Communication between nurses, children and their parents in asthma review consultations

ORIGINAL ARTICLE

Communication between nurses, children and their parents in asthma

review consultations

Peter Callery and Linda Milnes

Aim and objective. To examine communication between nurses, children and parents in asthma review consultations.

Background. Communication is an essential component of asthma care, but there has been little examination of nurses’

consultations with children and parents.

Design. Observation of communication in consultations examined in the context of the perspectives of parents and nurses.

Method. Qualitative analysis of audio recordings of nine consultations with nurses by children aged 7–12 years and their

parents; and interviews with 18 parents and six nurses.

Results. The triadic relationship between child–nurse–parent was constructed from dyads of nurse–parent, nurse–child and

parent–child. Both cooperation and conflict were identified in the analysis of interaction in dyads although direct confrontations

were minimised or avoided. Conflicts arose from differing beliefs about asthma and its treatment and from different perspectives

on the impact of asthma and the goals of treatments, and about the roles of children, parents and practitioners. There was

uncertainty about the appropriate role of children in their asthma management.

Conclusions. The dyads of nurse–parent, nurse–child and parent–child each make distinct and important contributions to

triadic communication. Personal and task elements of therapeutic alliance are important elements in communication between

nurses, children and their parents in asthma review consultations.

Relevance to clinical practice. Communication is an essential component of children’s asthma care. Guidance encourages

practitioners to use review consultations to help children and parents to identify areas where they want treatment to have effect

and to negotiate personalised action plans with practitioners. There is potential for conflict as well as cooperation. There is a

need for more research into nurses’ communication with children and parents to provide an evidence base for practice,

education and training.

Key words: asthma, child, child nursing, communication, therapeutic relationships

Accepted for publication: 4 September 2010

Introduction and background

Review consultations are an important component of asthma

self-management education (Gibson et al. 2002). Communi-

cation with practitioners is important so that both children

and parents can identify areas where they want treatment to

have effect and negotiate personalised action plans with

practitioners (British Thoracic Society & Scottish Intercolle-

giate Guidelines Network 2008). Reviewing the long-term

therapeutic plan with the parent and providing criteria for

decision-making at home, tailoring the medical regimen to

daily routines and reviewing short-term goals of therapy can

Authors: Peter Callery, BA, RN, MSc, PhD, Professor of Children’s

Nursing, School of Nursing, Midwifery & Social Work, University of

Manchester, Manchester Academic Health Science Centre; Linda

Milnes, RN, MPhil, PhD, Lecturer in Children’s Nursing, School of

Nursing, Midwifery & Social Work, University of Manchester,

Manchester Academic Health Science Centre, Manchester, UK

Correspondence: Peter Callery, Professor of Children’s Nursing,

School of Nursing, Midwifery & Social Work, University of

Manchester, Manchester Academic Health Science Centre,

University Place, Oxford Road, Manchester M13 9PL, UK.

Telephone: 0161 306 7755.

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, doi: 10.1111/j.1365-2702.2011.03943.x 1

reduce the need for health service use (Clark et al. 2008). As

children attend school, spend time away from their parents

and develop independence, they need to be involved in

communication about their own health care, particularly if

they live with a long-term condition such as asthma. Some

health information can only be collected directly from

children because their experiences and perspectives can differ

from those of their adult carers (Guyatt et al. 1997, Callery

et al. 2003). Children also need to receive information

directly from practitioners if they are to develop their own

contributions to self-care (Wissow et al. 1998). There has

been little study of communication between children, parents

and nurses conducting asthma review consultations.

Methods

The aim of this study was to examine asthma review

consultations in the context of perspectives of parents and

nurses about the purpose and process of communication

about asthma. The design incorporated observation of

consultations by audio recording and interviews with parents

and nurses.

The data presented in this paper are from nine recordings

of asthma review consultations between nurses, children (age

7–12 years) and parents; and interviews with 18 parents, (or

other adult carers) and six nurses. These data were collected

alongside a pilot trial in which a control group was

compared with a group receiving a ‘Toolkit for Child

Centred Asthma Care’, comprising a child completed diary

to identify features of ‘good’ and ‘bad’ days; a semi-

structured interview schedule for nurses to use when assess-

ing children; and a template for a child-centred asthma plan.

