Holding and restraining children for clinical procedures within an acute care setting: an ethical consideration of the evidence

Nursing experiences and knowledge of paediatric delirium: Analysing knowledge-practice gaps

BACKGROUND

Delirium commonly occurs in paediatric patients with acute critical illness and negatively affects clinical outcomes. Variations in delirium knowledge levels and its management have been noted among nurses.

AIMS

This study investigated nurses' experiences and knowledge levels regarding paediatric delirium. Additionally, we aimed to assess the gap between knowledge levels and practical experiences with paediatric delirium.

STUDY DESIGN

This cross-sectional descriptive study conveniently sampled paediatric nurses from a university hospital in South Korea between September 2022 and March 2023. Nursing experiences with paediatric delirium and delirium knowledge levels were measured using structured survey questionnaires. Delirium knowledge was scored 0 to 47, and higher scores indicated higher levels of delirium-related knowledge. Data were analysed using descriptive statistics and presented as mean, standard deviation, frequency and percentage.

RESULTS

A total of 127 paediatric nurses participated in this study; 40.2% had experience with 1-5 delirium cases in the previous year, and 86.6% (n = 110) had never used assessment tools for paediatric delirium assessment. The mean total delirium knowledge score was 34.45 ± 5.4; the mean scores of knowledge regarding aetiology, signs and symptoms and nursing management of delirium were 8.93 ± 1.31, 13.24 ± 2.81 and 12.3 ± 2.7, respectively. Interventions associated with a lower level of delirium-related knowledge and a lower performance rate included avoiding restraint use and maintaining hydration and electrolyte levels. Interventions associated with a higher level of delirium-related knowledge but a lower rate of performance comprised providing orientation, offering emotional support, allowing participants to stay with family members and administering medications to manage delirium.

CONCLUSIONS

Although nurses working in paediatric units exhibited high rate of delirium nursing care, there was the gap between their delirium-related knowledge and practice. Nurses need to be aware of the insufficient part of delirium care, and paediatric delirium education should be reinforced.

RELEVANCE TO CLINICAL PRACTICE

Preventing, assessing and systematically managing paediatric delirium is crucial, and considering the study results, delirium education among nurses is needed.

The Concept of Child-Centred Care in Healthcare: A Scoping Review

Although child-centred care is increasingly referred to within the nursing literature, a clear definition of child-centred care and clarity around the concept is yet to be achieved. The objectives of this review were to examine the following: (1) What constitutes the concept of child-centred care in healthcare? (2) How has the concept of child-centred care developed? (3) What is the applicability of child-centred care and what are its limitations? (4) How does the concept of child-centred care benefit and inform children's healthcare? In total, 2984 papers were imported for screening, and, following the removal of duplicates and screening, 21 papers were included in the scoping review. The findings suggest that child-centred care is an emerging, ambiguous poorly defined concept; no clear consensus exists about what constitutes child-centred care. Although it seems antithetical to argue against child-centred care, little robust evidence was identified that demonstrates the impact and benefit of child-centred care. If child-centred care is to be a sustainable, convincing model to guide practice and compete with other models of care, it needs to establish robust evidence of its effectiveness, the impact on children and their families, as well as the wider impacts on the healthcare system.

Living bioethics, theories and children's consent to heart surgery

Background

This analysis is about practical living bioethics and how law, ethics and sociology understand and respect children's consent to, or refusal of, elective heart surgery. Analysis of underlying theories and influences will contrast legalistic bioethics with living bioethics. In-depth philosophical analysis compares social science traditions of positivism, interpretivism, critical theory and functionalism and applies them to bioethics and childhood, to examine how living bioethics may be encouraged or discouraged. Illustrative examples are drawn from research interviews and observations in two London paediatric cardiac units. This paper is one of a series on how the multidisciplinary cardiac team members all contribute to the complex mosaic of care when preparing and supporting families' informed consent to surgery.

Results

The living bioethics of justice, care and respect for children and their consent depends on theories and practices, contexts and relationships. These can all be undermined by unseen influences: the history of adult-centric ethics; developmental psychology theories; legal and financial pressures that require consent to be defined as an adult contract; management systems and daily routines in healthcare that can intimidate families and staff; social inequalities. Mainstream theories in the clinical ethics literature markedly differ from the living bioethics in clinical practices.

Conclusion

We aim to contribute to raising standards of respectful paediatric bioethics and to showing the relevance of virtue and feminist ethics, childhood studies and children's rights.

It hurts to get forced: Children's narratives about restraint during medical procedures

According to the UN Convention on the Rights of the Child (UNCRC), children have the right to be involved in decisions about medical procedures affecting them. However, research has shown that healthcare professionals sometimes find this difficult to achieve and those procedures then are performed against the will of the child. The aim was to illuminate restraint from the perspective of children's and young people's experiences of feeling forced during medical procedures. Following the phenomenological hermeneutic method, a secondary qualitative analysis of narrative data from four datasets collected between 2001 and 2020 was performed. Twelve children and young people aged 6-19 years (three male, nine female) from central and northern Sweden narrated their experiences of restraint related to medical procedures in nine narrative interviews and three short written narratives. The analysis revealed that it hurts to get forced, this being illustrated in six themes: bodily misery, emotional rebellion, feeling disregarded, physically limited, desiring escape, and leaving deep traces. From the perspective of children and young people, restraint was interpreted with inspiration from the philosopher Michel Foucault, as being overpowered - not voluntary submission but offering resistance - and according to the theory of caring and uncaring, a relationship in which the healthcare professional is perceived as indifferent to the patient as a person. In conclusion restraint hurts and means powerlessness to the child, leaving deep traces that remain for a long time. The findings call the healthcare profession to take action to support children's self-determination, participation, and integrity in healthcare. How children experience restraint in healthcare merits further investigation from the children's own perspective.

