Children’s participation and experiential reflections using co-operative inquiry for developing a learning programme for children with asthma

Abstract

The aim of this article is to discuss methodological issues based on experiences involving the use of co-operative inquiry in a paediatric ward and to describe how the children’s own perspectives were taken into account. This project, which was conducted in Norway between 2004 and 2007, involved children, parents and health care professionals meeting in a mutual working process to apply a new pedagogic approach for children with asthma. Ninety individuals (children, parents, health care professionals, teachers and students) participated in the study that had a qualitative approach. The findings indicate that the adults considered the child perspectives throughout the project, while the children’s own perspectives were taken into account during the period of intervention. The children participated actively, which can support empowerment processes. Health care professionals and researchers responded to the children’s views using communication and research techniques adapted to the children’s age, development and sensitivity. Critical choices related to the project were made because of recruitment challenges involving children and families. Children between 7 and 10 years of age are competent actors who can be involved in research and thus represent activated sources of knowledge. Bringing about change requires endurance and a long-term perspective.

Keywords

children’s perspectives co-operative inquiry health promotion methodological issues pedagogic approach

Introduction

Action research is a research strategy that combines the production of knowledge with changes in practice. By using an empirical study as a case, this article discusses methodological issues regarding the use of co-operative inquiry, which is one specific type of action research approach (Reason & Heron, 1986). The case discussed here focuses on a support and learning programme for children with asthma that involves children, their parents and health care professionals (HCP) in paediatric care. A particular focus of this present study is concentrated on the research process and how the children’s perspectives were taken into account.

The Convention on the Rights of the Child (Unicef, 2008) enshrines the rights of children to participate in decision-making, and there is a growing interest in the active involvement of children in the decision-making process (O’Kane, 2008). Sommer, Pramling Samuelsson, and Hundeide (2010) previously defined ‘children’s perspectives’ and ‘child perspectives’ in the following manner: children’s perspectives represent children’s experiences, perceptions and understanding of their life-world, and the child perspectives direct adults’ attention towards an understanding of children’s perceptions, experiences and actions in the world. Söderbäck, Coyne, and Harder (2011) highlight that both the child perspective and the children’s perspective are required to perceive and encounter children as equal human beings in child-centred health care settings. However, children are rarely involved in decision-making in health care settings; children often play a passive role in health care, and little research has been performed regarding children’s role in the health care decision-making process (Coyne, 2008). Children often wish to be involved in discussions about their care, but it is unclear to what extent this happens in practice (Moore & Kirk, 2010).

Hart (2008) underscores the need for describing children’s real participation in projects and search for fruitful ways to encourage children and adults to work together, rather than using existing models of participation. Jensen (2009) argues that processes in projects are participatory if they are based on a mutual dialogue between the target group and the professionals, if both the target group and the professionals are active participants and if the process progresses towards a joint decision at the end.

Participation, empowerment, holistic approaches, interdisciplinary and intersectoral work (collaboration between sectors) are guiding principles in health promotion (Rootman et al., 2001; WHO, 1986), and these principles are similar to the guiding principles of co-operative inquiry. Earlier studies evaluating the effect of educational interventions on childhood asthma (Boyd et al., 2009; Wolf, Guevara, Grum, Clark, & Cates, 2002) demonstrated improved outcomes and fewer hospital admissions, although little data were gathered regarding the participation and involvement of the children. This present article begins with a description of the case and the context, which is followed by a description of the four steps of the co-operative inquiry research process. The findings include interpretations of the children’s perspectives and critical reflections on methodological choices made during the inquiry process, together with reflections on the co-operative inquiry process.

Co-operative inquiry: A mode of action research

Action research originated during the middle of the 20th century, when Lewin (1997) attempted to combine research with practical changes. Over time, the concept of action research has gained a broader application, and the research tradition was defined by Starrin (1993, p. 23) as ‘a close interplay between action and research and between theory and practice in a change process’. This definition also implies that action research is closely connected to the concept of empowerment (Gibson, 1991). Holter and Schwartz-Barcott (1993) identified three modes of action research: technical collaborative approach, critical-emancipatory approach and mutual collaborative approach. The present case represents a mutual collaborative approach that is characterized by a hermeneutic perspective and an inductive working model.

The idea of research-driven change in practice is prominent in co-operative inquiry (Reason, 1994; Reason & Heron, 1986) and the research process includes four steps: preparation, orientation, intervention and evaluation. Co-operative inquiry has been further developed and adapted to a Norwegian context, especially in terms of the use and refinement of multistage focus group interviews and dialogue-based teaching as fruitful methods for co-operative inquiry (Granerud, 2008; Hummelvoll, 2003, 2008; Hummelvoll & Severinsson, 2005).

This research strategy is based on three cornerstones (Reason & Heron, 1986). 1) Participatory and holistic knowing is involved, which suggests that the point of departure is humans’ search for meaning and comprehensive understanding of the world. In the present study, children, parents and HCP meet in a collaborative working process in order to create knowledge that would be relevant for coping with the challenges of everyday life. The knowledge that could be developed would therefore be based on an integration of practical, experiential, and theoretical knowledge. 2) Critical subjectivity is a quality in our understanding that implies an ambition to bridge the gap between objectivity and subjectivity. Critical subjectivity indicates an accepting of one’s understanding of reality but at the same time also implies an awareness of its relativity and the state of being consciously self-reflective. Thus, an individual’s picture of reality is critically scrutinized together with those of others. By means of this self-reflection, individual knowledge can create or be ‘refined’ into general knowledge. 3) Knowledge-in-action, meaning that knowledge in co-operative inquiry is created in practical situations, with the aim of this knowledge becoming practically and scientifically useful (Heron & Reason, 2006; Reason & Heron, 1986). The research strategy has to a large extent been used in studies where learning holds a strategic position in relation to different groups of professionals. The aim of this article is to discuss methodological issues based on experiences involving the use of co-operative inquiry in a paediatric ward and to describe how the children’s perspectives were taken into account.