Nurses were provided with digital recorders and asked to

record consultations with consenting children and parents.

Parents and nurses were interviewed about asthma care.

Children were also interviewed but as they said little about

consultations or communication with nurses, their interviews

are not reported here. The study was approved by Salford

and Trafford and Central Manchester Local Research Ethics

Committees. Pseudonyms are used for the names of the

participants referred to in the text.

Sample

The sample was drawn from the carers of children receiving

asthma care in paediatric respiratory outpatients’ clinics,

community children’s nursing services and general practices

in inner city and suburban areas of the North West of

England. Interviews were conducted with 18 parents and six

nurses including Asthma Nurse Specialists (ANS), a specialist

health visitor (SHV), Children’s Community Nurses (CCN)

and Practice Nurses (PN). Nine consultations were recorded,

four with children from the Toolkit intervention group and

five from the control group (Table 1).

Interviews

Interviews were open-ended conversations loosely structured

by topic guides. The topics discussed included living with and

managing asthma, children’s involvement in their own care

and communication between children, parents and health

professionals. Interviews were recorded and transcribed with

the participants’ permission. Qualitative analysis of the

interview data was carried out using Framework (Ritchie &

Lewis 2003), a method widely used in social policy research.

The first stage of analysis was familiarisation, in which the

data were closely examined to describe recurring themes and

key ideas. The process continued with the development of an

increasingly conceptual thematic framework. Data were

indexed to the framework, and paragraphs summarised

retaining the original language. This framework provided a

systematic basis for the development of an interpretation of

the perspectives of parents and nurses as reported in the

interview data.

Table 1 Sample details

Recording ID Toolkit study group Child age Child gender Parent/adult carer Nurse

CH001 Control 10 Female Mother Asthma Nurse Specialist

CH004 Control 10 Male Mother Asthma Nurse Specialist

CH019 Control 8 Female Mother Practice Nurse

CH021 Control 9 Female Mother Children’s Community Nurse

CH022 Control 12 Female Mother Children’s Community Nurse

CH041 Intervention 9 Female Father Practice Nurse

CH051 Intervention 12 Male Unidentified female Asthma Nurse Specialist

CH061 Intervention 9 Female Mother Practice Nurse

CH028 Intervention 8 Female Mother Practice Nurse

P Callery and L Milnes


2 Journal of Clinical Nursing

Consultation recordings

Consultations between the nurse, children and their carers

took place in clinics or during home visits and were audio

recorded by the nurses. Recordings were transcribed and

examined using principles of conversation analysis (Drew &

Heritage 2006). The initial focus of analysis was the

examination of children’s contribution to conversation

sequences including invitations to and interruptions of turn

taking. The analysis then progressed to examine interactions

between nurses and parents including comparison of themes

discussed in interviews and the topics discussed in consulta-

tions. Thus, consultations were analysed in the context of the

perspectives of parents and nurses (Bensing et al. 2003). The

findings reported are therefore a synthesis of interview and

consultation data. The authors analysed data independently

and then met to compare, discuss and resolve disagreements.

Results

Consultations between nurses, children and parents were

informal, including social talk as well as discussion of

asthma. Nurses took the lead in opening the discussion. In

three consultations, the nurses were following the protocol

for the use of the toolkit. Although systematic comparison of

control and intervention groups was not feasible with this

sample, it was notable that on these occasions the nurses

started the consultations by explaining that they would

review the child’s completed diary and then draw up a self-

management plan. In other recordings, there was little

explicit discussion about the purpose, form and content that

consultations would take. Thus, the negotiation of roles in

interactions was implicit rather than explicit.

Nurse–child patient–parent relationships

Consultations that involve three participants (child, parent

and nurse) are described as ‘triadic’. However, interactions

principally occurred between two members of the triad at any

one time, with the third member an observer of this ‘dyad’.

