Nurses’ use of pliable and directed strategies when encountering children in child and school healthcare

Abstract

Nurses in Swedish child and school healthcare need to balance their assignment of promoting children’s health and development based on the national health-monitoring programme with their responsibility to consider each child’s needs. In this balancing act, they encounter children through directed and pliable strategies to fulfil their professional obligations. The aim of this study was to analyse the extent to which nurses use different strategies when encountering children during their recurrent health visits throughout childhood. A quantitative descriptive content analysis was used to code 30 video recordings displaying nurses’ encounters with children (3–16 years of age). A constructed observation protocol was used to identify the codes. The results show that nurses use pliable strategies (58%) and directed strategies (42%) in encounters with children. The action they use the most within the pliable strategy is encouraging (51%), while in the directed strategy, the action they use most is instructing (56%). That they primarily use these opposing actions can be understood as trying to synthesize their twofold assignment. However, they seem to act pliably to be able to fulfil their public function as dictated by the national health-monitoring programme, rather than to meet each child’s needs.

Keywords

Children child healthcare health visits nurses quantitative content analysis school healthcare video recordings

Introduction

Nurses in child and school healthcare promote children’s health and development by regularly inviting them to health visits. These visits are part of nurses’ public health assignment. All children aged 0–19 are invited according to the Swedish health-monitoring programme. The visits include assessing and evaluating each child’s development and health, and the nurse’s work varies depending on the child’s age. Examples of content are measuring the child’s physical growth, conducting visual tests and having conversations about health and everyday life. Also, the nurses need to consider individual needs and issues arising during the visit (Socialstyrelsen, 2014a, 2014b). To accomplish this public health assignment, nurses need child competence. This means being aware of one’s own child perspective (Sommer et al., 2010), having knowledge about children’s development related to age and experience (Bronfenbrenner, 1979), acknowledging one’s responsibility to implement children’s rights (United Nations, 1989), and recognizing children’s skills in expressing their needs and desires (Sommer et al., 2010). Further, child competence implies synthesizing the public health perspective and the perspective on the child’s individual needs (Olander, 2003). Therefore, nurses need various strategies when encountering children in different ages and with various experiences and maturity (Golsäter et al., 2014). They need a situational perspective when encountering children (Coyne and Harder, 2011).

Research exploring nurses’ ways of encountering children at health visits has found that they use directed and pliable strategies to fulfil their commission towards both the national health-monitoring programme and the individual child’s needs. The directed strategies enable the nurse to conduct the health visit according to the health-monitoring programme, while the pliable strategies help the children complete the examinations. These strategies are intertwined as a continuously negotiated guiding process throughout the health visit (Golsäter et al., 2014). Further, Olander (2003) exploring child healthcare nurses’ way of working, discovered that their assignment implies synthesizing the public health perspective and the health-monitoring programme. This synthesizing process should also be carried out from the perspective of each child or family to respond to issues, needs, and wishes. This finding is transferrable to the school healthcare area, since nurses’ assignments are similar. Mäenpää et al. (2013) show the discrepancy between nurses’ and children’s experiences of how nurse balances between the health-monitoring programme and the needs of the child. The nurses reported that they were pliable toward the child, but the children found that the nurses performed the health visits in a directed way. This is also elucidated by Magnusson et al. (2012), who show nurses’ difficulties in grasping the child’s needs during health visits due to their inability to listen to the child, and only act according to their own agenda. According to Holmström et al. (2013) aggravating circumstances when attempting a balancing act can be due to the nurse’s attitude, for example, showing disrespect or not organizing the health visit based on the child’s needs.

Health visits are complex encounters, as the nurses have to follow the health-monitoring programme and simultaneously take into account the circumstances of each child’s everyday life. The nurses’ strategy for fulfilling this twofold assignment has been explored to some degree; however, this topic needs additional exploration to further elucidate the extent to which nurses use different strategies. Such knowledge might help nurses to deal with the asymmetry between adults and children. The aim of this study was to analyse the extent to which nurses use different strategies when encountering children during the recurrent health visits throughout childhood.

