Child involvement in the paediatric consultation: a qualitative study of children and carers' views

Effective healthcare communication with children and young people: a systematic review of barriers and facilitators

OBJECTIVE

To identify children and young people's preferences for effective healthcare communication.

DESIGN

A systematic review of qualitative studies was conducted to identify evidence from children and young people on effective healthcare communication. Electronic databases and reference lists of relevant articles were searched to July 2020.

RESULTS

A total of 13 studies were included. Five major themes were identified: medical information (timing, amount, coordination and futures), person not patient (creating relationships, time, nurse involvement, sensitivity), type of communication (creative and interactive, behavioural, talking and listening, written communication), consultations (first impressions, with and without parents, actively promoting involvement, open and honest, age appropriate) and communication with parents (using parental knowledge, support).

CONCLUSIONS

Research in this area remains sparse and consistent implementation is debateable. Children and young people articulate a preference for two-way healthcare communication. General principles for effective communication are identified as well as the need to avoid making assumptions and to tailor approaches to individuals. Establishing and maintaining relationships is essential and requires time and resources. Parents and carers have a positive role in healthcare communication which needs to be balanced with the needs and rights of children. All these factors also apply to children with communication difficulties or from marginalised groups, but additional extra support may be required.

PROSPERO REGISTRATION NUMBER

CRD42019145539.

Role of Patients and Parents in Pediatric Drug Development

Patient engagement in health care has been an emerging priority in the global effort and move toward the consideration of patients as experts of their own conditions. However, the input of pediatric patients and their families have not been consistently requested nor regarded as valuable when deriving protocols for, as well as assessing the outcomes of, pediatric clinical trials. Extending this mutual collaboration further upstream is important, especially in the area of pediatric drug development where the lack of formalized trials for children and adolescents result in the increased use of off-label prescribing and risk of adverse effects. While recent changes to European and North American legislation contributed to the inclusion of children and youth in pediatric drug development, the lack of systematic guidelines and methodologies in literature serve as barriers for practical application. When combined with the work of external pediatric advocacy and patient advisory groups, the hope is that pediatric patient voices can be brought forward for the future. This article brings together international experts to review current best practices, progress from regulatory agencies, as well as global advocacy efforts to involve patients and families in the pursuit of drug development processes that value the voice of children and youth.

Improving Identification and Child-Focused Collaborative Care for Children of Parents With a Mental Illness in Tyrol, Austria

Background: Children of parents with a mental illness (COPMI) are more likely to experience negative long-term adversities. However, interventions to support their needs early can significantly enhance adjustment and reduce negative outcomes. Approximately one in four children currently lives with a parent with mental illness worldwide. The lifelong impact for individuals, governments, and broader society is likely to be substantial. There are significant workforce barriers to the early identification of COPMI and addressing their needs, particularly within the adult mental health care system. The current study aims to reduce such barriers and to improve identification of COPMI in the current health care systems. Objectives: The project "The Village" is a multidisciplinary health and social care policy intervention and seeks to improve child development and well-being outcomes for children of parents with a diagnosed mental illness. This will be achieved through the co-development, implementation, and evaluation of a practice approach to the early identification and collaborative care for COPMI, through establishing child-focused support networks. This will be done with open innovation science (OIS) approaches engaging the public in Tyrol, a geographical region of Austria, throughout 4 years. As part of the co-development process, we will work with stakeholders to co-develop the practice approaches based on evidence-based approaches and determine the most appropriate study design to evaluate those, as well as the implementation processes we will undertake. Methods: The project is underpinned by theories from different disciplines (i.e., public health, psychology, sociology, linguistics, economic sciences) as well as drawing on different approaches (i.e., co-development, implementation science, symbolic interactionism, and realist evaluation). It is based on the seven content work packages (WPs): 1) management, 2) focusing on children and methods to understand their "voice," 3) scoping, 4) co-development, 5) implementation, 6) evaluating the practice approaches, and 7) knowledge dissemination. "Scoping" will involve exploring the existing evidence, practice, and current state of identification and collaborative care in Tyrol, Austria. "Co-development" involves the co-design of practice approaches to identify and support children in partnership with key stakeholders and service providers working in Tyrol. The "implementation" of practice approaches will be based on the results of the co-development phase and will involve working with organizations to develop support strategies that draw on known organizational drivers from the field of implementation science to support the rollout of the practice approaches. In "Evaluation" we will follow principles of a realist approach; this includes developing program theories and logic models for the practice approaches. Those will set out the outcomes hypothesized to achieve and the processes that are expected to lead to those changes. This will refer to changes in children, parents, and practitioners. We expect that the main focus will be on measuring child quality of life and mental health outcomes, and outcomes that are on the path to those (such as social support needs, resilience, mental health literacy, stigma, and help-seeking behavior) as well as costs. The "child voice" WP focuses on children's perceptions and needs as the importance of "assent" and support of children to develop their own "voice" in health care is increasingly recognized within child health research. The "dissemination" step focuses on reaching a broad public audience of different stakeholders, researchers, and families involved. Discussion: The research project aims to directly improve identification and support of vulnerable children across selected regions in Tyrol, Austria, and by doing so, improve the health and well-being of future generations, through breaking the cycle of intergenerational transfer of adverse childhood experiences.

