Pre-school children frequently seen but seldom heard in nursing care.
Abstract: A significant number of users of nursing services are pre-school children, and have a right to be heard in matters affecting their health. Despite nurses' duty to seek and take seriously the views of children in matters concerning children's health, children are rarely directly consulted as consumers of health care. Thus, children's voices are largely unheard in nursing practice. Furthermore, research about children's experience of illness generally excludes preschool children. Therefore, preschool children's voices are also mostly unheard in nursing research about the experience of being ill. Consequently, there is little evidence from nursing practice or research to show the potential benefits of ensuring these voices are heard. This line of reasoning forms the basis of recommending the need for research that seeks to understand how preschool children experience being ill and how they communicate those experiences to others.

Key Words: Preschool children, children's voices, paediatric nursing.
Article Type: Report
Subject: Nursing (Research)
Children (Health aspects)
Pediatric nursing
Medical research
Medicine, Experimental
Author: Watson, Paul
Pub Date: 11/01/2008
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2008 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: Nov, 2008 Source Volume: 24 Source Issue: 3
Product: Product Code: 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs
Accession Number: 206603854
Full Text: Introduction

The importance of hearing children's voices in health care is evident in the following example from my experience as a registered nurse caring for a primary school aged child admitted for elective surgery. While completing a routine preoperative checklist with a child (approximately 8-years-old) and his mother, I asked the mother whether the child was allergic to anything. The mother said "no", but the child interrupted saying something like "what about at the party when I was blowing up the balloon?" The mother shrugged off the child's comment as not important. However, I asked the child to tell me more, and he mentioned having tingly lips after blowing up a balloon. I explained to the mother and the child the possible significance of the tingly lips as a sign of an allergy to latex. The anaesthetist was informed; precautions against exposure to latex were taken during the operation and the remainder of the child's stay in hospital. Subsequent testing confirmed the child had a latex allergy. This incident highlights the potential benefits of ensuring children's voices are heard and given due weight in their health care.

Preschool children (being those less than five years of age), rather than school aged children, are the group of children seen the most by nurses in primary, secondary, and tertiary health care settings (Ministry of Health, 2008). Despite this fact the potential benefits of ensuring preschool children's voices are heard and given due weight in their health care are largely unknown. In part this is because contemporary nursing practice in child health tends to rely on adults, usually a parent, to represent the views of children, particularly preschool children, and also because preschool children are largely excluded from the research on children's experience of illness. My argument is not about the rights of children versus the rights of their parents, or about who decides what is in the best interests of the child, or about the competence of children. In this article I detail my line of reasoning that all children including preschool children have a right to be heard and that, because preschool children's voices are largely unheard in nursing practice and nursing research, nurses do not know the potential benefits of this source of data.

Children's Right to be Heard

The Child Health Strategy (Ministry of Health, 1998) which forms the basis of the New Zealand Government's plans for improving child health through to 2010, is framed around a vision of "our children/tamariki: seen, heard [italics added] and getting what they need" (p. 17). This vision is consistent with Article 12 of the United Nations Convention on the Rights of the Child (United Nations High Commissioner for Human Rights, [UNHCHR] 1989). Under Article 12 of the Convention, States that have ratified the convention have agreed to:

Assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child. (UNHCHR, p. 4)

Lansdown (1994) argues Article 12 is "fundamental both to the Convention and the recognition of children as people with a right to be heard" (p. 37). The Convention therefore guides health professionals to treat children as people with a right to be heard (Melton, 1998).

The abovementioned Convention is central to the international movement on children's rights. Those rights include the provision of health care, protection from harm, and the right to full participation in decisions that affect their lives. The Convention was adopted by the General Assembly in 1989 and ratified by New Zealand in 1993. Subsequently the children's rights movement is starting to have an impact on practices in the New Zealand justice, social welfare and education systems (See Atwool, 1998, 2000; Carr, 2000; Smith, Gollop, & Taylor, 2000; Taylor, Gollop, 8v Smith, 2000 for examples). However, in relation to children's health the Children's Commissioner (2006) suggests little has changed since McDowell's (1997) claim that there was, scant evidence of children's rights affecting practices in the New Zealand health care system.

