Holding children for procedures: An international survey of health professionals

Abstract

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.

Keywords

Assent children clinical procedures clinical holding consent

Introduction

Children receiving care in acute hospital environments are often subjected to clinical interventions and procedures for which they are unwilling to comply. This can be due to a variety of reasons including the child’s anticipation of pain (Racine et al., 2016; Uman et al., 2013), fear of the clinical environment (Darby and Caldwell 2011), lack of preparation and information (Claar et al., 2002; Duff et al., 2012; Uman et al., 2008), previous negative experiences (Blount et al., 2006) and differences in a child’s understanding for the need and importance of a procedure. Despite the availability of positive strategies such as pain relief, distraction and guided imagery, some clinical procedures rely on parents or health professionals physically holding a child in order to complete the procedure. Holding children still against their wishes for clinical procedures can cause upset, anxiety and stress for the children, parents and health professionals involved (Brenner, 2007a, Brenner et al., 2014; Bray et al., 2016; Coyne and Scott, 2014). There are a variety of terms used in the literature to describe the phenomenon of physically holding a child still for a clinical procedure. These terms include restraint (Brenner, 2007a, 2007b; Folkes, 2005; Homer and Bass, 2010; Hull and Clarke, 2010), supportive holding (Jeffery, 2010), clinical holding (Lambrenos and McArthur, 2003), therapeutic holding (Jeffery, 2002; RCN, 2010; Stacey et al., 2000), restrictive physical intervention (RCN, 2010), restricting movement (Brenner, 2007a, 2007b), physical holding (Page and McDonnell, 2013) and immobilization (Darby and Cardwell, 2011; Graham and Hardy, 2004; Hardy and Armitage, 2002). The literature suggests a continuum based on levels of described force and child agreement; with one end of the continuum linked to the use of limited force with the child’s permission (RCN, 2010) and the other end indicated by the use of restraint and force is applied to either restrict movement or mobility or to disengage a person from harmful behaviour. The range of terms are poorly defined and used interchangeably within the guidance and literature. This lack of clarity can create conceptual confusion and an absence of shared understanding between professionals and within professions involved in holding children for procedures. For the purpose of this study, we used the term ‘holding children still’, which referred to the restriction of a child’s (aged under 16) movement in order for a clinical procedure such as cannulation, dressing change or investigations to be completed.

This study aimed to provide an international perspective of health professionals’ reported practices of holding children still for clinical procedures. This study aims to add to previous work that has explored health professionals’ perceptions within the United Kingdom of restricting a child for a procedure (Brenner et al., 2015). An international perspective across countries and professions has not been previously investigated. The research questions underpinning the investigation were to examine the factors that health professionals report influence their holding of children still for clinical procedures and to investigate the reported practices used when children are held still for clinical procedures.

Methods

Data were collected using a short structured anonymous electronic questionnaire developed for this study, which was piloted with 18 health professionals across three countries (United Kingdom, Australia and New Zealand). The piloting of the questionnaire resulted in the rephrasing of two questions and the layout of the questionnaire being simplified in some sections. The questionnaire consisted of 16 closed questions (some based on Graham and Hardy, 2004) and three scenarios based on common clinical encounters that may require a child to be held still. This article reports on the quantitative findings from the closed questions. The findings from the qualitative data based upon responses to the scenarios will be reported elsewhere.

The beginning of the questionnaire defined to participants that we were interested in including the views of health professionals who over the last 12 months had work(ed) in a setting where children and young people are held still to undertake clinical procedures but for the purposes of this study, we were excluding episodes of holding in response to challenging behaviour arising from a child’s mental health or learning disability.

The questionnaire collected the characteristics of respondents (country of residence, profession, length of time working in clinical setting and age of patients with whom they work); frequency of holding in a clinical setting (1 = not often, 2 = quite often and 3 = very often); who undertakes the holding of a child for a procedure (1 = parent/carer, 2 = nurse, 3 = doctor, 4 = other staff member, 5 = parent/carer and staff member and 6 = other); factors influencing health professionals’ decision to hold a child for a procedure (age of child, safety of child, time restrictions, urgency of procedure, child’s level of distress, parents’ preference for child to be held and child’s level of understanding); training relating to holding a child still during a procedure (yes, no); resources available related to holding (yes, no); and processes of obtaining consent/assent for holding during a procedure (1= no consent required, 2 = written and/or verbal consent obtained, 3 = don’t know). The questionnaire was administered and collated using Survey Monkey™ software (Survey Monkey Inc).

