Bernie Carter, Professor of Children's Nursing within UCLan’s School of Health provides some illuminating insights based on her award-winning research.
Feedback from patients is increasingly being used to inform and improve health services. But while obtaining such feedback from adults is relatively easy, gaining feedback from and insight into children’s experiences is far more challenging, not least because their verbal skills are still developing.
Increasing numbers of health care researchers are using arts-based research methods including dance, drama and art to gain a better understanding of what children really experience when receiving health care. While these methods are gaining in popularity, they have limitations and researchers need to be aware of the pitfalls associated with them.
Although these methods can be wonderful and creative approaches to use when working with children, they are often used with little sensitivity or sufficient consideration as to how they can shape or frame the data they generate. Dr Karen Ford from the Royal Hobart Hospital in Tasmania and I have considered some of the factors associated with using arts-based methods so that researchers can be confident in using these methods as effectively as possible.
An important thing to consider is that details matter – from whether you use feathers or clay through to what colour paints you provide.
Arts-based research methods help us gain rich data and, when combined with a child-centered approach, we can discover fascinating new insights into how children experience health care. Methods including narrative, music, drawing, sculpture, theatre and play also help us engage with children on their own level.
By making serious research ‘fun’ we can help children feel more comfortable in what can sometimes be an intimidating environment and encourage children to share more openly. The possibilities of generating exciting and insightful data are amazing when the right arts-based methods are selected. For example, one child who was receiving community nursing support completed a scrapbook containing several drawings where she depicted herself standing up despite her being wheelchair dependent. These drawings helped us gain a unique understanding of the child’s perceived identity, which may have not been generated from a traditional interview. In turn, the drawings also helped us view the child as the child saw herself. In another study in which the children receiving community nursing support were asked to take photos about their lives, the children became incredibly animated when describing an apparently simple photo of their cat. When prompted, the children explained that the cat – a core member of their family - had to be taken out of the room when the nurses visited due to the nurses’ allergies. The children’s reaction towards the cat being taken out of the room was that nurses who were allergic to pets were not ‘much use’ to them. A good, albeit radical, point which then opened up discussion about the future recruitment of nurses.
As much as possible, we suggest that researchers should try to put themselves on ‘the same level’ as children they work with by adjusting language and keeping in mind the particular child’s abilities and personal experiences. Trying to perceive things from the child’s perspective is essential. The importance of achieving accurate insights from children can in turn, help nurses and care givers empathize and ensure that organisations improve services provided to children.
I say this because it seems that researchers engaging in arts-based methods do not always take a robust approach in questioning either how the data produced can be shaped by the methods they use or how their own positioning as an ‘adult’ frames their interpretations. Decisions about whether you opt for collage, drama, narrative or maybe sculpture are some of the more obvious decisions researchers have to make. Even decisions about how wide or narrow a range of paint colours to provide can have a major impact of the outputs that the children can create.
So, for example, choosing collage will open up different potentials and opportunities for children to share their experiences in comparison to modelling clay, while the range of paint colours may inhibit what a child can paint and share. In one case study we looked at, a child used feathers in a collage representing how her stomach felt “fluffy and wobbly” prior to her operation. The meaning that child wanted to express through the collage only became clear when the child explained why she had used the feathers. If she had been presented with different materials – say, foil instead of feathers – she might not have been able to share her feelings at all.
Arts-based methods, used correctly, open up a fascinating world that helps us understand health services through a child’s eyes. For them to be truly effective, the researchers must be self-aware enough to recognise the impact the method is having on the output. So think carefully before choosing foil over feathers!
Bernie Carter is Professor of Children's Nursing at the School of Health, University of Central Lancashire. This article is based on her research paper “Researching Children’s Health Experiences: The Place for Participatory, Child-Centered, Arts-Based Approaches”, awarded Best Methods Paper 2013 by Research in Nursing and Health (RINAH).