Case description

The context

From 1995 to 1998, the HCPs in a paediatric ward of an urban hospital in Norway were actively involved in developing an asthma educational programme (AEP) for parents of children with asthma. The pedagogic approach at that time was primarily based on the assumptions of the HCPs regarding the issues that the parents needed to learn. The content and approach were therefore determined by the HCPs. After 2001, a new strategy for educating children with asthma was implemented in paediatric wards and in primary health care settings in Norway (National Strategy for Asthma Education, 2001). The target group included children with asthma between 5 and 10 years of age and their parents. In 2004, the paediatric ward in this hospital was introduced to this strategy. The purpose of the project was to apply the pedagogic approach described in the National Strategy for Asthma Education and to develop a new AEP at the ward based on children’s perspectives.

Asthma education materials

The AEP used Ane and Bronky – On the move, a book written for children with asthma (Aspeli & Bø, 2001; National Strategy for Asthma Education, 2001). This material was previously developed by an interdisciplinary team along with children and parents and was based on asthma guidelines (GINA, 1998). The author of the book visited children with asthma and wrote stories based on their perspectives and narratives. An artist was also engaged to draw pictures based on these stories. Thirty pictures are included with the stories in the book, together with a pedagogic guide (National Strategy for Asthma Education, 2010) that provides instructions for how HCPs could use the pictures and stories. The guide also suggests follow-up questions to encourage children to express themselves and to assist them with verbalizing their stories and experiences. This material highlights the importance of the participation of children in the educational process. Their experiences and views are the starting point for dialogue and communication. The idea is that HCP shows a picture to the group and asks for their responses, and based on the children’s responses, the HCP either involve them in the ‘story’, or the children tell personal stories in their own words. Storytelling and pictures (in the book Karius and Baktus) have previously been used to teach Norwegian children about dental care (Egner, 1949).

Participants

A total of 90 individuals participated in the project. Of these, 31 individuals (18 children with asthma between 7 and 10 years old, three parents, one lay person, five nurses, one nurse assistant, one paediatrician, one physiotherapist and one public health nurse) actively participated in individual and focus group interviews. The children and parents were selected consecutively from children with asthma and their parents who were admitted to the paediatric ward between 2004 and 2007. The HCP were strategically selected (working on the ward or the outpatient clinic; profession) from the two asthma collaboration groups in the ward. The public health nurse was selected from the primary health care setting. The remaining 59 individuals participated in meetings, dialogue-based teaching and/or communicated with children when they were admitted to the hospital. Some of these participants worked as staff in the paediatric ward, in primary health care settings or in school. Other participants included nursing students and other children who attended the AEP (Table 1).

Table 1.

Participants.

	Children	Parents	Health care professionals/ office staff	Primary health care/teacher	University college
Interviews with children before asthma education programme (AEP)	15
Observation of children	3^a
Interviews with children after AEP	7^b
Children participating in AEP	21^c
Focus group parents		3
Nurses working on the ward			17
Nurses working in outpatient department			4
Nurse assistant			5
Paediatrician			4
Physiotherapist			1
Office staff			2
Public health nurse				1
Physician from primary health care				1
Teacher from elementary school				1
Lay person from asthma association		1
Supervisor					1
Researcher					1
Mediator in focus group					2
Nursing students					15
Total	31^d children	4 parents	33 HCP/office staff	3 HCP/teachers	19 researchers/students

Of the observed children, two had had been interviewed before AEP.

Of the children interviewed after the AEP, five had been also interviewed before AEP.

Of the children participating in the AEP, seven had also been interviewed.

The total number of participating children is 31; of them 18 participated actively.

A four-step research process

The research process of co-operative inquiry includes four steps (Hummelvoll & Severinsson, 2005; Reason & Heron, 1986). Although the inquiry process that was applied in this project appears to be linear, it actually followed a traditional spiral of steps, each of which is composed of a circle of planning, action and fact-finding about the results of the various of actions (Coghlan, 2011; Lewin, 1997).

Step I: Preparation (February–December 2004)

The research project was initiated by a joint proposal from RN and AT. AT is the researcher and project leader who previously worked in the paediatric outpatient department. RN is a nurse specializing in asthma treatment who worked in the same department and is later mentioned as the local project coordinator (LPC). An experienced researcher, JKH, supervised the project. The research protocol was designed as a co-operative inquiry consisting of four steps and was presented, discussed and negotiated with the management and HCPs in the paediatric ward as well as a layperson (parent) from the local Norwegian Asthma and Allergy Association (NAAF). A detailed research plan, including ethical considerations and an application for financial support, was developed by the researcher with support from the supervisor. The applications were sent to the ethical board and authorities for financial support.

Step II: Orientation (January–September 2005)

In this step, the empirical foundation of the study was developed. The project group was established and consisted of two researchers (the supervisor and the project leader from the University College), the ward nurse, the LPC and a lay person from the local NAAF. A contract of collaboration between the hospital and the University College was established, and a LPC (the nurse specializing in asthma treatment who was previously involved in step I) was selected. A grant of financial support was received.