Mothering children at a paediatric intensive care unit with strict visiting hours: A qualitative study

BACKGROUND

Although a child- and family-centred care (CFCC) philosophy has been emphasized and adopted for decades in paediatric critical care settings in several countries, numerous issues from parents' perspectives regarding the philosophy remain unresolved. To facilitate the full translation of CFCC into clinical practice, health care professionals need an in-depth understanding of family experiences. Real-life mothering experiences, including maternal roles and identities, remain largely unknown at paediatric intensive care units (PICUs) in the Republic of Korea, where family visitation, presence, and participation are restricted.

AIM

To explore mothering experiences at a PICU where family visitation is strictly constrained, and to identify maternal needs and values.

STUDY DESIGN

We conducted a qualitative descriptive study of eight individual in-depth interviews with seven mothers of hospitalized children. Qualitative data were analysed using inductive thematic analysis.

FINDINGS

Five major themes, along with four subthemes, emerged: (1) shifts in maternal roles and responsibilities, (2) shifts in interpersonal relationships, (3) desire for CFCC in the PICU, (4) practising self-defined mothering roles, and (5) reconstructing maternal identities. The themes revealed the experiences of becoming mothers of a child in a constrained PICU. Ultimately, mothers demanded that the unit improve its physical and cultural environments through, for example, liberalized family visitation and participation in the care of their children.

CONCLUSIONS

Nursing professionals should lead the charge for humanizing a restrictive PICU in the Republic of Korea by ensuring a safe and open environment and mothering continuity based on child- and family-centred holistic care.

RELEVANCE TO CLINICAL PRACTICE

Effective interventions must be developed and tested to globally establish and fully implement strong evidence-based CFCC in PICUs; constant co-commitment among children, families, health care professionals, and institutions is also necessary.

Developing rights-based standards for children having tests, treatments, examinations and interventions: using a collaborative, multi-phased, multi-method and multi-stakeholder approach to build consensus

Children continue to experience harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. The international ISupport collaboration aimed to develop standards to outline and explain good procedural practice and the rights of children within the context of a clinical procedure. The rights-based standards for children undergoing tests, treatments, investigations, examinations and interventions were developed using an iterative, multi-phased, multi-method and multi-stakeholder consensus building approach. This consensus approach used a range of online and face to face methods across three phases to ensure ongoing engagement with multiple stakeholders. The views and perspectives of 203 children and young people, 78 parents and 418 multi-disciplinary professionals gathered over a two year period (2020-2022) informed the development of international rights-based standards for the care of children having tests, treatments, examinations and interventions. The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.    Conclusion: This is the first study of its kind which outlines international rights-based procedural care standards from multi-stakeholder perspectives. The standards offer health professionals and educators clear evidence-based tools to support discussions and practice changes to challenge prevailing assumptions about holding or restraining children and instead encourage a focus on the interests and rights of the child. What is Known: • Children continue to experience short and long-term harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. • Professionals report uncertainty and tensions in applying evidence-based practice to children's procedural care. What is New: • This is the first study of its kind which has developed international rights-based procedural care standards from multi-stakeholder perspectives. • The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.

Pediatric pain knowledge and attitudes among health care professionals-A National Danish Survey

Aim

To explore and compare Danish health-care professionals' attitudes and knowledge towards pain management of children.

Methods

The cross-sectional study was carried out using the Pediatric Pain Knowledge and Attitudes Questionnaire. The questionnaire was distributed to all health care professionals caring for children in three hospital settings, including nurses and physicians in departments of pediatric, emergency, and anesthesia and medical laboratory technologists.

Results

The study was conducted in 2020 and 765 health care professionals participated. Within the six main categories included in the questionnaire, there were significant differences between nurses and physicians in three subcategories: view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Comparing nurses with medical laboratory technicians, there were significant differences in the subcategory "view on the care of children in pain." Comparing types of clinical departments, there were significant differences in the subcategories' view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Overall, we found that the participating health professionals did not have a uniform understanding of pain management and therefore might treat children differently.

Conclusion

The present study highlights the need to align health care professionals' knowledge regarding pain assessment and management of children, as well as the need to develop and test interventions that support the use of knowledge in practice.

Children's understanding and consent to heart surgery: Multidisciplinary teamwork and moral experiences

Mainstream law and ethics literature on consent to children's surgery contrasts with moral experiences of children and adults observed in two heart surgery centres. Research interviews were conducted with 45 practitioners and related experts, and with 16 families of children aged 6 to 15, admitted for non-urgent surgery, as well as an online survey. Thematic data analysis was informed by critical realism and childhood studies.Impersonal adult-centric mainstream literature assumes young children cannot consent. It is based on dichotomies: adult/child, competent/incompetent, respect or protect children, inform or distract them, use time swiftly or flexibly, verbal/non-verbal communication, respect or control children and reason/emotion.Through their moral experiences, adults and children resolve these seeming dichotomies. Through understanding young children's reasoning and emotions about complex distressing decisions related to heart surgery, adults share knowledge, control, trust and respect with them. They see children's consent or refusal before non-urgent surgery as a shared personal moral experience within the child's life course, beyond mere legal compliance. Adults help children to understand and 'want' the surgery that offers things they value: better health or to 'be more like their friends'. If children are not convinced, sometimes surgery is postponed or occasionally cancelled.

