The role of felt or enacted criticism in understanding parent's help seeking in acute childhood illness at home: A grounded theory study

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Abstract

Background

Parents with young children often worry about whether or not to seek medical help for a sick child. Previous research identified parents’ anxieties surrounding help seeking from health services but did not explore or explain the underlying psychosocial processes taking place in families at these times.

Objectives

This paper presents findings from a British grounded theory study on family management of acute childhood illness at home, which provide an explanation for parent's helping seeking behaviours.

Design

Glaserian grounded theory methodology was used for the study.

Setting

The sampling sites for the study were in two towns in the East Midlands with population profiles close to the national average for the UK.

Participants

Initial purposeful and later theoretical sampling resulted in a sample of fifteen families with children aged between 1 month and 8 years of age.

Methods

Four sets of data collection took place between 2001 and 2007. Unstructured family interviews were conducted with adult family members and a draw, write or tell technique was used to interview any children over 4 years of age. Theoretical sensitivity and constant comparative analysis were employed to achieve theoretical saturation around a core category.

Findings

Felt or enacted criticism teaches parents informal social rules which direct how they are expected to behave. Their desire to avoid such criticism of their moral status as ‘good’ parents creates significant hidden anxiety about when to seek medical help. This anxiety sometimes leads to late consultation with potentially serious consequences for their child's health.

Conclusion

The grounded theory indicates the need for significant investment in the training of nurses and other health professionals to reduce parents’ (and other patients’) experiences of felt or enacted criticism and the consequent hidden anxiety. When parents are worried about their child's health, they need to be able to seek help from health professionals without fear of criticism. These conclusions are primarily limited to universal health care environments.

Introduction

Acute childhood illness is an inevitable part of family life with young children. These are the common childhood illnesses such as coughs, colds, ear infections, viral rashes, chickenpox, vomiting and diarrhoea. The majority of these are managed at home without seeking help from health services (Bruijnzeels et al., 1998, Holme, 1995, Mayall, 1986). Parents are concerned not to bother the doctor unnecessarily (Ehrich, 2000, Houston and Pickering, 2000, Neill, 2000). Yet in the UK those that do decide to seek help constitute a significant proportion of the workload in primary care (Royal College of General Practice, 2007). A different picture might emerge in countries which do not have a universal health care system. Despite the commonality of such illness there is a paucity of research which investigates family processes at these times. The research from which findings are presented here set out to ‘discover the psychosocial processes which take place in families when a child is acutely ill at home, and the influence of these processes on families’ response to such episodes of illness.’ This paper presents findings drawn from this British grounded theory study which provide an explanation for parents’ decisions concerning whether or not to seek help from health services for an acutely sick child at home. Readers are referred to Neill, 2000, Neill, 2008 for more detailed critical review of the limited literature in the substantive area of the research.

In grounded theory it is usual to avoid immersion in the literature at the beginning of a study as there is a risk that preconceived ideas from prior research will result in foreclosure of the analysis (Heath, 2006, McGhee et al., 2007). Relevant literature is only identified and explore for its ‘fit’, in Glaser's (1967, 1978) terms, with the emergent theory once the core category has been identified. In this project the core category directed a review of sociological theory concerned with social rules of behaviour, an overview of which is presented below. This literature is then referred to within the findings section to show how this research contributes to pre-existing theory.

Classic sociological theory purports to inform the behaviour of everyone in social life. It presents the back drop to all social encounters and it is therefore important to consider in the interpretation of behaviour in social life. Society is viewed by symbolic interactionists as created through social interactions (Blumer, 1969/1986, Mead, 1934, Sandstrom et al., 2001). It is these interactions which lead to shared meanings from which people coordinate social action and create social order. Denzin (1970) conceptualised these meanings as rules of conduct for society. These social rules are, Denzin (1970) suggests, reaffirmed every day through the rituals of interactions and individual's reflections on those interactions. Here these rules are seen in the context of managing acute childhood illness within the family.