Ethical considerations

The LPC recruited children, parents and HCPs after providing verbal information about the project. After individuals agreed to participate, written information was sent to these individuals by the researcher involved. The 31 individuals that participated actively provided written, informed consent prior to participation. All information was treated confidentially; the participants’ names were omitted from all publications, and data files were protected by passwords. In addition, research ethics principles according to the Declaration of Helsinki (2008) were followed. Ethical approval from Regional Norwegian Committee for Medical Research Ethics (953/05) was received.

Step III: Intervention (October 2005–February 2007)

During this step, interventions occurred co-operatively among professionals, laypersons (children and parents) and researchers. These individuals constituted a ‘community of inquiry’ for implementing changes in practice, analysing, reflecting and documenting. The third step was the most comprehensive part of the project and it was in this step that the children actively participated.

Interaction with the children

To obtain the children’s perspectives and tailor the AEP based on their views, qualitative interviews were carried out with 15 children with asthma prior to the AEP. An interview guide was used that covered the following topics: 1) experiences of asthma in daily life, at home, during leisure time and at school; 2) feelings, bodily sensations and verbal expressions of asthma; and 3) communication concerning asthma with teachers and peers. In addition, the children drew pictures. After four interviews had been performed, the preliminary findings of the interviews (and the findings of all 15 subsequent interviews) were incorporated into the inquiry process by means of focus group interviews, meetings and dialogue-based teaching. In this way, the HCP obtained insight into the children’s perspectives and experiences.

Interaction with the parents

One focus group interview was performed with three parents of children with asthma. Two of these parents had previously participated in an AEP for parents, and the other had not. The topics of interest for this focus group interview included the parents’ experiences regarding their participation in an AEP, their reflections on the educational materials, and their views on the existence of an AEP for children.

Interaction with the health care personnel

A multistage focus group interview (Morgan, 1997) is typically characterized by several meetings with the same group members in order to explore consistent topics in depth, and these have been shown to be a relevant method for a collaborative research design (Hummelvoll, 2008). Three multistage focus group interviews were carried out with HCPs and they were performed at the beginning, in the middle and at the end of the intervention and reflected the co-operative research process. The focused topics included the participants’ views of the situation for children with asthma, the child perspectives, the inquiry process, and their views and experiences regarding interdisciplinary and intersectoral collaboration. On the ward, the staff participated in two collaborative groups. The previously established group dealt with general quality assurance issues regarding asthma, and a new collaborative group was formed and worked with pedagogical approaches and issues. Both groups were involved in this project. Dialogue-based teaching sessions were arranged with the staff by the researcher and the LPC. In total, six sessions were held, which related both to the educational questions or aspects and the challenges or problems with the project. The staff members were free to propose topics to discuss, which included the following: reflections on dialogue as a communication method with children, sharing experiences and the use of the educational materials. Fifteen nursing students under education on the paediatric ward contributed to the project by writing assignments about the educational material, children’s learning and pedagogic approaches as well as by presenting their project reports to the staff.

Carrying out the asthma education programme

The AEP was group based and a total of 21 children divided into six groups, with three to four children in each group participated in the AEP. A nurse, who specialized in the treatment of asthma, and a physiotherapist led the AEP sessions. One of the six AEPs, the third one conducted, was observed for a total of three hours. This AEP was selected after the HCP tested the program and were satisfied with its function. In the observed AEP, three participants, two girls and one boy, all aged between 8 and 10 years, participated. The observations focused on how the activities of the AEP were performed, the pedagogical approach, and the educational dialogues of the AEP, and the children's response to the AEP.

Notes and minutes of meetings

The researcher and the LPC recorded notes from the research process that served as a diary. This diary was used as a tool for documenting thoughts, feelings, observations and reflections and as such, they are also being a co-subject in the research process (Hummelvoll & Severinsson, 2005).

Step IV: Evaluation (March 2007–December 2007)

The evaluation was characterized by methodological reflections that were related to the co-operative inquiry process and summaries of the findings. The quality and sustainability of the knowledge gained as well as the changes in practice were critically evaluated. Feedback and notes from meetings and teaching opportunities were presented to the staff in writing as well as orally.

Data analysis

Transcribed interviews, notes from observations, notes from the project leader and the LPC and meeting documents were analysed by means of manifest qualitative content analysis, as described by Graneheim and Lundman (2004). The present study focused on the involvement of the children in the project, how their perspectives were taken into account and the critical reflections regarding the choices that were made during the inquiry process.

Findings

The co-operative inquiry process with the main outcomes

The findings showed that the management were enthusiastic and wished to implement the project. The asthma collaboration groups worked intensively, and the staff members from the ward and the outpatient clinic were actively involved, which was not the normal practice. A new information routine regarding inhaled asthma medications was developed. An information leaflet, which was intended for parents and teachers concerning children and physical activity, was developed. The staff routinely informed the children and their families about the educational materials and asked the children and their families if they wished to participate in the AEP. The staff members themselves initiated the practical work more quickly than expected, and they were energetic and demonstrated a willingness to change. A change in the attitude of staff members working with children with asthma was noted; these members wished to learn more about pedagogy and were eager to use the new educational methods, such as dialogue and narratives. The findings also showed improvement in the follow-up procedures of children with asthma; children and families received the educational material, the staff used the educational material in new settings (individually as well as in groups), the AEP was held regularly, and experiences from the AEP were transferred to the ward. Findings from the interviews that were performed with children in step III were analysed and published in a scientific journal (Trollvik, Nordbach, Silén, & Ringsberg, 2011). Observations of the children and the two HCP in the AEP, which was collected in step III, showed that communication methods used during the AEP took the children’s views as a starting point.

