Experiencing Support During Needle-Related Medical Procedures: A Hermeneutic Study With Young Children (3–7 Years)

Journal of Pediatric Nursing (2016) xx, xxx–xxx

Experiencing Support During Needle-Related Medical Procedures: A Hermeneutic Study With Young Children (3–7 Years) Katarina Karlsson PhD a,⁎, Ann-Charlotte Dalheim Englund PhD a , Karin Enskär b , Maria Nyström a , Ingela Rydström PhD a a

Faculty of Caring Sciences, Work Life and Social Welfare, University of Borås, Borås, Sweden Department of Nursing Sciences, CHILD Research Group, School of Health Sciences, Jönköping University, Jönköping, Sweden

b

Received 29 July 2015; revised 15 June 2016; accepted 17 June 2016

Key words: Younger children; Support; Needle-related medical procedures; Caring science; Reflective lifeworld research; Lifeworld hermeneutic

Background Needle-related medical procedures (NRMPs) are something that all young children need to undergo at some point. These procedures may involve feelings of fear, pain and anxiety, which can cause problems later in life either when seeking healthcare in general or when seeking care specifically involving needles. More knowledge is needed about supporting children during these procedures. Aim: This study aims to explain and understand the meaning of the research phenomenon: support during NRMPs. The lived experiences of the phenomenon are interpreted from the perspective of younger children. Method: The analysis uses a lifeworld hermeneutic approach based on participant observations and interviews with children between 3 and 7 years of age who have experienced NRMPs. Results: The research phenomenon, support for younger children during NRMPs, is understood through the following themes: being the centre of attention, getting help with distractions, being pampered, becoming involved, entrusting oneself to the safety of adults and being rewarded. A comprehensive understanding is presented wherein younger children experience support from adults during NRMPs in order to establish resources and/or strengthen existing resources. Conclusions: The manner in which the child will be guided through the procedure is developed based on the child's reactions. This approach demonstrates that children are actively participating during NRMPs. Supporting younger children during NRMPs consists of guiding them through a shared situation that is mutually beneficial to the child, the parent and the nurse. Play during NRMP is an important tool that enables the support to be perceived as positive. © 2016 Elsevier Inc. All rights reserved.

IN CARE ENVIRONMENTS, children may become stressed by their unfamiliar surroundings and by unpredictable stress factors (Salmela, Aronen, & Salanterä, 2011), such as fear due to unfamiliar people, strange equipment and an unrecognizable environment. Children are vulnerable to such factors (Lindeke, Nakai, & Johnson, 2006), which is partly due to the child's cognitive development level. Due to the child's fantasy, which dominates thinking among children aged 3–7 years ⁎ Corresponding author: Katarina Karlsson, PhD. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2016.06.004 0882-5963/© 2016 Elsevier Inc. All rights reserved.

(Bibace & Walsh, 1980), the child may fear health care in general (Salmela, Salanterä, & Aronen, 2009; Salmela et al., 2011), and needles in particular (Kettwich et al., 2007; Salmela et al., 2009; Salmela et al., 2011; Taddio, Ilersich, Ilersich, & Wells, 2014). Despite these feelings, children must undergo different medical procedures during childhood, and needle-related medical procedures (NRMPs) are common (Blount, Piira, Cohen, & Cheng, 2006; Uman, Chambers, McGrath, & Kisely, 2006; Uman et al., 2013). In this present study, NRMPs are diagnostic needle-based procedures that aim to prevent and treat illness (c.f. Uman et al., 2006, 2013).