Methods

Study design

To obtain a detailed description of the extent to which nurses use different strategies when encountering children, a quantitative descriptive content analysis design was used with an observation protocol and video recordings of health visits (Krippendorf, 2004).

Participants and data collection

The sample constitutes 30 video recordings conducted during ongoing health visits in the nurses’ consulting rooms in child and school healthcare, in three counties in Sweden. There was an even distribution of boys and girls among the children, who were aged 3, 4, 5, 10, 14 and 16 years. Five health visits within each age group were video recorded in their entirety. There was a parent present during the health visits regarding the children in the age 3–5 years. The study comprises 26 nurses with various working experience (1–20 years) in child and school healthcare. All nurses except one were specially trained as a public health nurse or paediatric nurse. For coding the video recordings, an observation protocol was constructed (Table 1) from the findings of a previous qualitative study (Golsäter et al., 2014).

Table 1.

Distribution of strategies (category), actions (subcategory) and codes.

Category level 1	Sucategories level 2	Codes level 3	All children	Age group 3–5	Age group 10–16
Pliable strategy n = 5313	Being sensitive n = 2374	Showing interest in the child’s everyday life	41% n = 971	**51% n = 249	38% n = 722
		Asking for permission to conduct examination	4% n = 89	6% n = 32	3% n = 57
		Verbalizing the child’s attention	2% n = 44	6% n = 33	1% n = 11
		Verbalizing actions	25% n = 589	18.5% n = 90	27% n = 499
		Repeating talk, writing	28% n = 681	18.5% n = 91	31% n = 590
	Encouraging n = 2712	Praising	27% n = 741	***46% n = 326	21% n = 415
	Encouraging n = 2712	Supporting	73% n = 1971	54% n = 383	***79% n = 1588
	Providing space n = 227	Awaiting	59% n = 134	55% n = 87	67% n = 47
	Providing space n = 227	Following the child	41% n = 93	45% n = 70	33% n = 23
Directed strategy n = 3886	Informing n = 1643	Describing health visit or examination	8% n = 135	13% n = 47	7% n = 88
		Describing following event	15% n = 250	**26% n = 95	12% n = 155
		Describing own actions	22% n = 354	26% n = 98	20% n = 256
		Describing and informing of examination outcome	36% n = 597	13% n = 51	***43% n = 546
		Describing purpose of health visit or examination	3% n = 52	4% n = 14	3% n = 38
		Asking informing questions	16% n = 255	18% n = 67	15% n = 188
	Instructing n = 2186	Clarifying the situation	17.5% n = 379	24% n = 161	14% n = 218
		Forming the situation	75% n = 1642	55% n = 370	***84% n = 1272
		Asking about ability	7.5% n = 165	21% n = 138	2% n = 27
	Restricting n = 57	Verbally restricting	82% n = 47	65% n = 19	100% n = 28
		Bodily restricting	18% n = 10	35% n = 10	0% n = 0

**p < .01; ***p < .001.

Observation protocol

The protocol comprises three different levels (Table 1). Level 1 corresponds to the categories pliable and directed strategies. The nurses’ pliable strategies facilitate the children’s ability to continue with and complete the examinations. The strategy includes the nurses’ actions of being sensitive, encouraging and providing space (subcategories, level 2), and their belonging codes (level 3). The nurses use a directed strategy (ds) to describe an examination to the child by telling or showing how to carry out the different parts in the health visit. The strategy consists of the nurses’ actions of informing, instructing and restricting (subcategories, level 2), and their belonging codes, sub-actions (level 3).

