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.

Children's active participation in decision-making processes during hospitalisation: An observational study.

AIMS AND OBJECTIVES: The aim was to explore and describe the child's active participation in daily healthcare practice at children's hospital units in Sweden. OBJECTIVES: (a) Identify everyday situations in medical and nursing care that illustrate children's active participation in decision-making, (b) identify various ways of active participation, actual and optimal in situations involving decision-making and (c) explore factors in nursing and medical care that influence children's active participation in decision-making. BACKGROUND: Despite active participation being a fundamental right for children, they are not always involved in decision-making processes during their health care. There still remains uncertainty on how to support children to actively participate in decisions concerning their health care. DESIGN: A qualitative study with overt, nonparticipant observations fulfilling the COREQ checklist criteria. METHODS: Observations of interactions between children aged 2 and 17 years with both acute and chronic conditions, their parents, and healthcare professionals were conducted at three paediatric hospitals in Sweden. The Scale of Degrees of Self Determination was used to grade identified situations. The scale describes five levels of active participation, with level one being the least and level five being the most active level of participation. Normative judgements were also made. RESULTS: Children's active participation was assessed as being generally at levels four and five. Children demonstrated both verbal and nonverbal ways of communication during decision-making. Findings indicated that children's, parents' and healthcare professional's actions influenced children's active participation in decision-making processes involving healthcare. CONCLUSIONS: Healthcare professionals specialised in paediatrics need to embrace both a child perspective and a child's perspective, plan care incorporating key elements of a child-centred care approach, to ensure children's active participation at a level of their choosing. RELEVANCE TO CLINICAL PRACTICE: There is a need for awareness creation to help healthcare professionals facilitate children's active participation in their care and decision-making.

Using an interactive communication tool in healthcare situations: Patterns in young children's use of participation cues.

This study forms part of a larger project about developing and using interactive technology to facilitate young children's participation in healthcare situations. Children's participation in these situations improves their motivation and situated understanding. Likewise, their participation helps professionals to more fully understand the child's perspective. In the project, an interactive communication tool, that is, an application suitable for tablet use, was developed with children, aged three to five, in two clinical settings. When tested, the children's participation cues, identified from video recordings of healthcare situations, were understood as having curious, thoughtful or affirmative meanings. This study aimed to investigate the similarities and differences in the young children's use of participation cues when using an interactive communication tool in healthcare situations. A secondary analysis of the identified cues was performed focusing on age, setting and examination or procedure. In total, 2167 cues were identified representing either curious, thoughtful or affirmative cues. The curious cues were mainly used (66%), followed by thoughtful (28%) and affirmative (6%) cues. Differences in cue usage were seen in relation to the children's age and setting. Knowing how children may react to common healthcare procedures may help increase healthcare professionals' awareness of the need to support children in an individual and situational way.

The complexity of integrating a behavioral medicine approach into physiotherapy clinical practice.

Introduction and Aim: The implementation of a behavioral medicine (BM) approach in physiotherapy is challenging, and studies regarding the determinants are sparse. Thus, the aim of this study was to explore determinants of applying a BM approach in physiotherapy for patients with persistent pain across the micro-, meso-, and macro-levels. Methods: A qualitative multiple-case study design was used. Data were collected from four cases through semi-structured interviews with physiotherapists (PTs), patients, and managers; observations of video-recorded treatment sessions; and reviews of local directives and regulations. Data were analyzed with inductive content analysis and cross-case analysis, followed by mapping to the domains of determinants at the micro-, meso-, and macro-levels within the Implementation of Change Model. Results: Similar determinants were found across the cases. At the micro-level, these determinants concerned the PTs' ambivalence toward a BM approach, a biomedical focus, embarrassment asking about psychosocial factors, BM knowledge, skills for applying the approach, and self-awareness. Others concerned the patients' role expectations of the PT, patients as active or passive agents in the treatment process, patients' focus on biomedical aspects, and confidence in the PT. At the meso-level, support from managers and peers, allocation of time, and expectations from the organization were identified as determinants. No determinants were identified at the macro-level. Conclusion: The complexity of integrating a BM approach into physiotherapy clinical practice arises from multiple determinants functioning as both facilitators and barriers. By selecting strategies to address these determinants, the implementation of a BM approach could be supported.