This is evident even when positive and cooperative triadic

relationships were described as in this parent’s interview

account:

And they’ve got that relationship with her and I wouldn’t go

anywhere else with them and it’s trust as well because … I know that

she’s done so much work for them and their asthma like I said was so

out of control when we went to see her she’s actually worked with

them and she has been with them right the way through and it’s

settled down now and it’s all through (.1) because of hard work she’s

done with them (C0361)

This mother’s quotation highlighted the importance of per-

sonal relations between her children with asthma and the nurse

as well as the trust engendered as a result of her perception that

the nurse had used her expertise to achieve control of asthma.

However, it is notable that the mother presented herself as an

observer of a dyadic relationship between nurse and children.

This is exemplified by her statements that: ‘they’ve got that

relationship with her’; ‘she’s actually worked with them’;

and ‘because of the hard work she’s done with them’. Thus,

within her presentation of triadic alliance, the mother

emphasised the roles of dyadic relationships. It was also

notable that interactions in consultations followed a pattern

of dyadic interaction between nurse and parent, nurse and

child, and parent and child (Table 2). Therefore, each of

these dyadic relationships is now considered in turn.

Nurse–parent relationships

As the quotation aforementioned suggests, relationships

between nurses and parents were key to the successful

development of alliances. Parents valued the expertise of

nurses, their availability and responsiveness:

I could go and ask anything I wanted because they specialised in that

… not have to make an appointment …and they’re dead nice and

they understand your situation and you can ask any silly question you

want. (PC018)

Detailed advice and monitoring of how parents were looking

after their children could also be valued:

she showed me how to use the inhalers properly, the spacer and then

the blow one, … you’re not over or under medicating because you go

there and you write it down on your chart and you show it, because

you have a diary and stuff like that, then you show it to her and she

goes ‘Yes, that is great’. (PC048)

However, some parents preferred to limit their contact with

professionals:

I don’t think I would like too many people…like somebody come

round and say ‘You’ve got to do this and do that and do that’ I would

just rather be told once and that’s it. (PC002)

Interactions between parents and nurses took place in the

context of their respective motivations, expectations and

health beliefs. Differences between therapeutic goals emerged

Table 2 Dyadic relationships in children’s consultations

Nurse with Child patient

Nurse with Parent/carer

Parent/carer with Child patient

Original article Communication in children’s asthma consultations


Journal of Clinical Nursing 3

in interviews and in some consultations. Preventer medica-

tion was one of the topics about which views differed. Parents

could share health professionals’ positive view of asthma

preventer treatments, particularly when children had suffered

severe or intractable symptoms. This mother was asked what

advice she would give to a parent with asthma:

Well to make sure the inhalers they’re taking, whether or not the

child seemed all right or not, because I think a lot of people they don’t

take the inhalers because at that time they’re feeling all right. (PC056)

However, other parents commented on their concerns about

potential, but mostly unspecified, risks that they associated

with medication:

I don’t want to be pumping this into them if it’s not completely

necessary… especially the children being so young…I was frightened

really whether they should have it or not as I didn’t know what the

side effects of this...these inhalers were. (PC018)

Parents often expressed a sense of reluctance about the use of

medication. Some acted on their doubts by stopping their

children’s preventer medication. Conflicts could result if

health professionals were not involved in these informal

experiments:

I got told off like for taking him off it and then I put him back on the

Seretide twice a day and he said ‘If you feel that he doesn’t [need] it

after like six weeks then take him off it six weeks before he was likely

to go back, and then we’ll see how he is when he goes to clinic’ so

that’s what we’ve done. (PC002)

Practitioners appeared to recognise that parents might be

reluctant to give their children prescribed medication and in

some circumstances were willing to negotiate planned trials

off medication:

I did tell [Name] this the first time I took them off it, she said ‘That’s

fine, up to you’ she said ‘but really best to keep them well’ and I said

‘Well they’ve been fine’ and she said ‘Well it’s up to you if you want

to take them you can’ and then she said ‘I would keep them on for a

bit longer’ which I did, I put them back on it and then this time I have

decided to take them off which has been about a month and like I say

there has been no real change. (PC018)

Parents of children with milder asthma sometimes expressed

doubts about the diagnosis of asthma in their children. This

could be because they were uncertain that a diagnosis was

correct:

he has just been re-diagnosed but it wasn’t a proper diagnosis he did

the peak flow chart and it was a case of being borderline…but it

wasn’t really asthma it’s just they seemed to get viruses and one thing

after another. (PC018)

Some who accepted a previous diagnosis hoped that their

children had ‘grown out of it’:

I don’t think he’s got the asthma but I need to know whether he has

or he hasn’t … if he has actually grown out of it which I hope he has.

