www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 1
REVIEWS
Child en as decision-make s in heal h ca e - An
in eg a i e e iew
Ma jo Vi kki ∗1, Ta ja Heino Tolonen1,2, Tapio Koskimaa3, Eija Paa ilainen2,4
1The child en’s and women’s di ision, Tampe e Uni e si y Hospi al, Finland
2School o Heal h Sciences, Uni e si y o Tampe e, Finland
3Imaging Cen e, Finland
4E elä-Pohjanmaa Hospi al Dis ic , Finland
Recei ed: Sep embe 1, 2014 Accep ed: No embe 5, 2014 Online Published: No embe 19, 2014
DOI: 10.5430/cns. 3n1p47 URL: h p://dx.doi.o g/10.5430/cns. 3n1p47
Abs ac
The aim o his in eg a i e e iew is o desc ibe a child’s pa icipa ion in he decision-making p ocess ela ed o ea men . The
goal is o inc ease knowledge o he ways ha heal hca e p o essionals can use o suppo a child’s decision-making abili y.
The da a we e ga he ed om he Medline and Cinahl da abases and he da a consis ed o 23 a icles which we e published in
scien i ic jou nals du ing 2002-2013. The a icles we e analyzed wi h an induc i e con en analysis. The esul s o he e iew
show ha a child’s knowledge skills, wishes and alues we e o en no aken in o accoun and hei pa icipa ion was limi ed.
Child en we e aken in o accoun o a ying deg ees, depending on he ime a ailable and he indi idual heal hca e p o essional.
The pe sonnel o en made he ea men decisions on behal o he amilies. This was g ea ly in luenced by he a i udes o he
pe sonnel and pa en s and he abili y o he heal hca e pe sonnel o wo k wi h child pa ien s. The p o essional language used in
discussions was shown o be an obs acle o lexible coope a ion.
Key Wo ds: Child, Mino s, Decision-making, Pa icipa ion, Heal hca e pe sonnel, Re iew
1 In oduc ion
In he Uni ed Na ions (UN) Con en ion on he Righ s o he
Child (1989), i is s a ed ha o icials should ake child en
in o accoun in all ac ions and decisions conce ning hem
and hey should e alua e he e ec s o he decisions on he
child. The child mus always come i s and he child’s opin-
ion mus be hea d. The child has he igh o pa icipa e
in decision-making conce ning himsel o he sel based on
hei age and le el o de elopmen .[1] In Finland, as well as
elsewhe e in Eu ope, he igh s o child en a e moni o ed by
an ombudsman o child en. The ombudsman ac s based on
he UN Con en ion on he Righ s o he Child.[2,3]
In he Cons i u ion o Finland (1999), child en’s basic igh s
include equal ea men , which also includes he igh o
ha e an in luence on ma e s conce ning hem, based on
hei le el o de elopmen .[4] Acco ding o he law pe ain-
ing o a pa ien ’s posi ion and igh s (1992), he child’s opin-
ion mus be asked when i is possible based on his o he age
and le el o de elopmen . When a child is able o decide
abou ac ions ela ed o hei ea men , he ea men deci-
sions mus be made oge he wi h hem. The law men ions
ha in o ma ion on a child’s heal h and ea men canno be
gi en o hei legal gua dian i i is he child’s own wish.[5]
In he e hics o he heal hca e o child en, i is s essed ha
a child should be asked o hei consen when hey ha e he
∗Co espondence: Ma jo Vi kki; Email: [email p o ec ed]; Add ess: The child en’s and women’s di ision, Tampe e Uni e si y Hospi al,
PL2000, 33521 Tampe e, Finland.
Published by Sciedu P ess 47
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capabili y o i . The heal hca e wo ke has he esponsibil-
i y o in o m he child abou coming ea men s and make
he ea men expe iences as posi i e as possible. The aim
is o ask o he child’s consen o he coming p ocedu e.
Heal hca e wo ke s mus suppo he child in making de-
cisions ela ed o ea men . A he same ime, heal hca e
wo ke s mus make su e ha he child does no ha e o make
decisions ha su pass hei unde s anding.[1,6,7]
The pa icipa ion o a child in hei ea men is di e se. The
child’s poin o iew, wishes and will a e aken in o accoun
o a ying deg ees. Some o he heal hca e wo ke s who
pa icipa ed in he s udy hough ha he child’s iew canno
always be aken in o accoun , and some said ha he child’s
iew will be aken in o accoun whene e i is possible om
he poin o iew o hei own wo k.[8]
Child en a e an impo an cus ome g oup in heal hca e se -
ices bu li le esea ch on child en’s heal hca e expe iences.
The esea ch is mainly ocused on he pa en s’ poin o iew.
The p oblem in esea ch on child en is de e mining he
me hodological s a ing poin , as he e is a lack o sui able
measu emen s. Resea ch on child en also aces he e hical
challenge o child en’s abili y o gi e consen . Views ha
s a e ha a child canno unde s and o desc ibe hei own
expe iences and hei wo ld due o hei imma u i y may de-
c ease he amoun o esea ch ocusing on child en.[9]
In heal hca e decision-making, he companionship and dis-
cussion be ween he pa ien and he p o essional is empha-
sized. The pa ien ’s opinion and iewpoin s a e aken in o
accoun in ea men and in decision-making. Explici in e -
ac ion and coope a ion ensu e ha he decision-making is
open and nego iable o he pa ien .[10]
Views on child en’s pa icipa ion in decision-making a y
g ea ly. In he p o ec ionis poin o iew, pa en s should
hinde and p o ec child en om making bad decisions.
