Communication can be challenging in consultations involving children and their parents, as they may have different views and priorities
Nurses are expected to treat children, young people and their parents as individuals and respect their dignity. Some information about asthma symptoms and about what is most important to children can only be obtained by communicating directly with children themselves rather than relying on parents.Consultations about children’s asthma usually have three participants - nurse, parent and child. Children often take a passive role or are marginalised, sometimes by parents’ interventions . Nurses need to take account of children’s views and preferences, and build alliances with parents and children. Nursing needs to develop its own evidence base for practice, to underpin training and education.
Citation: Callery P (2013) Communicating with children with asthma. Nursing Times; 109: 7, 22-23.
Author: Peter Callery is professor of children’s nursing, School of Nursing, Midwifery and Social Work at University of Manchester
- This article has been double-blind peer reviewed
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Nurses are expected to treat children, young people and their parents as individuals and respect their dignity. The skilled nature of communication with children and young people about their healthcare is emphasised by Nursing and Midwifery Council (2012) guidance. It states:
“Use your knowledge and expertise to communicate directly with children and young people; listen and respond appropriately to what they say themselves.”
The guidance also recognises that parents cannot always be assumed to speak for their children. There do not need to be major disputes in a family for there to be differences of views and perspectives about children’s health and its effect on their quality of life (Eiser and Jenney, 2007; Guyatt et al, 1997).
Asthma and communication
It can be striking how differently children and parents talk about a common health condition such as asthma. Perhaps this is not surprising if we recognise that children are people in their own right, with their own concerns, experiences and priorities.
A child’s focus can be on the daily impact of appearing different from peers at school, whereas parents may be more concerned about acute asthma attacks (Callery et al, 2003). Some information about symptoms and about what is most important to children can therefore only be obtained by communicating directly with them.
Effective communication is important because reviewing asthma management plans and ensuring that the medical regimen is tailored to children’s and families’ daily routines can reduce the need for urgent care (Clark et al, 2008). Practitioners need to identify, with individual children or young people and their parents, those areas where they want treatment to have effect and to negotiate personalised plans for their care (British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2008).
Communication in triadic consultations
Communication is important in all practice, central to nursing consultations and a key element of nurse-led services (Chandler, 2007; Madge et al, 1997) and practice nursing in primary care. Nursing practice should be based on the best available evidence (NMC, 2012) but there is limited research to guide nurses in communicating with children, young people and parents. Available research includes the identification of topics raised by nurses and opportunities for parents to express their views in child health promotion consultations (Baggens, 2001), and use of “small talk” to prepare mothers and children for immunisation by injection (Plumridge et al, 2009).
Consultations with children are usually triadic, meaning that they involve a parent or other carer as well as the patient. Triadic communication presents challenges for respecting the needs and preferences of children as well as parents. Research into medical consultations has shown children can have few opportunities to contribute and the nature of their involvement can also be limited, for example, to social interaction rather than discussion of health problems and treatments (Tates and Meeuwesen, 2001). Children can also feel marginalised in consultations: “they’re talking about me… but sure I wouldn’t be listening” (Savage and Callery, 2007).
Sometimes children may wish to adopt passive roles in triadic interactions (Lambert et al, 2011) and nurses may need to adapt their approach to children’s changing preferences for involvement.
Encouraging children to speak
In conversations, we take turns to speak and often end our turn by indicating an expectation about who will talk next. This can be explicit, for example by asking a named person a question, implicit, verbal and/or non-verbal. Nurses used these techniques to encourage children to take turns in our study of asthma review consultations (Callery and Milnes, 2012).
In this study, we analysed audio recordings of nine asthma review consultations between nurses, parents and children aged 7-12 years. We also interviewed 18 parents or other adult carers and six nurses to provide the context of communication in asthma consultations (Bensing et al, 2003). The initial focus of analysis was examination of children’s contribution to conversation sequences. The analysis then progressed to examine interactions between nurses and parents, including comparison of themes discussed in interviews and the topics discussed in consultations.
How interactions took place
Although the consultations studied were triadic, the interactions principally occurred between two members of the triad at any one time, with the third member an observer of the dyad of nurse-parent, nurse-child, or parent-child.
Nurses often directed questions to children or used other verbal indications that they expected children to take the next conversational turn. Parents could therefore be in the role of observer for some time. In interviews, they explained that they valued the attention given to their children and the relationships they observed nurses forming with them. They wanted their children to have friendly interactions with nurses, which could give them opportunities to provide information themselves. Children could tell nurses things of which parents were not aware.
However, parents found ways to intervene in the conversation. This could be by expanding on children’s responses, to add details that children had not mentioned. They sometimes intervened to contradict their child, or to raise topics that had not been discussed. After responding to such interventions, nurses often sought to offer the next turn to the child, either by a direct question or a clear verbal indication.
Implications for nursing practice
These patterns of interaction illustrate the complex dynamics that can occur in triadic consultations. Parents and nurses talked about the importance of involving children in communication but parents wanted to be sure nurses were given information that children might not offer themselves. They could also have their own concerns about asthma and treatment. Nurses expressed concerns that children could look to their parents to answer questions that the nurses wanted the children to answer.
This was a small study but it indicates the need for more research into interactions between nurses, children and parents.
There are further messages for practice in the literature.
Although non-focused, general questions can give more opportunity for children to influence consultations, they can find it easier to respond to focused, more specific questions (Clemente et al, 2008).
Building alliances has been identified as a key objective of healthcare consultations (Heritage and Maynard, 2006). Collaboration depends on personal relationships based on mutual trust and respect. Thus nurses need to consider how they can form therapeutic alliances with parents and children, by promoting personal relationships and shared work on the tasks of managing health problems (Hougaard, 1994).
Communication is central to nursing practice and can be particularly challenging in the care of children or young people and their families. More research into communication with children and families is needed. Paediatricians assess their communication practice as part of their postgraduate training (Howells et al, 2010). Nursing needs to develop its own evidence base for practice and to underpin training and education of children’s nurses.
- The NMC advises nurses to talk directly to children about their healthcare
- Children with asthma may have different priorities from their parents
- Children may be marginalised in consultations about their asthma
- More research is needed into how such consultations can be most effective
- Nurses need to consider how they can create therapeutic alliances with children and their families
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