Parental perspectives on child participation in prehospital emergency care: A rights-based analysis using Shier's pathways to participation

Abstract

Children have the right to express their views and to have those views considered respectfully in matters affecting them, as articulated in Article 12 of the United Nations Convention on the Rights of the Child. In emergency care, this right must be balanced with the child's best interests, particularly when illness, distress or developmental or cognitive factors limit a child's ability to participate directly (Article 3). Little is known about how this is implemented in prehospital emergency care. This study explores how children's participation occurs during ambulance care, as perceived by their parents, using Shier's ‘Pathways to Participation’ model. A qualitative study involving semi-structured interviews with 12 parents (nine mothers and three fathers) of 12 children (five females and seven males, aged 0–14) who received ambulance care in Sweden was conducted. A deductive content analysis was performed, guided by Shier's five-level participation model. Ethical approval was obtained. Participation was described at the first levels of Shier's model: children being listened to, supported in expressing their views and having their views considered. Parents described how emergency medical services clinicians used age-appropriate language, adjusted tone and body language and made meaningful adaptations. Preverbal children were included through non-verbal interaction and emotional presence. However, higher levels of participation were absent. Participation appeared relational and dependent on individual clinicians’ communication style. Participation was more likely when time allowed and less likely during urgent interventions. Children's participation in prehospital emergency care is not only feasible but already realised through relational and responsive clinical behaviours. However, participation is inconsistent and dependent on individual clinicians rather than embedded structures. To align practice with Article 12, clinicians should consider implementing training and clinical routines that facilitate child participation. These findings contribute to evidence that child-centred care is possible in fast-paced emergency contexts.

Introduction

Children's rights to be heard and involved in matters affecting them are firmly established through the United Nations Convention on the Rights of the Child and, in Sweden, through its incorporation into domestic law via the United Nations Convention on the Rights of the Child Act (2018:1197).^1,2 Article 12 of the United Nations Convention on the Rights of the Child (UNCRC) asserts that children capable of forming their own views have the right to express them freely and that these views should be given due weight as per the child's age and maturity. ¹ In emergency care, the realisation of this right is closely intertwined with the Convention's wider obligations, including Article 2 on non-discrimination, Article 3 on the child's best interests, Article 16 on privacy, and Article 24 on the right to health and health services, which together shape how participation can be enacted in practice.^1,3 In healthcare, this principle has been operationalised through various models of child-centred and family-centred care and is embedded in ethical standards, professional guidelines and legal frameworks.^3,4

Despite this normative foundation, realising children's participation in practice, particularly in acute and time-pressured settings, remains complex. Prehospital emergency care presents specific challenges: brief encounters, uncertain clinical status and logistical constraints can limit opportunities for dialogue, shared decision-making and inclusive communication.^5–7 Moreover, much of the literature focuses on the hospital setting, while participation in out-of-hospital contexts is rarely explored.^6,8

In paediatric emergencies, parents are often physically present and may play an important role in mediating communication. Their accounts offer valuable insight into how their child's needs, preferences and emotions were addressed or overlooked during care.^6,9 While some studies suggest that children are frequently excluded in acute care, ¹⁰ others emphasise the efforts made by professionals to involve them, even in stressful circumstances. ¹¹

While safety concerns in prehospital paediatric care, such as limited training, lack of paediatric equipment and communication challenges, have been documented,^12–15 less is known about how children's perspectives are acknowledged during prehospital emergency care. This study builds on that foundation by shifting the focus from clinical risk to the child's right to be heard and involved, as emphasised in the UNCRC. Despite growing recognition of children's rights in healthcare, there is limited knowledge about how participation unfolds in high-stakes, time-sensitive environments such as prehospital emergency care.

Building on previous research into children's roles in emergency care,^5,9,10 the present study focuses on how children's opportunities for participation are realised during ambulance care, as perceived by their parents. Guided by Shier's ¹⁶ ‘Pathways to Participation’ framework, it examines how these parental perceptions correspond to different levels of participation within the model.