Child en a e unquali ied o make decisions especially e-
la ed o ea men . Because o his, adul s should de end
and gua d child en. The libe alis iew us s in a child’s
igh o sel -de e mina ion and abili y o make independen
decisions. Acco ding o his iewpoin , child en a e a mi-
no i y wi hou ci izenship igh s. Especially in heal h ca e,
a child’s abili y o discuss hei own ea men s and p oce-
du es is no app ecia ed. In he p agma is iew, he child’s
own opinion is espec ed and hey a e p o ec ed om ques-
ionable decisions. This iew cons i u es a syn hesis o p o-
ec ionis and libe alis app oaches, ying o main ain a bal-
ance be ween a child’s igh s o sel -de e mina ion and he
pa en s’ esponsibili ies.[11,12]
The pa ien ’s pa icipa ion can be desc ibed as a con in-
uum. I includes he di e en models o pa icipa ion and
decision-making and he le els o pa ien pa icipa ion. In
in o med decision-making, expe s gi e he pa ien su i-
cien in o ma ion so ha hey can make decisions ela ed
o hei ea men hemsel es. The pa ien makes he i-
nal decision himsel /he sel . In sha ed decision-making,
he p o essional discusses he di e en ea men op ions o-
ge he wi h he pa ien so ha he decision-making is based
on a sha ed unde s anding. In sha ed decision-making, he
decision-making ega ding ea men op ions is di ided be-
ween he expe and he pa ien . The expe , “p o essional-
as-agen ”, has in luence when he o she has he echni-
cal expe ise, and he child has he igh o ake pa in
he decision-making. Acco ding o pa e nalism, he expe
knows wha he bes op ion o he pa ien is and in o ma ion
is sha ed o a limi ed ex en wi h he pa ien . The pa ien ’s
low au ho i y means ha he pa ien will no pa icipa e in
decision-making and he o she will no be in o med abou
p ocedu es and ea men . In his case, he pa ien canno
gi e in o med consen o coming ea men s.[13]
Aim
The aim o his in eg a i e e iew is o desc ibe a child’s
pa icipa ion in he decision-making p ocess ela ed o ea -
men . The goal is o inc ease knowledge o he ways
ha heal hca e p o essionals can use o suppo a child’s
decision-making abili y.
The li e a u e e iew looks o answe s o he ollowing
ques ions:
(1) How is a child aken in o accoun in decision-making
ela ed o ea men ?
(2) How can heal hca e pe sonnel suppo a child’s pa -
icipa ion and decision-making ela ed o ea men ?
2 Me hods
The in eg a i e e iew is used o collec and analyze exis ing
esea ch on he opic and o inc ease c i ical and sys ema ic
knowledge by using he abo e s a ed esea ch ques ions in
he analysis. The quali y o he da a was e alua ed and he
esul s we e syn hesized e ospec i ely as comp ehensi ely
as possible.[14–16]
The esul s om he in e na ional esea ch a icles and li -
e a u e e iews selec ed o analysis in his s udy we e ana-
lyzed wi h an induc i e con en analysis acco ding o he e-
sea ch ques ions. Con en analysis is a me hod ha is based
on he sys ema ic and objec i e analysis o documen s.[17,18]
2.1 Da a collec ion
When de ining he sea ch e ms, he MeSH (Medical Sub-
jec Heading) subjec e minology was used, as well as e e -
ence books and a icles om he subjec a ea. The sea ches
we e complemen ed wi h na u al language sea ches, and
some sea ches we e conduc ed wi h he help o an in o -
ma icis .[15]
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Table 1: Inclusion and exclusion c i e ia o he da a
Inclusion c i e ia Exclusion c i e ia
Child, young pe son o mino
in his s udy e e s o a pe son
unde 18 yea s old acco ding
o he UN Con en ion on he
Righ s o he Child
S udies ela ed o he men al
heal h, d ug abuse, physical
abuse, e minal ca e and o gan
dona ion o child en and
young people
Scien i ic a icles on he
decision-making o child en
and mino s ela ed o
ea men
S udies ela ed solely o he
decision-making o legal
gua dians, pa en s o
heal hca e pe sonnel
S udies and sys ema ic
li e a u e e iews
Yea o publica ion 2000–
oday
A icle in English
Sea ch e ms:
•Decision making and pa ien pa icipa ion, consen
•Limi : y = “2000-2013” and “p eschool child (2 o 5
yea s)” o “child (6 o 12 yea s)” o “adolescen (13
o 18 yea s)”
Da abases ele an o nu sing science we e he p ima y
sou ces in he li e a u e sea ch. The inclusion and exclusion
c i e ia o he da a a e p esen ed in Table 1. Based on he
sea ches, he Medline and Cinahl da abases eme ged as he
bes sou ces o a icles when ying o answe he esea ch
ques ions (see Figu e 1).
2.2 Desc ip ion o he da a and quali y e alua ion
Al oge he 23 comple e ex s we e included in he inal anal-
ysis which answe ed he esea ch ques ions and ul illed he
inclusion c i e ia. The choice o da a was also in luenced by
a ailabili y.[14,19] The a icles we e published du ing 2002-
2013. The a icles we e w i en in No h Ame ica (n= 11),
G ea B i ain (n= 5), Sweden (n= 4), Is ael (n= 1) and
I eland (n= 2).