Some legislative support for article 12 of the United Nations Convention on the rights of the child is provided through Section 74 of the Health and Disability Commissioner Act (1994) which includes a regulation allowing for the prescription of a Code of Health and Disability Services Consumers' Rights. The rights in the Code of Health and Disability Services Consumer Rights (1996) apply to all consumers of health and disability services in New Zealand, regardless of whether they are children or adults. The Code therefore provides regulatory protection for the rights of children as consumers of health and disability services. Those relevant to this discussion include:

* The right to be treated with respect (right 1), which includes the right to be provided with services that take into account the needs, values and beliefs of different cultural, religious, social and ethnic groups, including the needs, values, and beliefs of Maori (right 1 (clause 3)).

* The right to have services provided in a manner that respects the dignity and independence of the individual (right 3).

* The right to effective communication (right 5), which includes the right to an environment that enables both consumers and provider to communicate openly, honestly, and effectively (right 5 (clause 2)).

* The right to make an informed choice and give informed consent (right 7) which includes a presumption of competence, unless there are reasonable grounds for believing that the consumer is not competent (right 7 (clause 2)). Furthermore, individuals with diminished competence are extended the right to consent, to the extent appropriate to his or her level of competence (right 7 (clause 3)).

One message for providers of child health services within these regulatory rights is that they have a duty to seek and take seriously the views of children in matters concerning children's health. Unfortunately despite these regulatory rights, the United Nations Convention, and the vision for child health, it is still the case that children are rarely consulted as health care consumers (Coyne, 2006; Dickinson, 2004; Hart & Chesson, 1998).

Children's Voices in Nursing Care

Not only are children rarely consulted as consumers, but historical, and to a large extent contemporary nursing practice in child health has relied on adults, usually a parent, to give an account of their child's illness experience. At first it seems eminently reasonable for nurses working with children to rely on parents'/ caregivers' accounts of their child's illness. After all parents/ caregivers have privileged access to their children's life experiences and they tend to know and understand their children well (van Manen 8v Levering, 1996). However, the assumption that these accounts of the child's illness experience coincide with the child's experience or the child's account is questionable.

Child health nurses' reliance on adult accounts of children's illness experiences may reflect their commitment to family-centred care. The concept of family-centred care is widely regarded as fundamental to the provision of nursing care to children, at home, in the community and in hospital (Darbyshire, 1995; Nethercott, 1993; Power 8v Franck, 2008). The orientation of child nursing towards the family can create a paradox between the rights and needs of the child and the rights and needs of the family. While there is no question that nursing children requires a strong orientation towards caring for the child and the family/ wh[??]nau, it is regrettable that very little of the literature on family-centred care acknowledges that the best interests of the child shall be the primary consideration and may not always be addressed by focusing on the family rather than the individual child.

The dominant perspective that regards children as developmentally immature and unable to understand and describe their world and life experiences may also contribute to nurses' reliance on adults' accounts of children's illness experiences rather than the accounts of children themselves. While children's biological immaturity is a fact, the way in which that immaturity is understood and enacted is socially and culturally constructed (Prout & James, 1997). The view that preschool children are unable to understand and describe their world and experiences is not supported by research. Research demonstrates that under some conditions children under 5-years-old and as young as 2-years-old can recall quite accurately, information about personally experienced events (Docherty & Sandelowski, 1999; Fivush, Gray, & Fromhoff, 1987; Fivush & Hamond, 1989; Follmer Greenhoot, Ornstein, Gordon, & Baker-Ward, 1999; Liwag & Stein, 1995; Merritt, Ornstein, & Spicker, 1994; Ornstein, Gordon, & Larus, 1992).

