“Follow the Leader”: The Role Assumptions which Can Influence the Use of Holding and Restraint within children’s Procedural Trajectories. A Qualitative Multimethod Study

Holding children for procedures is often perceived as a routine, uncontested aspect of pediatric practice. There has been an increase in literature describing parents' experiences of holding their child and professionals reported practice. However, limited research has observed practice and explored what influences healthcare professionals' decisions to hold a child or to encourage parental holding. This study examined how and why healthcare professionals decide to initiate, continue, or stop holding a child during a procedure, and identified the factors that influence these decisions. A descriptive qualitative multi-method design was employed, incorporating semi-structured observations focused on verbal and nonverbal interactions, vignettes constructed from each observation, and semi-structured interviews with healthcare professionals. Purposeful sampling identified children under 10 years of age undergoing a procedure in a tertiary children's hospital in Northwest England. Data from the field notes and transcripts were analyzed thematically. Eight children (aged 1 month to 10 years) and their parents were observed, along with 12 healthcare professionals (doctors, nurses, healthcare assistants, and play specialists). Eleven professionals were interviewed in this study. The findings revealed a lack of explicit discussion or planning regarding the roles of professionals, parents, and children before the procedures. Two themes were identified which highlighted "healthcare professionals assumptions about parents' role" to comfort, distract, support and hold their child during a procedure, and "expectations about children's responses and behaviors during procedures," led professionals to expect that children who had been resistant previously and younger children would be distressed leading to holding being inevitable. This study provides the first in-depth exploration of healthcare professionals' decision-making about holding children based on observed practices. The findings demonstrate that unspoken assumptions and expectations influence procedural trajectories with implications for practice and training.