Lay evaluation of services for childhood asthma

How do children and adolescents experience healthcare professionals? Scoping review and interpretive synthesis

OBJECTIVE

Explore children's and adolescents' (CADs') lived experiences of healthcare professionals (HCPs).

DESIGN

Scoping review methodology provided a six-step framework to, first, identify and organise existing evidence. Interpretive phenomenology provided methodological principles for, second, an interpretive synthesis of the life worlds of CADs receiving healthcare, as represented by verbatim accounts of their experiences.

DATA SOURCES

Five key databases (Ovid Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Web of Science), from inception through to January 2019, reference lists, and opportunistically identified publications.

ELIGIBILITY CRITERIA

Research articles containing direct first-person quotations by CADs (aged 0-18 years inclusive) describing how they experienced HCPs.

DATA EXTRACTION AND SYNTHESIS

Tabulation of study characteristics, contextual information, and verbatim extraction of all 'relevant' (as defined above) direct quotations. Analysis of basic scope of the evidence base. The research team worked reflexively and collaboratively to interpret the qualitative data and construct a synthesis of children's experiences. To consolidate and elaborate the interpretation, we held two focus groups with inpatient CADs in a children's hospital.

RESULTS

669 quotations from 99 studies described CADs' experiences of HCPs. Favourable experiences were of forming trusting relationships and being involved in healthcare discussions and decisions; less favourable experiences were of not relating to or being unable to trust HCPs and/or being excluded from conversations about them. HCPs fostered trusting relationships by being personable, wise, sincere and relatable. HCPs made CADs feel involved by including them in conversations, explaining medical information, and listening to CADs' wider needs and preferences.

CONCLUSION

These findings strengthen the case for making CADs partners in healthcare despite their youth. We propose that a criterion for high-quality child-centred healthcare should be that HCPs communicate in ways that engender trust and involvement.

Creating a communication space in the healthcare context: Children’s perspective of using the eHealth service, Sisom

According to the United Nation's Convention of the Rights of the Child, children have the right to participate in their own healthcare and make their opinions heard. The aim of this study was thus to explore the impact of using an eHealth service, Sisom, to gain the children's perspectives during their healthcare appointments. Data were gathered through individual interviews with a purposeful sample of 16 children, aged 6-13 years old, treated for different diseases and using the eHealth service, Sisom, during their healthcare appointments. The interviews were analysed using a constructivist grounded theory. The results showed that using Sisom made children's voice heard by creating a communication space in the healthcare setting. This meant that the children got involved in the communication, were acknowledged as an important person who could give the answers to questions and were given time. Implementing the use of Sisom is a way to make children's needs and preferences explicitly visible for decision-making in practice and thereby supporting the further development of child-centred care in practice.

Experiences of parents and carers in managing asthma in children: a qualitative systematic review

OBJECTIVE

The objective of the review was to identify, critically appraise and synthesize the best available qualitative evidence to understand the lived experiences of parents and carers caring for a child aged 0-18 years with asthma in any setting and managing their condition.

INTRODUCTION

Asthma affects around 14% of children and despite the availability of effective therapies, asthma control is suboptimal and hospitalization rates remain high. Mothers predominantly manage their child's asthma and experience stress and exhaustion due to complex treatments and balancing work and family life. This review provides an understanding of the barriers parents and carers face in managing their child's asthma and highlights the needs of families throughout their asthma journey.

INCLUSION CRITERIA

The review considered qualitative studies examining the experiences of parents and carers caring for a child with asthma, wheeze or bronchiolitis and managing their condition. Research designs included, but were not limited to, phenomenology, grounded theory, ethnography, and action and feminist research.

METHODS

A comprehensive search using PubMed, CINAHL, Embase, PsycINFO, Web of Science and ProQuest for published and unpublished studies was undertaken in June 2017 and December 2017. Studies published in English from 1972 to 2017 were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used.

RESULTS

Seventy-seven qualitative studies were included in this review, including grounded theory, phenomenology and ethnography methodologies. From these 77 studies, 1655 participants from a variety of cultural backgrounds and socio-economic status groups were represented. The methodological quality of included articles was sound and participants' voices were strong. A total of 1161 findings (966 unequivocal and 195 credible) were extracted and grouped into 41 categories, based on similarity in meaning. From the 41 categories, seven synthesized statements were produced: i) Negotiating the meaning of having a child with asthma, ii) Impact on family life, iii) The process of getting a diagnosis and learning about asthma, iv) Relationships with healthcare professionals and the emergency department experience, v) Medication beliefs, concerns and management strategies, vi) With time, parents and carers become more comfortable managing their child's asthma, vii) The need for support.