Held still or pressured to receive dental treatment: self-reported histories of children and adolescents treated by non-specialist dentists in Hordaland, Norway

Aim

This study aimed to estimate the prevalence of a self-reported history of restraint in children and adolescents when receiving dental care by non-specialist dentists and to assess differences in dental fear and anxiety (DFA), intra-oral injection fear, and trust in dentists between patients with and without a self-reported history of restraint.

Methods

An electronic cross-sectional survey was distributed to all 9 years old (n = 6686) and 17 years old (n = 6327) in the Public Dental Service in Hordaland County, Norway, in 2019. For statistical evaluation, we generated descriptive statistics and Mann–Whitney U tests.

Results

The response rate ranged between 43.5 and 59.9% for the different questions. The prevalence of a self-reported history of being held still against one’s will during dental treatment and pressured to undergo dental treatment against one’s will was 3.6% and 5.1%, respectively. In general, these patients reported higher DFA, and higher intra-oral injection fear compared with those without such histories of restraint. Patients who had reported being held still against their will during dental treatment had significantly higher distrust in dentists than those who did not report restraint (p < 0.001).

Conclusion

To feel pressured to receive dental treatment and to be held still against one’s will overlap with the concepts of psychological and physical restraint. Patients with a self-reported history of restraint recorded significant differences in DFA, intra-oral injection fear, and trust in dentists compared to those who did not report restraint. Future studies should explore the role that restraint may play in relation to a patient’s DFA, intra-oral injection fear, and trust in dentists.

How Children's participation ought to be practiced: A preliminary ethical framework to optimise the participation of children with osteogenesis imperfecta in health care

BACKGROUND

A three-phase ethnography was conducted at a paediatric orthopaedic hospital exploring the actual and desired participation of children with Osteogenesis Imperfecta in discussions, decisions and actions in the hospital and community. Phase I and Phase II revealed how childhood ethics are understood and practiced in the hospital using artmaking to engage children in discussions about their health-related experiences. Children expressed frustration, anger and disappointment when their desired level of participation in care was not actualized due to forgone opportunities for engagement by clinicians or lack of child-oriented health resources.

OBJECTIVES

The objective of this study (Phase III) was to specify how childhood ethics ought to be understood and practiced in the hospital by (1) convening hospital stakeholders in a collaborative setting to disseminate findings, identify ethical concerns and generate action steps; and (2) develop a preliminary ethical framework to optimise the participation of children with OI in health care.

DESIGN

Focused ethnography reported using the SRQR checklist.

METHODS

A focus group was conducted with 14 interdisciplinary hospital stakeholders. Data were analysed using qualitative, thematic analysis to understand primary ethical concerns and accompanying action steps. The findings were consolidated into a preliminary ethical framework and worksheet for clinicians.

RESULTS

Four main factors impeding children's voices and desired participation were identified: legal and contextual factors; variations in clinicians' skills, practice and knowledge; difficulties incorporating alternative engagement methods into practice; and need for interprofessional collaboration. Five action steps were identified: Recognise, Elicit, Interpret, Act and Optimise.

RELEVANCE TO CLINICAL PRACTICE

The focus group and creation of clinician resources were important steps towards addressing the ethical concerns of children with OI, such as marginalisation or exclusion in their OI care. This study better prepares us to disseminate our findings on a larger scale and create ethical frameworks and resources to improve how vulnerable children's voices are heard, understood and acted upon in healthcare settings.

The involvement and autonomy of young children undergoing elective paediatric cardiac surgery: a qualitative study

Background

Standards generally reported in the literature about informing children and respecting their consent or refusal before elective heart surgery may differ from actual practice. This research aims to summarize the main themes in the literature about paediatric anaesthesia and compare these with research findings on how health professionals counsel young children before elective heart surgery, respect their consent or refusal, and maintain patient-centred care.

Methods

This qualitative research involved: literature reviews about children’s consent to surgery and major interventions; observations of wards, clinics and medical meetings in two paediatric cardiology departments, October 2019 to February 2020; audio-recorded semi-structured interviews with 45 hospital staff, including 5 anaesthetists, and related experts, November 2019 to April 2021; interviews with 16 families, with children aged 6- to 15-years and their parents shortly after elective heart surgery, and some months later (reported in other papers); thematic data analysis; and research reports on how different professions contribute to children’s informed decisions for heart surgery.

Results

The medical, ethics and English legal literature tend to assume legal minors cannot refuse major recommended treatment, and cannot consent until they are 12 years or older. Little is said about informing pre-competent children. If children resist, some anaesthetists rely on sedation and distraction, and avoid much informed discussion, aiming to reduce peri-operative anxiety. However, interviewees reported informing young children, and respecting their consent or refusal before elective surgery. They may delay elective surgery and provide further information and support, aiming to reduce fear and promote trust. Six years of age was commonly cited as the threshold for respecting consent to heart transplantation.

Conclusion

Differing views about younger children’s competence, anxiety and best interests support different reactions to children’s consent and refusal before elective heart surgery. This paper reports the zero-restraint policy followed for over a decade in at least one leading surgery centre. The related law and literature need to be updated, to take more account of evidence of actual practice.

