire to be skilled in managing examinations and to have control in a situation.

The expression of children as vulnerable manifests as viewing them as feeling small, being sensitive and as being torn between the professionals' and parents' advice. Children can be in an exposed position and in a position of dependence on parents and professionals.

Reflections on the parents

The professionals’ reflections concerning the parents in care situations are that they are responsible for their child and also they are responsible in the care situation.

Parents being responsible for the child includes a responsibility to inform and prepare their child, and to clarify the situation for them. They are supposed to make the child feel comfortable and secure. Further, the parents are responsible for making decisions on the child’s behalf regarding examinations and treatment.

In what way the parents are responsible in the situation may either facilitate or obstruct the situation for the child. Facilitating actions will make the child feel comfortable and secure. Obstructive actions, such as placing demands on the child to make them manage the situation, are reflected on as the parents wishing to be pliable towards the professionals. The following quote illustrates an example of a view of how parents can obstruct the situation for the child:

We had a father and boy a few days ago – I cannot remember what we were going to do, a quick sedimentation test or something like that … and the boy was screaming and very frightened – I’m not sure how old he was, perhaps four or five, or thereabouts – and the father held him really tight and was very angry with the boy because he would not sit still and … well … he said if you don’t sit still you’re going to get a needle in your backside.

The responsibility of parents in care situations is that they are supposed to cooperate with the professionals, and that they are expected to facilitate examinations.

Reflections on the health care professionals

The professionals’ reflections on themselves being in care situations with children and parents are that they are pliable towards the child, the parent, and their profession. However, their reflections also include challenges and restraints when being with children and parents in care situations.

The professionals’ actions to be pliable towards the children comprise giving information and instructions, acting intuitively and being aware of the children’s experiences. Functional communication originates in continuous encounters and involves adjusting bodily, and for health care professionals this may mean getting down on their knees, or visualizing instructions to create understanding. Information is given to the children so that they can acquire their own understanding of the situation and the examination. This is necessary to make the situation work and to allow the children to become involved on their own terms, to mediate security, control and self-determination within given frames. The professionals express that giving instructions during an examination is done in such a way that the child can understand what is expected. Information and instructions are given to prevent the child being made a fool of. A reflection made, demonstrating the difference between adults and children, was that children have the same right to information and instructions as adults. However, adults and children can misunderstand instructions in a similar way. Another reflection is that adults are given freedom of choice, which is not the case with children:

Acting intuitively implies using one’s imagination and humour as tools in a situation. The idea that children and adults should be treated the same in health care situations doesn’t hold. Both children and we [adults] are different as individuals, so you can’t always treat everybody the same. You have to use your imagination and adjust to the situation. You have to read the situation.

The professionals express that acting intuitively implies having time to be sensitive towards each child and to bear in mind their level of maturity in every situation. For instance, letting children have the same space for asking questions as adults, being sensitive in posing questions, interpreting the child and the situation to know how to interact with them, and the use of distractions according to each child’s wishes. Intuitive actions present the opportunity to acknowledge the child as an individual in various situations.

Being aware of a child’s experiences involves professionals understanding and following up the child’s experiences and reflections. This is conducted by professionals asking questions, being aware of which examination is necessary for whom, and being ready for whichever examination is chosen. Being aware of a child’s experience implies being able to end a situation in a positive way. Creating contact and cooperation in examinations, regardless of age, is achieved together with the patient.

The professionals’ actions of being pliable toward the parents are manifested by giving information about examinations and treatments. Pliability means being attentive to the individual parent. For instance, professionals can choose to calm down the child with sedatives to make the parents feel more comfortable:

But sometimes I feel that I am not administering the sedative for the child’s sake, but actually for the parent because I believe it calms their conscience. Perhaps they remember their own experiences, or think that the situation is stressful, and then one has to carry out the examination, and if the child has been given a sedative, well … the child may scream and protest, but they do that because you’re holding onto their legs … very often I feel that I administer a sedative for the parents’ sake, because it makes them feel better.