CONCLUSIONS

This review highlights the difficulties parents and carers face when caring for a child with asthma and managing their child's condition. Attaining a definitive diagnosis of asthma can be challenging, and parents and carers express uncertainty and fear due to continuing symptoms and repeated hospitalizations. Healthcare professionals should ensure that a clear diagnostic strategy and treatment plan are communicated so parents and carers have an understanding of the pathway to receiving an actual diagnosis. Comprehensive asthma education is essential at the onset of asthma symptoms, with accurate, easy to understand and culturally relevant information. Supportive relationships, with healthcare professionals taking a partnership approach, ensuring adequate time, continuity of care, regular follow-up, and addressing the psychosocial and cultural needs and concerns of parents and carers, are recommended. Support groups and training for education staff is imperative to ensure they can support parents and carers, provide asthma friendly environments and respond appropriately in an asthma emergency.

Health care experiences of mothers of children with bronchiectasis in Counties Manukau, Auckland, New Zealand

BACKGROUND

Bronchiectasis is a worsening public health problem in New Zealand. This study aimed to explore the health care experiences of mothers of children with bronchiectasis in the Counties Manukau District Health Board area of Auckland, New Zealand.

METHODS

Semi-structured interviews were undertaken with ten mothers of children with bronchiectasis. Data were analysed using thematic analysis.

RESULTS

Five themes emerged: 1) Searching for answers, describing mothers' search for a diagnosis; 2) (Dis)empowerment, describing mothers' acquisition of knowledge, leading to empowerment; 3) Health care and relationships, describing the impact of relationships on the mother's health care experiences; 4) A juggling act, describing the challenges of juggling health care with school, work and family; 5) Making it work, describing how mothers overcome barriers to access health care for their child.

CONCLUSIONS

The health provider-parent relationship was crucial for fostering positive health care experiences. Mothers' acquisition of knowledge facilitated empowerment within those relationships. Additionally, mothers' perceptions of the quality and benefit of health services motivated them to overcome barriers to accessing care. Study findings may help to improve health care experiences for parents of children with bronchiectasis if identified issues are addressed.

Patient participation, a prerequisite for care: A grounded theory study of healthcare professionals' perceptions of what participation means in a paediatric care context

Aims

To explore healthcare professionals' perceptions of what patient participation means in a paediatric care context .

Design

A qualitative explorative design with grounded theory.

Methods

Fifteen healthcare professionals who worked in paediatric care settings were either interviewed or asked open-ended questions in a survey, during December 2015-May 2016. Grounded theory was used as a method.

Results

The study results provide a theoretical conceptualization of what patient participation meant for healthcare professionals in paediatric care and how participation was enabled. The core category "participation a prerequisite for care" emerged as the main finding explaining the concept as ethical, practical and integrated in the care givers way of working. However, the concept was implicit in the organization. Four additional categories illustrated the healthcare professionals' different strategies used to enhance patient participation; "meeting each child where the child is," "building a relationship with the child," "showing respect for each individual child" and "making the most of the moment."

Hospitalized children's representations of their relationship with nurses and doctors

This article reports an explorative study which aims to investigate hospitalized children's views of their relationships with nurses and doctors. Twenty-seven school-aged children and adolescents from 6 to 15 years old in the paediatric haematology and oncology ward of an Italian hospital participated in the study. Each participant was asked to draw him or herself with a doctor or nurse from the ward while they were doing something. The drawings were analysed using Pictorial Assessment of Interpersonal Relationships (PAIR) and a qualitative analysis. The results showed that the participants viewed their relationships with health professionals positively, in particular with the nurses. This relationship was perceived as close, intimate, cohesive and without conflict. In some cases it became an emotional bond. Finally, this relationship helped the patients to cope with painful and uncomfortable medical procedures, which gradually became familiar and accepted. The clinical implications of this study are discussed.

A qualitative evaluation of a pre-consultation guide intended to promote the participation of young people in asthma review consultations

OBJECTIVE

Young people's (age range 14-19 years) participation in consultations with health professionals can be limited. There has been little research into pre-consultation support for young people. This study evaluated a pre-consultation guide developed to promote young people's participation in asthma review consultations.

METHODS

A pre-consultation guide was evaluated in qualitative exit interviews with 24 young people and 9 primary care nurses in the United Kingdom.