(PC002)

The absence of a specific diagnostic test or explanation of the

cause of asthma appeared to contribute to the uncertainty

they experienced about the diagnosis, and so parents had to

rely on assessments by nurses and doctors:

she was first supposedly diagnosed she was about four, they said that

she had it and I didn’t think she did at that time, and I thought there

would be more conclusive sort of tests to be done at that time like you

could blow into those little peak flow things and say ‘Yes, she’s got

asthma’ but it’s not that clear cut is it? (PC022)

These doubts did not usually surface explicitly in consulta-

tions, but one episode illustrates how a parent and nurse dealt

with a challenge to the diagnosis (Table 3). The nurse started

the consultation by questioning the child about when she had

needed to user her inhalers. After a series of turns between

nurse and child, the mother interrupted by saying: ‘As far as I

can see, and I’ve said this to everyone all along, as far as I can

see I still, I’m still not sure whether she’s got asthma’. The

nurse gave a neutral response (‘Right’), and the mother went

on to suggest physical activity requirements at school as an

alternative explanation to asthma. The nurse again gave a

neutral response (‘Right okay.’) The mother elaborated

further and mentioned cat allergy. The nurse, having now

responded neutrally at six turns started to address the

challenge to diagnosis by talking about different types of

asthma, with the mother now giving neutral responses:

Nurse: So it’s very much kind of an allergic

Mother: Yeah.

Nurse: Reaction, because you probably know this, and Una probably

does too, there’s different types of asthma,

Mother: Yeah,

Nurse: One’s that were, you know, very much the allergic element,

like you say, cat and cat hair, um, dust um, things in the atmosphere,

and there’s other asthmas that tend to come on in later life,

Mother: Mm hmm. (CH061)

The nurse then listed the symptoms of concern and re-directed

the questioning to the child, with no further discussion of the

diagnosis. This interaction indicates the tentativeness with

which both parents and nurses approached discussion of the

diagnosis of asthma, with both using conversational strategies

to avoid direct disagreement. Once the nurse had indicated

her implied disagreement with the challenge she re-directed

the conversation to focus on the child’s symptoms and




re-directed the interaction by a question that indicated that

the child should take the next conversational turn:

Nurse: …I know it’s difficult to tell me how you feel, but when you

feel it coming on, can you describe how you feel?

Child: Wheezing. (CH061)

The interactions aforementioned illustrated how conflicts

between health beliefs could underlie consultations. Parents

appeared to prefer to raise concerns about the appropriate-

ness of a diagnosis or the value of medications implicitly

rather than directly. Explicit challenges might be seen as

contravening the ‘ceremonial order’ of the consultation in

which the practitioner is expected to have authority over

medical information (Strong 1979). Nurses were cautious in

their responses, avoiding explicit contradiction of parents’

beliefs. Instead, they sought to re-direct attention to

Table 3 Example of conflict about diagnosis

Transcription of speech Summary of interaction

Mother: As far as I can see, and I’ve said this to everyone all along, as far as I can see I still, I’m still

not sure whether she’s got asthma,

Nurse: Right.

Mother raises challenge to

diagnosis

Nurse neutral response

Mother: But then it’s like what the definition of asthma,

Nurse: Yeah.

Mother: Um, because to me there seems to be um, it’s only when she’s been exerting herself that

she will say that she’s wheezing, and there’s times where she’s not been at school, she’s been at

home, and said that she’s definitely breathless and wheezing, and to me it’s no more than

when someone’s exhaling, and you can make that wheeze come by, uh huh, you know,

by pushing a little bit.

Nurse: Right okay.