The professionals’ actions of being pliable to their profession are dependent on which profession it concerns, who they are, and the professional tools they possess to interpret the child’s feelings in a specific situation. Qualities that influence the encounter are level of confidence regarding their own profession, and the ability to evaluate their own actions. Pliability relates to the child’s demonstrated answers to given instructions. There is a need for the professional to know that the child has understood the information and instructions, and for the child to know that he or she is the principal actor. If the child’s answer is lacking, it will become a failure for the child. The professionals’ actions to be pliable to their professional duties belong to different professional categories depending on how the responsibilities and routines are distributed among them.

The professionals’ challenges and restraints in being pliable are described as not possessing a holistic perspective that includes all actors in the situation.

Being pliable towards a child is challenging since it demands creative involvement from professionals. Working under time pressure may generate restraints in the understanding of what is best for a child. To act according to the child’s perspective is easier to verbalize than actually do. This implies demands on the health care organization regarding making sufficient time when being with children in care situations. Challenges arise depending on whether the care situation is acute or planned, and the extent of illness. The challenges, when being with a child in a care situation, are to find out their earlier experiences, and to observe and interpret the child’s body language. This is different from encounters with adults, with whom you have a spoken dialogue:

With adults you can discuss matters and have a dialogue. That’s not the case with children; you have to read the situation.

Being pliable toward one’s own profession presents a further challenge depending on one’s competence. Formal competence can be achieved through education. However, if one lacks the reflected experience of encountering children, this may restrain one’s awareness of what is best for the child. This may then influence communication and create uneasiness in the situation.

Discussion

The findings from the reflections of the professionals show three areas of challenge in handling the care situation: in relation to the child, to the parents and to one’s own and other professionals’ responsibilities.

In their reflections the professionals seem to pay the least attention towards the child, that is, the individual child’s expression and understanding in a care situation. Reflections on the child as vulnerable or as competent came forth. Reflections on the child were also that he/she is squeezed between the parent and the professional. This relates to Lambert et al. ⁹ who found that professionals tend to place children as passive onlookers and give information to the parents instead of to the child. Other research also promotes the finding that children’s own opinions and views are found to be under-used because their involvement seemed to be dependent on the child’s maturity, and on being defined as a rational subject. ³ In such situations the child’s perspective evaporates. However, research focusing on young children’s bodily and verbal expressions when participating in a health care procedure found a progression in the children’s actions through various states of being in the same situation. Through states of getting ready, being ready and by strengthening themselves, four-year-old children acted using affirmative or delaying negotiation strategies towards adults (nurse and parent) to deal with a health care situation. ²⁵

Why is it such a challenge to take account of the child’s perspective? A possible answer from this study is that it needs awareness, sensitivity, time, imagination and effort to encounter the child in his/her state of being as reflected from the professionals’ viewpoint. Such efforts aren’t automatic for professionals; rather, they need to be cultivated by training professionals to reflect on their own experiences and actions. ²⁶ With attentive awareness and sensibility, professionals may facilitate their abilities to recognize the children’s unspoken needs. When a child will share his/her experiences, professionals may more easily respond with an open mind, as in a state of ‘not knowing’. When professionals come from a state of already knowing, they run the risk of only having their existing beliefs confirmed. The child’s opportunities to expose something new are then lost and he/she becomes silent. The professionals in this study reflect that what challenges them when in care situations with a child is finding out about earlier experiences and observing and understand the child’s body language. As they emphasize, this is different from encounters with adults, with whom professionals can have a spoken dialogue.