RESULTS

Young people found the guide to be reassuring and supportive; peer written content, particularly example questions, helped to develop confidence and an intention to participate. Nurses suggested the guide could be a useful tool to aid young people's communication of asthma-related experiences.

CONCLUSION

Quotations from young people were highlighted as of particular value. Self-efficacy can be increased through observing how peers perform. Confidence and intention to change behavior are linked with actual behavior change. Future research should explore the impact of the pre-consultation guide on increased self-efficacy, developing an intention to change behavior and whether this is acted upon.

PRACTICE IMPLICATIONS

Used as a tool in a consultation may support change in practice nurses' consulting style and enable young people's participation.

Ascertaining children's wishes and feelings about hospital life

It is increasingly accepted that children have the right to have their views taken into consideration by healthcare providers. Children's opinions and experiences of hospitalisation are essential for monitoring and evaluating the effectiveness of health services provision. In this paper we report on children's views and wishes about hospital and healthcare professionals. The children held both positive and negative views of hospital and healthcare professionals. Dissatisfaction was caused by insufficient information, lack of involvement, and inadequate play facilities. Their wishes were mainly concerned with the need for more information and more involvement in communication interactions with doctors and nurses. They wished to express their opinions, ask questions and receive information about care and procedures. They recommended that healthcare professionals make a better effort to listen and to take account of their views.

Developing an intervention to promote young people's participation in asthma review consultations with practice nurses

AIM

The article is a report of a study to develop an evidence-based pre-consultation guide for young people to use prior to an asthma review with a practice nurse.

BACKGROUND

The participation of young people aged 13-19 in consultations with health professionals can be limited by the lack of opportunity to learn the appropriate skills in triadic consultations. Evidence-based interventions to promote participation of adults in consultations have been developed but young people's needs have not been specifically addressed.

DESIGN

Multiple methods design informed by guidelines for the development of complex interventions.

METHODS

A pre-consultation guide for young people was developed in 2007 by application of a model of health behaviour change, development of criteria by an expert panel and in consultation with young people using a nominal group technique.

RESULTS

The concepts of the Health Action Process Approach model were applied to the development of criteria underpinning the pre-consultation guide. In the nominal groups young people agreed that they had different needs to other children and adults. The consensus was that the preconsultation guide should include disease-specific information, realistic photographs rather than Clip Art, consistent styles of fonts, bullet points and colours, short words and mature language. Statements and example questions written by young people were included in the evidence-based guide.

CONCLUSION

Young people's views can contribute to the development of interventions designed to promote communication in consultations with nurses. There is potential for this approach to be used to develop interventions in primary and secondary care of a range of long-term conditions.

A qualitative study of families of a child with a nut allergy

OBJECTIVES

The aim of this study was to explore, using qualitative methods, the experiences of children and their parents living with nut allergy.

METHODS

Children with a confirmed diagnosis of peanut allergy were identified from a database of patients maintained at an allergy clinic at a large teaching hospital. Interviews with 26 families were conducted involving 11 children, 25 mothers and 12 fathers.

RESULTS

The diagnosis of nut allergy signalled a critical transition-or biographical disruption-in the life of the family. Parents took on the role of 'alert assistant' and sought to create 'safe places' where nuts were not permitted, but often struggled when outside the home environment. The option of 'passing as normal', often used by people with a chronic illness to avoid stigma, was not available to them. Consequently, parents often reported being treated as faddy, demanding, and neurotic, and children suffered from teasing and exclusion. The social consequences of nut allergy were worsened by poor labelling and control of foods and products containing nuts.

DISCUSSION

In many ways, nut allergy may be considered a form of disability, because it imposes social barriers on participating fully in society.

Which experiences of health care delivery matter to service users and why? A critical interpretive synthesis and conceptual map

OBJECTIVE

Patients' experiences are often treated as health care quality indicators. Our aim was to identify the range of experiences of health care delivery that matter to patients and to produce a conceptual map to facilitate consideration of why they matter.

METHODS

Broad-based review and critical interpretive synthesis of research literature on patients' perspectives of health care delivery. We recorded experiences reported by a diverse range of patients on 'concept cards', considered why they were important, and explored various ways of organizing them, including internationally recognized health care quality frameworks. We developed a conceptual map that we refined with feedback from stakeholders.