At times, however, it was challenging to gather staff due to shift and work patterns and because the emergency room needed to be staffed. The delivery of new practices was time consuming, and the implementation of changes was met with some resistance. The project competed with other activities on the ward, and the staff had problems selecting an activity to prioritize. The following is an excerpt from the researcher’s diary:
The distribution of material is fine, and there are good practices. Teaching the children is still difficult to get started, staff resort to the old, what they know, they feel uncertain about the new and wish for more knowledge about how to use it.

Practical changes (i.e. developing an information leaflet, giving the educational materials to the children) were visible and easy to monitor, whilst attitude changes were more complicated to observe. During the project, signs of resistance were subtle and were not verbalized among the staff. It proved difficult to emphasize the positive developments to maintain staff motivation. Our experience has been that in spite of time constraints, it is crucial to set aside time for reflection together with management, staff, laypersons and the project group from the beginning to the end of the project.

Reflections on how the children’s perspectives were taken into account

The result of the analysis of the children’s participation in interviews is presented according to the following three themes: 1) ‘safe and empowering conditions are important for children’: 2) ‘emphatic communication – a way of involving children’ and 3) ‘involving techniques – drawings and meta-communication’. Participation, empowerment and safe conditions are all central components of health promotion in children. The result concerning the focus group interviews with HCPs is presented according to the following theme: ‘Adjust the education programme towards the children’s perspectives’.

Safe and empowering conditions are important for children

Most of the children were interviewed in a child-friendly room in the paediatric ward. At first, the parents sat together with the child and when the child felt safe the parents left. Two interviewers AT and RN, sat with the child around a low table, one at the same side as the child to avoid negative power relations which are recognized as critical in ethical practice with children (Christensen & James, 2008). The interviewers alternated in leading the interview and monitoring the children’s non-verbal expressions to identify any discomfort. Fargas-Malet, McSherry, Larkin, and Robinson, (2010) underline the importance of the research context that might affect what children talk about. If any discomfort was noticed the child was asked if he/she needed a break or wished to stop the interview. None of the children wanted to stop the interview but some requested a break. When the children were asked to relate their experiences of being interviewed they did not indicate any negative feelings concerning the presence of two interviewers. However, we were aware that the children may have had difficulty in expressing negative experiences immediately after the interview, and in the presence of the interviewers.

Emphatic communication: A way of involving children

The interview guide was developed by the researcher and used flexibly in accordance to the child’s age and maturity level. The first part of the interview was similar to a free conversation and consisted of safe ‘get to know each other’-type questions. The communication was experienced as flowing when the children answered trustfully and when we observed the children looking pleased:
Interviewer: I am curious about something … do you think of taking medication yourself before visiting your friend (who has a dog), or did your parent advise you?

Child: Sometimes I think about it myself … I don’t like having an allergic reaction so I think about it myself or Mum or Dad reminds me, but sometimes I forget it.

The communication was experienced as stilted when the child did not understand the question or the child became silent, did not answer or looked unhappy:
Interviewer: If I say ‘asthma attack’, have you experienced it?

Child: No... I haven’t.

Interviewer: It’s not asthma attack for you?

Child: No... what’s that?

As interviewers, we learned that the children expressed their thought about asthma differently. When the children expressed their feelings about asthma in their own words, we better understood their language and could use their vocabulary in our questions, that is ‘difficult to breathe’, ‘tired … tight in my chest … sore in my throat’. Both interviewers were experienced in communicating with children, and reflected on how to allow the children to speak as freely as possible. Christensen and James (2008) emphasize the value of the interviewer’s experience for communication with children and the importance of paying attention to the culture of communication as a way of including children.

Involving techniques: Drawings and meta-communication

The children were encouraged to make a drawing of a thought that had been expressed in the interview and to narrate its contents. The interviewers felt that the use of drawings further involved the children. During the interviews, a meta-communication technique was used to involve the children and to maintain their concentration. The interviewer made a drawing of two faces with speech bubbles and introduced a new setting, wherein the two faces were communicating with each other. The questions and answers were written inside of the speech bubbles:
The interviewer (pointing at one of the faces): This girl will tell the class that she has asthma, what do you think she will tell the class?

Child: It is no fun with asthma.

Interviewer: If she has to explain what it is, what can she say?

Child: It is an illness where you cannot run so much and you can be allergic.

When this technique was used, the children distanced themselves and spoke in the third person. Our experience indicated that the use of this technique resulted in a shift in communication and worked well when the children were tired or had complex thoughts to express. Additionally, we found that the child talked about the faces in the drawing, even though the information represented their own narratives.

Adjust the education programme towards the children’s perspectives

One of the HCP described the development of the AEP as ‘a kind of a round-dance to find its shape’, and this ‘round-dance’ consisted of planning, implementation, evaluating and experimenting. From the preliminary findings of the interview study, the HCPs obtained insight into topics that were discussed by the children, and these topics were emphasized in the AEP. This served as a lay perspective, and one HCP described how the children’s perspective was taken into account during the AEP:
We are sitting around the table... we get to know each other... we are talking about asthma... we encourage the children to narrate from their own experience. It is not easy for an eight-year-old to memorize... so we try to concretize a bit... do you remember something? How was your breathing? And then suddenly they can talk about it... this is one way to get the user perspective of children; try to engage them at their level...

The parents were satisfied by the children’s participation in the AEP, as one of the interviewed parents stated the following:
The fact that my child met with other children in the AEP made a change back home.