2 Research shows that younger children perceive NRMPs as painful and frightening experiences (Karlsson, Rydström, Nyström, Enskär, & Dalheim Englund, 2015). Sixty-three per cent of children and 24% of parents state that they are afraid of needles (Taddio et al., 2012), and it seems that the actual needle stick can be intensified due to this fear (Bird & McMurtry, 2012). If the child has had a previous painful and/or frightening experience during needle procedures, this could act as a distress factor and complicate the current procedure (Noel, McMurtry, Chambers, & McGrath, 2010). Experiencing feelings of fear and pain can also cause problems in the future in relation to NRMPs as well as health care in general (McMurtry et al., 2015). In a study by Salmela, Salanterä, and Aronen (2010a) and Salmela, Salanterä, Routsalainen, and Aronen (2010b), semi-structured interviews were used to identify children's coping strategies for hospital-related fears. The most prominent coping strategies among children were having their parents present (Salmela et al., 2010a) and being reminded of things from their everyday life, such as playing (Salmela et al., 2010b). Lindeke et al. (2006) interviewed children using three open-ended questions and found that the worst things about being hospitalized were related to “shots” and painful procedures. Other consequences from NRMPs that were described by children included seeking security, realizing the adult's power, struggling for control, feeling ashamed and surrendering. These findings were obtained through meaning-oriented interviews and participant observations (Karlsson et al., 2015). Harder, Christensson, Coyne, and Söderbäck (2011) used video-observations and found that children need to be active participants during vaccination using strategies of “tuning-in, affirmative negotiation, and delaying negotiation” (p. 818). Söderbäck (2013) also used video-observations and found that children use different expressions to convey their experiences during venepuncture, such as “watchful engagement, curious engagement, and adaptive engagement, as well as avoidance, forced engagement and resigned engagement” (p. 636). In a study with older children (6–15 years) interviews were performed by asking them about feelings (sadness, fear, anger and happiness). The results showed that hospitalized children also experience feelings of positive character in contact with health care staff. This is described as happiness which would enhance the link between children and health care staff (Corsano et al., 2015). The support given by healthcare professionals during NRMPs can be divided into pharmacological, non-pharmacological or merged types (Blount et al., 2006). Pharmacological support can be offered through topical anesthesia (Abuelkheir et al., 2014; Lander, Weltman, & So, 2006; Shah, Taddio, & Rieder, 2009) and/or by inhaled nitrous oxide (Ekbom, Jakobsson, & Marcus, 2005; Zier, Tarrago, & Liu, 2010). Non-pharmacological support can be provided by staff and/or parents, although, as McCarthy and Kleiber (2006) point out, not all parents are capable of helping to distract their child in a good way. It is also important to be aware that what helps one child will not necessarily help another. Therefore, it requires a customized approach to determine the most appropriate pharmacological

K. Karlsson et al. and/or non-pharmacological actions that suit the individual child (Coyne & Scott, 2014). Examples of non-pharmacological support include distraction and hypnosis, all of which have shown the best results when used by nurses (Taddio & McMurtry, 2015). Additional examples of non-pharmacological support during NRMPs include squeezing a soft ball during intravenous catheter insertion (Sadeghi, Mohammadi, Shamshiri, Bagherzadeh, & Hossinkhani, 2013); blowing soap bubbles or using a heated pillow (Hedén, von Essen, & Ljungman, 2009); watching an animated film (Yoo, Kim, Hur, & Kim, 2011) or looking at distraction cards (Inal & Kelleci, 2012). Gaskell, Binns, Heyhoe, and Jackson (2005) summarized these types of support as “breathing techniques, relaxation techniques, books, games and puzzles, imagery and make believe, sensory experiences, and positive reinforcement” (p. 26). Overall, these studies show positive results regarding reducing pain, fear and anxiety in children undergoing NRMPs. In the last few years, an increasing number of studies have given voice to children's thoughts and feeling about being hospitalized. However, few studies have been based on younger children's experiences about illness, treatment and medical procedures (Irwin & Johnson, 2005; Kortesluoma & Nikkonen, 2006; Kortesluoma, Nikkonen, & Serlo, 2008). Instead, a proxy, such as parents or nurses, has often been used (c.f. Hedén et al., 2009; Hedén, von Essen, & Ljungman, 2015; Jonas, 2003; Twycross, 2002; von Baeyer & Spagrud, 2007). As there is reason to believe that younger children are more vulnerable during needle procedures and therefore may need a different kind of support compared to older children, it is important to ask the younger children (3–7 years) themselves in order to further understand how adults can help them during these procedures. Therefore, the aim of this study is to explain and understand the meaning of support during NRMPs from the perspective of younger children.

Methods Approach This study is interpretative in order to reach an in-depth understanding of the research phenomenon (i.e. support during NRMP) as a lived experience (hereafter called the phenomenon). The theoretical framework is lifeworld hermeneutics, and it aims to understand the phenomenon from young children's perspective, not to create evidence in terms of testing a hypothesis (Dahlberg, Dahlberg, & Nyström, 2008). Lifeworld research requires an open attitude to the phenomenon throughout the entire research process, which is indeed easier said than done. It can be clarified as the efforts undertaken to hold back what one knows or thinks that one knows. The German philosopher Hans-Georg Gadamer (1960/2004) emphasized that a researcher must try to ignore his/her pre-understanding in order to see something new and different. In hermeneutics, it is customary to view Gadamer's (1960/2004) philosophy as a basis for the openness that is required in a lifeworld hermeneutic approach. However, the process of interpretation also includes the distancing, questioning and critical approach advocated by

Young Children and Support During NRMP French philosopher Paul Ricoeur (1976). Therefore, the interpretative process includes suggestions on how to explain and understand the meaning of data. This is especially fruitful when an open understanding has reached its furthest end.

Participants Data were collected at four pediatric health care settings in south-western Sweden on units that care for patients up to the age of 18. These units were as follows: a pediatric specialist clinic (caring for children with different medical diagnoses); a pediatric inpatient care unit (consisting of one unit divided into two departments that care for children with all diagnoses); a pediatric outpatient care unit (serving children with all diagnoses except on-going infections); and a pediatric primary care services unit (caring for children with different medical diagnoses). Twenty-one Swedish-speaking children aged 3–7 years were recruited by nurses working in these services a few days before the NRMP or on the day that the NRMP was scheduled to take place. Additional inclusion criteria were if the child was about to undergo an NRMP and the parents and nurses had given informed consent. The only exclusion criterion was if the child had an acute or life-threatening illness at the time of the NRMP. Children had different experiences in relation to NRMP as well as diagnoses, and they varied by age and sex (Table 1).