RESULTS

Patients identify many health care experiences as important. Existing health care quality frameworks do not cover them all. Our conceptual map presents a rich array of experiences, including health care relationships (beyond communication) and their implications for people's valued capabilities (e.g. to feel respected, contribute to their care, experience reciprocity). It is organized to reflect our synthesis argument, which links health care delivery to what people are enabled (or not) to feel, be and do. The map highlights the broad implications of the social dynamics of health care delivery. Experiences are labelled from a patient's perspective, rendering the importance of responsiveness to individuals axiomatic.

CONCLUSIONS

Our conceptual map identifies and helps explain the importance of diverse experiences of health care delivery. It challenges and helps policy-makers, service providers and researchers to attend to the range of experiences that matter, and to take seriously the need for responsiveness to individuals.

Constructing illness: how the public in eight Western nations respond to a clinical description of "schizophrenia"

According to classic and contemporary social theory, the community is crucial to how individuals respond to the onset of health problems. Cultural response to symptoms provides the foundation for lay diagnosis; offers a gauge for marking individual and societal health literacy; and reflects the cultural embeddedness of modern medical knowledge. Using data collected between 2004 and 2007 from the Stigma in Global Context - Mental Health Study (SGC-MHS) on the recognition of schizophrenia from vignettes describing individuals meeting DSM-IV criteria, we examine the nature and correlates of lay diagnosis. Focusing on Western societies in the SGC-MHS, we ask three questions regarding problem recognition in Bulgaria (N = 255), Cyprus (N = 253), Germany (N = 382), Hungary (N = 352), Iceland (N = 291), Spain (N = 327), Great Britain (N = 289), and the United States (N = 449): (1) What is the cross-national variation in recognition of schizophrenia as a mental illness? (2) Is lay diagnosis associated with individuals' socio-demographic characteristics and/or their evaluation of underlying causes? (3) Are lay diagnoses likely to shape the nature and direction of the illness career? We find lay diagnosis of "mental illness" to be high across these Western nations with some, though modest, difference across countries. Variation for the more specific diagnosis of "schizophrenia" is greater, though fairly consistent in country ordering. Lay diagnoses are shaped most consistently by attributions, inconsistently by socio-demographics, and generally associated with respondents' treatment recommendations and expected outcomes. In light of assumptions about public beliefs and knowledge that often underlie research, community efforts, clinical programs, and health policy, these findings suggest that a greater understanding of the complexities of lay diagnosis is warranted.

Health Professionals’ Preparation for Supporting Children and Parents Affected by Asthma and Allergies

Although social support originates from sources both informal (eg, family, peers) and formal (eg, health professionals), most reported research focuses on informal support providers. The perspectives and learning needs of health professionals as potential support providers for children and families affected by asthma and allergies form a gap in the reported research. The objective of this study was to assess health professionals’ learning needs and preferences pertinent to the support and education of children with asthma and allergies. A 26-item online survey and qualitative interviews (n, 10) elicited information from health professionals about the perceived support and educational needs of children with asthma and allergies, experience and challenges working with children, health professionals’ educational needs regarding support of children, and continuing education needs and barriers. Health professionals believed that children needed professional education, support, and strategies to reduce the effects of asthma and allergies on their lifestyle. Time (66.0%) and cost (80.9%) were significant barriers to non-Web-based education, but only 14.6% rated time and cost a barrier to Web-based education. Family or work commitments were slightly greater obstacles for non-Web-based education (63.8%) than for Web-based education (51.2%). Although these health professionals were interested in learning from and connecting with their peers, promoting peer support for children with asthma and allergies received a lower rating on their list of educational needs. This needs assessment study confirms that health professionals have limited time, funds, and options for asthma- and allergy-related professional development activities. It validates the need and value of Web-based education with access to an instructor, experts, and group discussions, and it supports the inclusion of asthma-specific information and practical skills for teaching children and for addressing challenges when teaching. Exposure to and understanding of the value of incorporating peer support and social support into existing health programs may be limited.

A literature review of children's and young people's participation in decisions relating to health care

AIMS AND OBJECTIVES

To review and critique the research literature on children's and young people's participation in health care decision-making, to highlight gaps in the research and to identify implications for nursing practice.

BACKGROUND

Children have a right to participate in decisions about their lives. The recognition of this, along with greater acknowledgement of children's capabilities, has led to an increasing awareness that children's views must be given value in both national policy and individual decisions. Health professionals have also been given explicit direction to ensure that children are actively involved in decision-making.

DESIGN

Literature review.

METHOD

Search of electronic databases and manual searching of journals and reference lists between 1990-2009.

