Hallström I & Elander G (2004) Decision-making during hospitalization: parents’ and children's involvement. Journal of Clinical Nursing 13, 367–375


  • Philip Darbyshire PhD, MN, Dip.N. (Lond.), RNT, RSCN, RNMH

    1. Chair of Nursing, Women's & Children's Hospital, University of South Australia and Flinders University, Department of Nursing & Midwifery Research & Practice Development, Women's & Children's Hospital, Adelaide, South Australia
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Philip Darbyshire, Women's & Children's Hospital, University of South Australia and Flinders University, Department of Nursing & Midwifery Research & Practice Development, Women's & Children's Hospital, 72 King William Road, Adelaide 5006, South Australia. Telephone: 08 8161 6468/6497; Fax: 08 8161 7704/08 8395 8756; E-mail: philip.darbyshire@adelaide.edu.au

The notions of ‘family-centred care’ and ‘parental participation’, in relation to child health care in general and children's hospitalization in particular, continue to be the incantations that promise to transform our paediatric services – if only we repeat them earnestly and often enough. The problem of no small import is, of course, that unless we have a much more detailed and sophisticated understanding of what these security-blanket terms might actually look like in practice, then they are doomed to a life of vacuous utility spent padding out the mission, vision and philosophy of care statements of any paediatric facility anywhere that wants to be seen to make all of the right noises. Hallström and Elander are to be commended for their sustained research that has consistently sought to explore the intricacies of ‘parental participation’ and helped us to understand the practices, perceptions, experiences and subtleties that comprise parents’, children's and nurses’ experiences of hospitalization and care.

In this paper they ask a variant of the crucial question, ‘participation in what?’ and focus on how both the everyday and more clinical decisions are reached in the context of a child's hospitalization. They are correct to highlight the significance of this issue for it impacts on children's sense of self and autonomy, parents’ and children's satisfaction with communication, reactions to treatment and doubtless more (McCabe 1996). If we think ourselves momentarily into an anxious parent's shoes it is not hard to imagine how unsettling and distressing it would be to feel that we were ‘losing control’ of our child to the hospital. We would be rightly concerned if we felt swept along by an army of professionals who ‘knew best’ and who seemed unable or unwilling to listen to us, talk with us and at the very least, ask us what we thought of possible or particular courses of treatment for our sick child. Conversely, it may be no more reassuring to be in the hands of professionals who seemed incapable of advising or suggesting possible best options and whose stock response to any question was that it was ‘your decision’ (at a time when your decision-making abilities may well not be at their sharpest).

However I do have some qualms about various aspects of this paper. I should say at the outset that these concerns do not apply only to this paper but that they have a wider applicability across much qualitative research and indeed I and many other interpretive researchers have probably fallen into similar traps. The paper reveals a structural issue for qualitative researchers and that is how to get the balance right between the various necessary aspects of a research report. My sense is that less than two pages of a nine page paper devoted to findings or results is probably inadequate and leaves the authors open to the criticism that such findings are likely to be thin or inconsequential.

The paper's central issue – decision-making, seems to have been introduced into the study as if it were largely self-explanatory and almost unproblematic. The nature of what constitutes ‘decisions’ seems unexplored as we move straight into looking at how these are made. A problem here is that this may lead us to see decisions as a fairly one-dimensional concept and simply something that is made or not made by someone or other. A more critical and questioning approach to the analysis of decisions might suggest that decision-making is much more of a complex perceptual social process than it is an event to be observed and counted off. ‘Unpacking’ this phenomena more closely would surely reveal other dimensions of decision-making that seem to have been glossed over or assumed here (see e.g. Young et al. 2003).

Related to this point is my concern about the place of numbers in essentially qualitative studies. I have no problem at all with the idea of counting what is meaningful to count. If a hypothetical qualitative study of nurse–patient interaction involving 50 patients found that 49 of them claimed that they never saw a nurse during their entire stay in hospital then that, to me, would be a figure worth mentioning. It would certainly contribute to any subsequent interpretive claim that patients feel less cared for but of course it would not replace the need for the interpretive analysis that would help us understand what was happening in this situation. In this study, however, the numbers contribute little to our understanding of the nature, essence or practices involved in decision-making. For example, on p. 372 we read that:

‘in 43 of the identified situations all involved accepted the decision without any observed reaction:

The auxiliary nurse says to the mother: We are going to weigh him now. The mother takes the child to the weighing scales. The nurse bends forward and reads the result. The mother asks about the weight.

It is hard to see how this mother's actions can be classed as ‘no observed reaction’, but perhaps harder to see how the ‘43’ helps us to understand what may be happening here. What for example should we make of the claim here that ‘all involved accepted the decision'? Did all 43 react in exactly the same way? Is observing an action or a behaviour synonymous with observing a meaning behind it? Does this supposed ‘no reaction’ infer a weary resignation, a passivity in the face of professional power, or does it mean that the parents happily concurred with the decisions and readily accepted them? Such possible distinctions should, at least, be highlighted and preferably explored. Some of the problems with invoking numbers in qualitative studies are that they can divert more than they illuminate, that they may confer an authority over the data that is questionable and that they may close off lines of thinking and questioning when what is required is a deeper engagement with the data and with the nascent interpretations that are being developed.

Another general concern in the reporting of qualitative studies highlighted by this paper is the potential for such studies to fail the ‘so what?’ test and risk being derided as ‘trite or banal’ (Caan 2001). When we seek to publish a study we really need to have something substantive to report lest we simply produce ‘bloodless findings’. I am not at all sure that this paper avoids these charges. This study tells us that parents and children tend not to make decisions on their own but in consultation with staff and that children and their parents sometimes disagree about a decision or course of action. Looking at the findings and conclusions reported it is difficult to discern any new knowledge or challenges to our everyday understandings of parental and child decision-making during hospitalization.

A final observation raises another general issue but, again, one that relates to my concerns about this paper's substantive content. While I absolutely accept that it is often desirable to report different aspects of a study in different papers, the danger is always that we may try to spread a study's findings too thinly across several papers and certainly well beyond what the data or depth and extent of analysis will support. In publishing our studies there are certainly times when less may indeed be more.