Data Collection Data were collected with help from participant observations documented as video-recorded observations and/or field notes and meaning-oriented interviews that were audio-recorded and transcribed verbatim. Information was sought on the consequences and support related to NRMPs from the child's perspective. The consequences were analyzed in a previous study (Karlsson et al., 2015). The present study will address and discuss the meaning of support during an NRMP from the younger children's perspective. The data collection began during the NRMP. The video-recorded observations were performed by the first author, who stayed behind the video camera without directly participating in the NRMP unless required to answer questions or assist with the procedure. Field notes were documented immediately after the NRMP was finished. When the NRMP was over, the children were interviewed. However, during the first six interviews, participant observations were performed with the use of field notes only. As this method was not enough to capture the nuances of the phenomenon (such as the children's bodily expressions), video-recorded observations were added during the remaining 15 interviews after additional ethical approval was received. Thus, 15 video-recorded observations were conducted at the same time as the audio-recorded interviews. Moreover, immediately after the interviews, the field notes were written down. The interviews were preceded by a preparatory session of play with the goal of familiarizing the child with the situation, as was successfully done in studies by Irwin and Johnson (2005) and MacDonald and Greggans (2008). This

3 Table 1 Demographics, diagnoses and treatment-related data for the children Demographics of the children (n = 21) Age of children (years) 3 4 5 6 7 Gender of the child Female Male Parents present during the NRMP Mother Father Both mother and father Type of visit Not scheduled Scheduled Diagnosis Allergy Cancer Gastro and bowel disease Genetic disease Infection Nonspecific Obesity Rheumatoid arthritis Tonsillectomy Reason for visit Investigation Infection Treatment (e.g. cancer, RA) Scheduled surgery Type of NRMP Capillary blood sample Venous blood sample Intravenous cannula insertion (IV) Needle insertion into a central venous port Injections into the joints Skin testing for allergies Pharmacological treatment Inhalation/Sedation with N2/O2 Topical anesthesia: EMLA® Topical anesthesia: Rapydan® (Children received pharmacological aids according to the regular routines established within each unit) Time for the procedures NRMP Interval Mean Median Interviews Interval Mean Median

n 4 3 5 6 3 11 10 14 3 4 5 16 3 4 1 1 3 4 1 2 2 8 3 8 2 5 5 3 5 1 2 2 13 1

Minutes 4–30 11 10 9–60 36 37

4 preparatory session also helped the interviewer to form an opinion about the child's current condition and level of maturity in order to articulate the questions in a suitable way, as proposed by Irwin and Johnson (2005) and Spratling, Coke, and Minick (2012). Children were asked age-appropriate questions where the initial question was, Can you tell me about the needle stick? In order to obtain a more profound understanding, questions like Can you tell me more? and What happened? were also asked in relation to the aim. Younger children may find it difficult to express experiences when direct questions are posed, so different aids were used. The interviews were then performed with the help of play to simplify the children's understanding of and responses to the questions. In order for the children to answer the questions, they were invited to look into a “secret bag” filled with dolls, stuffed animals and medical equipment. The children used the equipment to re-enact what they had experienced during the NRMP while the questions were asked. Similar methods have been used with success by Aldiss, Horstman, O'Leary, Richardson, and Gibson (2009) and Gibson, Aldiss, Horstman, Kumpunen, and Richardson (2010). A method in which the doll indirectly asked the child questions was also used (Darcy, Knutsson, Huus, & Enskär, 2014; Gibson et al., 2010). In order to stimulate additional reflection, the video-recorded observations of the NRMPs that had previously been carried out were introduced to the child. After the child left the room, the data collection was complete.

Data Analysis The data were analyzed using the lifeworld hermeneutic approach described by Dahlberg et al. (2008). Initially, an open reading of the transcribed interviews and a viewing of the recorded observations were made. These actions were carried out to become better acquainted with the data and to get a sense of the original whole. Aspects of the children's utterances and bodily expressions that were related to the aim of the study were identified. Then the attention shifted toward how to understand the meaning of these aspects. This analytic step consisted of comparisons of both similarities and differences. Aspects deemed to have the same meaning created a theme, and six final themes emerged. After the six themes were established, the work with the interpretations began. This process followed the dialectic principle of thesis, antithesis and synthesis. In the presentation of the findings that follow, the theses consist of the conditions that are needed for certain aspects of the data to be supportive. The antitheses describe the opposite: a suggestion to explain and understand why some attitudes and behaviors, etc., are unsupportive. Each theme is concluded with a synthesis, in which it is suggested what conditions or factors must be present for support to be given. In the final interpretative step, a comprehensive understanding was formulated and tried against the data. In the findings, this comprehensive understanding suggests how to understand the meaning of the phenomenon as a new whole.