The me hodological app oach in he a icles selec ed o he
e iew was quali a i e in 14 cases, quan i a i e in ou cases,
and i e a icles we e e iews. Based on he selec ion c i e-
ia and esea ch ques ions, each s udy o e iew discussed
he pa icipa ion and decision-making o child en o young
pe sons in he con ex o heal hca e. The a icles o en dis-
cussed he iewpoin s o pa en s and heal hca e pe sonnel
as well. In wo s udies, he decision-making and pa icipa-
ion o amilies was ocused on moni o ing e en s du ing a
doc o ’s appoin men .
The quali y o he da a was e alua ed acco ding o he G ade
(G ading quali y o E idence) classi ica ion.[20] Acco ding
o his classi ica ion, he g ading quali y o he 14 quali a i e
s udies is D. Th ee quan i a i e s udies we e e alua ed o
ha e a g ading quali y o B, as in hese s udies he decision-
making p ocess had been de eloped wi h a new model based
on he esul s. One quan i a i e s udy was e alua ed o ha e
a g ading quali y o C. Two o he e iews we e classi ied
in o he B class, one in o he C class and wo in o he D
class. Bo h o he e iews classi ied in o he B class we e
s ongly based on empi ical esea ch.
Figu e 1: The li e a u e sea ch
Ha ing a g ading quali y o C o D does no mean ha
a s udy o e iew is bad o ha he esul s canno be
us ed.[20] In nu sing science, s udies o en ocus on sen-
si i e issues, which a e be e analyzed quali a i ely han
quan i a i ely. The esea ch and unde s anding o nu sing
phenomena equi es people’s pe sonal desc ip ions o expe-
iences.[18]
The quali y e alua ion also included he impac ac o (IF)
o he publica ion and he ci a ion index o he au ho .[21]
The IF alues in 2012 a ied be ween 0-5.391 and IF al-
ues wi hin i e yea s a ied be ween 0-5.850. The ci a ion
alues o he au ho s a ied be ween 0-39. The IF alues
o ou a icles a e missing and hei ci a ion indexes a ied
be ween 2-14. The a icles we e included in he da a be-
cause hey desc ibed he phenomenon simila ly o he o he
s udies and e iews.
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2.3 Da a analysis
The analysis o he esea ch da a was s a ed by eading he
a icles ca e ully and ge ing amilia ized wi h hem. The
essen ial esul s o he s udies we e w i en down in a a-
ble. The close eading was ollowed by an induc i e con-
en analysis. The analysis was guided by he esea ch ques-
ions, and simpli ied exp essions we e o med om he da a.
These exp essions we e compa ed wi h each o he . Based
on he compa ison, subca ego ies we e o med whe e sim-
ila exp essions we e combined in o hei own ca ego ies.
Th ough his g ouping, he ca ego ies we e named (see Ta-
ble 2).[17,18]
Table 2: Subca ego ies and ca ego ies
Subca ego ies Ca ego ies
Obs acles o pa icipa ion and possibili ies o ha e an in luence A child in he decision-making ela ed o ea men
Limi a ions ela ed o age c i e ia and le el o de elopmen
Weaknesses in communica ion
Taking he child in o accoun in decision-making and pa icipa ion
The communica i e skills o he heal hca e pe sonnel The eadiness o he pe sonnel o suppo he
decision-making o a child
Abili y o lis en o a child
Obs acles o child en’s pa icipa ion in heal h decision- making
3 Resul s
3.1 A child in he decision-making ela ed o ea -
men
Acco ding o he umb ella ca ego ies, he esul s we e o-
cused on obs acles o pa icipa ion and in luence, age c i e-
ia and limi a ions ela ed o le el o de elopmen , as well as
de iciencies in communica ion. The da a also included de-
sc ip ions o si ua ions when he decision-making and pa -
icipa ion ook he child in o accoun .
Obs acles o pa icipa ion and possibili ies o ha e an in-
luence. The esea ch esul s show ha a child’s knowledge
capabili ies, wishes and alues a e o en no aken in o ac-
coun and hei pa icipa ion is p e en ed.[22–30] Heal hca e
p o essionals make he decisions on behal o he child en
and o en on behal o pa en s as well.[24,25,27, 31] The ea-
sons behind his we e he a i udes o he pe sonnel and he
pa en s[26,32,33] and he desi e o p o ec he child.[22, 33] The
inexpe ience o he pe sonnel in handling pedia ic pa ien s
also has an e ec on how ac i ely he amilies pa icipa ed
in he decision-making.[24,34,35]
The heal hca e pe sonnel could no always ind he ime o
ask abou he child’s iew[23] and he decision had o be
made as quickly as possible.[25,27] Some imes he e was no
in o ma ion a ailable ha would be a ge ed o child en[23]
o he in o ma ion was only a ge ed o he pa en s.[28] The
esul s o Runeson’s (2007) s udy show ha pa en s assume
ha a child has ecei ed he necessa y in o ma ion on he
ea men s. This assump ion was shown o be e oneous
based on he child en’s esponses.[28]
Limi a ions ela ed o age c i e ia and le el o de elop-
men . In he analysis o he child’s posi ion, he iden i i-
ca ion o cogni i e skills and he child’s age we e empha-
sized.[23,27,34–37] In Coyne’s s udy, he communica ion o
heal hca e p o essionals was sugges ed o be mo e abou
iden i ying he knowledge skills o a child han hei capa-
bili y o unde s and he coming ea men e en s.[24] Nu ses
alued he opinion o a child, bu he child’s capabili ies and
age limi ed he discussion. Some o he nu ses wan ed o ge
he pa en s’ pe mission i s be o e asking abou he child’s
opinion.[11] The pa icipa ion o he child was in luenced by
eading skills and eading comp ehension as well as legisla-
ion.[33]
Weaknesses in communica ion. The p o essional lan-
guage used in discussions dec eased he pa icipa ion o
child en and pa en s and hei willingness o make deci-
sions.[24,35,38] The child en and pa en s el ha he heal h-