Social rules can be categorised as formal or informal rules. Formal rules are those official rules enshrined in law, codes of ethics and official morality (Stokes et al., 2006), such as legal and ethical frameworks for the wellbeing and safeguarding of children (Children Act, 2004, Department for Children Schools and Families, 2010, Department for Education and Skills, 2003). Informal rules, with which this paper is concerned, include ceremonial rules, which function to maintain social and moral order (Denzin, 1970, Goffman, 1972), and rules of relationships (Denzin, 1970). Rules of relationships are, of course, relevant to relationships within family groups, whilst ceremonial rules apply to interactions between families and health services (Strong, 1979). These rules may be symmetrical or asymmetrical, reciprocal or non-reciprocal. Where asymmetry exists, these (Goffman, 1972) – part of the ‘micro-politics’ of everyday life (Williams, 1993). An individual may not be aware of these social rules, becoming aware only when transgressed and s/he fails to perform as expected and feels shame or guilt (Goffman, 1972).

Talk of rules suggests clear definitions of what is acceptable or ‘normal’ in social life. However, the nature of these social rules, particularly informal rules, may be less clear than at the time of Denzin's (1970) and Goffman's (1972) writings. Patterns of social change in contemporary Western society, such as more flexible working patterns, increasing emphasis on engaging mothers in the workforce and fathers in parenting, has created a world of ‘less determinative social structures’ (p. 56) with recognition of a wide range of appearances and lifestyles, although these are not always accepted (Williams, 2000). This ambiguity, about social expectations of families, may have created a situation in which parents are increasingly sensitive to the impression they create in interactions with others, particularly where they feel they may be subject to scrutiny.

Families with young children are regularly exposed to public scrutiny (Voysey, 1972), in, for example, child health surveillance programmes (Bloor and McIntosh, 1990, Department of Health, 2009), in schools and other child care settings (Department for Children Schools and Families, 2010). It should not be surprising, therefore, that parents engage in managing the impressions they make on those who scrutinise them.

Parents are concerned with the impressions they create, either directly in their capacity as parents or through their children's behaviour or appearance (Collett, 2005, Smart and Cottrell, 2005, Voysey, 1972). It is concerned with others perception of one's moral worth or moral character – the desire to develop positive identities – which appears to be one of the key motivators for impression management (Goffman, 1959, Leary and Kowalski, 1990). Parents want to be seen as moral or ‘good’ parents. Presentation behaviours which obtain the desired reward or positive regard from others raise self-esteem (Collett, 2005, Leary and Kowalski, 1990, Myers, 2008). Therefore, when parents’ self-presentation elicits positive regard for their parenting ability, their self-esteem in their parenting role is likely to increase. The converse also appears to be true. Parents’ knowledge that they are being scrutinised, in a situation of ambiguous expectations, may act as an alert or sensitisation to signs that they have conformed or transgressed the informal social rules of the encounter.

How people present themselves is affected by how individuals think they are regarded by others now, and how they think they may perceive them in future (Leary and Kowalski, 1990). Goffman (1959) has suggested that people will be less guarded in their self-presentation in longer term, more intimate relationships, suggesting that within families interactions are likely to be more relaxed. However he has also written that one-off encounters leave the individual free to create either a positive or negative image of themselves (Goffman, 1972) as there are no or few consequences of such encounters in the future. This may have a bearing on where parents choose to seek help for their children. Goffman (1959) suggests that individuals will take actions to minimise any threat through managing the impression they make and selecting an audience which presents the least risk.

‘It is apparent that care will be great in situations where important consequences for the performer will occur as a result of his conduct’   (Goffman, 1959, p. 219)

Such situations may include families’ interactions with health care professionals, as these professionals have power to affect access to treatment, expert advice and other services. The findings presented below illustrate how these social rules shape how parents behave in response to acute childhood illnesses in the home.

Section snippets

Methodology

Glaserian grounded theory methodology was chosen as it ensures that the analysis stays close to the data, facilitating the inductive emergence of an explanatory grounded theory (Glaser, 1992, Glaser, 2001). The project followed the tenets of Glaserian grounded theory, evolving from initial purposeful to later theoretical sampling, using theoretical sensitivity and constant comparative analysis to achieve theoretical saturation around a core category (Glaser, 1978, Glaser, 1998, Glaser, 1992).

Implications for health professionals

Parents’ decision making in acute childhood illness is driven by their understanding of informal social rules. They learn that breaching these informal rules puts them at risk of experiencing felt or enacted criticism. This creates hidden anxiety around any decisions to ask others, particularly those in positions of authority such as nurses and doctors, for advice. Doctors, in particular, appear to be acting as moral agents creating an official morality for parents caring for acutely sick

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