K. Karlsson et al. Throughout the entire process of interpretation, the following quality criteria have been applied. In each theme, different preliminary interpretations were considered. The preliminary interpretation, which was most consistent with both the data and the aim of the study, was tested once again. This time, it was verified that there was nothing in the data that contradicted this interpretation. For a more comprehensive understanding, one additional criterion was applied by repeatedly going back and forth between the original whole (the entire set of data), the parts (aspects and themes) and the new whole (the comprehensive understanding) to test the internal consistency of the structure of interpretations presented in the findings (Dahlberg et al., 2008; Gustavsson, 1996).

Ethical Considerations Ethical agreement was obtained from the Regional Ethical Review Board of Gothenburg (Dnr 724–10). A supplementary ethical agreement to perform video-observations during interviews was obtained after the study had begun (TO99–12). The Helsinki Declaration (2008) was followed. The children received verbal information about the aim of the study, their optional involvement and the ability to withdraw at any moment without influencing their care. They were also assured that their confidentiality would be maintained, which is important in more general research and not just in research that includes children (Morse, 2007). The children's informed assent was obtained (Ford, Sankey, & Crisp, 2007). Verbal and written information containing the same content was given to the parents, and they also provided their written consent. If the children or the parents felt the need for assistance after the interview, they were offered contact details for the interviewer and supervisors.

Findings Each of the six themes suggests what is supportive for children undergoing an NRMP and what conditions are required for those factors to be supportive (thesis) as well as what conditions prevent the same aspects from being supportive (antithesis). Each theme analysis ends with suggestions about how to better understand why certain conditions or factors are favorable to providing support versus preventing support during an NRMP (synthesis). The findings are presented by moving from the themes toward a more abstract level of the findings (i.e. comprehensive understanding, which seeks to explain and understand the phenomenon as a whole). Below, the following themes are presented: being the centre of attention, getting help with distraction, being pampered, becoming involved, entrusting oneself to the safety of adults and being rewarded.

Being the Centre of Attention Being the centre of attention during an NRMP means that, for the attention to be supportive, it has to be encouraging. This happens when adults make children their central concern and communicate with them on the child's own terms. In this situation, it seems easier for the child to allow the procedure to proceed. Encouraging comments from parents and nurses are

Young Children and Support During NRMP parts of being supportive. Examples of supportive comments are as follows: ‘You're doing this really well’ or ‘You are the best in the world’. Staff can also pay attention to a child's difficult feelings and lend support by saying: ‘It's okay to be sad and cry’. Being the centre of attention during an NRMP can also be unsupportive. For example, an adult can say ‘This must be done’ or ‘It just gets harder if you keep on doing this’. This unsupportiveness is also exemplified as follows: The child is sitting on his mother's knee; he is huddling and crying.Mum: ‘You know what, you're crying but you're not in pain now because theblood sampling is not in progress.’ The boy looks sad when his mother tells him that he is not in pain. He tries to stop crying and hide his hand to prevent the blood sampling procedure from proceeding [Observation, NRMP, five-year-old boy]. The support may not last if encouragement only serves the purpose of persuading the child to agree to the procedure: The child sits on his dad's knee; the child's head is heavily bent forward; he is holding his hands and sobbing. The dad says firmly: ‘Now, be a good boy. Child: ‘I do not want this needle’. He bends his upper body forward so that his dad has a hard time holding him [Observation, NRMP, four-year-old boy]. If the adult's attention is perceived as being supportive, then being the centre of attention during an NRMP has an increasing effect on how a child experiences support; otherwise, it has a reducing effect. Children tend to feel proud and important when adults focus on them in encouraging ways. Attention can be perceived as favorable and can also partially compensate for any negative feelings.

5 During play, the child may demonstrate how supportive distraction can be during an NRMP: Child: ‘Check it out’. He keeps his lizard in front of Pippi's face [a doll] while the blood sample is taken. The child laughs [Observation, interview, four-year-old boy]. For distraction to be supportive, it needs to be perceived as safe, secure and voluntary. This often occurs when children can recognize for themselves what the adults are doing or saying. Getting help with distraction during an NRMP is not something that all children prefer. When children would rather observe the procedure, distractions are not supportive. In such cases, forced distractions involve a loss of control. Instead, the adults need to help the child by affirming his or her curiosity. If the staff members still distract the child by shielding the procedure, they are not actually being supportive: Nurse: “Do you want to watch or read a book”? The child looks at what the nurse is doing. A book is put in front of the child's face. Child: “I want to see”. The child looks upset and quickly takes the book away with one hand [Observation, NRMP, six-year-old girl]. For distraction to be supportive during an NRMP, it needs to be about something that is understandable and it cannot be perceived as frightening. Typically, the goal is to allow the child to concentrate on something other than the procedure. However, if the child wants to observe the procedure, it would be unsupportive to distract him or her. Therefore, the needs of each child must be adhered to. Each child may also have different needs at different times. Most children seem to want to be distracted, but not all children feel that way.