Sampling and recruitment

A network or snowball sampling approach (Dragan and Isaic-Maniu, 2013) was used to reach a wide range of participants (health professionals and students practicing in child health settings). Participants were recruited through emails outlining the study that were distributed via professional networks (e.g. Children’s Healthcare Australasia, Australian College of Children and Young People, Paediatric Society of New Zealand, Royal College of Nursing and Association of British Paediatric Nurses), emails to known colleagues and through social media (e.g. closed professional Facebook groups and professional Twitter accounts of the researchers) over the period of February to March 2016.

Analysis

Questionnaire responses were exported from Survey Monkey™ and analysed using SPSS (version 23) (IBM Corp, 2015). Descriptive statistics are reported and comparisons made between groups using t-tests and analysis of variances. A p < .05 was considered statistically significant.

Ethical approval

Ethical approval was provided by the authors’ respective relevant university ethics bodies within each country; UK (FREC SC 22), New Zealand (AUTEC 15/414) and Australia (H0015373). Informed consent was assumed through return of completed questionnaires.

Results

Characteristics of respondents

Questionnaires were completed by 919 respondents. Approximately half resided in Australia (52%, n = 477) with the remaining respondents from New Zealand (26%, n = 237) and the United Kingdom (17%, n = 158). As the remaining 5% of respondents lived in 12 different countries (Sweden, Norway, United States and Greece), their responses were excluded from the analysis for this article in order to present clear findings from three Western countries with adequate sample sizes to conduct statistical analyses. The data set therefore comprised of 872 questionnaires.

The majority of respondents were nurses (75%, n = 651) and approximately one-fifth were doctors (18%, n = 159), a minority were students (10%, n = 89), all of whom were nurses. The remaining 6% of respondents (n = 53) were categorized as ‘other’ and included play and child-life specialists, allied health professionals (radiologists, radiographers, physiotherapists, electroencephalogram technician), academics and psychologists.

Most respondents (69%, n = 601/865) had worked within their clinical setting for over five years, 25% between 1 and 5 years (n = 214/ 865) and 6% for 12 months or less (n = 50/865). Most (78%, n = 673/864) worked only with children aged under 16 years, 22% (n = 191) worked with children and adults.

Frequency of holding children in a clinical setting

Respondents reported holding children still for procedures in their work setting quite often (48%, n = 411/ 860), very often 33% (286/860) or not often (19%, n = 163/860; Table 1).

Table 1.

Frequency of holding, training and resources.

	Frequency of holding		Training			Resources
	1 = not very often, 2 = quite often, 3 = very often			Yes	No		Yes	No	Unsure
	N	Mean (SD)	N	n (%)	n (%)	N	n (%)	n (%)	n (%)
Country	F = 5.840, p = .003		χ ² = 14.869 (2), p = .001			χ ² = 52.617 (4), p > .001).
Australia	477	2.20 (.690)	477	175 (37%)	302 (63%)	461	135 (29%)	159 (35%)	167 (36%)
New Zealand	237	2.15 (.725)	233	117 (50%)	116 (50%)	229	112 (49%)	58 (25%)	59 (26%)
United Kingdom	156	1.97 (.718)	157	53 (34%)	104 (66%)	149	35 (23.5%)	32 (21.5%)	82 (55%)
Profession	F = 4.100, p = .017		ns			ns
Doctors	158	2.28 (.678)	159	61 (38%)	98 (62%)	153	43 (28%)	52 (34%)	58 (38%)
Nurses	646	2.11 (.719)	651	263 (40%)	388 (60%)	632	215 (34%))	183 (29%)	234 (37%)
Other	53	2.06 (.633)	53	20 (38%)	33 (62.3%)	52	22 (42%)	14 (27%)	16 (31%)
Student status	t = 3.773, p > .001		ns			χ ² = 60.714 (2), p > .001
Student	88	1.88 (.692)	89	31 (35%)	58 (65%)	85	10 (12%)	11 (13%)	64 (75%)
Non-student	772	2.17 (.705)	778	314 (40%)	464 (60%)	754	272 (36%)	238 (32%)	244 (32%)
Length of time in setting	F = 4.258, p = .014		ns			χ ² = 35.792 (4), p > .001
Under a year	49	1.86 (.736)	50	21 (42%)	29 (58%)	46	9 (20%)	7 (15%)	30 (65%)
One to fiveyears	213	2.15 (.698)	214	81 (38%)	133 (62%)	210	50 (24%)	63 (30%)	97 (46%)
Over five years	596	2.16 (.707)	601	242 (40%)	359 (60%)	581	221 (38%)	179 (31%)	181 (31%)