ca e pe sonnel ga e in o ma ion in an unclea manne , so
ha hey we e no able o p ope ly conside all he possible
isks ela ed o ea men s. Exis ing guidelines ega ding
he sha ing o in o ma ion we e complied wi h o a ying
deg ees.[39] Excessi e in o ma ion can also be an obs acle
o pa icipa ing in a clinical s udy o eenage s and young
adul s.[38]
Taking he child in o accoun in decision-making and
pa icipa ion. Making a decision oge he o discussing
hei decision wi h pa en s was signi ican o child en’s
sel -es eem and hei adhe ence o ea men .[31,40–42] The
posi i e a i ude o pa en s and heal hca e pe sonnel had
an e ec on he child’s pa icipa ion.[31,42] The decision-
making ela ed o ea men did no ha e a big impo ance
o he child en when hei physical condi ion was bad o
hei ea men was jus beginning. In such cases, he need
o he suppo o o he s in decision-making was empha-
sized.[29,43]
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Decision-making and pa icipa ion we e es ed in a s udy
by Hankins e al. The pa ien s and pa en s ecei ed w i -
en ma e ial, me a nu se, made a choice and hen discussed
he inal decision wi h he doc o . The esul s showed ha
his me hod inc eased he pa ien s’ and pa en s’ adhe ence
o ea men . The child en we e also able o be e exp ess
hei opinion and e en disag ee wi h hei pa en s. A e he
s udy ended, he me hod was kep in use a he hospi al.[40]
3.2 The eadiness o he pe sonnel o suppo he
decision-making o a child
Desc ip ions we e chosen om he da a which answe ed he
esea ch ques ion o how he heal hca e pe sonnel can sup-
po a child’s pa icipa ion and decision-making ela ed o
ea men . The esul s emphasized he communica i e skills
o he pe sonnel, hei abili y o lis en o a child and hei
a i udes.
The communica i e skills o he heal hca e pe sonnel.
Sui able in o ma ion educes a child’s ea and misunde -
s andings.[11,24,33] In o ma ion is sui able when a child has
a clea iew o he na u e and pu pose o he ea men p o-
cedu es and he e ec o he ea men on his o he condi-
ion.[22,29,33] Child en who had ecei ed a lo o in o ma-
ion and a possibili y o pa icipa e in discussions ega d-
ing hei ea men adhe ed o hei ea men he bes .[22,24]
Adhe ence o ea men was connec ed o he amoun and
quali y o in o ma ion.[27,28] The child en also expec o be
in o med on as many di e en issues as possible.[11, 29]
Pa icipa ion in ea men and decision-making canno be
ied o a ce ain age because cogni i e de elopmen and
willingness a y g ea ly among child en.[11,26, 34] Gi ing in-
o ma ion o child en and young people is challenging be-
cause he amoun o in o ma ion should no be oo small o
oo much.[43] The in o ma ion ela ed o he illness, isks
and he child’s eal unde s anding should be ealis ic.[34]
The beha io and communica ion skills o he heal hca e
pe sonnel a e key ac o s in he pa icipa ion and decision-
making o child en in hei ea men .[23,29,42]
Child en a e mo e calm and p epa ed o hei ea men
when hey ecei e in o ma ion and a e consul ed ega ding
hei illness.[24,27] The in o ma ion is gi en acco ding o
he child’s wishes and needs, and hey a e asked wha hey
hink abou he planned ea men . The child needs ime
o hink and o ask ques ions.[27] Child en and young people
a e gi en a chance o pa icipa e, and i should be a ca e ully
conside ed p ocess.[35] Acco ding o s udies, hese consid-
e a ions imp o e he child’s abili y o unde s and wha hei
illness means.
Abili y o lis en o a child. The child should ha e he
igh o exp ess hei opinion[23,33, 35] and hey should be
gi en he possibili y o make hei own decisions.[22, 33] Lis-
ening o child en is impo an and hey should also be
us ed.[11,22,23, 26, 35] Child en a e able o p o ide a e y di -
e en poin o iew o he planning o ea men .[11]
Child en and mino s should be gi en a chance o sha e
he decision-making wi h hei pa en s o heal hca e pe -
sonnel[22,34,40] o hey should be p o ided an oppo uni y
o ha e someone else make decisions o hem.[22, 26, 34, 41]
The decision-making p ocess depends on how he amily
in gene al makes decisions be ween hem.[41,42] Adhe -
ence o ea men and us in he pe sonnel inc ease when
he child is gi en a chance o pa icipa e in he decision-
making.[11,22,25]
Obs acles o child en’s pa icipa ion in heal h decision-
making. The p ima y obs acles o child en’s pa icipa ion
we e he a i udes o he heal hca e pe sonnel and lack o
ime. The iews and alues o child en and young people
mus be us ed.[23,34] The nu ses should encou age chil-
d en o be ac i e in decision-making, and i is also pa o
he e hical esponsibili ies o nu ses.[11,38] Heal hca e pe -
sonnel should es hei own skills and gi e in o ma ion and
suppo hei pa ien s o pa icipa e in he decision-making
ela ed o hei ea men .[34]
Nu ses specializing in he ea men o child en a e in an
impo an posi ion ega ding his issue. They can p omo e
child en’s igh s and pa icipa ion in decision-making.[31]
When eamwo k be ween child en, pa en s and heal h-
ca e pe sonnel is combined wi h esea ch in o ma ion, he
decision-making p ocess o child en and mino s can be de-
eloped.[33,38]
4 Discussion
4.1 Discussion o esul s
Based on he esul s, in some cases he heal hca e pe son-
nel ocused oo much on iden i ying he cogni i e skills o
he child when examining he child’s posi ion, and he in-
o ma ion and issues ela ed o he ac ual ea men ecei ed
less a en ion. Based on he esul s, he pa icipa ion o a
child canno be ied o a ce ain age because cogni i e de-
elopmen and willingness o pa icipa e a y g ea ly among
child en.