Getting Help With Distraction Getting help with distraction during an NRMP is done when parents or a staff member help the child think about other things during the procedure. For the distraction to be supportive, the child must want to be distracted and must also understand the distraction. The following situations are examples of supportive distractions: a nurse and the child count together; a staff member talks to or sings with the child; parents read to or play video games with the child; a nurse and the child name the drops being placed on the child's arm during an allergy skin test. A sibling who is playing in the same room where the procedure is performed can also function as a distractor: The child turns to the sibling, who is playing on the floor. The child is not looking at what the nurse is doing during the blood sampling. The child talks to the younger sibling. For a while, the child is completely focused on other things besides the procedure [Observation, NRMP, three-year-old girl].

Being Pampered Being pampered during an NRMP occurs when adults make the procedure convenient and comfortable. When such support works, it seems to compensate for the children's negative feelings to some extent. Holding the child's hand, fetching the child's cuddly toy, patting the child on the head or massaging the child's legs during procedure are ways that a parent provides pampering. Likewise, staff members can ensure that the stasis [tourniquet] is not too tight and that the child has a pillow under his or her arm during the sampling. Nurse: ‘Are you lying comfortably now’?Child: ‘No′. Nurse: ‘You've got to jump up a little with your butt’. The nurse fixes the pillow and raises the child's head in the bed. The child settles in and begins to read a book [Observed, NRMP, six-year-old girl].

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For pampering to be supportive, it needs to be perceived as comforting. This type of comfort reflects a need for closeness and physical contact, as described by the child in this example: Child: ‘It should be said quietly [the conversation] and hold hands’. Interviewer: ‘Who should hold hands’? Child: ‘Mom or Dad’ [Observation, NRMP, sevenyear-old girl]. In the form of play, a child can demonstrate how supportive it is to be pampered during an NRMP. Interviewer: “Yes, but how do you think we should comfort Pippi”? Child: “Like this”. The child hugs Pippi [Observation, NRMP, three-year-old girl]. Pampering may also be done by using medications to make the procedure less painful and to make the child more relaxed. Being pampered during an NRMP is not supportive when the child perceives it to be sloppy or unpleasant. For example, this might occur if a nurse is overly tightening the stasis [tourniquet] while attempting to pamper a child. Being pampered is not also perceived as supportive when the child is simultaneously being restrained: Mum is holding the child's legs and hands in a firm grasp while she tries to kiss and cuddle the child. Child: ‘I don't want this needle; let me go’. The child tries to avoid the mother's attempt to pamper by trying to turn away from her [Observation, NRMP, four-year-old boy]. When pampering efforts are recognized during an NRMP, they are appreciated, which makes it easier for the children to handle the procedure. When the child reacts with extreme fear, such as when they are being restrained, the intention of care is not reached, and the child will shut out the adult's actions.

local anesthetic patch from a central venous port, wash the area where the sample will be taken, put an identifying label on the test tube or hold the syringe connected to a central entrance. Likewise, participation increases when staff members ask about the routines that the child has developed: Nurse: ‘What do you usually say?’ Child: ‘Sawing.’ [The nurse should pretend to ‘saw’ while the patch is removed]. The child is smiling. Nurse: ‘And then what?’ Child: ‘Slow as a snail when it slides.’ [The needle should be slowly inserted into the central venous port]. The child sings, ‘Slow as a snail when it slides,’ giggles and looks a little tense [Observation, NRMP, five-year-old girl]. The importance of becoming involved is also reflected in play. During play, the child controls what he or she knows and understands about the procedure by talking out loud: Child: ‘Look, there is a [mechanical] spring [a capillary device]. First, I did it like this. I pressed like this, and then a needle was pushed out. Can you only press it once’? The child asks this question while looking at the nurse [Interview, six-year-old girl]. Becoming involved is not supportive when children do not receive information that is tailored to them; instead, their imagination may take over. Consequently, procedures can be intimidating or difficult to understand. This makes it difficult for children to be involved, and they may feel detached from the procedure. Nurse: ‘May I borrow your arm so I can insert a plastic tube?’ [cannula] Child: ‘I want my arm’ The child holds the arm with one hand and at the same time looks at the nurse and then down at the arm. The child stares ahead blankly and shakes her head, not letting the nurse perform the needle procedure [Observation, NRMP, three-year-old girl].