Data analysis

The coding process began with testing the constructed observation protocol among the researchers by coding five video recordings simultaneously. The video recordings were coded on an item-by-item basis meaning that each nurse’s verbal and nonverbal actions were recognized and labelled as a code (level 3). This coding verified the codes found and their frequency. When consensus on the coding was reached, two additional recordings were coded individually by two of the authors (MG and MH) and compared to further verify the protocol. Then, the remaining video recordings were coded by the first and third authors. During the entire coding process, there was a dialogue between the authors to ensure reliability. Parts of the coded recordings were looked through together and discussed to reach consensus. The frequencies of the different codes were analysed using SPSS software version 22, and the χ ² test was used to analyse differences (Table 1; level 3). Since the health visits varied in duration, the frequency of the nurses’ strategies, actions and sub-actions was calculated in percentages.

Ethical considerations

The nurses and children, and the children’s parents, received written and oral information about the study and how it would be conducted, as well as their right to withdraw and confidentiality. Nurses, children and parents also gave their written consent. The study was approved by the appropriate research ethic committees (Dnr: 36-08 and 2004: M-333).

Result

The 30 video recordings ranged from 22 minutes to 77 minutes and incorporated 9199 codes (sub-actions). These are distributed as actions (being sensitive, encouraging and providing space) in the pliable strategy (ps; 58%) or as actions (informing, instructing and restricting) in the ds (42%; Table 1). In the results, children aged 3–5 years are called preschoolers and those aged 10–16 are called schoolchildren when referred to as age groups.

Distribution of strategies by age and gender

The nurses use a ps more often than a ds (Table 1; level 1). The difference of the occurrences of these strategies in the various ages is minor (Supplementary Table 1). Regarding gender, the distribution ofthe pliable and directed strategies is more equal for health visits with preschool boys (ps = 52%, ds = 48%), while the strategies used with preschool girls differ (ps = 60%, ds = 40%). The nurses’ ps towards schoolchildren is equal concerning gender (Supplementary Table 2).

Distribution of actions by age and gender

The nurses’ pliable and directed strategies contain different actions: the ps contains actions such as being sensitive, encouraging and providing space, while the ds contains actions such as informing, instructing and restricting (Table 1; level 2). The most common actions towards all children are being sensitive and encouraging.

When looking at actions in the ps by children’s age, the most common is the nurses’ action of encouraging the children aged 3–14. Regarding children aged 16, the nurses’ action of being sensitive is most common, while providing space is used the least. However, the nurses provide the children with space more in encounters with preschoolers (11%) than with schoolchildren (2%). The same comparison between actions in the ds shows that the nurses mostly use instructions with children in the ages of three and four. In encounters with children in other ages, the distribution is more equal between informing and instructing. The least used action is restricting the children. There are no differences regarding gender.

Distribution of sub-actions by age and gender

The nurses’ actions of being sensitive, encouraging, providing space, informing, instructing and restricting consist of different sub-actions (Table 1; level 3, codes).

Looking at the nurses’ action of being sensitive, they mostly show interest in the child’s everyday life (41%) followed by repeating talk and writing (28%). The least used is asking the child for permission to conduct the examination (4%) and verbalizing the child’s attention (2%). Both age groups are primarily encountered by the nurses’ showing interest in the child’s everyday life (preschoolers 51%; schoolchildren 38%). However, this is used primarily with preschoolers (p < .01). For both age groups, the nurses verbalize the child’s attention (preschoolers 6%, schoolchildren 1%) and ask for permission to conduct the examination the least (preschoolers 6%; schoolchildren 3%; Table 1; level 3). There are no major differences between genders in the different age groups.

Regarding the nurses’ actions of encouraging, they mostly support the children (73%). The nurses support the schoolchildren to a greater extent (79%) compared to preschoolers (54%; p < .001), while they praise preschoolers to a greater extent (46%) than schoolchildren (21%; p < .001). Looking at gender and age groups, preschool boys are encountered with more praising than schoolboys (53%/22%), while schoolboys are encountered with more support than preschool boys (78%/47%). The same pattern is found among the girls (Table 2).

Table 2.

Distribution of sub-actions in the actions of encouraging and providing space by age and gender.

