Nurses' knowledge and attitudes regarding children's pain assessment and management in Nepal.

Pain is frequently experienced by children in hospital, and international guidelines for appropriate pain assessment and management are available. Optimal management of paediatric pain has important long-term health, psychosocial, and economic benefits. However, evidence indicates that globally there are deficits in nurses' understanding of paediatric pain assessment and management. This study explored knowledge and attitudes regarding paediatric pain assessment and management among nurses at a tertiary children's hospital in Nepal. In this cross-sectional study all 140 nurses at a tertiary children's hospital in Nepal, were invited to complete the validated Paediatric Nurses Knowledge and Attitudes Survey. Findings revealed substantial deficits in nurse's knowledge and erroneous attitudes towards pain assessment and management in children. Test scores ranged from 14% to 56%, with mean scores of 38%, with no nurses achieving a recommended pass score of 80% regarding knowledge and attitudes in paediatric pain management. Consistent with previous research, nurses had insufficient knowledge and attitudes that did not reflect best practice regarding pain assessment and management in children. Education programmes targeting both trainees and registered nurses are essential to enable nurses to deliver evidence-based care and improve outcomes for children and their families.

Meeting Maternal and Reproductive Health Needs in a Post-Disaster Setting: A Qualitative Case Study From Indonesia.

Meeting and planning for maternal and reproductive health (MRH) needs during post-disaster scenarios is paramount, however, not without considerable challenges. This study was aimed at understanding the provision of MRH services in Siosar, a relocation site for a population displaced by the volcanic eruption in 2013 of Mount Sinabung, Indonesia. A qualitative case study approach was used, and data were collected through focus group discussions and individual interviews with women of reproductive age, community leaders, health personnel, and policymakers. The findings show that while considerable efforts were made to provide MRH services, these were described as "unfinished," due to challenges such as changes to funding, inadequate provision of supplies and health personnel, and geographical location. Recommendations are that health and other sectors design a relocation site that counts physical, psychological, and social needs of a community and policymakers integrate humanitarian and development plans that include MRH services into World Health Organization's Building Blocks of Health System.

Maternal and reproductive health (MRH) services during the 2013 eruption of Mount Sinabung: A qualitative case study from Indonesia.

Maternal and reproductive health (MRH) needs are particularly heightened during disasters, affecting the long-term maternal morbidity and mortality. This single case study, drawing on the 2013 eruption of Mount Sinabung, Indonesia, aimed to investigate the experiences of pregnant women and the perspectives of community leaders on the accessibility and the provision of MRH services during the emergency response phase. The study was conducted between August 2017 and April 2018 in the newly relocated villages in Siosar Kabanjahe, Karo district. Data were collected from two stakeholder groups over two phases. Phase 1 with 10 women who were pregnant at the time of the eruption. Phase 2 with 16 community leaders. Data were thematically analysed and utilised NVivo software. While there were considerable efforts to provide MRH services following the eruption, these were described as inadequate. The activation of local disaster management authorities and provision of free-of-charge MRH services were seen as imperative to improving the disaster responses. To improve responses in future disasters, health authorities are recommended to upscale health information systems in emergencies, educate health professionals on Disaster Risk Management (DRM), improve guidelines related to temporary shelter and improve multi-sectoral coordination to ensure MRH provision is aligned with DRM policies.

Ethical and practical challenges of conducting art-based research with children/young people in the public space of a children's outpatient department.

This article examines the ethical and practical challenges of undertaking a study using art-based methods with children/young people. It is argued that an important component of qualitative research and research with children/young people is researcher reflexivity and flexibility, particularly when the anticipated and actual implemented methods of a study differ. We draw on a study with 175 children/young people aged 5-16 years in a children's outpatients department where 'draw-and-tell' and 'letter writing' were used to elicit children/young people's perceptions of the outpatient environment. The challenges that arose during the study are critically reflected on including recruitment, the physical and social environment, time restrictions and interviewing. Recommendations for researchers using art-based methods to carry out research with children/young people are offered.

Differing perspectives: Evaluation of a new IV pole by children and adults.

Involving children in the evaluation of hospital environments has been recognized as important. It is argued that this should extend to engaging children in the evaluation of medical products. A study was undertaken to evaluate how children, parents/caregivers and nurses viewed the design of a new intravenous (IV) pole compared to the existing IV pole currently used. Children and adults were asked to give their perspectives on mobility, safety, aesthetics and functionality of the new and existing IV poles. The findings suggest that children value different aspects of medical product design than adults. We conclude that designers, manufacturers and healthcare organizations should recognize the importance and benefit of involving children in the design of medical products that will ultimately be used by them.