Becoming Involved Becoming involved in the NRMP is about being allowed to participate. To be involved, the child needs to know and understand what is occurring. When that happens, it makes it easier for the child to come to terms with the procedure and to perceive it as being supportive. This realization can take place through age-appropriate and individualized information that is given continuously. How the information is being expressed is also important. For example, information can be conveyed with metaphors or by using the child's world of reference or world of conceptions. The child can also learn why the procedure needs to be done, and staff can ask questions to determine whether the child understands the information. Additionally, the child should also be provided with opportunities to ask questions. The more children know and understand, the more they can tell the staff how they want the procedure to be done. In light of past experiences, it is possible for a child to remove a

Knowledge and understanding are essential for the involvement to be supportive. Children want adults to show them, through play, how the procedure is performed in order for them to understand. If information is not tailored to the child, it does not lead to knowledge and to involvement; thus, it is not supportive.

Entrusting Oneself to the Safety of Adults Entrusting oneself to the safety of adults during an NRMP is about letting go and trusting the adults' control. For this to work as a form of support, the child needs to feel trust and also a sense of security. Children can feel supportive when parents or close relatives are with them during the procedure; this presence can be a positive link to professional care. Children also feel safe when their parents are there, speaking on their behalf. Children can talk to the staff through their parents. The child can whisper to his or her parents, and the parents can

Young Children and Support During NRMP then tell the staff what the child has said. Sometimes a child does not have to whisper because the parents already know how he or she feels: Mom: ‘Is it possible to put on another patch because he thinks that this one is hard to remove’? Child: ‘Yes, I do not want that annoying one’. The child looks gratefully at his mother [Observation, NRMP, five-year-old boy]. Children may also feel supported when they entrust themselves to the safety of adults during play. A child can communicate using a doll where the doll becomes the link between the child and the adult. When the child already has an established relationship with a staff member or members, it becomes easier for him or her to entrust him/herself to the safety of adults. When people know each other, it is also easier to use humor and play during interpersonal interactions. Nurse: ‘Are you folding the tube [infusion tube] so that it beeps in the device’? Child: ‘Yes’. Nurse: ‘You're a little fairy’! [This is said with a positive tone]. The child looks at the nurse, giggles and then continues folding the infusion tube [Observation, NRMP, five-year-old boy]. Entrusting oneself to the safety of adults is supportive for children when a link or point of contact is present; preferably, there is already an established relationship, and play and humor that the child can understand are being used. A child may not feel safe when he or she does not understand the humor or when parents talk to staff about him or her in a way that excludes the child from participating: Nurse: ‘I′ll give the blood that I have borrowed from you [a blood sample] to a lady working at the laboratory.’ Mom: ‘You should ask the nurse when you will get it back’ [talking about the blood]. Everyone laughs except the child, who looks sad and starts crying [Observation, NRMP, three-year-old girl]. For children to entrust themselves to the safety of adults, they must let someone else protect them during the procedure; this must be done in a way that makes children feel safe. It becomes apparent that this has been achieved when children enjoy meeting the caregiver, joke with them and play with them, even if the caregiver is performing the procedure. This can occur when children do not feel left out or threatened by a situation. These children will feel that they can surrender to parents and staff in a mutual manner.

Being Rewarded Being rewarded implies that something positive will happen after the NRMP. Rewards can also serve as consolations if a child has not been able to control his or

7 her emotions. Knowledge of something positive afterwards also seems to help the child master his or her fears during the NRMP. Being rewarded by parents and/or staff after the NRMP can take the forms of gifts or verbal rewards, such as when an adult says ‘You have done this really well’. Candy or visits to a hamburger restaurant provide even more rewards. After the procedure, the children could also go visit the play specialist. Being praised for a choice of reward can further enhance the child's positivity. During play, rewards can create positive images of healthcare situations for children: Child: The child holds his gift in front of Pippi's face [Pippi is giving a blood sample]. Interviewer: ‘Do you always get a gift when blood samples are taken’? Child: ‘Yes’. The child smiles and looks pleased [Interview, four-year-old boy]. In some cases, the reward may not be perceived as supportive. For example, prior to the procedure, the child may be told that he or she will receive a gift if he or she agrees to the procedure. However, in this circumstance, it may be difficult to look forward to the reward with joy: Relative: ‘We will do it quickly so that I can go and fetch the gift’. Mom: ‘John will fetch the gift, okay’?Nurse: ‘Are you getting a gift’? The child's crying increases. He pinches his eyes together, holds his arm against his body and presses himself against his mother. The child does not seem to perceive it as a reward [Observation, NRMP, four-year-old boy]. When the adult uses the reward in a negative way, it does not seem to provide support.

