Holding children for procedures: An international survey of health professionals

[Measuring the intensity of restraint during care in children: Validation of the Pric scale]

Restraint is used relatively often during pediatric care. However, no scale has yet been validated to assess its intensity. The study presented here did this for the Procedural Restraint Intensity in Children tool in metrological terms (with some limitations). In the absence of a reference scale in this area, the reliability of this tool was studied under experimental conditions. It is nevertheless the first scale with metrological validation, measuring the intensity of physical constraint. Other work is underway to validate it in real clinical situations.

[Using restraint during treatment: Definitions, contexts and benchmarks]

The clinical practice of nursing sometimes leads to physically restraining the patient while carrying out a therapeutic or diagnostic procedure. This laconic observation says little about the many questions raised by the use of restraint on a person during treatment. The questions are professional, institutional, philosophical, ethical, legal and deontological. The role of the nurse in the decision to use coercion to provide care is preponderant, and the moral dilemmas that this decision provokes are most often carried out individually by the professionals.

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.

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.

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

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.

Young children's experiences of support when fearful during treatment for acute lymphoblastic leukaemia-A longitudinal interview study

AIM AND OBJECTIVES

To describe young children's experiences of valuable support in managing their fears about treatment for acute lymphoblastic leukaemia. The focus was specifically on support from parents and healthcare professionals.

DESIGN

The study had a qualitative descriptive longitudinal design.

METHODS

The study analysed 35 interviews with 13 children at three different times during their treatment period. Data were analysed using a matrix-based method. The Consolidated criteria for reporting qualitative research (COREQ) guidelines have been followed.

RESULTS

Parents and healthcare professionals provide important support to children undergoing treatment for acute lymphoblastic leukaemia, although their roles differ. Children valued their parents' closeness and advocacy, being able to participate in their own care, and being given pain relief during procedures known to create pain. Valued support from healthcare professionals changed over time, from providing information and showing the tools that would be used in procedures, to paying attention to the child's needs and desires. It was more important for children to be able to choose between different alternatives in medical procedures than deciding on major treatment issues.

'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.

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.

Restraint in paediatrics: A delicate balance

Patient restraint in health care is currently under intense review. There are two disparate groups that should be considered. First, infants and young children are commonly restrained while undergoing simple medical procedures such as venepuncture or immunisation, and this practice may be better framed as 'hugging' not 'holding'. Second, there is a distinct but significant group of children and adolescents with serious psychiatric or organic illness with behavioural disturbances necessitating restraint, who are the primary focus of this paper. Nevertheless, the balance between restraining any young person in health care and causing preventable harm is delicate: any form of child restraint, whether physical, chemical or seclusion, merits ethical reflection and should be undertaken judiciously. All clinicians should prioritise the dignity and privacy of the young person while weighing the vulnerability of this cohort of patients.

A simple tool to measure procedural restraint intensity in children: validation of the PRIC (Procedural Restraint Intensity in Children) scale

Purpose

Restraint is often used when administering procedures to children. However, no metrologically scale to measure the restraint intensity had yet been validated. This study validated the metrological criteria of a scale measuring the restraint intensity, Procedural Restraint Intensity in Children (PRIC), used during procedures in children.

Design and methods

The PRIC scale performance was measured by a group of 7 health professionals working in a children's hospital, by watching 20 videos of health care procedures. This group included 2 physicians, 1 pediatric resident, and 4 nurses. The intra-class correlation coefficients were calculated to evaluate the inter-rater and test-retest reliability and the construct validity with the correlation between PRIC scale and a numerical rating scale.

Results

One hundred and forty measurements were made. Inter-rater and test-retest correlation coefficients were 0.98 and 0.98, respectively. The 2 scales were positively correlated with a Spearman coefficient of 0.93.

Conclusions

This study validated the Procedural Restraint Intensity in Children (PRIC) scale in metrological terms with some limitation. However, there is not gold standard scale to precisely validate the reliability of this tool and this study has been conducted in “experimental” conditions. Nevertheless, this is the first scale measuring the intensity of physical restraint with a metrological validation. The next step will be to validate it in real clinical situations.

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.