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.

Trusted and doubted: Discourses of parenting training in two Swedish official inquiries, 1947 and 2008.

AIM: The aim of this study was to analyse discourses of parenting training in official inquires in Sweden that explicitly deal with the bringing up of children and parental education and how the representations of the problems and their solutions affect parental subject positions in the early welfare state and at the onset of the 21st century. METHOD: We carried out a discourse analysis of two public inquiries of 1947 and 2008, drawing on theories about governmentality and power regimes. Tools from political discourse analysis were used to investigate the objectives of political discourse practices. RESULTS: Both inquiries referred to a context of change and new life demands as a problem. Concerning suggestions for solutions, there were discrepancies in parents' estimated need of expert knowledge and in descriptions of parental capacity. In a discourse of trust and doubt, the parents in 1947 were positioned as trusted welfare partners and secure raisers of future generations, and in 2008, as doubted adults, feared to be faltering in their child-rearing tasks. CONCLUSIONS: The analysis revealed how governmental problem descriptions, reasoning about causes and suggestions of solutions influenced parents' subject positions in a discourse of trust and doubt, and made way for governmental interventions with universal parenting training in the 21st century.

Health care professionals' perspective on children's participation in health care situations: encounters in mutuality and alienation.

PURPOSE: Encounters between health care professionals, parents and children in health care services for children are complex as these encounters involve the various perspective and understanding of each person involved. The aim of the study is to describe health care professionals' understanding of significant encounters with children and parents to uncover the meaning of participation. METHOD: A qualitative descriptive design was applied. The health care professionals' narratives (n = 35) of their significant encounters with children were interpreted from the perspective of participation. A phenomenological-hermeneutical approach was used in the analysis. RESULTS: The findings show children's participation as a dynamic movement in mutuality and alienation which can vary within a situation or between different situations involving the same persons. The movement can occur in mutuality and or in alienation depending on what or towards whom the persons direct themselves. Understanding participation as a movement in health care situations is useful in supporting children's opportunities to participate from their own perspective and deal with health care examinations. CONCLUSION: The outcome of a situation can never be predicted. Still, professionals can be aware of their actions in encounters with children.

Curious, thoughtful and affirmative-Young children's meanings of participation in healthcare situations when using an interactive communication tool.

AIMS AND OBJECTIVES: To describe young children's demonstrated participation in healthcare situations while using an interactive communication tool. BACKGROUND: Participation is a multidimensional concept influenced by situational and contextual issues. In child participation, verbal and nonverbal communicative expressions are of interest, as both demonstrate the child's perspective. Children have a right to participate in all situations that matter to them, for instance healthcare situations. Children, understood as social actors, express a wish and a need to participate in these situations to get information and to enable preparation. DESIGN/METHOD: In a pilot study, video observations were used to capture the children's use of the interactive communication tool in healthcare situations. A hermeneutic analysis was conducted to achieve a deeper understanding of the children's demonstrated cues of participation. RESULTS: The expressed cues of participation were understood as having either a curious, thoughtful or affirmative meaning of participation and there was a continuous movement between them. Curious cues were expressed when introducing or reintroducing the tool in the situation and demonstrated a wish to get knowledge of the things shown on the screen or to perform the virtual tasks. Thoughtful cues slowed down the progression of the situation when the children needed time to think or adapt to the virtual procedures. Affirmative cues were self-rewarding and demonstrated at successful task performance. CONCLUSION: An interactive communication tool used in healthcare situations can promote young children's understanding and facilitate their situated participation, which potentially reduces feelings of distress or anxiety. This innovative use of interactive technology within paediatric health care provides new ways of revealing the child's perspective in the situation. RELEVANCE TO CLINICAL PRACTICE: Interactive technology improves understanding and participation of children in healthcare situations, which impact them positively, both in the present and for the future. A communication tool enhances professionals' opportunities to adopt a child-centred approach by responding sensitively to the children's expressions.

Thai people living with tuberculosis and how they adhere to treatment: A grounded theory study.