Critical reflections on choices made during the inquiry process

Focus group interviews or individual interviews with children

It has been suggested that the adult-centeredness of most societies and the unequal power relations that exist between children and adults are present during the research process (Kirk, 2007; Punch, 2002b). The initial plan was to conduct focus group interviews with children in order to establish a dynamic communication with them and to equalize this power imbalance. Morgan, Gibbs, Maxwell, and Britten (2002) state that the power balance between adults and children can be more easily maintained in groups. Due to recruitment challenges (see next section), only two children attended the first focus group interview, and only one child in the second focus group interview. After the second attempt, it was therefore decided to perform individual interviews instead of focus group interviews. A study by Punch (2002a) conducted individual and group interviews with children between the ages of 13 and 14 years old and found that the children found individual interviews more confidential and felt that this setting made it easier to share their personal thoughts. Additionally, group interviews were regarded as including a supportive company of peers, and although this setting was perceived as more fun, children were less likely to express personal feelings (Punch, 2002a). Through these interviews, we obtained valuable, in-depth knowledge from the children. Using a technique that combined interviews and drawings, the thoughts expressed by the children during the interviews were visualized and strengthened. Driessnack (2005) claims that the use of drawings can be an exciting way to engage and involve children in research, although not all children like this approach (Punch, 2002b). In our project, the children seemed to enjoy the drawings, as 14 out of 15 children made drawings.

Choices made due to recruitment challenges

In this project, it was time consuming to contact and motivate the participants, including children, parents and staff. At times, the participants did not keep their appointments, and several planned activities did not take place due to lack of participants. For example, two experience conferences (meetings between laypersons and professionals), which required the participation of children and parents, were cancelled, as was an educational day for teachers and public health nurses. Due to time constraint, these activities were not repeated. Therefore, we did not obtain these data from discussions between laypersons and professionals. In all, 40 children were identified as fulfilling criteria for participation in the project, but some subsequently failed to keep appointments for various reasons, including the following: the child or someone in the family was sick, long distances, bad weather and parents’ work schedules. Because of these recruitment difficulties, 31 children participated. Additionally, the recruitment process was viewed as an ethical dilemma by the LPC and the researcher, who had to weight the child’s need for protection with the child’s right to participate (Alderson & Morrow, 2004).

The children and families were recruited consecutively from children who were admitted to the paediatric ward. The included individuals presented home addresses throughout the county, which meant that families had travelled long distances to participate. Morgan et al. (2002) also experienced recruitment problems and found it easier to recruit children from schools or pre-existing groups. Recruitment from pre-excising groups may have been a solution for this study. Using focus group interviews, the same children could have met each other several times and could have been recruited from areas closer to the hospital, resulting in shorter travel distances. However, this could have lead to more limited representation.

Deciding the scope of the project

The educational material was developed to be used both in hospital and primary health care. It was seen as important by the project group that a holistic approach was an important component of the study. In accordance with health promotion strategies, this type of approach relies on interdisciplinary and intersectoral collaboration at all levels in the health care system (Rootman et al., 2001; WHO, 1986). As a result, staff members from the ward, representatives from the primary health care setting and a representative from primary school were included in the project. One of the benefits of this intersectoral collaboration for the care of children with asthma was that many people feel ownership of the project and a responsibility to adopt routines that would enable its progress. This wide demonstration of attention may have led to increased awareness about children with asthma among staff members in the paediatric ward, in the primary health care setting and in the school. One drawback was that, due to the large number of people involved, the project at times lost its focus on the pedagogic approach. The wide scope of the project also took some attention from the children. The researcher and the LPC were not able to fully appreciate the process being in ‘the middle of it’. It was not until after the project had been completed that it became possible to take a step back, analyse the data and reflect on the processes.

Discussion

The co-operative inquiry approach was comprehensively applied in this project, where staff members from the paediatric ward, the primary health care setting, and the school each participated in the project. Some advantages of such an approach are that the inquiry process adopts a health promotion perspective with a holistic view on health, has a bottom-up perspective, and is rooted in practice. One disadvantage of this approach is that the method is time-consuming and requires an experienced researcher. Additionally, it can be easy to lose individual perspective when in the middle of the process. In retrospect, a longer evaluation period would be needed to fully understand the meaning of this research for the participants involved, as they are all involved in a life-long learning process. New public health legislation in Norway (The Norwegian Public Health Act, 2011) encourages collaboration between professionals and disciplines, and the knowledge gained by this project can be applied and used at later stages of development.

The staff’s prior experience from 1995 to 1998 positively influenced their present work regarding the AEP for children with asthma. The staff members initiated the work more quickly than expected, and the findings showed improvement in follow-up procedures and the educational material was applied. However, after an initial enthusiasm, the project faced resistance. This alternation between enthusiasm and resistance is in line with previous co-operative inquiry studies and work in general that involve change (Watzlawick, Weakland, & Fish, 1974). The project took place over an extended period of time and there were challenges related to gathering staff members for discussions on new practices. Time pressure is known to be a challenge for participatory action research and can lead to a reduced quality of planned activities (Jacobs, 2010). Bringing about change requires endurance and a long-term perspective. However, resistance in a project may be a necessary prerequisite for development and has been described as a sound sign of reflective questioning (Hummelvoll, 2003; Hummelvoll & Severinsson, 2005). One potential way to mediate resistance is to provide positive feedback for progress continuously in the inquiry process.