‘We should have been told what would happen’: Children’s and parents’ procedural knowledge levels and information-seeking behaviours when coming to hospital for a planned procedure

Children continue to be poorly prepared and informed about clinical procedures, despite increased evidence of the worth of preparation and the availability of information resources. This study used a concurrent mixed-methods approach to explore the information accessed by children and their parents before attending hospital for a procedure. Information was collected separately from 40 children (aged between 8 and 12 years) and their parents using a paper booklet to examine self-reported perceived procedural knowledge and information-seeking behaviours. Data were analysed using descriptive statistics and content analysis techniques. The findings indicate that many children (70%, n = 28) and their parents (65%, n = 26) have low procedural knowledge levels. The majority of children (85%, n = 36) reported not receiving or seeking information about their procedure, despite identifying a desire and preference for more information. This study shows a mismatch between the current provision of procedural information and children and parents' expectations that information will be provided directly to them by health professionals. In order for this 'information hole' to be filled, there needs to be a concerted effort to develop and systematically use meaningful information materials and for children and their parents to have the opportunity to discuss their procedural knowledge with health professionals.

[Improving pain assessment of infants in paediatric emergency departments]

Not having access to language, the infant is deprived of an essential means of communicating its painful experience. The assessment of their pain in the emergency room is therefore quite complex. A study carried out in the paediatric emergency department of the Centre hospitalier intercommunal de Créteil shows that it is possible to improve this aspect thanks, among other things, to continuous training and the presence of experts in children's pain within the team.

Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis

Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.

A practical and ethical toolkit for last-minute refusal of anesthetic in children

Children's fear of a procedure, including the anesthetic, is a common issue that operating theatre staff face. This fear is generally mitigated by preesthetic preparation and information sharing. Last-minute refusal of a procedure creates unique difficulties for the anesthetist and proceduralist. Refusal for a procedure raises issues of whether the dissent is binding, and if not, how best to get the child to theatre without creating moral injury. In this case review of a young adolescent who refuses to go to the operating theatre, we explore practical and ethical options to resolve the situation. We discuss respect for persons (including assent and consent), best interests, truth-telling, harm minimization, and restraint. The importance of a postevent debrief is discussed. We also assess the value of a clinical ethics service with team members embedded in clinical teams.

Restraint in paediatric dentistry: a qualitative study to explore perspectives among public, non-specialist dentists in Norway

OBJECTIVE

The aim of this study was to explore the perspectives of non-specialist dentists on the use of restraint in paediatric dentistry in the Public Dental Service in Norway.

MATERIALS AND METHOD

Two focus group interviews involving four and five dentists, respectively, were conducted in one of the most populated counties in Norway in September 2019. The thematic analysis by Braun and Clarke informed the qualitative analysis.

RESULTS

According to the dentists, physical restraint in paediatric dentistry is usually used when dental treatment is absolutely necessary. The qualitative analysis revealed the following three main themes: (1) some dentists justify the use of restraint in paediatric dentistry; (2) physical restraint is often legitimised by the fact that the child is sedated; (3) the use of restraint evokes difficult ethical evaluations. Additionally, the dentists had an overarching perspective of acting in the child's best interest, but they sometimes struggled to find a justifiable path in situations involving restraint.

CONCLUSIONS

Dentists seem to consider the use of restraint combined with sedation as legitimate for absolute necessary dental treatment. Furthermore, the use of restraint involves difficult ethical evaluations.

Clinical Holding in Pediatric Venipuncture: Caring by Empowering the Caregiver

The use of restraint in the child-adolescent population is highly controversial due to the consequences it can have for patients and their families, although it is sometimes necessary to employ restraint to perform techniques safely and effectively. Clinical Holding is committed to the involvement of parents during venipuncture in the context of family-centred care. This study assesses levels of distress and pain in children undergoing this procedure, as well as satisfaction in parents and nurses. Parents assist in the restraint of children and provide accompaniment during venipuncture. Levels of distress and pain were not particularly elevated. Satisfaction levels among parents and nurses were high. A positive correlation was found between anticipatory and real distress (r = 0.737, p = 0.000), and between real distress and real pain (r = 0.368, p = 0.035). A negative correlation was observed between real pain and parent satisfaction (r = -0.497, p = 0.003). Parental participation during venipuncture contributed to better management of distress and pain. In the future, it would be advisable to incorporate the other pharmacological and non-pharmacological measures recommended by Clinical Holding to ensure care of the highest quality and safety.

How are children's best interests expressed during their hospital visit?-An observational study

AIMS AND OBJECTIVES

To describe ways in which children's best interests were observed to be expressed in paediatric settings during their hospital visit.

BACKGROUND

The best interests of the child are embodied in national and international legal systems, although the definition remains problematic. The child's limited autonomy mandates duty bearers to have both a child perspective and the child's perspective when considering what the best interest of the child entails in care situations.

DESIGN

A qualitative descriptive study with overt, non-participant observations fulfilling the COREQ criteria.

METHODS

Thirty-two observations of interactions between children aged 2 to 17 years with both acute and chronic conditions, their parents and healthcare professionals were conducted at three paediatric hospitals in Sweden. Inductive and abductive reasoning were used in the content analysis of data, which followed the identification, coding, categorising and abstraction of observed patterns of the best interest of the child.

RESULTS

Findings reveal facilitating and obstructing factors for the child's best interests to be safeguarded in healthcare situations. Children were guided in or hindered from exercising their competence. The observations showed a variation in actions taken by both parents and healthcare professionals to safeguard the best interests of the child.