To develop a conceptual framework of adherence to treatment among Thai people living with tuberculosis, a grounded theory approach was used. A purposive sample of 20 Thai people living with tuberculosis, aged from 23 to 85 years, was interviewed. From the participants' perspective, a core category of social belonging was highlighted, with three categories of conditions connected: personal barriers, personal resilience, and social facilitation. Personal barriers encompassed fear of stigma, concealing the illness, and lack of knowledge and motivation to complete the treatment regime. Personal resilience encompassed positive thinking and self-awareness. Social facilitation encompassed the ease of access to health services, continuity in the health service's ability to choose a directly-observed therapy observer, and social support. This study contributes a deeper understanding of the perspective of Thai people living with tuberculosis with regards to adherence to tuberculosis treatment. It might improve how local healthcare workers provide tuberculosis care, and inspire them to tailor care to people living with tuberculosis in a local community to increase personal resilience and reduce stigma.

Thai district Leaders' perceptions of managing the direct observation treatment program in Trang Province, Thailand.

BACKGROUND: Thailand is 18th out of the 22 countries with the highest tuberculosis (TB) burden. It will be a challenge for Thailand to achieve the UN Millennium Development target for TB, as well as the new WHO targets for eliminating TB by 2035. More knowledge and a new approach are needed to tackle the complex challenges of managing the DOT program in Thailand. Contextual factors strongly influence the local implementation of evidence in practice. Using the PARIHS model, the aim has been to explore district leaders' perceptions of the management of the DOT program in Trang province, Thailand. METHODS: A phenomenographic approach was used to explore the perceptions among district DOT program leaders in Trang province. We conducted semi-structured interviews with district leaders responsible for managing the DOT program in five districts. The analysis of the data transcriptions was done by grouping similarities and differences of perceptions, which were constructed in a hierarchical outcome space that shows a set of descriptive categories. RESULTS: The first descriptive category revealed a common perception of the leaders' duty and wish to comply with the NTP guidelines when managing and implementing the DOT program in their districts. More varied perceptions among the leaders concerned how to achieve successful treatment. Other perceptions concerned practical dilemmas, which included fear of infection, mutual distrust, and inadequate knowledge about TB. Further, the leaders perceived a need for improved management practices in implementing the TB guidelines. CONCLUSION: Using the PARIHS framework to gain a retrospective perspective on the district-level policy implementation of the DOT program and studying the leadership's perceptions about applying the guidelines to practice, has brought new knowledge about management practices. Additional support and resources from the regional level are needed to manage the challenges.

Reframing the focus from a family-centred to a child-centred care approach for children's healthcare.

In this article, we argue for a conceptual move from family-centred care (FCC) to a child-centred care approach and the implications for clinical nursing practice. Firstly, we argue that the parents and professional dominance constructs an asymmetric relationship towards the child, which may take away the focus from the child; Secondly, we need to renew efforts to promote the fundamental principles of protection, promotion and participation rights for children and young people according to the United Nations Convention on the Rights of the Child declaration and thirdly, we need to strengthen the child's perspective and to view the child as an agent representing own experiences and wishes to be respected and negotiated.

The child's perspective as a guiding principle: Young children as co-designers in the design of an interactive application meant to facilitate participation in healthcare situations.

During the last decade, interactive technology has entered mainstream society. Its many users also include children, even the youngest ones, who use the technology in different situations for both fun and learning. When designing technology for children, it is crucial to involve children in the process in order to arrive at an age-appropriate end product. In this study we describe the specific iterative process by which an interactive application was developed. This application is intended to facilitate young children's, three-to five years old, participation in healthcare situations. We also describe the specific contributions of the children, who tested the prototypes in a preschool, a primary health care clinic and an outpatient unit at a hospital, during the development process. The iterative phases enabled the children to be involved at different stages of the process and to evaluate modifications and improvements made after each prior iteration. The children contributed their own perspectives (the child's perspective) on the usability, content and graphic design of the application, substantially improving the software and resulting in an age-appropriate product.

Undergoing an immunization is effortlessly, manageable or difficult according to five-year-old children.