Reflections on the researcher’s and the local project coordinator’s roles and collaboration

The LPC, along with active support from the management, greatly assisted with the project. The researcher and the LPC had a close collaboration and used meetings and telephone calls to share their reflections and thoughts throughout the project. Moreover, the LPC and the researcher ran the project as a team as both were educated in the methods and ethics of action research and contributed to this collaboration. They both faced numerous tasks, which they found difficult to prioritize. Both perceived their roles as a difficult balancing act between the practical development work (i.e. planning dialogue-based teaching), formal research (i.e. planning how to perform the interviews with children together) and analysis and reflection (i.e. attempting to inspire the staff in a positive way and to encourage them to try the new approaches and education materials). The collaboration between the LPC and the researcher was very important, and in our view, the success of a co-operative inquiry project is dependent on an optimal level of collaboration between the LPC and the researcher.

The notes made by the researcher and the LPC highlighted the different roles of the researcher and LPC. Both positions were required to balance the active versus expectant role for their involvement and balancing between being ‘insider’ and ‘outsider’ researchers. During the first step, they were active in initiating and planning the project. In the next step, they played a more expectant role by transferring more responsibility to the staff and providing them with the opportunity to establish ownership of the project. This appeared to work well, as staff members initially worked intensively and were actively involved. Later, when the project was met with signs of resistance, a more active and supportive role from the researcher and LPC could have contributed to the staff’s motivation. The researcher had previously worked on the ward and had been a nursing instructor on the ward. Thus, she can be described as an insider researcher, given her previous understanding of the field and her knowledge of the unit’s language and culture. Because of this knowledge, it was easy for her to visit the ward and become a part of the social environment. Coghlan and Casey (2001) claim that insider action researchers may play important roles in framing action research projects, although they need to be aware of their own strengths and limitations. If they consider these challenges, the researchers should take advantage of the opportunity to perform such research because it contributes to increased knowledge for the field. Later, during step III, the researcher experienced a dilemma in terms of prioritising her resources and time spent between time and attention for the quality of the research and to the practical tasks in the ward.

Children’s participation

Co-operative inquiry can be a suitable research method with children because the method itself emphasizes a mutual understanding between the researcher and the groups involved. However, this method will only be successful if the researchers and health care professionals work with the children on their terms and from their perspective. The inclusion of children’s perspectives in research requires that the research is developed with the children: the researcher develops the initial ideas and structures but needs to offer flexibility and sensitivity in order to adapt to the children’s ideas and views. It was only in step III, the intervention, that children and adults worked together, and in this phase, both were active participants and the project succeeded in creating mutual dialogue and real participation with the children (Hart, 2008; Jensen, 2009). As part of step III, the children’s perspectives (Sommer et al., 2010) were taken into account using several techniques, including the interviews and group processes of the AEP, sensitivity while listening to the children, creation of safe and empowering conditions, emphatic communication and use of drawings and speech bubbles to encourage the children to freely express their views. In steps I, II and IV, the child perspectives were taken into account by adults (i.e. laypersons, researchers and HCPs). Davis (2009) states that there is a conflict that exist in participatory research with children, as children should be involved at an early age, but a range of institutional, ethical and legal issues may limit the ideal level of involvement. These ethical considerations suggest the existence of a clash between the child’s need for protection and the child’s right to participate (i.e. making their voices heard, having their own opinions and make their own decisions) (Alderson & Morrow, 2004; Unicef, 1989). For projects where the children’s perspectives are central, an additional challenge is manifest as the need to take care of children’s views and interests in a way that provide children with a voice and real participation. Collaboration with children between the ages of 7 and 10 as co-researchers requires that special attention is paid to their age and developmental stage. As this age group has a shorter attention span, participation cannot be too lengthy and should be organized round fun child-focused activities (Hill, Gallagher, & Whiting, 2009). Co-operative inquiry is a wide-ranging research method, and there is a risk that the child perspective may be neglected in the comprehensive processes in the project.

The three main cornerstones of co-operative inquiry seem to have been included in this project, specifically the aspect of creating knowledge in practical situations with the aim of becoming useful in practice. The project was based on participatory and holistic knowing, and all of the groups involved met in a mutual working process. From a broader perspective, it is reasonable to propose that this project contributed towards increasing general knowledge about how children can participate and learn in the context of paediatric care.

Validity

For co-operative inquiry, validity is dependent on a reflective and critical attitude of the researchers and co-researchers, which is known as ‘critical subjectivity’ (Reason, 1994). In this study, the researchers and co-researchers (children, parents and HCPs) reflected together during interviews, FGs and dialogue-based teaching. Validity is secured by all the steps in the co-operative research process are described thoroughly, such that others can evaluate the work. In the presentation of the findings, quotations from interviews and notes were used to illuminate the children’s perspectives and validate the findings. To achieve trustworthiness (Patton, 2002), four researchers with different perspectives (public health, mental health, nursing, social science) have analysed and discussed the findings. A qualitative analysis is typically conducted with small samples because the primary purpose is to yield rich, descriptive data. As a result, the findings become transferable to other settings and can serve to generate new hypotheses and ideas about how children can be involved in research and development projects.

Conclusion

The findings from this approach showed that co-operative inquiry is a suitable research method for use with children if researchers and health care professionals are able to work with children on the children’s own terms and from their perspectives. Health care professionals can create knowledge and learn new communication approaches for use with children and change their daily practice accordingly. Critical methodological choices related to recruitment challenges involving children and families were made, resulting in changes in research methods. The decision to include intersectoral collaboration widened the scope in the project, but might have weakened the main focus on the pedagogic approach. Bringing about change requires endurance and a long-term perspective. Children between the ages of 7 and 10 years are competent actors who can be involved in research and thus can represent an activated source of knowledge. Ethical guidelines in research should be followed, and special attention should highlight children as a vulnerable group, although this should not lead to their overprotection or to the rejection of children’s rights to participate. Further research should focus on research methods and techniques that involve children in a way that can be enjoyable and that gives children a voice and a meaningful avenue of participation.