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.

Child Centred Care: Challenging Assumptions and Repositioning Children and Young People.

THEORETICAL PRINCIPLES: Against a backdrop of increasing debate regarding children's voice and position within health care and the struggle to effectively implement Family-Centred Care (FCC) in practice, the concept of Child-Centred Care (CCC) has emerged. PHENOMENA ADDRESSED: The purpose of this paper is to explore the concept of CCC and its potential theoretical alignment with an ecological approach to health care. RESEARCH LINKAGES: The paper will draw on practice-based research, highlighting the differences and similarities of CC against the more established FCC. Arguments will be presented to show that rather than competing with FCC, CCC has the potential to complement or extend traditional FCC, by placing children in a more prominent and central position than that which they currently hold within health care.

Making space work: Staff socio-spatial practices in a paediatric outpatient department.

Studies of the characteristics of therapeutic landscapes have become common in medical geography. However, there is limited analysis of how therapeutic landscapes are produced. Based upon the qualitative theoretical thematic analysis of focus group data, this study examined the spatial work carried out by healthcare practitioners in a paediatric outpatients' department, turning unsatisfactory space into a therapeutic place. The study highlights the spatial strategies employed by staff to mitigate socio-spatial deficiencies in the healthcare environment. Staff perceived the task of making space work as an integral part of their duty of care to patients and an important facet of their professional identity. This study concludes that many of the spatial aspects of health care practice are often taken for granted. However this may hide the crucial role that health professionals have in producing places that heal.

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's not who I am": Children's experiences of growing up with a long-term condition in England, Australia, and New Zealand.

PURPOSE: Most studies of growing up with a long-term condition focus on older children and adolescents and are condition-specific. Relatively few studies address the experiences of children in middle childhood or consider their experience across a range of conditions, countries, and health settings. This study aimed to explore children's perceptions and understandings of how their lives are shaped (or not) by a long-term condition and its associated management. DESIGN AND METHODS: A qualitative, participatory methodology using autodriven photoelicitation interviews (PEIs) with 45 purposively recruited children (6-12 years) with long-term conditions (e.g., hemophilia, arthritis, Crohn's disease), from England, New Zealand, and Australia was utilized. PEI facilitated the construction of inductively derived understandings of the children's experiences as the children had control over creating and then selecting which photographs to discuss with the researcher. RESULTS: Interpretive thematic analysis of the interviews and content analysis of the photographs resulted in an overarching theme, "It's not who I am …" but it is part of me, and three subthemes: getting on with my life; the special value of family, friendship, support, and comfort; and things that get in the way of getting on. Across all ages and the three countries, the children actively projected their self-concept as "well" children and they strove, through their photographs and their accompanying explanations of their lives, to emphasize that they were "normal" children. They were active social agents who demonstrated their capacity to shape parts of their lives interdependently with their parents and the requirements of their condition. PRACTICE IMPLICATIONS: Pediatric nurses should be aware of the importance that children with long-term conditions place on projecting and protecting their sense of being normal and ensure that when they engage with children that they take account of the children's understandings and efforts to live a life constrained but not limited by the condition.

Working in the dark: a hermeneutic inquiry into health professionals' stories of ketamine sedation with children.

BACKGROUND: Physiological risks of ketamine have been well researched, yet for health professionals (HPs) undertaking paediatric ketamine sedation, questions of benefit and harm remain. RESEARCH QUESTION: What are health care professionals' experiences of undertaking ketamine sedation with children? METHODOLOGY: Hermeneutic narrative. METHODS: The study comprised hermeneutic narrative analysis of stories from seven HPs in nursing, medicine, paramedicine, and play therapy. FINDINGS: The theme, "seeking to control and protect" reveals the chaotic nature of paediatric emergency work and how ketamine can deliver control. The second theme "working in the dark" acknowledges that HPs try to balance perceived benefit and harm, adopting "dream-seeding" in an attempt to mitigate potentially negative psychotropic events. CONCLUSION: The study recommends further research into children's experiences of ketamine sedation and the use of dream-seeding to mitigate negative emergence phenomena. It also recommends education for clinicians to increase awareness of the potential for non-physiological risk and harm.

Participatory art-based research with children to gain their perspectives on designing healthcare environments.