In a nursing context the meaning of the illness experience from the child's perspective may be as important as the accuracy of their parent's account of the specific events that were part of that experience. Van Manen (1999) stresses the pathic nature of nursing practice, which focuses directly on the ill person rather than the diagnostic or prognostic aspects of the experience. Similarly, Gadow (1995) argues for the centrality of the patient's meaning of the illness experience in nursing assessment. The meaning of the illness experience from the child's perspective is also relevant within the medical context. Wulff (1995) distinguishes four components used by physicians in making clinical decisions: the biological, the empirical, the empathic/ hermeneutic, and the ethical component. The empathic/ hermeneutic component acknowledges that the state of illness cannot be identified without attention to "the patient's personal experience of the symptoms in the context of his or her own life" (Wulff, p. 305).

Reports by patients of their experiences of illness are a practical and integral part of the data interpreted by health professionals in the process of making clinical decisions (Good & Good, 1981). Adult accounts of children's illness experiences in child health care are undoubtedly significant to clinical decision-making. However, Ireland and Holloway (1996) have argued that to focus on adult accounts of children's illness to the exclusion of the child's perspective about their illness might prevent health professionals from obtaining important and relevant information. This is not an argument to exclude adult accounts of children's illnesses. Rather it is an acknowledgement that adult accounts of a child's illness provide only part of the picture. The missing piece of the puzzle is the child's perspective which should be obtained and given due weight in clinical decision-making.

Children's Voices in Research

There is now some research that addresses from the child's perspective how children experience various illnesses and aspects of being ill. However, researchers have tended to focus on school aged children with chronic illnesses such as, asthma (Yoos & McMullen, 1996), attention deficit hyperactivity disorder (Kendall, Hatton, Beckett, & Leo, 2003), cancer (Hockenberry-Eaton & Minick, 1994), diabetes (Miller, 1999), and liver transplant recipients (Wise, 2002), to name a few. Some researchers have included school aged children with a range of chronic illnesses (e.g. Sartain, Clarke, & Heyman, 2000; Woodgate, 1998). Researchers have also begun to address, from the child's perspective, how school aged children experience factors associated with being ill, such as hospitalisation (Boyd & Hunsberger, 1998; Carney et al., 2003; Forsner, Jansson, & Sorlie, 2005) and acute pain (Alex & Ritchie, 1992; Polkki, Pietila, & Vehvilainen-Julkunen, 2003; Woodgate & Kristjanson, 1996). Nevertheless research on the school aged child's perspective on various, mainly chronic illnesses, cannot be generalised to the experience of preschool children who predominantly are seen by nurses for well child health checks or because of short term passing illnesses.

Even though preschool children are significant users of health services, research literature has given scant attention to understanding the experience of illness, from the children's own point of view. Of the studies listed above only two--Woodgate and Kristjanson's (1996) study of young children's perception of postoperative pain and Carnevale's (1997) study of what it is like for a child to be critically ill--included preschool children. The scant attention in the research literature to understanding the preschool child's subjective experience of illness can be attributed in part to the methodological difficulties of conducting research with this young age group. The limits of preschool children's language abilities inevitably constrain research reliant on verbal fluency. When it comes to research with preschool children there is a need to develop new methodologies that move away from the traditional heavy reliance upon verbal data.


Despite international conventions and national statutes confirming the rights of children to have their voices heard in relation to health care, nurses and other health professionals face practical challenges in understanding and communicating with preschool children who because of short-term passing illnesses are frequent users of health services. Understanding the child's experience is an important component of nursing children but one that is progressively more difficult the younger the child. Therefore, particularly with preschool children, an understanding of the child's experience is often neglected in the provision of health services. There is little research based evidence about how preschool children express their views in matters affecting their health and its management. Similarly it is unclear whether their views are recognised and given due weight by adults making decisions related to the child's illness experience. It is likely there are clinical benefits to be gained from understanding how preschool children experience being ill, and to knowing how they communicate this experience to others. There is a need for research that specifically addresses this gap.


I wish to acknowledge Dr Irena Madjar from the University of Auckland and Professor Dianna Keatinge from the University of Newcastle Australia who reviewed an earlier draft of this manuscript.


Alex, M. R., & Ritchie, J. A. (1992). School-aged children's interpretation of their experience with acute surgical pain. Journal of Pediatric Nursing, 7(3), 171-180.