To have an open mind and interest, beyond the verbal dialogue, includes sensitiveness towards the child’s perspective. Everyday encounters are ‘pregnant with impressions of meaning’.^27(p.135) All impressions touch us emotionally giving opportunities to be open to what they will reveal. Expanded awareness is thus essential in everyday health care work. According to the findings in this study, an open awareness in care situations would give professionals a more nuanced understanding of the child’s perspective. A truly child-centred approach includes both the adults’ child perspective, concerning the children’s best interest, and the child’s perspective, with respect to the individual child’s experiences and personal preferences.^15,19 However, a recent study argues for the importance of not considering the qualitative differences of these two perspective positions, but, rather, for becoming aware of the continuum of the positions. ²⁸ This is a challenge since professionals need the ability to reflect on encounters with children and their families to be creative. Awareness of guiding and negotiating skills empowers one to become pliable and to exchange perspectives.^29–32 You cannot demand a professional, who is not trained or proficient in reading a child’s perspective, to understand this flexible exchange of perspectives. This stock of knowledge requires clinical interest, experience and continual reflection based on evidence-based theoretical knowledge.

Contemporaneously, the findings of this study explored the professionals’ reflections of being in a health care situation with a child, where a lack of competency is expressed. It will be a challenge to introduce clinical intervention using a reflection process with professionals who will enable an intertwining of theory and practice. ¹⁶ Such reflective forums will involve the perspectives of the child, the parent and the professional in care situations. By bringing theory into reflection on clinical practice, one might produce a fruitful forum where expanding knowledge will grow. An important aspect to have in mind, is to be aware of the risk of theories building a kind of ‘model-thinking’, or standard format for encountering what cannot be handled individually, or integrated in a specific situation. The result of such knowledge may create a futile and unnecessary gap between theory and practice, as stated in research. ³³

Bringing in the professionals’ reflections in this study, words describing both challenges and restraints became clarified. The reflections were inter-professional, which gave rise to variations in understanding. Taking heed of others’ understanding and interpretation of the same situation were expressed as contributing towards a widened perspective. The knowledge and experience of the individual professionals of being in situations with young children now has to be the object of further focus. This implicates theoretical as well as practical knowledge. The process of situated learning and understanding is dependent on experiences, viewpoints and comprehension, as what is to be learnt is anchored in the situation, and as such forms the foundations for development and new understanding. ³⁴ By conceptualizing experiences through reflection, beliefs that are taken for granted may become conscious, and tacit knowledge may become conceptualized. Through reflection, the world becomes more clarified and comprehensible, and this gives possibilities for the basis of an expanded consciousness. ³⁵

Methodological considerations and limitations of the study

To enhance trustworthiness in the study, an effort was made to achieve variation in the sample by inviting a variety of professionals. ²⁰ The number of participants in the study (n = 29), and the opportunity to mix various professionals in groups, contributed to the rich descriptions in the professionals’ reflections on situations with young children. The decision to not use a facilitator in the workshops made it possible to grasp the professionals’ undirected reflections. The presence of a facilitator could have contributed to richer descriptions. However, having access to professionals’ undirected reflections helped to recognize what areas needed further exploration and development. In this study it became clear that the professionals needed to be empowered to become more aware of the child in the care situation.

To achieve trustworthiness in the analysis, the two researchers (MH, AR) conducted the analysis both individually and together in a critical discussion. Also, it was valuable to have access to a third researcher (MS), who verified the ongoing analysis and confirmed the dependability of the final findings. This made it possible to reveal alternate interpretations in describing the professionals’ reflections. ³⁶ However, it is understood that the professionals’ reflections might be interpreted and described in another way.

Conclusion

An essential finding in this study is the significance of making reflections on clinical everyday caring situations. This study conveyed that the professionals’ undirected reflections of being with children in a care situation paid least attention towards the children themselves. This emphasizes the importance of proceeding with directed reflections to integrate theory and practice by which beliefs are reconsidered and new perspectives can be added. ¹⁶ Such directed reflections are not about intellectualizing. Rather, reflections are about generating knowledge that engages professionals to implement the rights of the child ¹⁸ in every situation, and to provide child-centred care. Consequently, the combination of deepening theoretical knowledge as well as increasing self-awareness in relation to experiences of caring situations with children seems to be what is needed.