Mother: Um, and there’s been times where she’s been like that, and I’ve said just, just wait and see,

just leave it for a little bit longer, and then it’s subsided,

Nurse: Seemed to settle down,

Mother: Yeah, and there’s been nothing, um, so when she’s at school, you know, as far as I know,

I mean the teacher has said, you know, she’s never seemed, um, there’s never been any episode

where she’s been really concerned about her,

Nurse: Right.

Mother goes on to suggest

alternative explanation to asthma

Nurse neutral response

Mother: So Una just goes when she feels she wants it, she just goes and takes her inhaler, um, and I

should imagine at school she will be exerting herself far more than when she’s at home,

you know, so I understand that, appreciate that maybe, you know, there is a problem there and

she needs to take something, um, but on the whole the only time that, that I’d say there’s definite

wheezing, well, and her eye swells up is when she’s in contact with some, and er, the cats over the

road, you know,

Nurse: Right.

Mother: Neighbour’s cats, like a cat allergy.

Nurse: So it’s very much kind of an allergic

Mother: Yeah.

Mother elaborates further then

mentions cat allergy.

Nurse having responded neutrally

to six turns starts to address

challenge to diagnosis by talking

about different types of asthma.

Mother gives neutral response

Nurse: Reaction, because you probably know this, and Una probably does too, there’s different

types of asthma,

Mother: Yeah,

Nurse: One’s that were, you know, very much the allergic element, like you say, cat and cat hair,

um, dust um, things in the atmosphere, and there’s other asthmas that tend to come on in later life,

Mother: Mm hmm.

Nurse: Um, I mean, from what you’ve, I mean the things we’re looking at particularly are kind of

any symptoms at night, um, like cough, you know, all the symptoms of asthma like cough,

wheeze, shortness of breath, and from what you’re telling me it sounds like it is kind of an activity

induced bit of asthma, when she’s running around. Um and I, you know, I get that from the diary

as well, I mean, (rustling paper) play-time, break, in the afternoon, that’s when you run around a

little, and that’s when you start to get a bit of, you know, a few of your symptoms. Una just kind

of explore a little bit about kind of how you feel, I know it’s difficult to tell me how you feel, but

when you feel it coming on, can you describe how you feel?

Child: Wheezing.

Nurse lists symptoms of concern

and re-directs questioning to child




children’s symptoms, and sometimes to the children them-

selves. Their efforts to involve children could therefore

sometimes have the effect of limiting parents’ opportunities

to pursue their own issues of concern.

Nurse–child relationships

Parents valued nurses’ communication with their children.

The personal element of therapeutic alliance was important

because parents wanted their children to have friendly

interactions with nurses:

I only moved to Doctor X because of the nurse … they have such a

good relationship with Alice I’m not going to move them … it’s that

personal one-to-one contact that the child has with the asthma nurse

and the child. (PC036)

Mother: ‘Oh Deirdre is coming’ you know it’s quite friendly ‘Deirdre

is here, Deirdre is here’ you know so it’s quite a nice sort of like a

friendly visit. (PC022)

As well as putting their children at ease, parents saw

that communication between nurses and children could

reveal information that would not otherwise have been

available:

they talk so freely with Alice she’s so good with them as well… She

can pick up things that maybe I can’t pick up…maybe I can’t

understand or relate to…she does all that so it’s for her and the child

knows that they’ve got that extra contact (PC036)

Nurses also wanted to hear from children themselves and not

just from parents speaking on their behalf. They described

trying to involve children in consultations to obtain infor-

mation from the child’s perspective about symptoms and

problems and about the use of inhalers and other aspects of

self-management. Concerns that there could be differences

between parents’ and children’s perceptions of asthma led

nurses to seek to understand children’s own interpretations

and the meaning to the children of words used to describe

their symptoms:

Nurse: they say ‘I’m breathless’, then what does it mean? Does it

mean they can’t take a full breath in? [….] Does it mean they are

actually breathing properly? or are they tight? [ ……] Really it’s just

about talking to them, so when you say ‘You feel like that’ this is

what it really means and then you can hopefully work on their plan

with that. (ANS)

Consultations all commenced with the nurse talking directly

to the child about asthma and its management, in some cases

preceded by social chat. Every consultation commenced with

a question or comment that made it clear that the child was

expected to take the next conversational turn. Such intro-

ductory questions included:

Nurse: Right, Joanne (.) How are you getting on? (CH022)

Nurse: Right Tracy (.) We see how you are after reducing the dose of

your fluxotide, so we saw you two months ago, and you have been

OK so we will reduce your dose of Flixotide to 50 mg twice a day.