Strategy level 1	Actions level 2	Sub-actions level 3	All children (%)	Age group 3–5 (%)	Age group 3–5 boys (%)	Age group 3–5 girls (%)	Age group 10–16 (%)	Age group 10–16 boys (%)	Age group 10–16 girls (%)
Pliable	Encouraging	Praising	27	46	53	41	21	22	19
	Encouraging	Supporting	73	54	47	59	79	78	81
	Providing space	Awaiting	59	55	48	63	67	63	76
	Providing space	Following the child	41	45	52	37	33	37	24

In the action providing space, the nurses mostly await the child (59%). Regarding differences between age groups, the nurses mainly follow the child in encounters with preschool boys (52%), as compared to schoolboys (37%). Regarding the girls, there is another pattern: they are encountered with the nurses’ awaiting them (school girls, 76%; preschool girls 63%; (Table 2).

Looking at the action of informing, the nurses mainly describe and inform the children of the examination outcome (36%), while they least often describe the purpose of the health visit (3%). Furthermore, the nurses describe the purpose of the health visit or examination least often for both age groups (preschoolers 4%; schoolchildren 3%). The nurses mostly encounter the preschoolers by describing the following event (26%) and describing their own actions (26%), while schoolchildren are primarily encountered by describing and informing of the examination outcome (43%). Comparing the two age groups, describing the following event is used to a greater extent with preschoolers (p < .01) and describing and informing of the examination outcome is used more with schoolchildren (p < .001; Table 1).

In instructing, the nurses mostly form the situation (75%). Comparing the different age groups, forming the situation is used to a greater extent with schoolchildren than with preschoolers (84%/55%; p < .001). The nurses ask about ability (7.5%) least often. There is a difference between the age groups, to ask about ability is distributed as 21% in encounters with preschoolers and 2% in encounters with schoolchildren.

Discussion

In this study, the nurses used their child competence to consider children’s age and experience (Bronfenbrenner, 1979) using pliable and directed strategies. Through the ps with action of being sensitive, the nurses showed interest in the child’s everyday life and acted encouraging by praising them. Through the ds with action of instructing, the nurses formed the situation. Preschoolers need to be encountered with sensitivity, encouragement and instruction to be able to understand and accomplish a health visit. Through these actions, nurses consider the children’s age and perspective, energy and patience and previous experience of taking part in health visits (Bronfenbrenner, 1979; Sommer et al., 2010). The fact that schoolchildren are older and have experience from school and several health visits may contribute to the nurses’ perception that schoolchildren do not need to be instructed to the same extent as preschoolers do. Therefore, the nurses can provide schoolchildren more space. Still, the nurses encourage schoolchildren, but by supporting rather than praising them.

A difference regarding nurses’ actions between age groups is their use of the ds with informing actions. This difference can be understood as the nurses adjust their actions based on their knowledge of the child’s age, development and experiences (Bronfenbrenner, 1979). When the nurses used informing actions, preschoolers were informed of the following event and schoolchildren of the examination outcome. This indicates that nurses have a preconception that preschoolers need to be prepared before participating in an examination, while schoolchildren are able to prepare on the spot without information or without repeating previously given information. Research exploring schoolchildren’s own perspectives on health visits shows they want to be prepared before the health visit takes place (Golsäter et al., 2010). Not informing them about following events may highlight nurses’ views that they do not need preparation before each examination. However, whether or not schoolchildren are informed before the health visit or have knowledge based on previous experience, nurses ought to consider the individual child’s needs. The child has grown older and developed further (Bronfenbrenner, 1979) and, therefore, may need additional or different information in the actual situation (Coyne and Harder, 2011). Not informing the schoolchildren of following events can be understood as the nurses not always being able to grasp the child’s needs (Magnusson et al., 2009) or organize the health visit based on the child’s needs (Holmström et al., 2013). The result that nurses inform schoolchildren to a greater extent than preschoolers about the examination outcome may also be related to the children’s age and experience (Bronfenbrenner, 1979). However, even preschoolers may want to participate in discussions concerning them.