BACKGROUND: A study was designed to understand the experiences and needs of children within the public spaces of the Outpatients Department of New Zealand's national children's hospital, Starship Childrens' Directorate. AIM: To find out from children what they thought about the outpatient environment. DESIGN: A participatory art based methodology was used. METHODS: Based around the key areas of the physical environment, wayfinding, noise, and uniforms, art-based methods (draw and tell and letter writing) were used to collect data from 175 children ages 5-16 whilst they attended outpatient clinics. The drawings and letters were analysed using descriptive/thematic analysis. RESULTS: The findings show that children are very aware of their environment and are able to clearly voice what is important to them. Children appreciate environments that are child friendly, and inclusive of colour and artwork; however, wayfinding remains a challenge for many families. Although the environment was seen as important, children placed significant value on the people who demonstrated warmth and care within these environments. CONCLUSION: Participatory art based approaches offer a child centred approach to finding out what children perceive is important in the design of hospital environments.

Children's perspectives in family-centred hospital care.

BACKGROUND: Children's nursing has developed into its current forms in large part as a result of broader sociopolitical and organisational influences. Family-centred, patient-centred and collaborative approaches are now well established within the lexicon of child healthcare. Children are central to this yet their role within the family-centred care approach is not clear. AIM: To ask children to share the narratives of their experience of hospitals and hospitalisation in New Zealand, in order to consider multiple factors influencing their experience in hospital. METHODS: A qualitative narrative study involving face-to-face interviews with families (adults and children) who have had the experience of a child in hospital in New Zealand. The family narratives have been explored elsewhere. In this study, the stories told by children were examined in context of the family interview and the broader sociocultural narratives influencing them. FINDINGS: The research findings offer insights into how children make meaning of hospital experience and how their roles are influenced by adults. Themes evident are that parent and child experience may be different; children's stories may not be consistent with family narratives; and, children's agency in hospital is variable. CONCLUSION: Children's stories provide insights to the interconnectedness of personal, familial and societal narratives and their influence on experience of hospitalisation. Nurses and families are able to both constrain and enable children's participation in hospital care.

Auto-driven Photo Elicitation Interviews in Research with Children: Ethical and Practical Considerations.

Children can sometimes find it difficult to articulate their experiences if they have to rely solely on words. Giving children the opportunity to use arts-based research approaches can support their participation in research and create a bridge that enables them to express their perspectives and feelings. This paper focuses on the ethical and practical considerations when using photo elicitation interviews (PEI) in research with children. The discussion and examples provided are drawn from an international study that used auto-driven PEI, where photographs are taken by children themselves, to explore children's experiences of living with a chronic condition and the impact condition management may have on their everyday lives. In this paper we critically explore the issues arising from our use of PEI including children's participation and engagement, balancing power and control, and keeping children safe. The main areas of focus for the paper are how PEI provided a means of shifting control; how setting photographic boundaries influenced our PEI study with children; and how we addressed risks associated with the method. Our experience shows that PEI is an engaging and valuable research method, providing a powerful medium for obtaining rich data with children. However, PEI is challenging and it requires researchers to conscientiously address ethical and practical aspects that extend beyond those inherent to standard (words-alone) interviews.

Patient advocacy by nurses - past, present and future.

BACKGROUND: Patient advocacy is central to the nursing profession yet a sense of certainty about the concept, its meaning and its implications for nursing practice remains elusive. AIM: This scholarly paper examines the concept of patient advocacy and its relevance to the nursing profession in Aotearoa/New Zealand. DESIGN: A broad historical overview of the evolution of the role of advocacy in nursing practice is provided including factors that encourage or discourage nurses to practice patient advocacy. CONCLUSIONS: This paper highlights the gap between the ideal of patient advocacy and the realities of everyday nursing practice. The responsibility for enacting advocacy sits with both individual practitioners and the organizations nurses work within.

What makes a child a 'competent' child?

Competence is a vital component of the informed consent process. The perceived level of a child's competence may influence their degree of participation in health decisions that affect them. It is the responsibility of the health professional to gauge a child's level of competence. Child competence, however, is not a static attribute that is linked to age. Rather, it is dynamic, changing in nature and dependent on a child's previous experiences, personal attributes, network of relationships around them and cultural and environmental context. Consequently, there is no single verified assessment tool to assist in the recognition of competence for New Zealand children. Adding to this complexity are the unclear interpretations of New Zealand health legislation and policy regarding whether or not a child can legally consent or refuse healthcare advice and treatment without the consent of a legal guardian. Under the Care of Children Act 2004 and the Code of Health and Disability Services Consumers' Rights 1996, the Health and Disability Commissioner states "a child may consent themselves [to health treatment] if and when the child achieves sufficient understanding and maturity to understand fully what is proposed". This paper poses the question: What is 'competency' and how is this decided? For the purpose of this article, 'child' pertains to those under the age of 16 years.