The esul s showed ha he posi i e a i ude o he pe sonnel
and pa en s and he possibili y o make decisions enhance
he child’s sel -es eem. Pa icipa ion and discussing he de-
cision we e impo an o he child’s adhe ence o ea men .
A child o a mino has o be gi en a chance o le someone
else make he decision on hei behal i hey do no wan o
o ha e he s eng h o pa icipa e in he discussions.
Based on he esul s, he communica i e skills and suppo
o he pe sonnel we e signi ican . Adhe ence o ea men
was connec ed o sui able in o ma ion and he nego ia ing
skills o he pe sonnel. Clea and comp ehensi e in o ma-
ion educed he child’s ea and misunde s andings. Gi -
ing in o ma ion o child en is challenging because he in o -
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ma ion should be gi en acco ding o he child’s wishes and
needs.
The abili y o lis en o a child and he a i udes o he heal h-
ca e pe sonnel eme ged as signi ican issues in he da a. Lis-
ening o a child and app ecia ing his o he opinions in-
c eased us in he pe sonnel and imp o ed adhe ence o
ea men . A child has he igh o pa icipa e in hei ea -
men and make decisions ela ed o i . A child is a eliable
sou ce o in o ma ion who can gi e a new poin o iew in o
he planning o ea men .
The a i udes o heal hca e pe sonnel eme ged as a signi i-
can obs acle o a child’s pa icipa ion. The a i udes o he
heal hca e pe sonnel we e ela ed o he lack o ime and
inexpe ience in ea ing child en. The esul s did no show
whe he he unce ain y o he pe sonnel in ea ing child en
and lack o ime we e ela ed o each o he .
The con lic ha eme ged in he s udy was ela ed o he
beha io o pedia ic nu ses. The need o nu ses specializ-
ing in pedia ics was poin ed ou in he obse a ion s udy
by Hälls öm and Elande . Acco ding o hem, pedia ic
nu ses ha e expe ience o encou aging child en o pa ici-
pa e in decision-making and ensu ing ha he child’s igh s
a e aken in o accoun .[31] In Coyne’s s udy, howe e , he
bigges inding was ha pedia ic nu ses made he decisions
wi hou hea ing he opinions o child en.[24]
In Runeson’s s udy, pa en s assumed ha hei child had e-
cei ed enough in o ma ion on he coming p ocedu es. The
esul s showed, howe e , ha he child en had no ecei ed
enough in o ma ion.[28] Acco ding o he disse a ion o
Salmela, child en canno always exp ess hei ea s ela ed
o hospi als because hey wan o p o ec hei pa en s. Chil-
d en do no wan o add o hei pa en s’ wo ies by exp ess-
ing hei own.[44]
4.2 Reliabili y o he e iew and e hical iewpoin s
The da a was sys ema ically ga he ed om da abases ha
a e ele an o nu sing science by using he MeSH subjec
e minology, e e ence books and na u al language sea ches.
The sea ch p ocess was made as sys ema ic as possible by
conduc ing some sea ches wi h an in o ma icis . The in o -
ma icis assis ed in speci ying he sea ch e ms. The choice
o sea ch e ms depended on he esea ch ques ions de ined
in he esea ch plan. The sea ches we e limi ed o yea s
2000-2013 in o de o ind cu en ly ele an esea ch e-
sul s. The ins uc ions o conduc ing he s udy and he in-
clusion and exclusion c i e ia also a ec ed he amoun o
a icles chosen. The sea ches showed ha esea ch on he
subjec is sca ce. Fo his eason, i was possible o ead he
majo i y o he abs ac s and comple e ex s.[45]
The eliabili y was enhanced by ca e ully classi ying he
da a in a able. The able helped o o m a comp ehensi e
iew o he da a and i helped in p ocessing he da a. Se -
e al indings om he da a we e ga he ed in o he umb ella
ca ego ies, so ha he analysis became mo e epea able and
answe s we e ound o he esea ch ques ions. The limi a-
ions in he s udy we e he small sample sizes, as is common
in quali a i e esea ch, and he small amoun o da a in gen-
e al.[17,46]
The quali y o he a icles selec ed o he s udy u ned ou
o be qui e di e se based on he e alua ion c i e ia. E en
hough he g ading quali y o he e idence o he majo i y
o he a icles was e alua ed as D, he impac ac o alues
and/o numbe s o ci a ion indexes suppo ed he choice o
he a icles included in he s udy.[20, 21]
The esea ch a icles and li e a u e e iews chosen o he
s udy we e mainly in English and elec onically a ailable.
This can cause language o publica ion bias, and he e is he
possibili y ha signi ican s udies ha e been le ou side o
he sea ches. In his s udy, based on he cohe en esul s,
he language and publica ion bias a e unlikely o be p esen .