Method

This qualitative study employed a deductive content analysis, inspired by Elo and Kyngäs, ¹⁷ using Harry Shier's ‘Pathways to Participation’ ¹⁶ framework as the analytical matrix. Shier's model outlines five progressive levels of participation (see Figure 1).

Figure 1.

Presentation of Shiers Pathways to Participation. Beginning at level one, the organisation then moves upwards in the model. Figure originally published in the author’s doctoral thesis ¹⁸ and reproduced with permission.

The current study is grounded in constructivist pragmatism, as outlined by Nørreklit et al., ¹⁹ which combines social constructionism with a pragmatic focus on practice and action. It perceives reality as socially constructed and influenced by human interaction, alongside practical considerations. Knowledge is regarded as context-dependent and co-created through meaningful activity.

Ontologically, the study assumes that multiple realities exist and are shaped through language and social interaction. Epistemologically, it adopts a relational perspective of knowledge, whereby understanding emerges from the interaction between researcher and participants, and where practical usefulness is valued alongside theoretical insight.^19,20

The theoretical framework guiding the analysis is Shier's ¹⁶ ‘Pathways to Participation’, which offers a structured approach to examining children's opportunities for participation as perceived by parents in prehospital care.

Reflexivity ²¹ was addressed throughout the study. The first author, a male registered nurse with 8 years of prehospital emergency care experience and specialist education and a doctoral student at the time, led the interviews and analysis. The co-authors, two professors and one senior lecturer, are registered nurses with specialist education and extensive clinical experience in paediatric care (n = 2) and intensive care/emergency care (n = 1), providing complementary clinical and methodological perspectives. During data collection and analysis, the first author maintained reflexive awareness of prehospital clinical preunderstanding and its potential influence on pattern recognition. Interpretations and level assignments were reviewed iteratively within the team, with discussion of alternative readings, attention to discrepant cases, and return to original transcript excerpts when uncertainty arose until agreement was reached. None of the researchers had a prior clinical relationship with any participant. Trustworthiness ²¹ was supported through an audit trail of analytic decisions, illustrative quotations and repeated team discussions to ensure interpretations remained grounded in participants’ accounts.

Setting

Swedish emergency medical services (EMS) are publicly funded and regulated at national level, with operational responsibility organised regionally. Ambulance care is governed by national regulations for ambulance services, including requirements related to staffing and competence. ²² Prehospital care in Sweden has developed towards a nurse-led model, including established roles and specialist education pathways in ambulance nursing.^23–25 Ambulance care is delivered in teams; Swedish ambulances have been described as staffed by at least one registered nurse (RN) and an emergency medical technician (EMT), and team configurations may include nurses working together or a specialist nurse working alongside an EMT.^26,27

Recruitment and data collection

Participants were recruited through purposive sampling ²¹ via social media, posters in children's wards and the Emergency Department and snowball sampling. ²¹ Inclusion criteria included being the legal guardian, being present during the EMS care and being fluent in Swedish. Initially, 15 parents expressed interest in participating and provided consent. However, three participants were excluded: one for not being present during the care encounter, another for not responding despite having an appointment for the interview and the third for changing their mind after the initial contact.

Interviews were conducted one-to-one by the first author between May and June 2023, with no one else present. Participants were informed that the interviewer was a doctoral student at a university and a specialist nurse in prehospital emergency care. They were also told that the interviews were conducted for research purposes to explore child-centred care in the ambulance service. As a Prehospital Emergency Nurse and doctoral researcher interested in children's rights and participation in health care, the first author recognised how clinical preunderstanding could influence interviewing and interpretation. Reflexive awareness was maintained, and emerging interpretations were discussed within the research team, referring to transcripts to consider alternative readings. The interviews were semi-structured, featuring open-ended questions that allowed participants to discuss their experiences freely. ²⁸ The interviews commenced with the question, ‘Tell me about the meeting between the ambulance personnel and your child’, and continued with questions such as, ‘How did the ambulance personnel cooperate with your child?’ Clarifying questions, including ‘Could you elaborate on that?’ and ‘What do you mean?’, were used to deepen and enrich the narrative. No repeat interviews were undertaken. The interview guide is provided as Supplementary File 1.