The result shows that the nurses’ child competence primarily involves using a ps by being sensitive and encouraging. This can be understood as an attempt to involve the children in the health visit (Mäenpä et al., 2013). They are eager to facilitate the child’s participation (Golsäter et al., 2014). However, the result shows that they don’t ask the child for permission to conduct the examination. Regarding the competence to acknowledge one’s responsibility to implement children’s rights (United Nations, 1989), it is obvious that the nurses don’t consider this when using a ds with actions of informing. Informing a child is a basic foundation for their participation (United Nations, 1989). The result shows that the nurses only to a minor extent describe the purpose of the health visit. Concerning preschoolers, nurses may assume that parents are responsible for and able to inform the child about the health visits. Being a parent does not imply that one knows what will happen or how to explain this to one’s child. Having child competence as a nurse also involves using pedagogical skills to inform about and explain the various examinations. The benefits of informing and preparing children are documented in previous research (Carney et al., 2003). Lambert et al. (2012) emphasize that health professionals need to develop strategies for assessing children’s information needs regarding content, how it is expressed and by whom. Children wish to participate in discussions about health and medical treatment to a greater extent than they currently do (Carpenter et al., 2014). Supporting children in understanding examination outcomes while growing up may facilitate their skills in taking part in future discussions about actions for promoting their health. Such support and involvement are part of implementing children’s rights (United Nations, 1989). Yet, preschoolers need to be given information about their examination outcome in collaboration with their parents.

Child competence involves considering the various contents of a health visit in order to organize them in relation to each child’s age, experiences and rights. The nurses’ organization of the health visit according to its content becomes clear in the study, in their use of the ds of instructing actions and sub-actions of forming the situation. The health visit that occurs at 4 years of age entails several examinations, for example, hearing and sight (Socialstyrelsen, 2014a). These examinations, from a child’s perspective, can be considered demanding (Harder, 2009). Therefore, there may be a need to use instructions such as forming the situation in encounters with preschoolers to be able to conduct the health visit according to the assignment. Forming the situation is also the most used sub-action among schoolchildren when nurses use a health and lifestyle tool as the starting point for their communication rather than the child’s own expressed needs (Golsäter et al., 2011). The applicability of a programme involves a balancing act in obtaining a picture of the child’s health and development (Golsäter et al., 2009), as this could take over the examination and exclude the child’s own perspective.

Limitations

The study is based on 30 video-recorded health visits, five in each represented age group, which can be seen as a methodological limitation. However, 26 nurses took part in the study, which contributed to a variation of actions identified as two main strategies. The total number of coded actions indicates that the results can contribute to ongoing research concerning how to encounter children at health visits.

The use of recordings implied acknowledging both verbal and nonverbal actions in the coding process, which would have been impossible if only audio recordings had been used. The presence of a researcher and a camera during the health visit may have influenced the nurses’ way of acting, even though their spontaneous expressions reflected that they were fully occupied with conducting the health visits and could not pay any attention to the researcher holding the camera. It is possible that the nurses’ actions towards the children differ depending on their earlier interaction in previous health visits. However, the result shows that the nurses focus on conducting the various examinations and not the individual child’s needs. If earlier interactions influence the nurses’ actions, the need of the child would be prioritized.

Conclusion

This study shows the nurses’ difficulties in synthesizing their twofold assignment in encounters with children (Olander, 2003). They primarily consider the content of the health-monitoring programme and acknowledge the child’s individual experiences, needs and rights secondarily. The dominant use of pliable strategies can thereby be understood as an effort to compensate for subordinating the child’s needs. From another point of view, this strategy can be understood as necessary for conducting the various examinations and minimizing the asymmetry present when children and adults share a situation (Allmark, 2002).

Further research regarding nurses’ actions towards children to develop a child-centred care is needed. The nurses in child- and school healthcare are lone workers, for example, they themselves may need to develop their clinical practice without the opportunity to reflect with others. Nurses’ perceptions on how they conduct health visits with children and how they actually do need to be explored. There may be a discrepancy regarding the intention beyond an action and the shown action.