What adolescents living with long-term conditions say about being involved in decision-making about their healthcare: A systematic review and narrative synthesis of preferences and experiences

OBJECTIVE

To understand the preferences and experiences of adolescents (age 10-19) with long-term conditions (LTCs) towards involvement in discussions and decisions regarding management of their condition.

METHODS

A systematic review and narrative synthesis of mixed-methods, quantitative and qualitative and research was performed. Six databases were searched from inception to March 2017. The quality of the articles was assessed, and relevant data were extracted and coded thematically.

RESULTS

The search yielded 27 articles which met the inclusion criteria. Decision-making involvement preferences and experiences were reported from the adolescents' perspectives. Adolescents often report that they do not have any choice of treatment options. Variability in preferences and experiences were found within and between individuals. Mismatches between preferences and experiences are common, and often with negative emotional consequences.

DISCUSSION

Adolescent preferences for involvement in the decision-making process are situational and individualistic. Healthcare professionals can encourage involvement by ensuring that adolescents are informed of treatment options, and aware of the value of their contribution. Future research should explore adolescent perceived barriers and facilitators to SDM.

PRACTICAL IMPLICATIONS

Interventions are needed to effectively train HCPs in the delivery of shared decision-making, and to support the participation of adolescents with LTCs in shared decision-making.

General practitioners' accounts of how to facilitate consultations with toddlers - an interview study

OBJECTIVE

To describe general practitioners' (GPs') accounts of how to facilitate consultations with children aged 1-2 years.

DESIGN

A qualitative study based on focus group interviews.

SETTING AND SUBJECTS

Five focus group interviews were conducted with a total of 25 GPs at Swedish primary health care (PHC) centres. The GPs regularly invited toddlers to consultations.

RESULT

The GPs' accounts of how to facilitate consultations with toddlers revealed descriptions of making efforts to instil confidence in the situation to enable the consultation. Toddlers in need of health care always visit the GP with adults such as their parents, guardians or other relatives. Therefore, the GP directs efforts towards the adults and the child more or less simultaneously, as they both need to rely on the GP. The GPs describe how they instil confidence in the adults by establishing a mutual understanding that the consultation is necessary to secure the child's health. Regarding the child, the GP instils confidence by establishing a relationship in order to approach the child and accomplish bodily examinations.

CONCLUSION

The result shows that GPs' encounters with children in consultations are two-sided. The GP needs to conduct bodily examinations to secure the child's health and development, but to do so he/she needs to establish purposeful relationships with the adults and the child by instilling confidence. This indicates that establishing relationships in the consultation is significant, and a way to achieve a child-centred consultation. KEY POINTS Research regarding GPs' encounters with toddlers in consultation is limited, even though toddlers frequently visit PHC. • GPs make efforts to instil confidence by establishing mutual understanding with parents and a relationship with the child. • Establishing purposeful relationships with both the child and parent is significant in enabling the consultation. • Establishing a relationship with the child overrides conducting the bodily examination, to promote the child's feeling of ease and allow a child-centred consultation.