The interviews were conducted by phone or via video conferencing tools, depending on the participant's preference or practicality, and were recorded digitally. They lasted between 14 and 46 min (M = 30). Field notes were taken during each interview to capture contextual details and initial analytic reflections. The interviews were conducted in Swedish, transcribed verbatim and translated into English by the first author during the manuscript preparation. Transcripts and findings were not returned to participants for comment or correction, as participant validation was not planned within the study design. During manuscript development, the team reviewed wording and translations to ensure meaning and context were retained. The manuscript was then professionally edited in English. After editing, all authors independently checked the manuscript to verify that interpretations and quotations remained true to participants’ accounts. The team then met to resolve discrepancies and finalise wording. No independent verification of transcripts or back-translation was performed.

Data analysis

A deductive content analysis was conducted following Elo and Kyngäs. ¹⁷ A structured matrix was developed (Figure 2) based on Shier's participation model and used as the analytical framework. The dimension concerning obligations in Shier's model was excluded because it pertains to organisational conditions that participating parents were unable to assess. The transcripts were read repeatedly to obtain an overall understanding. The transcripts constituted the unit of analysis. Meaning units relating to children's participation in ambulance care were identified and deductively coded into the matrix categories (Shier's levels). After coding, the research team reviewed the categorisation and compared it with Shier's model to ensure conceptual consistency. Data were managed manually during analysis using the analytic matrix derived from Shier's framework. Analytic decisions were discussed iteratively within the research team. Consensus was reached through discussion and refinement of interpretations and category placement until shared agreement was achieved. Where interpretations differed, the team returned to the original transcript excerpts to consider alternative readings before finalising the categorisation. Data saturation was not used, as the study included the participants available from a previous study; however, recurring patterns and similar accounts were observed across interviews. For example of analysis (see Supplementary File 2).

Figure 2.

Structured matrix inspired by and developed from Shier's Pathway to Participation, used to explore parents’ perspectives on children's participation in prehospital care encounters.

This study is based on a secondary qualitative analysis of interviews originally conducted within a related project on paediatric prehospital care. The previous study explored parents’ perceptions of the quality of care their child received from EMS clinicians, informed by the Quality of Care from a Patient Perspective (QPP) framework. ²⁹ The present analysis addresses a new analytic aim: how parents perceive their child's opportunities for participation during prehospital ambulance care, using Shier's ¹⁶ Pathways to Participation as the analytic framework.

Secondary analysis of qualitative data is recognised as a valid and increasingly used approach in the health and social sciences, especially when the existing data are rich, ethically gathered and suitable for re-analysis from a new perspective.^30,31 In this instance, the data met these criteria: participants had provided broad informed consent for future use, the original interviews were in-depth and reflective, and the current research question differs from that of the primary analysis.

Ethical considerations

The project received ethical approval from the Ethics Committee in Umeå (No. 2017/222-31), and further approval for this study was obtained from the Swedish Ethical Review Authority (No. 2022-05988-02). The research group applied the Helsinki Declaration, ³² ensuring that all participants were informed that their participation was voluntary, they could withdraw consent at any time and their identities would be kept confidential. Participants provided informed consent digitally and reconfirmed it verbally at the start of the interview. The study explores parents’ experiences of their children's care encounters with EMS clinicians, which may evoke troublesome memories or emotions. Therefore, the researchers were prepared to assist parents in accessing healthcare support if needed; however, no such need was identified.

Findings

Twelve parents participated (nine mothers and three fathers), aged 31–51 years (mean 40.5 years). Their children (five females and seven males) were aged 0–14 years (mean 5 years) and had received care from Swedish EMS. Among the ambulance contacts described, 10 related primarily to medical cases and two to injury-related cases. Information on whether this was the child's first EMS contact was not collected systematically and therefore cannot be reported reliably.

The analysis was structured deductively using Shier's ¹⁶ five-level model of participation. The themes correspond to the first three levels of the model, progressing from basic recognition (being listened to) to more advanced forms of involvement (having one's views taken into account). These categories reflect how parents perceived their child's opportunities to participate during ambulance care. No descriptions corresponded to Levels 4 or 5. Each theme is presented below, accompanied by illustrative quotations and descriptions of recurrent patterns.