Clinical implications

One area to improve in clinical practise with children is asking for permission to conduct an examination. Such improvement will recognize the individual child’s involvement in the health visit. Asking for permission implies the nurse has to consider how to act if the child says ‘no’. Since the examinations are needed to secure the child’s health and development, the nurses rather need to improve how they ask for permission than choose to not ask at all. Such clinical practice can promote children’s involvement in health visits according to their maturity and age as part of the health-monitoring programme over time. The result of this study is useful to nurses’ ability to recognize their own actions for improving their child competence. Nurses’ knowledge and attitudes may influence evidence-based healthcare for children.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material

The online data supplements are available at .

References

Allmark

(2002) The ethics of research with children. Nurse Researcher 10(2): 7–20.

Bronfenbrenner

(1979) The Ecology of Human Development – Experiment By Nature And Design. Cambridge: Harvard University Press.

Carney

Murphy

McClure

. (2003) Children’s views of hospitalization: an exploratory study of data collection. Journal of Child Health Care 7(1): 27–40.

Carpenter

Stover

Slota

. (2014) An evaluation of physicians’ engagement of children with asthma in treatment-related discussion. Journal of Child Health Care 18(3): 261–274.

Coyne

Harder

(2011) Children’s participation in decision-making: balancing protection with shared decision-making using a situational perspective. Journal of Child Health Care 15: 312–319.

Golsäter

Enskär

Harder

(2014) Nurses’ encounters with children in child and school health care: negotiated guidance within a given frame. Scandinavian Journal of Caring Sciences 28(3): 591–599.

Golsäter

Enskär

Lingfors

. (2009) Health counselling: parental-oriented health dialogue – an innovation for child health nurses. Journal of Child Health Care 13(1): 75–88.

Golsäter

Sidenvall

Lingfors

. (2010) Pupils’ perspectives on preventive health dialogues. British Journal of School Nursing 5(1): 26–33.

Golsäter

Sidenvall

Lingfors

. (2011) Adolescents’ and school nurses’ perceptions of using a health and lifestyle tool in health dialogues. Journal of Clinical Nursing 20: 2573–2583.

10.

Harder

Christensson

Soderback

(2009). Exploring three-year-old children in a primary child health care situation. Journal of Child Health Care 13(4): 383–400.

11.

Holmström

Asplund

Kristiansen

(2013) Promoting a relationship-based health practice: a challenge for school nurses. British Journal of School Nursing 8(1): 30–38.

12.

Krippendorf

(2004) Content Analysis: An Introduction to its Methodology. Thousand Oaks: Sage.

13.

Lambert

Glacken

McCarron

(2012) Meeting the information needs of children in hospital. Journal of Child Health Care 17(4): 338–353.

14.

Mäenpää

Paavilainen

Åstedt-Kurki

(2013) Family–school nurse partnership in primary school health care. Scandinavian Journal of Caring Sciences 27(1): 195–202.

15.

Magnusson

Hulthen

Kjellgren

(2009). Misunderstandings in multilingual counselling settings involving school nurses and obese/overweight pupils. Communication Medicine 6(2): 153–164.

16.

Magnusson

Kjellgren

Winkvist

(2012) Enabling overweight children to improve their food and exercise habits school nurses’ counselling in multilingual settings. Journal of Clinical Nursing 21: 2452–2460.

17.

Olander

(2003) Health counselling in child health care, synthesizing two missions (In Swedish) [Doctoral Thesis]. Malmö: Malmö University.

18.

Socialstyrelsen [National Board of Health and Welfare] (2014a) Guidelines for Child Health Care (In Swedish). Stockholm: National Board of Health and Welfare.

19.

Socialstyrelsen [National Board of Health and Welfare] (2014b) Guidelines for School Health Care (In Swedish). Stockholm: National Board of Health and Welfare.

20.

Sommer

Pramling

Hundeide

(2010) Child Perspectives and Children’s Perspectives In Theory And Practice. London: Springer.

21.

United Nations (1989) Convention on table 2the Rights of the Child. Geneva: United Nations.

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