CONCLUSIONS

Determining the best interest of the child requires a case-by-case basis, as it is context-dependent, situational, flexible and dependent on all actors involved and actual decisions made.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals' actions can facilitate or obstruct observed expressions of the child's best interest. It is essential to enhance healthcare professionals' communication skills, knowledge awareness and continuing education about the rights of children receiving healthcare services. Reflections and discussions on how to protect the best interests of children may help healthcare professionals to uphold children's best interest in daily clinical practice.

Health anxiety among adults with congenital heart disease

PURPOSE OF REVIEW

Adults with congenital heart disease (CHD) may experience anxiety specifically related to their medical condition. This review introduces the concepts of health anxiety and heart-focused anxiety, summarizes what is currently known about heart-focused anxiety among adults with CHD and offers suggestions to help adult CHD providers address heart-focused anxiety in their patients.

RECENT FINDINGS

Although minimal research has been conducted specific to this outcome, health anxiety may occur at any point across the lifespan of individuals with CHD. A recent study found that children and adolescents with CHD reported greater health anxiety than community peers. Health anxiety was commonly reported among adults with CHD presenting for psychological assessment. It was linked with older age, trait anxiety, perceived parental overprotection and greater CHD complexity in one study.

SUMMARY

Adults with CHD face many potential health-related stressors, including cardiac symptoms, treatments and interventions throughout the lifespan (including surgeries and other invasive procedures), the impact of CHD on daily lives and longer-term health expectations. Providers should be aware that heart-focused anxiety among patients is understandable and perhaps common. Patient-centred education and psychological intervention should be integrated within a comprehensive approach to long-term disease management.

Health care provider's responses to children's resistance to peripheral vein cannulation: A qualitative observational study

AIMS AND OBJECTIVES

Health care and treatment should be voluntary, but restraint is often used during treatment of children. Knowledge about how health care providers respond to preschool children's resistance is lacking and can help understand current paediatric care in hospitals. The aim of the present article was to provide knowledge about how healthcare providers respond to preschool children's resistance during the clinical procedure of peripheral vein cannulation.

DESIGN

An explorative qualitative research design was developed for this study.

METHODS

Observations with video recording were used to collect data. Eight nurses and seven physicians participated in the study (n = 15). Their responses to preschool children's (n = 6) resistance were studied during 14 attempts of peripheral vein cannulation. Consolidated criteria for reporting qualitative research (COREQ) were used.

RESULTS

The healthcare providers made 380 responses to children's resistive expressions, interpreted within four main types, responses to acknowledge the child, responses to distract the child, responses to persuade the child and responses to reject the child. All main types of responses were used by both nurses and physicians. Regardless of the amount of resistance the children expressed, all children received distracting and acknowledging responses. Rejecting responses were used approximately twice as much in the implementation phase as in the preparation phase. Distraction, persuasion and rejection began in the preparation phase and increased in the implementation phase.

CONCLUSIONS

The main types and sub-types of responses showed how healthcare providers use a wide array of responses to meet children's resistance during peripheral vein cannulation.

RELEVANCE TO CLINICAL PRACTICE

The results can enable health care providers to become aware of their own practices during peripheral vein cannulation and other clinical procedures and to elaborate on their use of responses that can be considered intrinsically less child-friendly.

I don't want to think about it: a qualitative study of children (6-18 years) with rheumatic diseases and parents' experiences with regular needle injections at home

BACKGROUND

Overall outcomes of pediatric rheumatic diseases (RD) have improved due to treatment with biologic agents and methotrexate. For many children, this treatment often entails regular needle injections. Pain and fear of needle injections are common in childhood, but how children and parents handle long-term needle injections at home has not been fully explored. This study aimed to explore how regular needle injections affect children with RD and their parents in their daily living.

METHODS

This explorative qualitative study used individual interviews and focus groups to ensure a comprehensive investigation of the topic. Children aged 6 to 16 years (n = 7) and their parents (n = 8) were interviewed individually 4 to 6 months after the onset of needle injection treatment. The focus groups included children aged 11 to 17 years (n = 9) and parents (n = 8) with a minimum of 6 months of experience with injection treatment. Data were analyzed using thematic analysis.

RESULTS

The main themes; "challenges," "motivational factors," and "routines" captured experiences and strategies that influenced the continuation of needle injections at home. Many children feared the moment immediately before the needle stick, although they had become accustomed to the pain. Most parents felt insecure about handling needle injections and lacked follow-up from healthcare providers. The children's experience of treatment effects and self-confidence were essential to maintain motivation for further injections. A number of coping strategies helped children focus away from injection related discomfort, often discovered by chance. Facilitating firm routines and shared responsibility within families helped children develop self-confidence during the procedure. Children and parents struggled to find suitable information on the Internet.

CONCLUSIONS

Children and parents experienced long-term needle injections challenging. They used their own limited resources and cooperated within the families to create routines and to introduce coping strategies necessary to manage and keep up with the procedure. Although the injection itself was not experienced very painful, the discomfort, worries and impact on daily life represented far more than a little needle stick, and thus needs more attention from healthcare providers.

'The mean mummy way' - experiences of parents instilling eye drops to their young children as described in online forums and blogs

BACKGROUND

Adults often have difficulty instilling eye drops in their own eyes, but little has been documented about the difficulties experienced by parents when administering eye drops to their young children, where the challenges of instillation are accentuated by their inability to cooperate. This qualitative study explores parents' experiences of administering eye drops to their children as described in online forum discussions and blog posts.