Children are listened to

Parents consistently described the clinicians as attentive and genuinely receptive to listening to their children. They perceived the clinicians as making conscious efforts to communicate directly with the child, regardless of the child's age or verbal ability. This approach was viewed as a deliberate attempt to prioritise the child as the primary patient, rather than treating the parents as proxies.

‘… it is clear that she felt that she was listened to. She was given … She got what she needed there and then. And [clinician’s name] listened’ (No. 10).

Several parents noted a structured division of roles within the EMS team, with one clinician focusing on engaging with the child, while the other managed logistical or medical tasks in the background. This arrangement was described as reassuring, as it ensured that at least one adult maintained close, continuous contact with the child.

Communication strategies were described as age-appropriate, calm and inclusive. Parents appreciated that while some information was naturally conveyed to them, the clinicians consistently addressed the child directly, affirming the child's position as the centre of the encounter. This was true even in cases involving preverbal children, where clinicians used tone of voice, body language and proximity to create a sense of safety and presence.

These behaviours were perceived as enhancing the child's opportunity to express themselves, either verbally or non-verbally. By consciously slowing the pace of care and avoiding haste, the clinicians created what one parent described as ‘space to think and respond’, thereby reinforcing a sense of dignity and respect for the child's perspective.

‘By not making it something hasty and stressful but giving her those extra seconds to talk or to think about how this … it feels good and safe’ (No. 4).

This theme aligns with Level 1 in Shier's model – children being listened to – but demonstrates how this can be profoundly relational, embodied and sensitive to context within prehospital emergency care.

Children are supported in expressing their views

Many parents described how clinicians used deliberate and creative strategies to encourage their children to express themselves, even in stressful or unfamiliar environments. These strategies included allowing the child time to respond, using age-appropriate explanations and integrating playfulness or familiar objects to foster comfort and a sense of agency.

‘But they were very much aware that she might be shy towards them. It wasn’t as if she didn’t understand what they wanted and would do. And talk to her in a very good way and so on. So, no, no, they were very gentle with her’ (No. 6).

Some parents emphasised how the clinicians adapted their tone, body language and choice of words to match the child's developmental level. The clinicians were described to have crouched down to eye level, used a gentle tone and asked simple questions rather than issuing instructions.

From the parents’ perspective, the clinicians seemed to grasp opportunities to support the children in expressing their views, employing a wide range of ideas and activities to assist them. Parents mentioned the use of symbolic or playful communication, such as asking about the child's stuffed animal or giving the child a small task (e.g., holding a stethoscope or pressing a button), which, in the parents’ view, appeared to reduce the child's anxiety and increase their willingness to communicate.

‘There was a part that made it a little more pleasant where they accommodated the choice of music in the ambulance when my son had some requests. That you try to find something as a common factor and that music. That he had requests for music’ (No. 5).

Parents described that when caring for disabled children, clinicians endeavoured to gather information from parents or care staff about how the children typically expressed themselves.

‘That way, they actually communicate with him. Even though he may not be able to answer everything, they are good at body language, and when they get a piece of me, maybe a map, of his body language because he has no speech, I think they can really pick up that information’ (No. 12).

Parents perceived this as an effort to gain insight into the children's signals and desires. This theme corresponds with Level 2 in Shier's model, where children are supported in sharing their views. However, it also highlights the level's relational and situational fragility, as well as the staff's interpersonal skills, availability of time and willingness to persist, which often determine whether an expression is facilitated or overlooked.

Children's views are taken into account

Parents described situations in which clinicians adjusted their actions based on the child's expressed preferences, either verbally or through non-verbal cues such as body language. These adaptations were often subtle but meaningful, and parents perceived them as concrete evidence that their child was not only heard but also taken seriously as a participant in their care.

‘It was not that she had to sit … Now, you can sit on this chair next to me, but they adapt to where she was. That now, it seems that she feels safe there on the sofa with her mother. Then that's where we should be’ (No. 3).