As a esea ch me hod, an in eg a i e e iew has limi a ions
which a e acknowledged in his s udy. Resea ch on chil-
d en is sca ce due o me hodological challenges and p eju-
dices, which causes limi a ions o he selec ion o s udies
and he analysis o esul s.[14–16] Resea ch s udies ocusing
on di e en age g oups we e no analyzed sepa a ely in his
s udy, e en hough he esea ch g oup acknowledges ha
he cogni i e, social and emo ional skills and knowledge o
2–18 yea s old child en a y g ea ly be ween di e en age
g oups.[47]
The s udy was conduc ed acco ding o he ules o good sci-
en i ic p ac ice. The collec ion and analysis o da a was as
p ecise and esponsible as possible. The s udy was based on
a esea ch plan. The c i e ia in he esea ch plan we e ol-
lowed acco ding o he phases p esen ed ea lie in his s udy.
The quali y e alua ion o he esea ch a icles and e iews
was conduc ed aking in o accoun e hical iewpoin s. The
di e en s ages o he s udy ha e been desc ibed as speci i-
cally as possible so ha he eade can e alua e he au ho ’s
choices.[17,18,48]
5 Conclusions and opics o u he e-
sea ch
This s udy suppo s he iew ha he pa icipa ion o chil-
d en in he decision-making in heal hca e is i egula . The
s udy esul s can be u ilized in p ac ice o de eloping ea -
men discussions wi h child en and mino s. The aining
o heal hca e pe sonnel should emphasize he iden i ica ion
and unde s anding o he cogni i e skills, wishes and alues
o child en.
The posi i e a i ude o he s a and pa en s, he possibili y
o pa icipa e in discussions as an equal, and he oppo u-
ni y o pa icipa e in decision-making we e ac o s ha in-
c eased he child’s sel -es eem and adhe ence o ea men .
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The child mus also be gi en a chance o e use o ake pa
in he decision-making o nego ia ion ela ed o ea men .
To achie e his, he s a should ha e good communica ion
skills, he abili y o lis en o he child and expe ience o
ea ing pedia ic pa ien s.
The need o u he de elop and s udy he decision-making
p ocess eme ged as a opic o u he esea ch ha can help
in inc easing he pa icipa ion o child en in he con ex o
heal hca e. The esul s om he in e en ion s udy by Han-
kins e al ha ocused on decision-making and pa icipa ion
a e wo h es ing. In his model, he pa ien s and pa en s e-
cei ed w i en ma e ial, me a nu se, made he choice and
hen discussed he inal decision wi h he doc o . The e-
sul s o he s udy and i s e ec s we e signi ican o bo h he
pa ien s and pa en s.[40]
In he s udy by Hankins, e al., he pa ien s and pa en s we e
gi en w i en ma e ial.[40] In he ollow-up s udies, i should
be de e mined i s wha kind o w i en ma e ial exis s o
child pa ien s and hei pa en s. I should be s udied how he
ins uc ions could be de eloped and s anda dized so ha a
child can unde s and he ma e ial. W i ing such ma e ial is
demanding because di e en age g oups should ha e di e -
en ma e ial a ailable ha akes in o accoun hei age and
le el o comp ehension.
In he u u e, mo e esea ch is needed on how nu sing pe -
sonnel ake child en in o accoun in ea men decision-
making. Fo ins ance, by using an obse a ion s udy, i
is possible o a ge he possible weaknesses ela ed o he
discussions om he child en’s and hei pa en s’ poin s o
iew. This kind o app oach would also gi e in o ma ion on
he aining needs o he heal hca e pe sonnel.
Con lic s o In e es Disclosu e
The au ho s decla e ha hey ha e no compe ing in e es .
Re e ences
[1] Con en ion on he Righ s o he Child [In e ne ]. Adop ed and
opened o signa u e, a i ica ion and accession by Gene al Assem-
bly esolu ion 44/25 o 20 No embe 1989 [ci ed 2010 No 27].
A ailable om: www2.ohch .o g/english/law/c c.h m
[2] The Law on he Ombudsman o Child en [In e ne ].
21.12.2004/1221 [ci ed 2010 No 27]. A ailable om:
h pp://www. inlex. i
[3] Eu opean Ne wo k o Ombudspe sons o Child en (ENOC) [In-
e ne ]. Es ablished in 1997 [ci ed 2012 Ma 29]. A ailable om:
h p://www.c in.o g/enoc
[4] The Cons i u ion o Finland [In e ne ]. 11 June 1999/731 [ci ed 2010
No 27]. A ailable om: h pp://www. inlex. i
[5] Ac on he S a us and Righ s o Pa ien s [In e ne ]. 17.8.1992/785
[ci ed 2010 No 27]. A ailable om: h pp://www. inlex. i
[6] Leino-Kilpi H, Välimäki M. E hics in Nu sing. 5 h e . ed. Po oo:
WSOY; 2009.
[7] Pa ekh SA. Child consen and he law: an insigh and discussion in o
he law ela ing o consen and compe ence. Child: Ca e, Heal h &
De elopmen . 2006; 33(1): 78-82. h p://dx.doi.o g/10.1111
/j.1365-2214.2006.00641.x
[8] Pekki A, Tamminen T. The Condi ions o he Child. Vammala; Kun-
nallisalan kehi ämissää iön u kimusjulkaisu , n o 33; 2002.