A preliminary evaluation of the Visual CARE Measure for use by Allied Health Professionals with children and their parents

The Consultation and Relational Empathy (CARE) Measure (Mercer et al., 2004) is a patient-rated experience measure of practitioner empathy, developed and validated within adult health services. This study reports the feasibility, acceptability, reliability and validity of three adapted versions of the original CARE measure for the paediatric setting, namely the Visual CARE Measure 5Q, 10Q and 10Q Parent (also known as the Paediatric CARE Measure). Three hundred and sixty-nine participants (N = 149 children (40%) and N = 220 parents (60%)) completed the measure following consultation with an Allied Health Professional (AHP). AHPs felt it was feasible to use the measure in routine practice and the majority of children and parents found the measure easy to understand (98%) and complete (98%). Internal reliability (Cronbach's α) was .746 for the 5Q, .926 for the 10Q and .963 for the 10Q parent. Few participants used the 'not applicable' response (N = 28 (8%)), suggesting high content validity. AHPs found the measures relevant (95%) and useful (90%) and reported that they were likely to use them again (96%). The Visual CARE Measure shows promise as a useful tool to enable children and their parents to give their views. Further research on the tool's reliability and validity is required.

The pediatric surgeon-patient relationship

Though technical aspects of surgical practice are commonly emphasized, communication is the most frequent "procedure" employed by surgeons. A good patient-physician relationship enhances the quality of surgical care by improving outcomes and patient and family satisfaction. There are general principles that can enhance communication with all children and families. Employing a developmentally sensitive approach that adjusts communication style based on a child's cognitive abilities and emotional concerns can further enhance the relationship with children of different ages. These communication skills can be learned and are improved by practice and self-reflection.

The experience of disabled children as inpatients: a structured review and synthesis of qualitative studies reporting the views of children, parents and professionals

Disabled children are a broad group that includes those with complex, special or additional health needs as a result of chronic physical, cognitive, communication or behavioural problems. These children are more frequently admitted to hospital than other children; however, there appears to be relatively little research on their experience as inpatients. The aim of this structured review and synthesis was to integrate findings from qualitative studies reporting the experience of disabled children when they are hospital inpatients. Inclusion criteria were: qualitative studies that focused on the experience of children less than 18 years old, with a chronic health condition or neurodisability, during an inpatient stay. Studies of outpatient episodes or intensive care units were excluded. A systematic search identified relevant abstracts, selected papers were reviewed and data were extracted. The synthesis involved elucidating and integrating common themes. Eight relevant papers were identified; data were gathered from children, parents and staff. Communication between children and staff was a dominant theme and comprised giving the child information about their condition and appropriate involvement of the child/young person in discussions and decision making that affected them. Also important was communication between parents and staff, particularly around the division of care for their child. Other themes included emotions, particularly fears, the ward environment and confidence in staff. The review suggests that disabled children's experience as inpatients is not always optimal. Improving the communication skills of ward staff and providing information to disabled children and their families would improve disabled children's experience when they are inpatients.

Children with high and intermediate imperforate anus: their experiences of hospital care

PURPOSE

The purpose of this study was to examine the experiences of children with high and intermediate imperforate anus (IA), and specifically their experiences of hospital care.

METHODS

Twenty-five children born with high and intermediate IA participated; 9 boys and 16 girls. The mean age was 10.5 years (range 8.0-13.6). Two control groups were involved in the study. A self-report questionnaire was used to gather the data concerning children's experiences of hospital care. Items were scored on a 5-point Likert scale.

RESULTS

The children's responses on hospital care items scored high. The children with IA reported being less satisfied with the information given, and understood less why they needed to visit the hospital than did the children in the two control groups.

CONCLUSION

The children's experiences of care seemed to be positive even though the children born with IA are subjected to invasive treatment. More research is called for in the unexplored area of information to the children, and particularly to the children born with a defect. Children's views are important and should always be considered, as their answers most certainly reflect a genuine experience, contributing to the further development of their specific care.

Children's expressions of negative emotions and adults' responses during routine cardiac consultations

OBJECTIVE

One function of expressing emotion is to receive support. The aim of this study was to assess how children with heart disease express negative emotions during routine consultations, and examine the interaction between children's expressions and adults' responses.

METHODS

Seventy children, aged 7-13 years, completed measures of anxiety and were videotaped during cardiology visits. Adult-child interactions were analyzed using the Verona Definitions of Emotional Sequences.

RESULTS

Children expressed negative emotion, mainly in subtle ways; however, adults rarely recognized and responded to these expressions. The frequency of children's expressions and adults' responses were related to the child's age, level of anxiety, and verbal participation.

CONCLUSION

Children do not openly express negative emotions frequently during routine cardiac consultations; they are more likely to provide subtle cues of negative emotion. When expression of negative emotions does occur, adults may consider using the opportunity to explore the child's emotional experiences.