Comprehensive Understanding The basis of supporting younger children during NRMPs is about how children perceive the adults' ability to generate resources and/or strengthen existing resources. This is achieved when children are guided by adults through the procedure until they think: I can manage this. To provide that type of support, the adult needs to control potential worry and ensure that the child's need for a calm, responsible companion is met. This process requires adults who can adequately balance the risks of either being in a hurry or prolonging the procedure unnecessarily. Such an attitude from parents and nurses creates a caring situation, which is characterized by wanting what is best for the child. Moreover, it is very possible that the child will recognize this concern. If the child then responds by being calm, it will provide the adult with further guidance for how to offer support that is tailored to meet the specific needs of this particular child. By being supportive, adults can enable a child to play. Play can link the procedure to adults as the child demonstrates his or her experience of the procedure. Play can also help children

8 process their experiences so that their resources are strengthened during the NRMP. Wanting to play and also being able to play requires all participants to be sensitive to each other's roles during the procedure to understand how the support should be designed. Adequate support enables a caring situation characterized by mutual trust and the shared belief that the procedure will be carried out without harming the child. As shown above, the child, the parents and the staff have different roles in the process of creating trust. As trust grows, the NRMP becomes easier to implement and the support develops with a successively enlarged pliability to the child's reactions. In this manner, adequate support enables the child to be active in the procedure and also to participate in the struggle for a supportive, caring situation.

Discussion This study shows that supporting younger children during an NRMP is about guiding them through the procedure by being the centre of attention, getting help with distractions, being pampered, becoming involved, entrusting oneself to the safety of adults and being rewarded. When children are successfully guided by adults, their resources to handle the situation are generated, and/or existing resources are strengthened. Being guided by adults during an NRMP can be understood as providing care based on nurse theorist Katie Eriksson's (1987) Theory of Caritative Caring. This theory consists of concrete bodily tending as well as symbolic playing and learning. The most basic form of caring is tending, which can be summarized as taking care of and providing for another human being. Play is a natural way of being, and health can be expressed through play. The basic concepts of play include ‘exercise, testing, creativity, and imagination, and desires and wishes’ (Lindström, Lindholm Nyström, & Zetterlund, 2014). Through motivation, encouragement and guidance from a mentor, an individual's learning process is developed. Similar to playing, learning is related to natural behavior; therefore, there is a close association between playing and learning, and they are defined in relation to each other. In a caring context, all three elements—tending, playing and learning—are included, but, depending on the situation, one or the other is more or less prominent (Eriksson, 1987; Lindström et al., 2014). This theory has also been described by Johansson, Landahl, and Adolfsson (2011) in a caring context with children. The concept of tending is basically about helping another human being tend to himself or herself (Eriksson, 1987). In this study, tending is seen as the act of guiding children through the NRMP with the goal of helping them manage the procedure. Thus, what emerges strongly from the present study is the significance of play when guiding children during an NRMP, which is also highlighted by Lindeke et al. (2006) as important for children while in hospital. Play is a way of training and testing children's skills, and it is also an opportunity to let their creativity flow (Eriksson, 1987). Guiding children through an NRMP is about helping them dare to play, and this is done by giving them time, space and a place for doing so; this approach

K. Karlsson et al. has also been described by Ford, Tesch, and Carter (2011) and the European Association for Children in Hospital (EACH) (2006). Children gain information through play; they also talk about their emotions and process the procedure with the help of play. Play may give children the ability to control their fears and learn to understand the unpleasant experiences that may occur (Ford et al., 2011; Haiat, Bar-Mor, & Shochat, 2003; Jun-Tai, 2008). Eriksson (1987) explained play as an expression of health but also as a means to achieve health. Since healthcare may be perceived by children as an environment that is not very child friendly, play may be the most vigorous and effective way of guiding children in order to diminish negative feelings during an NRMP. It is important for staff to bear this in mind when guiding children to engage in play. This study also leads to the conclusion that in order for adults to guide children in a supportive way, adults need to control their own negative feelings about procedures. Parents have an important role to play as the link between the child and the staff, and their guidance is facilitated when humor and play are included in the encounter. It is found that children's fears decrease when humor is used in care (Salmela et al., 2010a) and that children themselves cope with fear by using humor and play (Salmela et al., 2010b). Several studies have highlighted that being fun and using humor are important qualities of a good nurse who works with children; they are also beneficial for children and staff in general (Brady, 2009; Carter, 2005). However, as Brady (2009) noted, children emphasize the importance of finding a balance in the use of humor. In a caring situation when guiding children, staff may have difficulty feeling confident about using humor; they might feel sufficiently sensitive in interpreting the situation, or they may even think that the child and the parents could take offense at its use. The staff must support each other so that the child does not work with a nurse whose demeanor is either overly cheerful or deadpan; this will help the child feel trust and a sense of security in the encounter. Eriksson (1987) also emphasized that staff should not be afraid of making fools of themselves (in a professional way), which suggests the importance of humor and play when meeting with patients. This present study's findings indicate that children need to trust adults and feel secure in order for the guiding to be supportive. Therefore, knowledge is needed about the procedure. Information provided by adults is a way of guiding children and an important method to gain knowledge about procedures and enable feelings of support. Or, as Runeson, Mårtenson, and Enskär (2007) claimed: ‘Information is a pre-requisite for participation’ (p. 510). Here, one can see a similarity to Eriksson's (1987) concept of learning that stresses the importance of the staff having a learning attitude in a caring situation. From a caring perspective, supporting children by guiding them in receiving information about the procedure is vital to increase the child's co-determination in receiving care, as