How’s your asthma since reducing that=

Child: ermm =

Nurse: =any changes? (CH019)

Nurse: Have you got your inhalers with you?

Child: I’ve got one I have forgot the other one (001C)

Both focused questions (e.g. about specific inhalers) and non-

focused (e.g. how are you getting on?) questions were used.

Non-focused questions might give more opportunity for

children to influence the agenda of consultations but children

appeared to find it easier to respond to focused questions as

has been found in studies of other settings (Clemente et al.

2008).

Nurses described some of the problems they experienced in

attempting to engage with children. Younger children in

particular did not necessarily have the vocabulary to

communicate symptoms:

Nurse: he can’t tell you what it is he is feeling, can’t [get that] out into

words, hasn’t got the vocabulary.. (ANS)

Children could talk about feelings, whereas nurses needed

them to talk about symptoms:

Nurse: it’s more about feelings, terms about feeling different, about

feeling let down and not being able to do what they want, so it’s

never about wheeze, cough, occasionally you will get ‘out of puff’.

(PN)

Nurses reported that children could defer to their parents, so

some children would look to their parents for answers to

questions that nurses had clearly directed to a child, or

parents would respond on their children’s behalf:

Nurse: often it’s the parents doing all the talking and the child almost

takes on their role that, ‘well they’re here to see my mum, they’re not

here to see me’ so I have to keep bringing the child into the

conversation. (SHV)

Parents also observed that children could be unwilling to

contribute to consultations with health professionals:

just answer the doctor, you know like that, tell him the truth…and I

sit there and I think ‘but you were, you were wheezing the other day,

you were’, [… ] it’s just like ‘Well yeah, I’m all right now, I’m not

bothered, you know, I want to just get going’, … get out of here as




quick as possible, where maybe then your concerns are is that, you

know, things have happened in that you want that opportunity to

kind of talk about them, and to get some, some help or some way of

dealing with it. (PC056)

Nurses continued to address comments and questions to

children throughout consultations, inviting children to iden-

tify symptoms and other aspects of the experience of asthma

from their own point of view and to check children’s use of

inhalers. In addition to collecting information, nurses also

communicated information about asthma and its manage-

ment directly to children (Table 4).

However, parents were also a listening audience for

messages about expectations of activity, use of regular

preventer and reliever medications and taking responsibility.

One nurse described involving children in consultations to

show parents that their child was becoming independent.

Parent interventions during nurse–child interaction

At the beginning of the consultation, parents were on the

sidelines while their children were approached directly by

nurses. Occasionally, parents were invited to contribute to

the discussion by nurses but most parental contributions were

not invited. Parents sometimes intervened to join in the

nurse’s questioning of the child:

Nurse: you’ve been doing everything at school?

Child: responds with unclear statements about tag rugby and

running,

Mother: Cross-country, have you done that this week?

After child has had one turn to respond ‘OK’

Mother: yesterday you said you had a sore throat (.) is it still sore

now? (CH022)

Most interventions were to supplement or clarify information

provided by children:

Mother: cos her chest has been tight (CH021)

They could be to contradict the child:

Nurse: have you forgotten it at all?

Child: no

Father: she has a couple of times

Nurse: just a couple?

Father: yeah

Nurse: but nothing on a regular basis do you think

Father: no (CH041)

Sometimes, the parent took a child’s conversational turn to

answer a question directed to the child:

Nurse: is it stopping you doing things that you like to do day to day?

Mother: she goes swimming (.) she horse rides. (CH001)

In some cases, nurses gave no verbal response, apparently

ignoring parents’ interventions. More typical was a pattern of

response to the parent, followed by a question or comment

that made it clear the child was expected to take the next

conversational turn:

Nurse asks child about inhalers, checking and reinforcing under-

standing of purpose and use.