Children's voices in public hospital healthcare delivery: intention as opposed to practice.

AIM: To determine the extent to which children have the opportunity to provide feedback on public hospital care in New Zealand. METHOD: A scan of the web sites of the Ministry of Health and the Health Quality and Safety Commission New Zealand (HQSC) together with a search of core District Health Board publications was conducted to identify existing or planned processes to capture the hospital experience of patients under 18 years. RESULTS: The importance of gathering patient feedback was recognised but, currently, ad hoc strategies are being used to put these good intentions into practice. Although some DHBs are introducing novel methods of gathering patient feedback, details of data collection methods and characteristics of participants are often not publicised. The HQSC has developed an adult Inpatient survey to provide a coherent means of assessing patient experience nationally but there is currently no children's survey available. CONCLUSIONS: Our analysis suggests a lack of opportunity for children's perspectives to be taken into account in secondary health service delivery. The current 'paternalistic' approach, based upon children being a vulnerable population, is contrary to the emerging recognition that children are individuals who can contribute to their own care and well-being.

Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism.

In children and youth with disability, the risk of obesity is higher and is associated with lower levels of physical activity, inappropriate eating behaviors, and chronic health conditions. We determined the effectiveness of a program in managing weight, through changes in physical activity and nutrition behaviors in overweight and obese New Zealand children and youth with intellectual disability or autism. Twenty-two children and youth 14±4 y (mean±SD) and their families participated in a 10-week school-based program. The program consisted of 18 sessions focusing on physical activity and nutrition. Changes were measured immediately after completion of the program (post 1) and at 24 weeks (follow up). Fitness was assessed with the six-minute walk-test (6MWT) and body fatness via waist circumference and BMI. Physical activity and nutrition changes were measured by means of proxy reporting and interviews with parents. Individual interviews were conducted with school teachers and program leaders at 24 weeks to gain feedback regarding the program. Most quantitative outcomes were either unclear or trivial. The only possible change was observed in the six-minute walk-test where 24 weeks post program where participants walked 51 m further. There was however, a substantial reduction in the consumption of confectionery and chocolate at the two measurement points. Parents commented that during the program there were less hospital visits and absences from school related to illness. The program assisted in the development of a supportive community network and participants' abilities to partake in family and community activities. This the first study to report on the results of a physical activity and nutrition program targeted in children and youth with intellectual disability and autism. The results of this study may support and inform future developments of an integrated weight management and prevention program to enhance the health and well being in children and youth with disabilities.

Physical activity is not play: perceptions of children and parents from deprived areas.

AIMS: To explore the perceptions of primary school aged children (n=9) and parents (n=21) from areas of socioeconomic deprivation in New Zealand in order to determine the factors which influence healthy and overweight children's after school activities. METHOD: We held focus groups with children, utilising photo-voice prompts for discussion. Focus groups and semi-structured interviews were also conducted with parents. Content analysis of data was undertaken. RESULTS: Both children and parents described physical activity and play as different constructs; physical activity was considered as an organised activity and play was identified as fun. Parents perceived that time, money and transport were all barriers to children participating in physical activities after school. Parents explained that children's enjoyment of a particular activity as well as self-esteem influenced whether or not children participated in physical activity. Community support and communication were also identified as important in creating safer communities and places to play for children. CONCLUSION: When developing after school community activity programmes, the emphasis should be on active play rather than physical activity.

Critical moments in preschool obesity: the call for nurses and communities to assess and intervene.

Thirty years ago obesity was rarely seen in children but is now described as a world wide pandemic. Previous research has focused on school age children; however, researchers have now identified critical moments of development during uterine life and early infancy where negative factors or insults could cause permanent changes in the structure and function of tissues and lead to epigenetic changes. Obesity in preschool children can cause premature and long term chronic health problems; has been associated with academic and social difficulties in kindergarten children; difficulty with social relationships; increased feelings of sadness, loneliness and anxiety; and negative self image in children as young as 5 years of age. The importance of identifying children under the age of five with obesity and associated risks is important yet less than half of health professionals intervene in cases of preschool obesity. This paper explores the concerns around antenatal and preschool obesity and the challenges for nurses and midwives in assessing and providing appropriate interventions for children and families in community settings.