Young Children and Support During NRMP was established in the Convention on the Rights of the Child (UNICEF, 1989). In this study, the adults provided support by guiding children through the procedure with the help of pharmacological or/and non-pharmacological treatments. Seven of the 21 children did not receive pharmacological treatment because skin testing for allergies and capillary blood samples cannot be performed with topical anesthesia. The comments from these children seemed similar regardless of the use of pharmacological means. However, when it comes to counteracting children's fears during an NRMP, this study shows that non-pharmacological measures are very important, which was also described by Hedén et al. (2015). In conclusion, when guiding works well and support is achieved, children actively participate in the procedure. Thus, their responses also guide adults to understand the meaning of support during an NRMP. In a sense, the children guide the adults through the NRMP.

Methodological Considerations When conducting research with younger children, an important methodological issue is related to the difficulty that arises when adults do not see the world the same way as children do; moreover, it can be difficult for children and adults to linguistically understand each other (Punch, 2002). By letting children be involved in the research design, ethical issues can be counteracted (Holland, 2009), and this will hopefully minimize the children's vulnerability during the research process. Therefore, in order to gain knowledge about children's experiences, child-focused-techniques have been used, such as working with dolls, stuffed animals and medical equipment, which is a useful method described by Aldiss et al. (2009). The use of this approach ensured that the opinions of 21 young children about support during an NRMP have been heard. In this present study, the nurse in charge of the child's care asked the child and the parent(s) for the child's participation. It was not revealed whether the nurses chose not to ask the children to participate or if the children declined. This fact may be a limitation of the study. However, due to the large variation in the data, it seems that this fact has not negatively affected the findings. Research has shown that children as young as three can be interviewed (Docherty & Sandelowski, 1999) and, in this present study, open-ended questions were used. The manners in which the questions are expressed and worded are important (Krähenbühl & Blades, 2005). Children need to feel that there are no right or wrong answers to the questions asked. This was done by letting the children know that they are the experts on the topic being studied, not the researcher. Therefore, words and expressions with reference to the child's world of experience were used in this study. Sometimes the children simply answered that they did not know and provided no other information. When the data from the interviews were less verbally pronounced, the field notes and video-recorded observations became more important. Two children were

9 given inhalation/sedation with nitrous oxide. This may have affected their ability answering questions during the interview which can be considered as a limitation. However, the narratives from the children who received nitrous oxide did not differ substantially from the narratives of the other children. During the first six interviews, the participant observations were recorded using field notes only. Since the remaining 15 interviews were conducted with the help of video-recorded observation, to a large extent, the results have probably not been affected. The children in this study had no previous relationship to the first author who performed the data collection or to the co-authors who contributed to the data analysis. Prior acquaintance can be an obstacle when it comes to interviewing younger children. Spratling et al. (2012) stated the importance of getting to know the child before the interview. In this present study, this step was done by conducting a preparatory session before the interviews began. Some of the children seemed embarrassed when they were interviewed. It is difficult to know how much this affected their answers. Based on this observation, parental presence was an obvious choice for helping the child to feel a sense of security (Irwin & Johnson, 2005) and to counteract any feelings of embarrassment. While the researcher must also be aware that the parents might do or say things that make the child more embarrassed, that behavior did not emerge in this study. After the interview had proceeded for a while, the children were allowed to see the video-recorded observation from the NRMP. Video-recorded observations can be perceived as an invasion of privacy (Heath, Hindmarch, & Luff, 2010), and seeing oneself on a video-recording may also make one uncomfortable. This was counteracted by thoroughly informing the children that the NRMPs and the interviews were going to be video-recorded beforehand and also by being sensitive to any signs of awkwardness that the children showed. On two occasions, the children looked sad when watching the video-recorded observation during the interviews, and the film was turned off. Those children had been restrained during the NRMP. However, none of the video-recorded observations resulted in any of the children declining to participate. The findings from this research are contextual, but even so, it is reasonable to assume that they are transferable to other comparable contexts as they are based on a sufficient variation in the data (Table 1). The hermeneutical analysis consists of interpretations that have been tested against the quality criteria, which were described under data analysis. It is, however, worth noting that there are always several possible interpretations of qualitative data (Selander & Ödman, 2004). The suggested interpretations are those that are most valid in relation to the aim of the study and the data that they are based on. According to Selander and Ödman (2004), it is nevertheless useful to present excerpts from the data, not only to show what kind of information that the interpretations are based on but also to allow for alternative interpretations. This approach makes hermeneutics both an interpretative and an argumentative discipline.

10

Acknowledgments We thank the children who participated in this study. The authors have no conflicts of interest. This research was funded by the University of Borås.

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