[9] Pelande T, Nuu ila L-M, Salan e ä S, e al. Child as In o ma ion
Sou ce: he Su ey o he Disse a ions o he Nu sing Science ha
ha e been done in Finland. Hoi o iede. 2006; 18(4): 160-171.
[10] Lind o s P. The Pa ien ’s pa o he Decision-Making wi h he Gen-
e al P ac i ione ’s and he Homoeopa h’s Recep ion. Sosiaalilääke i-
e eellinen aikakausleh i. 2004; 41: 185-198.
[11] Bas on J. Heal hca e decisions: a e iew o child en’s in ol emen .
Paedia ic Nu sing. 2008; 20(3): 24-6. h p://dx.doi.o g/10.
7748/paed2008.04.20.3.24.c6517
[12] Lowden J. Child en’s igh s: a decade o dispu e. Jou nal o Ad-
anced Nu sing. 2002; 37(1): 100-7. h p://dx.doi.o g/10.10
46/j.1365-2648.2002.02049.x
[13] Thompson AGH. The Meaning o pa ien in ol emen and pa ici-
pa ion in heal h ca e consul a ions: A axonomy. Social Science &
Medicine. 2007; 64: 1297-1310. h p://dx.doi.o g/10.1016
/j.socscimed.2006.11.002
[14] Rew L. The sys ema ic e iew o li e a u e: syn hesizing e idence
o p ac ice. Jou nal o Specialis s in Pedia ic Nu sing. 2011;
16(1): 64-9. h p://dx.doi.o g/10.1111/j.1744-6155.20
10.00270.x
[15] Holopainen A, Hakulinen-Vii anen T, Tossa ainen K. Sys ema ic
e iew - a me hod o nu sing esea ch. Nu se Resea che . 2008;
16(1): 72-83. h p://dx.doi.o g/10.7748/n 2008.10.16.
1.72.c6754
[16] Pudas-Tähkä S-M, Axelin A. Delimi a ion o he Subjec o he
Sys ema ic Li e a u e Re iew, Sea ch Te ms and E alua ion o he
Abs ac . Tu un yliopis o: Hoi o ie een lai oksen julkaisuja A: 51;
2007.
[17] Jones ML. Applica ion o sys ema ic e iew me hods o quali a-
i e esea ch: p ac ical issues. Jou nal o Ad anced Nu sing. 2004;
48(3): 271-8. h p://dx.doi.o g/10.1111/j.1365-2648.20
04.03196.x
[18] Elo S, Kyngäs H. The quali a i e con en analysis p ocess. Jou nal
o Ad anced Nu sing. 2008; 62(1): 107-115. h p://dx.doi.o g
/10.1111/j.1365-2648.2007.04569.x
[19] Du y ME. Sys ema ic Re iews: Thei Role and Con ibu ion o
E idence-based P ac ice. Clinical Nu se Specialis . 2005; 19(1):
15-7. h p://dx.doi.o g/10.1097/00002800-200501000-0
0005
[20] Higgins JPT, G een S (edi o s). Coch ane Handbook o Sys em-
a ic Re iews o In e en ions Ve sion 5.1.0. The Coch ane Collab-
o a ion[In e ne ]. 2011 Ma [ci ed 2012 Ma 29]. A ailable om:
h p://handbook.coch ane.o g
[21] G i i hs P, No man I. Wha is a nu sing esea ch jou nal? In e -
na ional Jou nal o Nu sing S udies. 2011; 48(11): 1311-4. h p:
//dx.doi.o g/10.1016/j.ijnu s u.2011.09.006
[22] Alde son P, Su cli e K, Cu is K. Child en’s Compe ence o Con-
sen o medical T ea men . Has ings Cen e Repo . 2006; 36(6):
25-34. h p://dx.doi.o g/10.1353/hc .2006.0000
[23] Coyne I. Child en’s pa icipa ion in consul a ions and decision-
making a heal h se ice le el: A e iew o he li e a u e. In e -
na ional Jou nal o Nu sing S udies. 2008; 45: 1682-9. h p:
//dx.doi.o g/10.1016/j.ijnu s u.2008.05.002
[24] Coyne I. Consul a ion wi h child en in hospi al: child en, pa en s’
and nu ses’ pe spec i es. Jou nal o Clinical Nu sing. 2006; 15: 61-
71. h p://dx.doi.o g/10.1111/j.1365-2702.2005.01247
.x
Published by Sciedu P ess 53
www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 1
[25] Ka nieli-Mille O, Eisiko i s Z. Physician as pa ne o salesman?
Sha ed decision-making in eal- ime encoun e s. Social Science &
Medicine. 2009; 69: 1-8. h p://dx.doi.o g/10.1016/j.soc
scimed.2009.04.030
[26] Knop JM, Ho nung RW, Slap GB, e al. Views o ea men de-
cision making om adolescen s wi h ch onic illnesses and hei
pa en s: a pilo s udy. Heal h Expec a ions. 2008; 11: 343-54.
h p://dx.doi.o g/10.1111/j.1369-7625.2008.00508.x
[27] Runeson I, Halls öm I, Elande G, e al. Child en’s Pa icipa ion in
he Decision-Making P ocess Du ing Hospi aliza ion: an obse a-
ional s udy. Nu sing E hics. 2002; 9(6): 583-98. h p://dx.doi
.o g/10.1191/0969733002ne553oa
[28] Runeson I, Mås e son E, Enskä K. Child en’s Knowledge and De-
g ee o Pa icipa ion in Decision Making When Unde going a Clin-
ical Diagnos ic P ocedu e. Pedia ic Nu sing. 2007; 33(6): 505-11.