Footnotes

Acknowledgements

The authors would like to thank the children, their families and health care personnel for participating in this study. We want to thank Reidun Nordbach, a nurse specializing in asthma, for her contribution in the study. We also thank Svante Lifvergren, for leading the review process for the authors of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Funding

We thank Hedmark University College, Innlandet Hospital Trust and Nordic School of Public Health which supported the study. No other commercial funding is involved.

Author biographies

Anne Trollvik is a public health nurse and obtained her PhD in Public Health at the Nordic School of Public Health NHV, Gothenburg, Sweden in 2012. Since 2001 she has been a lecturer at Hedmark University College, Faculty of Public Health. Her research interest is within children and family perspective, participatory research, health promotion and pedagogic approaches in health education.

Bengt G Eriksson has a PhD in social work and is Professor in Mental Health Work and Psychosocial Work at Hedmark University College, Norway. From 1998 he was an Associate Professor in Social Care/Social Work at Karlstad University, Sweden. Between 2000 and 2009 he was head of a Welfare Research & Development unit, conducting action research studies and practice change work in co-operation between university, municipalities and health care authorities. Research interests are mainly on practice-oriented evaluation work in the welfare sector, care for people with mental health problems and care for the elderly.

Karin C Ringsberg has a PhD in social medicine and public health. She is a Professor of Public Health at the Nordic School of Public Health NHV, Gothenburg, Sweden. Her research topics include health promotion, health education, communication and symptom and diagnosing; intimate partner violence, patients with asthma-like symptoms, drama education with patients suffering from dementia. She is the leader of a project about promoting health among Nordic children aged 3–5 years old.

Jan Kåre Hummelvoll is Professor of Psychiatric Nursing and Mental Health Care at Faculty of Public Health, Hedmark University College, Norway. He obtained his doctoral degree in Public Health at the Nordic School of Public Health, Gothenburg, Sweden. He has published several books and scientific articles in the field of psychiatric nursing/mental health care, research methodology and ethics. His main research interests are concerned with qualitative and action oriented research methodology.

References

Alderson

Morrow

(2004) Ethics, social research and consulting with children and young people, Ilford: Barnardo’s.

Aspeli, W., & Bø, H. (2001). Ane og Bronky- i farta! [Ane and Bronky – On the move]. Oslo: National Strategy for Asthma Education and The Norwegian Asthma and Allergy Association. Retrieved from http://www.naaf.no/Documents/Opplæring/Ane%20og%20Bronky%20-%20i%20farta!%202010.pdf.

Boyd

Lasserson

T. J.

McKean

M. C.

Gibson

P. G.

Ducharme

F. M.

Haby

(2009) Interventions for educating children who are at risk of asthma-related emergency department attendance. Cochrane Database of Systematic Reviews (Online), 2(2): CD001290–CD001290.

Christensen

James

(2008) Research with children: Perspectives and practices, 2nd ed. London: Routledge.

Coghlan

(2011) Action research: Exploring perspectives on a philosophy of practical knowing. Academy of Management Annals, 5: 53–87.

Coghlan

Casey

(2001) Action research from the inside: Issues and challenges in doing action research in your own hospital. Journal of Advanced Nursing, 35(5): 674–682.

Coyne

(2008) Children’s participation in consultations and decision-making at health service level: A review of the literature. International Journal of Nursing Studies, 45(11): 1682–1689.

Davis

J. M.

(2009) Involving children. In: Tisdall

E. K. M.

Davis

J. M.

Gallagher

(eds) Researching with children and young people: Research design, methods and analysis, London: SAGE, pp. 154–167.

Declaration of Helsinki. (2008). Ethical principles for medical research involving human subjects. Retrieved from http://www.wma.net/en/30publications/10policies/b3/index.html.

10.

Driessnack

(2005) Children’s drawings as facilitators of communication: A meta-analysis. Journal of Pediatric Nursing, 20(6): 415–423.

11.

Egner

(1949) Karius og Baktus, Oslo: Mittet.

12.

Fargas-Malet

McSherry

Larkin

Robinson

(2010) Research with children: Methodological issues and innovative techniques. Journal of Early Childhood Research, 8(2): 175–192.

13.

Gibson

C. H.

(1991) A concept analysis of empowerment. Journal of Advanced Nursing, 16(3): 354–361.

14.

GINA. (1998). Gina report. Global Strategy for Asthma Management and Prevention Retrieved from http://www.ginasthma.org/guidelines-pocket-guide-for-asthma-management.html.

15.

Graneheim

U. H.

Lundman

(2004) Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2): 105–112.

16.

Granerud, A. (2008). Social integration for people with mental health problems: Experiences, perspectives and practical changes. Dissertation, NHV, Gothenburg.

17.

Hart

R. A.

(2008) Stepping back from ‘the ladder’: Reflections on a model of participatory work with children. In: Reid

Jensen

B. B.

Nikel

Simovska

(eds) Participation and learning: Perspectives on education and the environment, health and sustainability, New York: Springer, pp. 19–31.

18.

Heron

Reason

(2006) The practice of co-operative inquiry: Research ‘with’ rather than ‘on’ people. In: Reason

Bradbury

(eds) Handbook of action research, London: SAGE, pp. 144–154.

19.