Note: ns: non sgnificant.

The frequency of reported holding differed significantly between countries (F (3) = 5.840, p = .003), with Australia having the highest frequency and the United Kingdom having the lowest (see Table 1). The rate of holding also differed according to profession, with doctors reporting the highest rate and professionals categorized as ‘other’ reporting the lowest rate (F (2) = 4.100, p = .017). Students had statistically lower rates of holding than non-students (t (858) = 3.77, p >.001). The length of time respondents had worked in their clinical setting was related to the frequency of holding: F (2) = 4.258, p = .014. Respondents who had worked in their clinical setting for less than a year reported the least amount of holding and those who had worked for over five years reported the most.

Approximately, a third of respondents reported that holding a child still was typically done by parents (33%, n = 279/836), a combination of parents and staff (33%, n = 277/836) or nurses (29%, n = 241/836). The remaining responses were another member of staff (3%, n = 24) or ‘it depends’ (2%, n = 15).

Ninety-six percent (n = 835) rated the following factors as being likely to influence a child being held still for a procedure in their setting: safety of the child (31%, n = 260), child’s age (31%, n = 259), urgency of the procedure (20%, n = 163), child’s level of distress (9%, n = 73), child’s level of understanding (6%, n = 50), parents’ preference (2%, n = 20) and time restrictions (1%, n = 10).

Training relating to holding a child still during a procedure

Most respondents had not received training on holding children still for procedures (60%, n = 522) (Tables 1). Those who had received training (40%, n = 345) had received this through mandatory training, undergraduate or postgraduate education, one-off sessions in the clinical setting and ‘on the job’ training from colleagues.

Table 2.

Level of parent consent and child assent obtained before a procedure.

	Consent from parents before procedure				Assent from child before procedure
		Consent not required	Written and/or verbal	Don’t know		Consent not required	Written and/or verbal	Don’t know
	N	n (%)	n (%)	n (%)	N	n (%)	n (%)	n (%)
Country	χ ² = 31.316 (4), p >.001				χ ² = 59.619 (4), p > .001
Australia	450	82 (18%)	324 (72%)	44 (10%)	446	175 (39%)	136 (31%)	135 (30%)
New Zealand	215	28 (13%)	181 (84%)	6 (3%)	212	75 (35%)	101 (48%)	36 (17%)
United Kingdom	140	8 (6%)	111 (79%)	21 (15%)	139	16 (11%)	62 (45%)	61 (44%)
Profession	χ ² = 54.239 (4), p > .001				χ ² = 63.067 (4), p > .001
Doctors	151	41 (27%)	101 (67%)	9 (6%)	150	86 (57%)	43 (29%)	21 (14%)
Nurses	606	68 (11%)	490 (75%)	48 (8%)	599	161 (27%)	248 (41%)	190 (32%)
Other	47	9 (19%)	24 (51%)	14 (30%)	47	19 (40%)	7 (15%)	21 (45%)
Student status	χ ² = 27.966 (2), p > .001				χ ² = 35.475 (2), p > .001
Student	81	4 (5%)	58 (72%)	19 (23%)	81	9 (11%)	27 (33%)	45 (56%)
Non-student	724	114 (16%)	558 (77%)	52 (7%)	716	257 (36%)	272 (38%)	187 (26%)
Length of time in setting	χ ² = 28.764 (4), p > .001				χ ² = 31.206 (4), p > .001
Under a year	43	3 (7%)	34 (79%)	6 (14%)	43	7 (16%)	16 (37%)	20 (47%)
One to five years	200	22 (11%)	144 (72%)	34 (17%)	200	50 (25%)	69 (34.5)	81 (40.5%)
Over five years	560	92 (16%)	437 (78%)	31 (6%)	552	209 (38%)	213 (38.5%)	130 (23.5%)

There was a significant difference in training according to the country (χ ² = 14.869 (2), p >.001), with those in New Zealand having the most training (50%, 117/223) and the United Kingdom the least (34%, 53/157). There was no difference in the likelihood of having received training according to profession, student status or the length of time within a particular setting.