PMid:18196714.
[29] S egenga K, Wa d-Smi h P. The Adolescen Pe spec i e on Pa ic-
ipa ion in T ea men Decision Making: A Pilo S udy. Jou nal o
Pedia ic Oncology Nu sing. 2008; 25(2): 112-7. h p://dx.doi
.o g/10.1177/1043454208314515
[30] Mille VA, Bake JN, Leek AC, e al. Adolescen pe spec i es on
phase I cance esea ch. Pedia ic Blood & Cance . 2013; 60(5):
873-8. h p://dx.doi.o g/10.1002/pbc.24326
[31] Hälls öm I, Elande G. Decision-making du ing hospi aliza ion:
pa en s’ and child en’s in ol emen . Jou nal o Clinical Nu sing.
2004; 13: 367-75. h p://dx.doi.o g/10.1046/j.1365-270
2.2003.00877.x
[32] Coyne I, Ha de M. Child en’s pa icipa ion in decision-making:
Balancing p o ec ion wi h sha ed decision-making using a si ua-
ional pe spec i e. Jou nal o Child Heal h Ca e. 2011; 15(4): 312-9.
h p://dx.doi.o g/10.1177/1367493511406570
[33] Må enson EK, Fäge skiöld AM. A e iew o child en’s decision-
making compe ence in heal h ca e. Jou nal o Clinical Nu sing.
2007; 17: 3131-41. h p://dx.doi.o g/10.1111/j.1365-270
2.2006.01920.x
[34] Alde son P. Compe en child en? Mino consen o heal h ca e ea -
men and esea ch. Social Science & Medicine. 2007; 65: 2272-83.
h p://dx.doi.o g/10.1016/j.socscimed.2007.08.005
[35] Cox ED, Smi h MA, B own RL. E alua ing Delibe a ion in Pedi-
a ic P ima y Ca e. Pedia ics. 2007; 120: 68-77. h p://dx.doi
.o g/10.1542/peds.2006-2602
[36] Gelle G, Tambo ES, Be nha d BA, e al. In o med Consen o
En olling Mino s in Gene ic Suscep ibili y Resea ch: A Quali a-
i e S udy o A - isk Child en’s and Pa en s’ Views Abou Chil-
d en’s Role in Decision-making. Jou nal o Adolescen Heal h.
2003; 32: 260-71. h p://dx.doi.o g/10.1016/S1054-139
X(02)00459-7
[37] Mille VA, Ha is D. Measu ing child en’s decision-making in ol e-
men ega ding ch onic illness managemen . Jou nal o Pedia ic
Psychology. 2012; 37(3): 292-306. h p://dx.doi.o g/10.10
93/jpepsy/js 097
[38] Read K, Fe nandez CV, Gao J, e al. Decision-Making by Ado-
lescen s and Pa en s o Child en Wi h Cance Rega ding Heal h
Resea ch Pa icipa ion. Pedia ics. 2009; 124(3): 959-65. h p:
//dx.doi.o g/10.1542/peds.2008-2878
[39] Reynolds WW, Nelson RM. Risk pe cep ion and decision p ocesses
unde lying in o med consen o esea ch pa icipa ion. Social Sci-
ence & Medicine. 2007; 65: 2105-15. h p://dx.doi.o g/10.
1016/j.socscimed.2007.06.021
[40] Hankins J, Hinds P, Day S, e al. The apy P e e ence and Decision-
Making Pa ien s Wi h Se e e Sickle Cell Anemia and Thei Fam-
ilies. Pedia ic Blood and Cance . 2007; 48(7): 705-10. h p:
//dx.doi.o g/10.1002/pbc.20903
[41] Mille VA, Reynolds WW, Nelson RM. Pa en -Child Roles in De-
cision Making Abou Medical Resea ch. E hics & Beha io . 2008;
18(2-3): 161-81. h p://dx.doi.o g/10.1080/10508420802
063947
[42] Sne hen JA, B oome ME, Kna l K, e al. Family Pa e ns o
Decision-Making in Pedia ic Clinical T ials. Resea ch In Nu sing
& Heal h. 2006; 29: 223-32. h p://dx.doi.o g/10.1002/nu
.20130
[43] Kelsey J, Abelson-Mi chell N, Ski on H. Pe cep ions o young peo-
ple abou decision making in he acu e heal hca e en i onmen . Pe-
dia ic Nu sing. 2007; 19(6): 14-8.
[44] Salmela M. Hospi al- ela ed ea s and coping s a egies in 4-6-
yea s-old child en. Helsinki; Helsingin yliopis o, lääke ie eellinen
iedekun a, kliininen lai os; 2010.
[45] Malmi aa a A. Sys emised Li e a u e Re iew – Tool o he
Ca ching o he S udy Display. Duodecim. 2002; 118: 877-979.
PMID:12238165.
[46] Woods L, P ies H, Robe s P. An o e iew o h ee di e en ap-
p oaches o he in e p e a ion o quali a i e da a. Pa 2: p ac ical
illus a ions. Nu se Resea che . 2002; 10(1): 43-51. h p://dx.d
oi.o g/10.7748/n 2002.10.10.1.43.c5878
[47] Nu mi JE, Ahonen T, Lyy inen H, e al. The Human De elopmen
and Psychology. Helsinki: WSOY; 2006.
[48] Tu kimusee inen neu o elukun a. Good Scien i ic P ac ice and
Dealing o i s O ence Wi h. Helsinki: Edi a P ima Oy; 2002.
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