BACKGROUND: To prevent diseases among children they regularly undergo immunizations. Previous research show different approaches available to facilitate immunization-procedures for children to protect them from harm. To complement this research and provide care suited for children, research recognizing their perceptions of undergoing such a procedure is needed. AIM: The aim of this study was to describe 5-year-old children's perceptions of undergoing an immunization. METHOD: A phenomenographic approach and analysis was used to describe the children's (n = 21) various perceptions. The data-collection was accomplished directly after the immunization to grasp the children's immediate perceptions. Drawings and reflective talks were used as they are considered as suitable methods when involving young children in research. The right to conduct research with children was approved by the appropriate research ethics committee and also by each child and the parents. RESULTS: The findings show that children's perceptions of an immunization-procedure may vary from effortlessly, to manageable or difficult. Regardless of how the child perceive the immunization-procedure each perception embrace the children's descriptions of actors and articles in the situation, their feelings in the situation and also their actions to deal with the immunization. Nevertheless, these descriptions vary according to how the children perceive the immunization as effortlessly, manageable or difficult. CONCLUSION: Children's and adults' perceptions of medical procedures may differ and children need guidance, time and space to deal with them. Recognizing children's perceptions of undergoing an immunization contributes to the promotion of their right to be involved in their own health care and towards the development of child-centred care.

The importance of a daily rhythm in a supportive environment--promoting ability in activities in everyday life among older women living alone with chronic pain.

PURPOSE: The aim of this study was to explore how older women living alone with chronic musculoskeletal pain, describe their ability in performing activities in everyday life and what could promote their ability in activities in everyday life as well as their perceived meaning of a changed ability to perform activities in everyday life. METHOD: Qualitative interviews were conducted with 12 women, and an inductive content analysis was used. RESULTS: The results showed the importance of a daily rhythm of activities. Activities included in the daily rhythm were socializing with family and friends, physical activities, doing own activities as well as activities supported by relatives and the community. The activities described by the women also promoted their ability in activities in everyday life. Other findings were the women's perceived meaning of being independent and maintaining that independency, along with the meaning of accepting and adapting to a changed life situation. CONCLUSION: This paper concludes that it is important to be sensitive of individual needs regarding the daily rhythm of activities when health-care professionals intervene in the activities in everyday life of older women living alone, promote the women's independency, and enable them to participate in the community. Implications for Rehabilitation A daily rhythm of activities is important for older women who live alone with chronic musculoskeletal pain. The importance of health-care professionals being sensitive to individual needs to promote ability in activities in everyday life and to encourage the everyday activities into a daily rhythm. Facilitate the women's desire and will of independency, despite their needs of help from their environment to manage their everyday life.

Nurses' experiences of managing sick-listing issues in telephone advisory services at primary health care centres.

INTRODUCTION: Over the last decade, Swedish health care has focused on improving the management of sick-listing issues. At primary healthcare centres, sick listing is mainly dealt with by the patient's physician but when patients have requests related to sick listing and contact the telephone advisory service, nurses will be involved. The aim of this study was to describe nurses' experiences of managing sick-listing issues in telephone advisory services in a primary healthcare setting. METHODS: The study was a qualitative focus group study. Data collection was conducted in three focus group conversations in a county in central Sweden in 2009. The conversations were recorded, transcribed and analysed using qualitative content analysis. The study included fourteen nurses, purposively sampled as having current experience of telephone advisory services at primary healthcare centres. FINDINGS: The management of sick-listing issues was described by the nurses as Nurses Actions that were affected by Enabling conditions and Obstructing conditions. The Nurses' Actions included making an assessment for appropriate action, making an appointment and/or giving information and guidance to the patient and/or monitoring patient's rights. Enabling conditions included documentation, routines, supportive cooperation and training in insurance medicine. The obstructing conditions were related to patients' expectations, cooperation with other professionals, lack of training and the nurses' professional role. CONCLUSION: The nurses experienced stress and difficulties related to being gatekeepers and related to the act of balancing different demands from patients, co-workers and the organisation. This in combination with the lack of training caused the nurses to state that they did not want responsibility for managing sick-listing issues. Sufficient documentation, education, routines, support of and discussions with other professionals at the primary healthcare centre could be ways of improving nurses' and other professionals' management of sick-listing issues.

Drivers' and conductors' views on the causes and ways of preventing workplace violence in the road passenger transport sector in Maputo City, Mozambique.