Other examples included children being allowed to choose whether to sit up or lie down, whether to hold a favourite object during transport or the order in which procedures would be performed. These decisions may seem minor from a clinical perspective, but were seen by parents as significant acts of respect and emotional atonement.

Parents also highlighted how these moments had a calming effect on their child and contributed to a sense of safety. Some described a visible shift in their child's body language or emotional state when their wishes were acknowledged and incorporated.

However, such adaptations were not universal. In more time-pressured or complex medical situations, decisions were made swiftly and without visible consultation with the child. While parents generally accepted this as necessary, they also noted the stark difference it made when their child's preferences were acknowledged, even if only briefly.

‘But like when she got Betapred, she was a bit sceptical at first, and then they explained that it was medicine to help her breathe and so on. Then she had to take a little sip. They said it doesn’t taste much, so she did try a little, and no, it doesn’t taste much, so we gave her the last of it’ (No. 6).

This theme corresponds to Level 3 in Shier's model, where the child's views are considered. It marks the point at which adult decisions start to be influenced by the child's expressed needs and preferences. Although not consistently achieved, parents highly valued these moments, which appeared to improve the child's comfort, dignity and trust in care.

Although many parents described behaviours consistent with Shier's levels 1–3, they also reported variation across encounters. In time-pressured or clinically complex situations, parents described interactions as more clinician-led, with fewer child-directed questions and less explicit elicitation of the child's preferences. In a small number of accounts, parents provided only limited descriptions of child-directed communication or adaptations to the child's expressed or observed preferences, indicating that the extent to which levels 1–3 were described differed across ambulance encounters.

Discussion

The following discussion reflects on how these findings relate to Shier's participation framework and the broader understanding of children's rights in prehospital emergency care. Although this study is anchored in Article 12 and operationalised through Shier's participation levels, it is important to note that children's ‘voice’ is not synonymous with participation. Lundy's ³³ conceptualisation of Article 12 emphasises that expressing a view is insufficient unless children are provided space, an attentive audience, and appropriate influence on what happens, which aligns with Shier's distinction between being listened to and having views taken into account.

This study shows that children's participation in prehospital emergency care is not only possible but, in some cases, actively pursued by EMS clinicians. Using Shier's model enabled the identification of structured yet flexible categories of participation, ranging from being listened to having one's views acknowledged and acted upon. Most of the encounters described by parents corresponded to Levels 1 to 3. In several cases, Level 3 – where children's views are taken into account – was evident. This represents a significant finding in relation to the UNCRC, which positions this level as the minimum requirement for rights-based practice.^1,16 This aligns with previous findings indicating that children's sense of safety and inclusion in healthcare can be enhanced when clinicians communicate directly with them and involve them meaningfully, even in fast-paced settings.^6,34

Although Article 12 provided the primary point of departure for this analysis, the findings also reflect wider UNCRC obligations that are highly salient in prehospital care. These include non-discrimination (Article 2), particularly where age, disability, language barriers or neurodevelopmental differences may shape children's opportunities to be listened to; the child's best interests (Article 3), which may constrain decision-making while still requiring that children's views are acknowledged and explained; privacy (Article 16), given the limited physical space and proximity of others during assessment and treatment; and the right to health and health services (Article 24), which foregrounds accessible, developmentally appropriate communication as part of quality care.^1,3

Simultaneously, participation was inconsistent and dependent on the clinicians’ behaviours. The presence of participation-enhancing actions was often relational rather than structural: determined by the interpersonal sensitivity and communication style of individual clinicians rather than by any routine or protocol. Similar patterns have been observed in paediatric care, where children's participation was closely linked to the presence of trusting and supportive relationships with specific healthcare professionals, rather than being guided by formal structures or protocols. ³⁵ Children's inclusion in care encounters often hinges on small but deliberate communicative choices, such as how staff physically position themselves, the tone they use and how they emotionally attune to the child. Recent studies affirm that these non-verbal and relational strategies can significantly enhance children's emotional comfort and sense of involvement, particularly in paediatric and emergency care settings.^36,37 This aligns with previous research suggesting that participation in paediatric care is often contextually bounded and adult-directed.^4,38 While parents valued the moments when participation occurred, they also noted how quickly it could dissolve under time pressure or clinical urgency. In such situations, clinicians may need to prioritise immediate safety and clinical stabilisation, which aligns with the UNCRC obligation to act in the child's best interests (Article 3). ¹ At the same time, urgent care does not necessarily preclude participation; brief acknowledgement of preferences and short, developmentally appropriate explanations may still support the child's right to be heard (Article 12).^1,3