After child’s 11th turn Mother intervenes to ask if the reliever inhaler

being discussed is needed when child is playing out.

Nurse answers mother’s question, redirects attention to child with

question ‘but first thing in the morning do you think that you need

it?’

Mother and child both respond

Nurse after clarifying responses resumes questioning child directly.

(CH001)

As well as asking for specific information, parents raised their

own topics of concern: a father interrupted at his child’s 3rd

turn to tell the nurse about an incident when the child was

quite poorly about a month ago and taken to see a doctor. A

mother identified a symptom that concerned her:

Mother: she does have a problem with this hacking cough… (CH001)

Providing supplementary information or clarification could

also imply assertion of the parent’s role in managing asthma.

This mother’s description of her child’s use of inhalers

implied the need for her to supervise inhaler use in the

morning:

Mother: Night time she is usually good at taking it’s usually in the

morning… (CH001)

Unusually, on this occasion, the nurse responded with a

direct challenge to the parent’s role and suggested that

asthma care should be seen as the child’s own responsi-

bility:

Nurse: ..well it’s her asthma isn’t it(.) it’s your asthma(.) which is why

we try and make her responsible for herself…. (CH001)

Table 4 Summary of nurse communicating information to a child

The nurse checked Geoffrey’s inhaler technique, then explained the

action plan to Geoffrey, including the function of inhalers and when

and how to take them. She asked about the frequency of his use of

inhalers, whether he used the blue (i.e. reliever) every day and

whether this was because of need or from habit. Once she had

confirmed that it was habit she advised Geoffrey that using his

preventer should mean that he needs the reliever less often. She then

advised him on emergency procedures, including taking 10 puffs of

the reliever if necessary. (CH041)




The nurse continued the consultation with direct questioning

and advice to the child. If parents persisted in seeking to

intervene, a polite tussle could ensue in which the nurse

continued to seek to involve the child while the parent

attempted to intervene.

Parent–child relationships

Parents were concerned about balancing protection, for

example by monitoring inhaler use, and encouraging inde-

pendence in their children:

they’ve got to grow and they’ve got to… get on with the [inhaler] but

on the other hand…like I say I’m checking. (PC032)

When children were given responsibility for their own

medication, parents would continue to keep a watchful eye

on them:

I don’t let him know that I’m watching I sort of try and give him the

responsibility, he’s got to do it himself but as I’m taking mine I make

sure, sort of like, he’s taking his, and he does them very well. (PC012)

Parents experienced tension between encouraging indepen-

dence and feeling the need to protect their children. This

could lead to feelings of guilt about not having allowed

children to take sufficient responsibility:

I would like him if he were on his own or if he went away on

holiday to be able to say ‘Look Miss I need my inhaler’ … but

maybe I took that away from him by doing it all myself and I

should have given him a bit more independence so that he can

realise himself … I should just let him grow up a bit but I will one

day but I don’t. (PC002)

Discussion

The purpose of review consultations was to support chil-

dren’s and parents’ self-care of asthma including prevention

and management of attacks and limitation of asthma’s

impact on quality of life. Building alliances with patients is

a key objective of all healthcare consultations (Heritage &

Maynard 2006), and it is an essential element of providing

support for self-care. Collaboration in tasks requires the

formation of personal relationships based on mutual trust

and respect. Both personal and task elements contribute to

therapeutic alliances (Hougaard 1994). There were contri-

butions to both personal and task alliance by children,

parents and nurses. Interactions were informal and friendly,

but they were also concerned with completing tasks of

identifying and addressing problems in children’s asthma

care. Therapeutic alliance is therefore a potentially useful

framework for analysing interactions in children’s asthma

review consultations.

Children’s health care involves the participation of at least

three parties: child patients, nurses and parents or carers. The

dyads of nurse–parent, nurse–child and parent–child interact to

form the triadic relationship that has features of a therapeutic

alliance. There is potential for both cooperation and conflict in

each of these dyadic relationships, with implications for the

potential for alliances to be therapeutic. Studies in mental

health settings suggest that therapeutic alliances with par-

ents and with children are independent (Green 2006),

which emphasises the importance of dyadic as well as triadic

communication between child, clinician and parent.