METHODS

This was an exploratory study using qualitative methods. We thematically analysed the written exchanges between parents participating in online forum discussions and blog posts about the administration of eye drops to their young children.

RESULTS

We found 64 forum discussion threads and 4 blog posts, representing 464 unique contributors expressing their experiences of eye drop administration to young children. Three major themes were identified - administration challenges, administration methods and role of health care professionals. Besides describing their children's distress, parents discussed their own discomfort and anxiety when administering eye drops. Parents used a variety of techniques to facilitate adherence with medication, including restraining the child, role-play, reassurance, distraction, or reward. The ideas exchanged about eye drop administration occasionally included reiteration of professional advice, but were dominated by parents' own ideas/suggestions; interestingly health care professionals were considered diagnosticians and prescribers, rather than sources of practical advice on administration.

CONCLUSIONS

Parents struggling to deliver eye drops to their young children may seek advice on how to administer treatment from parental on-line discussion forums. The distress experienced by the young child and their parents is a powerful reminder to clinicians that procedures common and routine in health care may be challenging to parents. The advice given to parents needs to go beyond the instillation of the eye drops, and include advice on child restraint, distraction techniques and allaying distress. Forewarned of the potential difficulties and provided with coping strategies parents can employ when the child resists, could alleviate their own and their child's distress.

Parent and Clinician Communication During Paediatric Burn Wound Care: A Qualitative Study

PURPOSE

To thematically describe parent-clinician communication during a child's first burn dressing change following emergency department presentation.

DESIGN AND METHODS

An observational study of parent-clinician communication during the first burn dressing change at a tertiary children's hospital. Verbal communication between those present at the dressing change for 87 families, was audio recorded. The recordings were transcribed verbatim and transcripts were analysed within NVivo11 qualitative data analysis software using qualitative content analysis.

FINDINGS

Three themes, underpinned by parent-clinician rapport-building, were identified. Firstly, knowledge sharing was demonstrated: Clinicians frequently informed the parent about the state of the child's wound, what the procedure will involve, and need for future treatment. Comparatively, parents informed the clinician about their child's temperament and coping since the accident. Secondly, child procedural distress management was discussed: Clinicians and parents had expectations about the likelihood of procedural distress, which was also related to communication about how to prevent and interpret procedural distress (i.e., pain/fear). Finally, parents communicated to clinicians about their own distress, worry and uncertainty, from the accident and wound care. Parents also communicated guilt and blame in relation to injury responsibility.

CONCLUSIONS

This study provides a description of parent-clinician communication during paediatric burn wound care.

PRACTICAL IMPLICATIONS

The results can assist healthcare professionals to be prepared for a range of conversations with parents during potentially distressing paediatric medical procedures.

Medical procedures in children using a conceptual framework that keeps a focus on human dimensions of care - a discussion paper

Purpose: Children’s perspectives in the context of health service delivery have historically been seen as unimportant. They have been viewed as unintelligent, unable to effectively share or tell of their experiences or fully participate in their care, potentially resulting in a sense of dehumanisation.

Method: The present paper illustrates children’s experiences when undergoing medical procedures, using application of the eight dimensions of humanised care theoretical framework.

Results: Findings from six published papers were reflectively interrogated to identify implicit findings related to the dimensions of humanised care. These implicit findings show ways of caring for childrenwhichcan lead to enhanced human sensitivity in care or conversely where the dimensions of being human are obscured to greater or lesser degrees and can result in forms of dehumanisation.

Conclusions: Inadvertent dehumanising features of practice can be mediated by encouraging the inclusion of children’s own lifeworld perspective and make room for their voices in both care and research. In this way the present well documented power imbalance could be addressed. Adding the value of the theoretical framework highlights areas of need for young children to be cared for as human beings.

Specialist hospital treatment and care as reported by children with intellectual disabilities and a cleft lip and/or palate, their parents and healthcare professionals

BACKGROUND

Research into hospital treatment and care of children with intellectual disabilities is extremely limited, but available literature points to difficulties. Some children have a co-occurring condition alongside an intellectual disability which requires ongoing treatment, such as a cleft lip/palate. To date, their experiences remain untapped.

METHOD

Semi-structured interviews with 23 participants; five children with intellectual disabilities (aged 11-16), their parents (n = 9) and nine healthcare professionals working in cleft care. Thematic analysis determined patterns across the data.

RESULTS

Three key themes were found: struggles (stress and distress, and power imbalance), tensions (perceived levels of choice and control in decision making, lack of training around intellectual disability assumptions and jargon) and good practice (appropriate communication and information, and tailored treatment).

CONCLUSION

Good practice was evident, but was ad hoc. Individualized treatment and communication based upon children's needs are required as is further investigation into general anaesthetic induction for children with intellectual disabilities.

Establishing a framework for listening to children in healthcare

The principle that children and young people are capable of forming their own views, have the right to express those views, and are entitled to have those views taken seriously was introduced by the United Nations Convention on the Rights of the Child (UNCRC) in 1989. The implications for the delivery of healthcare are clear; however, children and young people continue to experience difficulty in having their views heard and taken seriously during healthcare encounters and the effectiveness of the UNCRC, in particular Article 12 appears to be limited. This article will discuss how, 30 years on, significant barriers continue to impede the full implementation of Article 12. In recognition of the limited awareness of its scope or even existence by health professionals working with children, a framework that can facilitate a better understanding of the concept of voice, and articulate healthcare organisations' full responsibilities when it comes to Article 12, is presented.