Atwool, N. (1998). Evidential interviewing: Giving children a voice in the courtroom. Childrenz Issues, 2(2), 17-21.

Atwool, N. (2000). Children who have been exposed to risk and trauma. In A. B. Smith, N. J. Taylor & M. M. Gollop (Eds.), Children's voices: Research, policy and practice (pp. 56-71). Auckland: Pearson Education.

Boyd, J. R., & Hunsberger, M. (1998). Chronically ill children coping with repeated hospitalizations: Their perceptions and suggested interventions. Journal of Pediatric Nursing, 13(6), 330-342.

Carnevale, F. A. (1997). The experience of critically ill children: Narratives of unmaking. Intensive and Critical Care Nursing, 13(1), 49-52.

Carney, T., Murphy, S., McClure, J., Bishop, E., Kerr, C., Parker, J., et al. (2003). Children's views of hospitalization: An exploratory study of data collection. Journal of Child Health Care, 7(1), 27-40.

Carr, M. (2000). Seeking children's perspectives about their learning. In A. B. Smith, N. J. Taylor & M. M. Gollop (Eds.), Children's voices: Research, policy and practice (pp. 3755).

Auckland: Pearson Education.

Children's Commissioner. (2006). More than an apple a day: Children's right to good health. Wellington: Author.

Code of Health and Disability Services Consumers' Rights. (1996). Retrieved November 20, 2005, from

Coyne, I. T. (2006). Consultation with children in hospital: Children, parents' and nurses' perspectives. Journal of Clinical Nursing, 15, 61-71.

Darbyshire, P. (1995). Family-centred care within contemporary British paediatric nursing. British Journal of Nursing, 4(1), 31-33.

Dickinson, A. R. (2004). Within the web: Family practitioner relationships in the context of chronic illness. Unpublished doctoral dissertation. Auckland University of Technology, Auckland, New Zealand.

Docherty, S., & Sandelowski, M. (1999). Interviewing Children. Research in Nursing & Health, 22(2), 177-185.

Fivush, R., Gray, J. T., & Fromhoff, F. A. (1987). Two-year-olds talk about the past. Cognitive Development, 2, 393-409.

Fivush, R., & Hamond, N. R. (1989). Time and again: Effects of repetition and retention interval on 2 year olds' event recall. Journal of Experimental Child Psychology, 47, 259273.

Follmer Greenhoot, A., Ornstein, P. A., Gordon, B. N., & Baker-Ward, L. (1999). Acting out the details of a pediatric check-up: The impact of interview condition and behavioural style on children's memory reports. Child Development, 70(2), 363-380.

Forsner, M., Jansson, L., & Sorlie, V. (2005). The experience of being ill as narrated by hospitalized children aged 7-10 years with short term illness. Journal of Child Health Care, 9(2), 153-165.

Gadow, S. (1995). Clinical epistemology: A dialectic of nursing assessment. Canadian Journal of Nursing Research, 27(2), 25-34.

Good, B. J., & Good, M.-J. D. (1981). The meaning of symptoms: A cultural hermeneutic model for clinical practice. In L. Eisenberg & A. Kleinman (Eds.), The relevance of social science for medicine (pp. 165-196). Boston: D. Reidel Publishing Company.

Hart, C., & Chesson, R. (1998). Children as consumers. British Medical Journal, 316, 1600-1603.

Health and Disability Commissioner Act. (1994). Wellington, New Zealand. Hockenberry-Eaton, M., & Minick, P. (1994). Living with Cancer: Children with extraordinary courage. Oncology Nursing Forum, 21(6), 1025-1031.

Ireland, L., & Holloway, I. (1996). Qualitative health research with children. Children & Society, 10, 155-164.

Kendall, J., Hatton, D., Beckett, A., & Leo, M. (2003). Children's accounts of Attention-Deficit/Hyperactivity Disorder. Advances in Nursing Science, 26(2), 114-130.

Lansdown, G. (1994). Children's rights. In B. Mayall (Ed.), Children's childhoods: Observed and experienced (pp. 33-44). London: The Falmer Press.