There was a statistically significant difference in the reported frequency of holding between professionals who had received training and those who had not (t = 3.243 (693), p > .001). Those who had received training reported holding children less frequently (M = 2.24, SD = .73) than those who had not received training (M = 2.08, SD = .69).

Resources available related to holding

Respondents were asked whether resources (policies, tools and guidelines) informed the holding of children for procedures within their clinical setting . Approximately, a third were unsure (37%, n = 308), a third had access to resources (32%, n = 282) and a third could not identify such resources within their clinical setting (30%, n = 249; Table 1).

The presence of resources differed according to the country in which the respondent lived (χ ² = 52.617 (4), p > .001), with those in New Zealand having the greatest reported level of access to resources (112, 49%). The reported access to resources also differed according to the length of time respondents had worked in their clinical setting (χ ² = 35.792 (4), p > .001), with those having worked in their current setting for five years or more being the most likely to report having access to resources.

There was a statistically significant difference in the frequency of holding between professionals who had resources in their work setting and those who did not (t (529) = 2.509, p = .012). Those who reported having resources available held more often (M = 2.27, SD = .688) than those who were unsure of available resources (M = 2.04, SD = .71).

Obtaining consent from parents

Most respondents reported gaining verbal and/or written consent (76%, n = 616/805) from a parent before a child is held still for a procedure (Table 2). The remaining responses indicated that parental consent was not required (15%, n = 118/805) or that they did not know what level of consent was sought (9%, n = 71/805).

There was a significant difference in obtaining consent from parents according the country of practice (χ ² = 30.316 (4), p > .001), profession (χ ² = (4) = 54.239, p > .001), student status (χ ² = 27.966 (2), p > .001) and the length of time respondents had been working in their clinical setting (e² = 28.764 (4), p > .001). Respondents who were most likely to report gaining verbal and/or written consent from parents were those professionals working in New Zealand, and those who were nurses. Students and those working in their place of employment for less than five years were the most likely to respond ‘don’t know’ to this question.

The frequency of holding differed in relation to the level of consent obtained from parents (t = 4.090 (731), p > .001). Those who reported that consent was not required from parents held more frequently (M = 2.41, SD = .64) than respondents who obtained written and/or verbal consent (M = 2.12, SD = .72).

Obtaining assent from children

Approximately, one-third of respondents obtained verbal and/or written assent from a child (38%, n = 299/797), before they were held for a procedure (Table 2). The remaining respondents reported that children’s assent was not required (33%, n = 266/797) or did not know (29%, n = 232/797).

There was a significant difference in obtaining assent from children according to the country in which the respondent lived (χ ² = 59.619 (4), p > .001), profession (χ ²(4) = 63.067, p = .000), student status (χ ² = 35.475 (2), p >.001) and length of time working in their clinical setting (31.206 (4), p > .001). Once again, those respondents who were most likely to report gaining assent from children were professionals working in New Zealand and nurses from any of the three countries. Students and those working in their current setting for less than five years were the most likely to respond ‘don’t know’.

The frequency of holding differed in relation to the level of assent obtained from children (t = 4.508 (562), p > .001). Those who reported that assent was not required from children held more frequently (M = 2.34, SD = .64) than respondents who obtained both written and verbal assent (M = 2.07, SD = .74).