Interestingly, even preverbal children were perceived as included through non-verbal communication and affective presence. These findings challenge the assumption that participation requires verbal expression and point to a broader, more embodied understanding of communication. In this sense, participation may be enacted through how EMS clinicians attune to behavioural cues and regulate proximity, pace and reassurance, rather than through verbal ‘voice’ alone. This resonates with Lundy's ³³ conceptualisation of Article 12, which frames implementation as requiring space, facilitation of expression, attentive listening and appropriate influence. Elements that can be met through non-verbal forms of meaning-making when speech is limited. Evidence from paediatric procedural care further supports this interpretation: children's unpleasant emotions are often expressed primarily non-verbally, and clinicians’ provision of ‘space’ for children's communication preferences has been associated with increased involvement. ³⁹ From a developmental perspective, preverbal communication is organised through affective and behavioural signalling, and adult sensitivity and co-regulation, that is, bidirectional, moment-to-moment regulation of emotion and behaviour in interaction, are central mechanisms through which distress is contained and meaning is negotiated. ⁴⁰ In prehospital encounters, this supports interpreting parents’ descriptions of embodied clinician–child interaction as a substantive form of participation, even when time pressure constrains verbal exchange.

However, the absence of Levels 4 and 5 in Shier's model, where children participate in decision-making and share power, warrants reflection. It may not be developmentally or contextually realistic to expect shared decision-making in emergency care situations. At the same time, this finding should be interpreted cautiously: the absence of Levels 4–5 may reflect genuine constraints in time-critical prehospital care, but it may also be influenced by methodological constraints related to the secondary analysis, as the original interviews were not designed to explicitly probe children's participation or decision-making. Nonetheless, the lack of even aspirational movement towards these levels may suggest that children's participation remains largely adult-controlled, unlike in paediatric hospital contexts where structured child- and family-centred interventions have demonstrably enhanced engagement and agency.^41,42 Furthermore, recent reviews indicate that the concept of child-centred care remains inconsistently defined and applied, highlighting the need for clearer frameworks to support meaningful participation across settings. ⁴³

The findings suggest that EMS clinicians would benefit from practical tools and structured approaches to support consistent child participation. Recent evidence shows that even brief, targeted interventions can improve clinicians’ communication with children in prehospital settings. For example, Baş and Ecevit ⁴⁴ found that therapeutic play training reduced anxiety among paramedic students and enhanced their confidence in engaging with paediatric patients. Similarly, the implementation of the ‘Shield’ screening tool for child maltreatment has demonstrated high fidelity and feasibility among EMS clinicians, illustrating that structured protocols can be successfully integrated even under operational pressure. ⁴⁵ Furthermore, Lombardi, Lepore and Greer ⁴⁶ evaluated the use of sensory and communication kits, such as noise-cancelling headphones, pictogram boards and whiteboards, in EMS units and found that these tools significantly improved clinicians’ ability to provide inclusive, child-centred care. Taken together, these studies highlight that low-threshold, context-appropriate interventions can bridge the gap between intention and routine practice, making participation more accessible even in fast-paced emergency care environments. Building on these findings, practical improvement can be conceptualised across three interacting levels: clinician behaviours, team routines and organisational support. At clinician level, participation can be strengthened through consistent child-directed communication, including brief, developmentally appropriate explanations and opportunities for simple choices where feasible. At team level, a straightforward role division, where one clinician prioritises communication and emotional support while the other manages technical and logistical tasks, may protect the child's involvement under time pressure. At the organisational level, services can embed participation through brief training and simulation focused on paediatric communication and through ensuring access to low-threshold communication aids that can be used rapidly in the ambulance environment. A proposed multi-level model to support child participation in prehospital care is summarised in Figure 3.