RESULTS

Children want to be involved in discussions about their care but it is unclear to what extent this happens in practice. The research conducted has interpreted participation in different ways. Studies have compared decisions of differing importance in terms of risk and many have a wide age range in their samples, including children who are arguably too young for meaningful participation. However, this heterogeneity is often overlooked in the reporting of studies. Aspects of practice which can help or hinder participation are identified but there is little evidence on the outcome benefits of participation. In addition, there has been an over-reliance on interviews as the method of data collection.

CONCLUSIONS

Research using a combination of observation and interviewing would provide more in-depth knowledge about participation in practice. In addition, studies should consider decisions of similar consequence and children at an age when participation is appropriate.

RELEVANCE TO CLINICAL PRACTICE

The need for health professionals to ensure children are protected is undisputed but should not prevent children's rights to participate from being enacted. Practitioners, therefore, need further guidance on how to facilitate the participation of children.

Is children's choice in health care rhetoric or reality? A scoping review

AIM

This paper is a report of a scoping review examining children and young people's health services with respect to choice in order to inform future development of choice initiatives.

BACKGROUND

The importance of including children and young people in the choice agenda reflects the increasing acknowledgement that, individually and collectively, they are important consumers of health care in their own right. Data sources. A scoping review of all major health and medical research databases was undertaken using current guidelines to identify original relevant research papers and grey literature sources from 1990 to 2006.

REVIEW METHODS

Reference Manager software was used to collate, summarize, categorize, store and retrieve the search results. Papers meeting the inclusion criteria were read in full and descriptively summarized using a data extraction sheet. Each paper was repeatedly selected using a snowballing approach until saturation was reached. Results. Children and young people want more say in the planning and development of appropriate hospital and community health services. However, little evaluative research was found about whether these choices are acted upon and lead to more responsive services.

CONCLUSION

Choice for children and young people is viewed as a positive development in health care and many innovative examples of their involvement in decision-making were found. These illustrated that, given the opportunity, children and young people are willing and able to make decisions about their healthcare services. However, there is a long way to go before the rhetoric of the choice agenda is realized.

Review management for children with asthma in primary care: a qualitative case study

AIMS OF THE STUDY

To present an overview of review management of childhood asthma in one UK primary care trust with respect to organization and perceptions of key stakeholders and children's and families' needs.

BACKGROUND

Review management of childhood asthma in primary care is important in addressing the continuing high levels of morbidity. However, the delivery of this service appears to be fragmented, so it is not known how well primary care asthma clinics function. Children's, parents' and professionals' perceptions of such clinics and the roles they play within them are also poorly understood.

RESEARCH DESIGN

A qualitative case study design was used in the study. This is a form of enquiry that investigates contemporary issues within their real life contexts, using particular situations within the case to describe important phenomena.

METHODS

Eighteen children, 16 parents, 14 practice purses and 14 general practitioners from 14 general practices in one primary care trust were interviewed. Review appointments were observed and asthma-related documentation examined.

FINDINGS

Key findings point to diversity in the service and that key stakeholders' view practice nurses as primarily responsible for the review management. However, there are issues related to their levels of responsibility, other health professionals' roles and interdisciplinary communication. Finally, families felt some of their needs were neglected and professionals reported uncertainties in providing family-centred care.

CONCLUSIONS

This case study indicates that responsibility for review consultations in childhood asthma needs to be formalized, including a more proactive and family-centred approach. There are implications for the practice nurse role regarding professional education and preparation for family-centred care.

RELEVANCE TO CLINICAL PRACTICE

This paper shows that unstructured, diverse care delivery persists in primary care; children and their families identify both strengths and unmet needs in review management visits; and professionals have uncertainties about providing effective child and family-centred care.

Methodological and ethical issues in conducting qualitative research with children and young people: A literature review

BACKGROUND

There is an increasing interest in involving children in research that has been influenced by the recognition of children's rights and by the reconceptualisation of children within the social sciences as active agents rather than as the objects of research.

OBJECTIVES

To review the methodological and ethical issues involved in conducting qualitative research with children and to consider the implications for nursing research in light of recent debates within the social sciences.

DESIGN

Narrative literature review using a systematic search of computerized databases.

DATA SOURCES

Published papers, key texts, reports and policy documents that relate to the methodological and ethical issues in conducting qualitative research with children.