Discussion

The results provide an international overview of health professionals’ reported practice of holding children still for clinical procedures. The authors recognize that participants were situated within developed countries and therefore findings are most applicable to such healthcare systems. Findings indicate that there are significant variances in practices of different health professions and between different countries. The results support evidence that holding children still for clinical procedures is a common occurrence in children’s healthcare (Brenner, 2007a, 2007b; Bray et al., 2015; Coyne and Scott, 2014; Kirwan and Coyne, 2017) and highlights that this occurs internationally. Holding children still for procedures remains an area of uncertainty for professionals despite professional guidance recommending that ‘positioning of the child should only be for their comfort and not for restraint’ (Royal Australasian College of Physicians, 2005) and that any holding should be the ‘last resort’ (BMA, 2016; RCN, 2010). This uncertainty persists despite professional debate for the last 20 years in regard to best practice (Bradlyn et al., 1993; Robinson and Collier, 1997).

Most of the respondents (61%, n = 522/867) had not undertaken any formal training relating to a child being held still for clinical procedures. The findings from this study corroborates evidence that the preparation of health professionals for undertaking clinical holding is limited (Graham and Hardy, 2004; Kirwan and Coyne, 2017; Lewis et al., 2007; Pearch, 2005; Valler-Jones and Shinnick, 2005), this is despite professional guidance within the United Kingdom clearly stating that ‘all staff must not be asked to be involved in restraining a child without proper training’ (BMA, 2016). In contrast to previous evidence (Brenner et al., 2015), findings from this study indicate that those who had undertaken training (whether formal or informal) held children less frequently than those who had not received training. It remains uncertain what influence training has on the holding practices of professionals, whether this may be through an improved awareness of alternatives to holding such as preparation and distraction or an increased knowledge of legal implications and professional responsibilities. These hypotheses are outside the remit of this study and any further investigation would need to examine the content of the training delivered.

Our findings suggest that the presence of resources (guidelines, tools and policies) within a setting is, in itself, insufficient to influence health professionals’ practice. Many of the health professionals reported (67%, n = 557/839) that they were unaware of resources in their workplace or resources were absent, indicating a need for the development and promotion of clinically useful and clear evidence-based guidance. It is known from previous research conducted in different fields that professionals often are not aware of clinical guidelines or prefer to stick to their established and ingrained practices (Munteanu and Jordan, 2017) despite guidelines being directly linked to the integration of evidence into practice (Forberg et al., 2014) and improved outcomes for patients (Rutten et al., 2016). There is a need to further investigate healthcare professionals’ reasoning behind their adherence to and use of clinical practice guidelines in relation to children undergoing clinical procedures.

Of concern, many health professionals, particularly doctors, reported not asking children for their assent to be held (33%, n = 266/797) or parents to provide consent (15%, n = 118/805). Health professionals who reported not obtaining consent or assent were significantly more likely to report holding a child for a procedure. Other work has also highlighted that professionals are more likely to gain consent from parents than they are to gain children’s permission for holding (Kirwan and Coyne, 2017) and there is further work to be undertaken to explore the reasons for different professionals’ approaches to gaining assent and consent. Obtaining and recording permission for holding a child is highlighted as important in professional guidance (e.g. BMA, RCN and RACP) and without obtaining these permissions professionals may risk poor advocacy on the child’s behalf and even potential litigation if things do not go well. Not engaging children in making choices and asking for their permission to be held can marginalize them during procedures and reinforce that the parents and health professionals’ interests are prioritized (Bray et al., 2015). Health professionals’ need to ensure their practice is congruent with professional guidance and there is need for professionals to be trained and reflective regarding how children are approached for assent and held still for procedures. Engaging children in providing assent for procedures and ensuring they know, relevant to their developmental level, what will happen acknowledges their developing agency and provides them with an opportunity to develop skills in making choices and decisions within a healthcare context. There is a need to ascertain children’s perspectives on how they are approached for assent before clinical procedures.

The questionnaire did not enable us to judge the nature and level of force involved in the reported holding of children. We acknowledge that safe and supportive holding is often part of working with children when they need procedures. We recognize that the non-probability sampling technique means that as participants self-selected to participate there is a potential for bias.

Conclusion

Holding children still for procedures remains common practice, and this is consistent across the three countries involved in this study. There remain inconsistencies relating to how and why children are held for clinical procedures and practice is often not underpinned by training or professional guidance. This study has found that the reported holding still of children for procedures is influenced by training, access to guidance, country of practice and profession. There is a need for more evidence on how clinical practice guidelines inform professional practice and children’s views of how their opinions and choices should be sought and attended to in the process of a procedure being completed.

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.

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