Differences in motivations, expectations and beliefs about

asthma were evident in the interview accounts of parents and

nurses. Conflicts about diagnosis and treatment could emerge

in consultations, although parents and nurses appeared to

take care to avoid, or at least to minimise, direct confron-

tations. Nurses responded to challenges to diagnosis by

re-directing attention to children’s symptoms and problems

with asthma.

The roles of children, parents and nurses were not usually

discussed explicitly during review consultations. However,

nurses described seeking to involve children in consultations

and they used ‘local interactional practices’ (Clemente et al.

2008) to structure their interaction with children and parents.

These included directing questions to children and so identi-

fying them as the expected next speaker, and tacitly selecting

the child by limiting eligible respondents to a single partici-

pant by asking about ‘your asthma’. Through directing

questions about symptoms and treatment at children, and

involving children in the discussions of asthma and its

management, nurses demonstrated a patient-centred style

which supported child participation (Tates et al. 2002). Child

participation was supported by nurses throughout the con-

sultations, sometimes by responding to parents’ interventions

by local interactional practices to re-direct the sequence of

turn taking from parent to child. In this respect, the nurses

differed from General Practitioners in another study who were

reported to be supportive during history taking but less so in

discussions of diagnosis and treatment (Tates et al. 2002).

Parents commented favourably on nurses’ attempts to

involve their children in consultations but could intervene

during nurse–child interaction to clarify, elaborate or some-

times to contradict information provided by children, or to

raise their own concerns. Such interventions highlight

the importance of considering the third party during

dyadic interaction. Parents must be given information and

opportunities to express their own concerns during practi-

tioners’ interactions with children, just as children must not




be ignored during practitioners’ interactions with parents

(Wissow et al. 1998).

There was uncertainty about the appropriate role of children

in their asthma management. Parents had ambivalent feelings,

both asserting the need for children to take increasing roles in

their own care as they developed but also feeling the need to

continue to protect their children from the risks of asthma.

Nurses emphasised the importance of children learning to take

responsibility for their asthma, and while parents also

discussed the need to promote independence, differences of

view were evident in some consultations.

Strengths and limitations of the study

This is the first study to our knowledge of communication

between nurses, parents and children in asthma review

consultations. The recordings were made by nurses because

some reviews were conducted opportunistically when a child

presented for an unscheduled consultation, some took place

in patients’ homes and all the nurses reported working under

time pressures. This meant that the nurses were fully in

control over the selection of cases for recording from the

potential patients who had consented, and over the point at

which recording was commenced and concluded. The nurses

who volunteered to take part in this study could be expected

to be particularly interested in communication issues with

children and families rather than a representative sample. In

interviews, children did not talk readily about communica-

tion with nurses and this is a methodological issue that needs

to be addressed so that future studies include children’s

perspectives.

Conclusions

Both parents and nurses highlighted aspects of personal and

task alliance in interviews, and they were also evident in

consultations. Therapeutic alliance could be a useful frame-

work, but it needs to be adapted to take account of the roles

of children and their parents rather than a single ‘patient’.

This highlights issues that are faced by nurses, parents and

children about the distribution of responsibilities between

adults and children and the emphasis to be given to different

relationships, including nurse–parent and nurse–child.

Relevance to clinical practice

It is important to recognise the influence of dyadic relation-

ships that occur within the triadic child–parent–practitioner

relationship. There is potential for conflict as well as

cooperation. In task alliance, conflicts can arise from differ-

ing beliefs about the illness and about treatment. In personal

alliance, conflicts can arise from different perspectives on the

impact of asthma and the goals of treatments, and about the

roles of children, parents and practitioners. There is a need

for more research into nurses’ communication with children

and parents to provide an evidence base for practice,

education and training.

Acknowledgement

The authors would like to thank the children, parents and

nurses who participated in the study and Sam Rogers for her

contribution to data collection. This study was supported by

a donation from AstraZeneca.

Contributions

Study design: PC, LM; data collection and analysis: PC, LM

and manuscript preparation: PC, LM.

Conflict of interest

The authors declare that they have no conflict of interests.

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Communication between nurses, children and their parents in asthma review consultations