RESULTS

There are three ethical issues in relation to conducting research with children: power relations, informed consent and confidentiality. Two key methodological issues are identifiable in relation to conducting research with children. One is epistemological and relates to the different cultures of childhood and adulthood and the second relates to the heterogenous nature of childhood itself. Novel techniques and task-based activities are being increasingly used to establish rapport and as a method of data collection.

CONCLUSION

There are both differences and similarities in conducting qualitative research with children and with adults but often the similarities have been overlooked and the differences overstated. Nursing and other health-related researchers conducting research with adults could learn much from children's researchers, particularly in terms of sensitivity to ethical issues. Nursing research need to consider the methodological issues that have been debated in the social sciences and to critically reflect on the use of novel techniques in qualitative research.

Effect of gender and visit length on participation in pediatric visits

OBJECTIVE

To examine the effect of child, physician and parent genders as well as visit length on participation.

METHODS

We analyzed videotapes and sociodemographics from 100 pediatric visits. Using the Roter Interaction Analysis System, coded utterances were aggregated to reflect key visit tasks: information giving, information gathering and relationship building. Negative binomial models were used to analyze how participation was associated with participants' genders and visit length.

RESULTS

After adjustment, girls did twice as much relationship building as boys (incidence rate ratio = 2.33, 95% confidence interval = 1.01-5.36) and their physicians did 34% more information gathering (1.34, 1.16-1.55). Female physicians did 29% less information giving (0.71, 0.54-0.94). Having the father accompany the child reduced child relationship building 76% (0.24, 0.08-0.69) and reduced physician information giving 14% (0.86, 0.75-0.995), compared to having mother accompany. After adjusting for participants' genders, longer visits were associated with more participation for all participants.

CONCLUSION

Child participation was impacted by child gender and by the accompanying parent's gender as well as the visit length.

PRACTICE IMPLICATIONS

Because gender-based patterns of participation are evident in childhood, interventions to facilitate participation might begin early in life. To improve participation, interventions might include advocating for policies to support longer visit lengths.

Decision-making in community-based paediatric physiotherapy: a qualitative study of children, parents and practitioners

Approaches to practice based on partnership and shared decision-making with patients are now widely recommended in health and social care settings, but less attention has been given to these recommendations in children's services, and to the decision-making experiences of non-medical practitioners and their patients or clients. This study explored children's, parents' and practitioners' accounts of shared decision-making in the context of community-based physiotherapy services for children with cerebral palsy. Semi-structured interviews were conducted with 11 children with cerebral palsy living in an inner city area of northern England, and with 12 of their parents. Two focus groups were conducted with 10 physiotherapy practitioners. Data were analysed using the constant comparative method. When asked explicitly about decision-making, parents, children and practitioners reported little or no involvement, and each party saw the other as having responsibility for decisions. However, when talking in more concrete terms about their experiences, each party did report some involvement in decision-making. Practitioners' accounts focused on their responsibility for making decisions about resource allocation, and thereby, about the usefulness and intensity of interventions. Parents indicated that these practitioner-led decisions were sometimes in conflict with their aspirations for their child. Parents and children appeared to have most involvement in decisions about the acceptability and implementation of interventions. Children's involvement was more limited than parents'. While parents could legitimately curtail unacceptable interventions, children were mostly restricted to negotiating about how interventions were implemented. In these accounts the involvement of each party varied with the type of issue being decided and decision-making appeared more unilateral than shared. In advocating shared decision-making, greater understanding of its weaknesses as well as its strengths, and greater clarity about the domains that are suitable for a shared decision-making approach and the roles of different parties, would seem a helpful step.

The views of children and their families on being in hospital

This study aimed to elicit the separate views of children, young people and carers after a period in hospital as an inpatient. Questionnaires were administered to 130 children and their families discharged after a period as hospital inpatients in January 2003. Anonymized data were returned from 50 families. Data analysis indicated that there were differences in the way that the three groups perceived the period of admission. Although parental sleeping and other social arrangements were subject to some critical review, the nursing care experienced by families was highly rated. Although arrangements for discharge were deemed satisfactory, 38% of carers had to wait for medicines to arrive on the ward before they could go home. Only six of the young people felt there ward catered for their age group and five indicated poor levels of privacy. None of the young people indicated that they had used the equipped teenagers' room. Attempts to include the voice of the younger child in this study proved unsatisfactory as parents elected to act as proxies in completing the child-specific questionnaires. Child healthcare professionals attempting to involve all service users in determining optimum levels of care need to consider fully the methods of data collection and their applicability for differing age groups of children. Dependence on adult carers to reflect accurately the voice of the child is not fully satisfactory.