[The dilemma of restraint in paediatric care]

Restraint may be used in paediatrics when it is necessary to perform a technical care procedure on a child who is agitated and refusing to cooperate. Obliged to restrain, caregivers are torn between respecting the child and fulfilling the order to perform the procedure. It is important to explore ways in which professionals can overcome this dilemma by finding alternatives. The discussion takes place at the heart of a care philosophy characterised by the notion of movement.

Clinical holding: ethical guidance for children's nurses working in the UK

This article explores ethical decision-making surrounding clinical holding of children and young people in healthcare environments with the aim of enhancing autonomy and engagement on their behalf. A considerable body of evidence, published over the last 20 years, suggests that this complex and challenging area of practice is not always well managed, with mixed messages about the nature of consent, choice and negotiated practice countered by best interests decisions taking precedence ahead of the child's wishes. An ethical framework is proposed comprising four levels of value-based interventions and how they may be applied in clinical practice, allowing for increased engagement, empowerment and support on behalf of children and young people in relation to clinical holding decisions.

Australasian radiographers' choices of immobilisation strategies for paediatric radiological examinations

INTRODUCTION

Immobilisation may be necessary to ensure patient safety and examination success in paediatric medical imaging. Little guidance exists regarding the selection of different immobilisation methods. The purpose of this study was to explore radiographers' selection of immobilisation methods in paediatric medical imaging and the influences on their choices.

METHODS

Ethical approval was obtained. A mixed methods approach consisting of online questionnaire distribution followed by individual interviews was used to explore Australasian radiographers' self-reported patterns of immobilisation use and the underlying reasons and beliefs. Quantitative data were described using frequency data, with a Fisher's Exact test used to determine any association between demographic variables and immobilisation methods. Qualitative data were evaluated using content analysis.

RESULTS

Sixty-five radiographers returned completed questionnaires, with seven participating in interviews. Psychological immobilisation methods were preferred to minimise patient pain and distress, but physical methods were considered more effective, with parental holding the most likely method to be used (63/65, 96.9%). Participants assumed certain methods to be more appropriate based on patient age and examination type, but adapted their choices based on many other factors, seeking to provide personalised care. Further training was strongly desired (48/64, 75.0%). Participants disagreed on whether introducing written guidance would be beneficial (33/62, 53.2%).

CONCLUSION

Choosing an immobilisation method appears to be a case-by-case activity requiring critical assessment of multiple factors in order to balance patient care with examination success.

IMPLICATIONS FOR PRACTICE

Improvements in quality and quantity of education are recommended to enhance radiographers' ability to make choices based on all relevant factors.

Caregivers blinded by the care: A qualitative study of physical restraint in pediatric care

BACKGROUND

The phenomenon of forceful physical restraint in pediatric care is an ethical issue because it confronts professionals with the dilemma of using force for the child's best interest. This is a paradox. The perspective of healthcare professional working in pediatric wards needs further in-depth investigations.

PURPOSE

To explore the perspectives and behaviors of healthcare professionals toward forceful physical restraint in pediatric care.

METHODS

This qualitative ethnographic study used focus groups with purposeful sampling. Thirty volunteer healthcare professionals (nurses, hospital aids, physiotherapists, and health educators) were recruited in five pediatric facilities in four hospitals around Paris, France, from March to June 2013. The data were processed using NVIVO software (QSR International Ltd. 1999-2013). The data analysis followed a qualitative methodological process.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki. Written informed consent was collected systematically from participants.

FINDINGS

This study provides elements to help understand why restraint remains common despite its contradiction with the duty to protect the child and the child's rights. All participants considered the use of forceful physical restraint to be a frequent difficulty in pediatrics. Greater interest in the child's health was systematically used to justify the use of force, with little consideration for contradictory or ethical aspects. Raising the issue of forceful restraint always triggered discomfort, unease and an outpour of emotions among healthcare professionals. The findings have highlighted a form of hierarchy of duties that give priority to the execution of the technical procedure and legitimize the use of restraint. Professionals seemed to temporarily suspend their ability to empathize in order to apply restraint to carry out a technical procedure. This observation has allowed us to suggest the concept of "transient empathic blindness."

CONCLUSION

Using physical restraint during pediatric care was considered a common problem by participants. This practice must be questioned, and professionals must have access to training to find alternatives to strong restraint. Conceptualizing this phenomenon with the concept of "transient empathic blindness" could help professionals understand what happens in their minds when using forceful restraint.

A qualitative study of health professionals' views on the holding of children for clinical procedures: Constructing a balanced approach

Children undergoing clinical procedures can experience fear, uncertainty, and anxiety which can cause them to become upset and resist procedures. This study aimed to capture an international perspective of how health professionals report they would act if a child was upset and resisted a procedure. An online questionnaire, distributed through network sampling, used three vignettes to elicit qualitative open text responses from health professionals. Seven hundred and twelve professionals participated, resulting in 2072 pieces of text across the three vignettes. Many professionals reported that they would use distraction and spend time to inform and engage children in making choices about their procedure. However, most professionals indicated that if a child became uncooperative they would hold or instruct the holding of the child in order to get the procedure done 'as quickly as possible'. The findings demonstrate that professionals experience difficulty in balancing the different agendas, rights and priorities within the momentum which can build during a clinical procedure, often resulting in the child's voice and rights being undermined. A more balanced approach could be facilitated by a 'clinical pause' that would equip professionals with the time to consider children's expressed wishes and explore alternative approaches to holding.