Hill

Gallagher

Whiting

(2009) Group work toolkit. In: Tisdall

E. K. M.

Davis

J. M.

Gallagher

(eds) Researching with children and young people: Research design, methods and analysis, London: SAGE, pp. 128–150.

20.

Holter

I. M.

Schwartz-Barcott

(1993) Action research: What is it? How has it been used and how can it be used in nursing? Journal of Advanced Nursing, 18(2): 298–304.

21.

Hummelvoll

J. K.

(2003) Kunnskapsdannelse i praksis: Handlingsorientert forskningssamarbeid i akuttpsykiatrien, Oslo: Universitetsforlaget.

22.

Hummelvoll

J. K.

(2008) The multistage focus group interview: A relevant and fruitful method in action research based on a cooperative inquiry perspective. Norsk Tidsskrift for Sykepleieforskning, 1: 3–15.

23.

Hummelvoll

J. K.

Severinsson

(2005) Researchers’ experience of co-operative inquiry in acute mental health care. Journal of Advanced Nursing, 52(2): 180–188.

24.

Jacobs

(2010) Conflicting demands and the power of defensive routines in participatory action research. Action Research, 8(4): 367–386.

25.

Jensen, B. B. (2009). Et sundhetspædagogisk syn på sundhetsfremme og forebyggelse. In M. Carlsson, V. Simovska, & B.B. Jensen (Eds), Sundhedspædagogik og sundhedsfremme: Teori, forskning og praksis. Århus: Århus Universitetsforlag.

26.

Kirk

(2007) Methodological and ethical issues in conducting qualitative research with children and young people: A literature review. International Journal of Nursing Studies, 44(7): 1250–1260.

27.

Lewin

(1997) Resolving social conflicts, Washington, DC: American Psychological Association.

28.

Moore

Kirk

(2010) A literature review of children’s and young people’s participation in decisions relating to health care. Journal of Clinical Nursing, 19(15–16): 2215–2225.

29.

Morgan

D. L.

(1997) Focus groups as qualitative research, Thousand Oaks, CA: SAGE.

30.

Morgan

Gibbs

Maxwell

Britten

(2002) Hearing children’s voices: Methodological issues in conducting focus groups with children aged 7–11 years. Qualitative Research, 2(1): 5–20.

31.

National Strategy for Asthma Education. (2001). Nasjonal Plan for Astmaskoler. Oslo: The Norwegian Asthma and Allergy Association. Retrieved from http://naaf.no/no/tjenester/Flash/Astmaskoler—NPAS-/Nasjonal-Plan-for-Astmaskoler-NPAS-/.

32.

National Strategy for Asthma Education. (2010). Veilederen for helsepersonell [The guide to health care personnel]. Oslo: The Norwegian Asthma and Allergy Association. Retrieved from http://www.naaf.no/Documents/Opplæring/VEILEDEREN%20til%20helsepersonell%202010.pdf.

33.

O’Kane

(2008) The development of participatory techniques. In: Christensen

P. M.

James

(eds) Research with children: Perspectives and practices, London: Falmer Press.

34.

Patton

M. Q.

(2002) Qualitative research and evaluation methods, 3rd edn. Thousand Oaks, CA: SAGE.

35.

Punch

(2002a) Interviewing strategies with young people: The ‘secret box’, stimulus material and task-based activities. Children & Society, 16(1): 45–56.

36.

Punch

(2002b) Research with children: The same or different from research with adults? Childhood, 9(3): 321–341.

37.

Reason

(1994) Three approaches to participatory research inquiry. In: Denzin

N. K.

Lincoln

Y. S.

(eds) Handbook of qualitative research, London: SAGE.

38.

Reason

Heron

(1986) Research with people: The paradigm of cooperative experiential inquiry. Person Centred Review, 1(4): 456–475.

39.

Rootman

Goodstadt

Hyndman

McQueen

Potvin

Springett

Ziglio

(2001) Evaluation in health promotion: Principles and perspectives, Copenhagen: WHO Regional Office Europe.

40.

Söderbäck

Coyne

Harder

(2011) The importance of including both a child perspective and the child’s perspective within health care settings to provide truly child-centred care. Journal of Child Health Care, 15(2): 99–106.

41.

Sommer

Pramling Samuelsson

Hundeide

(2010) Child perspectives and children’s perspectives in theory and practice, Dordrecht: Springer.

42.

Starrin

(1993) Tillämpad social forskning. In: Holmer

Starrin

(eds) Deltagarorienterad forskning, Lund: Studentlitteratur, pp. 11–26.

43.

The Norwegian Public Health Act. (2011). Oslo: Norwegian Government: Ministry of Health and Care. Retrieved from http://www.regjeringen.no/upload/HOD/Hoeringer%20FHA_FOS/123.pdf.

44.

Trollvik

Nordbach

Silen

Ringsberg

K. C.

(2011) Children’s experiences of living with asthma: Fear of exacerbations and being ostracized. Journal of Pediatric Nursing, 26(4): 295–303.

45.

Unicef. (2008). The Convention on the Rights of the Child. Retrieved 29 December 2011, from http://www.unicef.org/crc/.

46.

Watzlawick

Weakland

Fish

(1974) Change: Principles of problem formation and problem resolution, New York: Norton.

47.

WHO (1986) The Ottawa Charter for Health Promotion, Geneva: WHO.

48.

Wolf

F. M.

Guevara

J. P.

Grum

C. M.

Clark

N. M.

Cates

C. J.

(2002) Educational interventions for asthma in children (review). Cochrane Database of Systematic Reviews, 326(4):