BACKGROUND: Workplace violence (WPV) is an occupational health hazard in both low and high income countries. To design WPV prevention programs, prior knowledge and understanding of conditions in the targeted population are essential. This study explores and describes the views of drivers and conductors on the causes of WPV and ways of preventing it in the road passenger transport sector in Maputo City, Mozambique. METHODS: The design was qualitative. Participants were purposefully selected from among transport workers identified as victims of WPV in an earlier quantitative study, and with six or more years of experience in the transport sector. Data were collected in semi-structured interviews. Seven open questions covered individual views on causes of WPV and its prevention, based on the interviewees' experiences of violence while on duty. Thirty-two transport professionals were interviewed. The data were analyzed by means of qualitative content analysis. RESULTS: The triggers and causes of violence included fare evasion, disputes over revenue owing to owners, alcohol abuse, overcrowded vehicles, and unfair competition for passengers. Failures to meet passenger expectations, e.g. by-passing parts of a bus route or missing stops, were also important. There was disrespect on the part of transport workers, e.g. being rude to passengers and jumping of queues at taxi ranks, and there were also robberies. Proposals for prevention included: training for workers on conflict resolution, and for employers on passenger-transport administration; and, promoting learning among passengers and workers on how to behave when traveling collectively. Regarding control and supervision, there were expressed needs for the recording of mileage, and for the sanctioning of workers who transgress queuing rules at taxi ranks. The police or supervisors should prevent drunken passengers from getting into vehicles, and drivers should refuse to go to dangerous, secluded neighborhoods. Finally, there is a need for an institution to judge alleged cases of employees not handing over demanded revenues to their employer. CONCLUSIONS: The causes of WPV lie in problems regarding money, behavior, environment, organization and crime. Suggestions for prevention include education, control to avoid critical situations, and a judicial system to assess malpractices. Further research in the road passenger transport sector in Maputo City, Mozambique and similar settings is warranted.

The importance of including both a child perspective and the child's perspective within health care settings to provide truly child-centred care.

The UN Convention on the Rights of the Child (1989) asserts the right of every child to self-determination, dignity, respect, non-interference, and the right to make informed decisions. The provision of quality care in health services tailored to children's preferences means that health professionals have a responsibility to ensure children's rights, and that the child is encouraged and enabled to make his or her view known on issues that affect them. This paper will help illuminate and differentiate between a child perspective and the child's perspective in health care settings. The issues are supported with research which illustrates the different perspectives. Both perspectives are required to perceive and encounter children as equal human beings in child-centred health care settings.

Five-year-old children's tuning-in and negotiation strategies in an immunization situation.

In this article, we have explored 5-year-old children's expressions when they as actors took part in an immunization situation in the Primary Child Health Care (PCHC) service in Sweden. Although children's health and development are the main concern in the PCHC service, their perspectives in such a setting have not been explored fully. To capture children's perspectives we used a hermeneutic design and video observations. The findings revealed children as competent and active participants, contributing to the construction of the PCHC situation in mutuality with the nurse and the parent. The conceptualization of children's expressions and actions revealed how they influenced and dealt with a PCHC situation by using strategies of tuning-in, affirmative negotiation, and delaying negotiation. Understanding children's actions will assist nurses to act with sensitivity when they encounter and support children.

Perceptions of the use of khat among Somali immigrants living in Swedish society.

AIMS: The aim of this study was to gain a better understanding of Somali immigrants' perceptions of the use of khat when living in Swedish society. Using khat is illegal in Sweden. METHODS: A phenomenographic design was used to capture different perception of using khat. Fourteen interviews were conducted with both men and women. The information was subjected to phenomenographic analysis. RESULTS: Perceptions of the habit of chewing khat among Somalis living in Sweden vary. The use of khat is perceived as a kind of food or as a drug. To use khat is perceived as having a physical impact on individual health, as well as an impact on social and family life. Using khat also has an impact on people's time, because time is needed to indulge the habit. Furthermore, using khat is perceived as a medium for cultural and community cohesiveness. The Somalis preferred preventive measures in place to counter the use of khat in Sweden. CONCLUSIONS: The use of a phenomenographic design which captured the variation in perceptions of the habit of using khat among Somali immigrants' living in Swedish society is helpful in guiding individual strategies in health promotion activities.