Figure 3.

Multi-level supports for child participation in prehospital emergency care (derived from study findings).

Methodological considerations

This study has both strengths and limitations concerning its overall trustworthiness, including credibility, transferability and dependability.

Credibility ²¹ was supported by the use of a recognised theoretical framework, Shier's model, which provided a structured lens through which to interpret the data. The analytical process involved reflexive discussions among researchers to increase interpretative depth and consistency. Parents provided rich, experience-near descriptions, thus offering insight into how participation was perceived and enacted in prehospital encounters. However, as the data were based solely on parental accounts, the findings reflect adult interpretations rather than the children's perspectives. Social desirability bias may also have influenced how parents reported the actions of EMS clinicians, especially in emotionally charged situations.

Transferability ²¹ may be limited by the relatively small and geographically specific sample. The small sample and the predominance of mothers may limit transferability. Parental interpretations of children's participation are likely shaped by the socio-cultural context, including norms regarding parenting roles, expectations of children's autonomy, and trust in health and welfare institutions. As the study was conducted in Sweden, these contextual factors may influence what parents notice, value, and report as ‘participation’ during ambulance care. The findings should therefore be transferred cautiously, particularly to EMS systems with different professional roles, family practices, or cultural understandings of children's rights. Nevertheless, the findings could be relevant to similar international prehospital care settings.

Dependability ²¹ was enhanced through a systematic and transparent analytical process. Meaning units were coded deductively ¹⁶ based on Shier's levels of participation, with analytic decisions documented throughout. However, the deductive approach also introduced constraints: by focusing on predefined categories, the analysis may have overlooked aspects of participation that fall outside Shier's framework. Future studies could benefit from employing complementary inductive methods or incorporating direct perspectives from children.

Limitations

A critical limitation of this study is its reliance solely on parental accounts. While these provide valuable insights, parent-proxy reports may not accurately reflect children's own experiences, especially in subjective or internalised domains. Recent findings indicate that proxy reports often differ from self-reports, with parents tending to underestimate children's functional abilities and overestimate their symptoms.^47,48

A further limitation is that this was a secondary analysis of interviews originally designed to explore parents’ perceptions of care quality rather than children's participation specifically. As a result, the material did not consistently include detailed descriptions of decision-making processes, which may have reduced the visibility of higher-level indicators in Shier's model (Levels 4–5). The absence of Levels 4–5 should therefore be interpreted cautiously as potentially reflecting both the time-critical prehospital context and the original interview focus.

Future research should include direct input from children wherever feasible, complemented by the perspectives of EMS clinicians.

Conclusion

This study demonstrates that children's participation in prehospital emergency care is both feasible and, in many cases, meaningfully realised.

By applying Shier's model to the context of prehospital care, this study offers a novel and systematic approach to assessing child participation in environments characterised by urgency and time constraints. Few studies have operationalised participation frameworks within prehospital settings; therefore, this application addresses a significant theoretical and practical gap. Moreover, the study provides empirically grounded insights into how EMS clinicians can facilitate participation by listening, supporting expression and valuing children's views, even during high-pressure encounters. By identifying and describing these practices, the study directly contributes to enhancing rights-based, child-centred care in emergency contexts. Using Shier's model as an analytical framework, participation was identified across a spectrum ranging from being listened to having one's views taken into account. Notably, many encounters reached Level 3, representing the threshold for rights-based practice as outlined in Article 12 of the UNCRC. ¹

However, participation seemed inconsistent. It often depended on the personal communication style of EMS clinicians, the child's communicative ability and the urgency of the clinical situation. In this sense, participation appeared relational and situational rather than structured or embedded.

By foregrounding parents’ perspectives, the study highlights both the possibilities and vulnerabilities associated with child participation in prehospital emergency care. Organisational support, training and simple clinical routines are needed to ensure that participation does not rely solely on individual discretion but becomes a routine element of care.

While full shared decision-making may be unrealistic in emergency contexts, acknowledging and responding to children's views, even in modest ways, can build trust, reduce anxiety and affirm their dignity as patients.