Using psychologically informed care to improve mental health and wellbeing for people living with a heart condition from birth: A statement paper

Over the last few decades, medical and surgical advances have led to a growing population of individuals living with congenital heart disease. The challenges of this condition can reach beyond physical limitations to include anxiety, depression and post-traumatic stress disorder. To date, these psychological outcomes have been neglected; yet, they need not be inevitable. The factors contributing to these difficulties are considered here, drawing on current evidence and neuropsychological theories including the novel application of polyvagal theory. Suggestions for developing psychologically informed medical and social care to improve mental health, wellbeing and recovery and influence policy and training are proposed (See supplemental material for video abstract).

Centeredness in Healthcare: A Concept Synthesis of Family-centered Care, Person-centered Care and Child-centered Care

BACKGROUND

Increasingly within healthcare, different kind of 'centeredness' are used to denote the focus of care which can create confusion for practitioners.

METHODS

A concept analysis was undertaken to identify the antecedents, attributes and relationship between family-, person-, and child-centered care. PubMed and CINAHL were searched from 2012 to 2017 and thirty-five papers were reviewed.

RESULTS

Both person- and child-centered care are focused on individuals, a symmetric relationship and the tailoring of care to individual needs while family- centered care is focused on the family as a unit of which the child is included. Person-centered care focuses on an adult person with autonomy, while the focus in child-centered care is the individual child as an own actor with rights but still close to a family.

CONCLUSION

It appears at a conceptual level that the concepts of centeredness contain both similarities and differences. Finding ways to structure nursing and focus the care that respects a person's dignity and humanity is essential in healthcare and should be a major goal of health policy and health systems worldwide.

IMPLICATIONS

The identification of the antecedents and attributes embedded in the concepts may help raise professionals' awareness of the different foci and how this will influence one's practice. There is a need to recognize strengths and weaknesses of the centeredness in different settings and environments. Furthermore, it is important to know which approach to apply within different situations so that quality care is enabled for every person, child and family.

Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians

The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care.

We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway.

The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities.

The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology.

Holding children for procedures: An international survey of health professionals

Children undergoing clinical procedures can experience pain and/or anxiety. This may result in them being unwilling to cooperate and being held still by parents or health professionals. This study aimed to capture an international perspective of health professionals' reported practices of holding children still for clinical procedures. An online questionnaire was distributed through network sampling to health professionals working with children aged under 16 years of age. A total of 872 responses were obtained from Australia ( n = 477), New Zealand ( n = 237) and the United Kingdom ( n = 158). Responses were from nurses ( n = 651), doctors ( n = 159) and other professionals ( n = 53). Health professionals reported children as held still for clinical procedures quite often (48%) or very often (33%). Levels of holding varied significantly according to country of practice, profession, student status, length of time working within a clinical setting, training received and the availability of resources in the workplace. Health professionals who gained permissions (assent from children and/or consent from parents) before procedures were less likely to hold children still for a clinical procedure than those who did not. Holding children still for procedures is an international practice, which is influenced by training, access to guidance, country of practice and profession. Children's permission and parental consent is often not sought before a child is held for a procedure to be completed.

"It goes against the grain": A qualitative study of the experiences of parents' administering distressing health-care procedures for their child at home

BACKGROUND

Parents caring for children with complex and long-term conditions at home take on responsibility for technical health-care procedures that may cause their child distress. Little evidence exists about parents' experience of this specific aspect of their caring role.

AIMS

To explore and understand parents' experiences of administering distressing health-care procedures as part of caring for their child at home.

DESIGN

An explorative qualitative study.

METHODS

A purposive sample of parents who were currently carrying out, or had previously carried out, health-care procedures they thought their child found distressing was recruited. Data were collected using in-depth interviews and analysed thematically.

FINDINGS

Administering these procedures was not just a clinical task. That the procedures caused distress for the child meant there were additional issues to consider and address. A major issue for parents was being able to prevent or minimize their child's distress, which in turn was closely linked to parents' own emotional discomfort in the situation. Parents also had to manage their child's physical and verbal resistance, their own emotional discomfort during the procedure, and the presence and reaction of siblings in the home. The types of support that were valued by parents included advice about managing their child's distress and resistance, occasional assistance with procedures, addressing the emotional aspects of the role, and adequate training and on-going supervision.

CONCLUSION

The "added" challenges of assuming this responsibility have implications for the support of parents caring for ill children at home.

Use of restraint with hospitalized children: A survey of nurses' perceptions of practices

Restraint is often perceived as necessary to ensure that medical procedures are carried out safely. The limited research into nurses' perceptions of restraint practices with hospitalized children hinders understanding the extent of the problem. A survey design was used to investigate nurses' perceptions of restraint use from five units in one children's hospital in Ireland. Findings revealed that restraint is a common practice, with physical and psycho- logical restraints most commonly used and newborn to 4-year-old children most likely to be restrained. Restraint was most often used for cannulation and latterly for administering medication and preventing interference to intravenous lines. To promote the use of thera- peutic holding for the safe delivery of procedures, nurses require education and skills training. Restraint should only be used as a last resort and in all situations, nurses should assess the need to use restraint and explore any alternatives in order to gain the child's cooperation. More research is needed into the situational variables that can lead to restraint usage in order to identify learning needs and promote the use of alternative interventions.