Liwag, M. D., & Stein, N. L. (1995). Children's memory for emotional events: The importance of emotion-related retrieval cues. Journal of Experimental Child Psychology, 60, 2-31.

McDowell, M. (1997). Medical treatment and children: Assessing the scope of a child's capacity to consent or refuse to consent in New Zealand. Journal of Law and Medicine, 5,81-96.

Melton, G. B. (1998). Children's rights in the health care system: The evolving framework in international human rights and law. Childrenz Issues, 3(2), 13-17.

Merritt, K. A., Ornstein, P. A., & Spicker, B. (1994). Children's memory for a salient medical procedure: Implications for testimony. Pediatrics, 94(1), 17-23.

Miller, S. (1999). Hearing from children who have diabetes. Journal of Child Health Care, 3(l),5-12.

Ministry of Health. (1998). Child health strategy. Wellington, New Zealand: Author.

Ministry of Health. (2008). A portrait of health: Key results of the 2006/07 New Zealand Health Survey. Wellington, New Zealand: Author.

Nethercott, S. (1993). A concept for all the family. Family centred care: A concept analysis. Professional Nurse, 8(12), 794-797.

Ornstein, P. A., Gordon, B. N., & Larus, D. M. (1992). Children's memory for a personally experienced event: Implications for testimony. Applied Psychology, 6, 49-60.

Polkki, T., Pietila, A.-M., & Vehvilainen-Julkunen, K. (2003). Hospitalized children's descriptions of their experiences with postsurgical pain relieving methods. International Journal of Nursing Studies, 40, 33-44.

Power, N., & Franck, L. (2008). Parent participation in the care of hospitalised children: A systematic review. Journal Advanced Nursing, 62(6), 622-641.

Prout, A., & James, A. (1997). A new paradigm for the sociology of childhood? Provenance, promise and problems. In A. James & A. Prout (Eds.), Constructing and reconstructing childhood: Contemporary issues in the sociological study of childhood (pp. 7-33). London: Falmer Press.

Sartain, S. A., Clarke, C., L, & Heyman, R. (2000). Hearing the voices of children with chronic illness. Journal of Advanced Nursing, 32(4), 913-921.

Smith, A. B., Gollop, M. M., & Taylor, N. J. (2000). Children in foster and kinship care. In A. B. Smith, N. J. Taylor & M. M. Gollop (Eds.), Children's voices: Research, policy and practice (pp. 72-90). Auckland: Pearson Education.

Taylor, N. J., Gollop, M. M., & Smith, A. B. (2000). Children and young people's perspectives on their legal representation. In A. B. Smith, N. J. Taylor & M. M. Gollop (Eds.), Children's voices: Research, policy and practice (pp. 110-133). Auckland: Pearson Education.

United Nations High Commissioner for Human Rights. (1989). The United Nations Convention on the rights of the child: United Nations.

van Manen, M. (1999). The pathic nature of inquiry in nursing. In I. Madjar & J. A. Walton (Eds.), Nursing and the experience of illness: Phenomenology in practice (pp. 17-35). Australia: Allen & Unwin.

van Manen, M., & Levering, B. (1996). Childhood's secrets: Intimacy, privacy, and the self reconsidered. New York: Teachers College Press.

Wise, B. (2002). In their own words: The lived experience of pediatric liver transplantation. Qualitative Health Research, 12(1), 74-90.

Woodgate, R., & Kristjanson, L. J. (1996). "My hurts": Hospitalized young children's perceptions of acute pain. Qualitative Health Research, 6(2), 184-201.

Woodgate, R. L. (1998). Adolescents' perspectives on chronic illness: "It's hard" Journal of Pediatric Nursing, 13(4), 210-223.

Wulff, H. R. (1995). The inherent paternalism in clinical practice. The Journal of Medicine and Philosophy, 20, 299-311.

Yoos, L. H., & McMullen, A. (1996). Illness narratives of children with asthma. Pediatric Nursing, 22(4), 285-290.

Paul Watson, RN, PhD, Senior Lecturer, School of Nursing and Human Services, Christchurch Polytechnic Institute of Technology.
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