Article

Journal of Child Health Care

1–13
Ethical and practical challenges ª The Author(s) 2018
Article reuse guidelines:
of conducting art-based research sagepub.com/journals-permissions
DOI: 10.1177/1367493518807318

with children/young people journals.sagepub.com/home/chc

in the public space of a children’s

outpatient department

Tineke Water1 , Shahin Payam2, Ema Tokolahi1 ,

Stephen Reay1 and Jill Wrapson1

Abstract
This article examines the ethical and practical challenges of undertaking a study using art-based
methods with children/young people. It is argued that an important component of qualitative
research and research with children/young people is researcher reflexivity and flexibility, partic-
ularly when the anticipated and actual implemented methods of a study differ. We draw on a study
with 175 children/young people aged 5–16 years in a children’s outpatients department where
‘draw-and-tell’ and ‘letter writing’ were used to elicit children/young people’s perceptions of the
outpatient environment. The challenges that arose during the study are critically reflected on
including recruitment, the physical and social environment, time restrictions and interviewing.
Recommendations for researchers using art-based methods to carry out research with children/
young people are offered.

Keywords
Art-based methods, children/young people, ethics, healthcare design, participatory qualitative
research, reflexivity

1
Auckland University of Technology, Auckland, New Zealand
2
Technical University of Munich, Munich, Germany

Corresponding author:
Tineke Water, Department of Nursing, Auckland University of Technology North Campus, 90 Akoranga Drive, Northcote,
Auckland 0627, New Zealand.
Email: tineke.water@aut.ac.nz
2 Journal of Child Health Care XX(X)

Background
Explicating the challenges inherent in carrying out qualitative research with children may help
promote more reflective and reflexive research practices (Irwin and Johnson, 2005; Powell et al.,
2016). Research papers often report on the use of concise, ‘sanitized’ methodological descriptions
that were successfully used. Consequently, the dynamic process that are integral to qualitative
research, including the many ‘side’, ‘extra’ or ‘mis’ steps that occur on the way are seldom dis-
cussed (Darbyshire et al., 2005). More recently, researchers using art-based methods in research
have described methodological, ethical and practical challenges that arise in research with children
and young people (Lyon and Carabelli, 2016; Phelan and Kinsella, 2013; Powell et al., 2016). It is
often in the ‘space’ between designing a study and subsequent implementation that challenges of
what was planned and what happens appear. This may highlight differences between procedural
ethics (review and approval from ethics committees) and situational ethical issues that arise while
doing the research (Guillemin and Gillam, 2004).
The need for flexibility in what is ‘planned’ and what then ‘happens’ is not a new idea in
qualitative research. The need for a flexible design is a hallmark of qualitative research, which
must often respond to changing research environments (Holloway and Galvin, 2016). However,
flexibility can bring extra complexities around the intended research design, balancing what is
approved by an ethics committee with the need to be responsive in finding different ways to make
research processes work. The need for flexibility means researchers must be responsive to both the
environment and participants. For example, when interviewing participants, the researcher needs
to be able to follow with new, unrehearsed questions in response to their answers. This requires
reflection on the part of the researcher and the ability to ‘think on the go’. Although flexibility is a
well-recognized part of qualitative research, there is still a need for congruence between the stated
methodology and aims and the changing methods that may occur along the way (Braun and Clarke,
2006). Holloway and Galvin (2016) describe this as the researcher being able to be reflexive, with
the ability to critically reflect on what was thought and what was done.
Holloway and Galvin (2016) describe reflexivity as including the researchers’ awareness of
their role in the research, and how this might impact on the relationship and any power dynamics
between them and the participant. Alongside this, a reflexive researcher must consider how the
research process may impact on the findings and how this may (or may not) benefit the participants
(Holloway and Galvin, 2016). Reflexivity is regarded as essential when conducting ethical
research with children/young people to ensure their safety, dignity and opportunities to have a
voice (Phelan and Kinsella, 2013). In this context, reflexivity requires researchers to critically
reflect on how children/young people will be positioned in the research. For example, will they be
positioned as objects of research or as active participants in research processes. As objects of
research, children/young people’s voices are silent, and perspectives on their experiences are
gained through the proxy voices of adults, usually parents/guardians or healthcare professionals
(Dickinson et al., 2014; Hill, 1997). As active participants of research, the importance of children/
young people’s views of what matters to them is held forefront, acknowledging their views may be
different than adults. As such, their developing competency and development is recognized
(Graham et al., 2013; United Nations Convention on the Rights of the Child (UNCRC), Article 12,
1989). Researchers are being called to critically reflect on how children/young people will be
included in research, while acknowledging their rights to participation and protection.
Gatekeeping, in the form of ethics committees, funding bodies, hospital administration and
parents/guardians, can limit children/young people’s participation in research (Campbell, 2008).
Water et al. 3

However, researchers equally need to carefully consider how children/young people’s vulner-
ability may influence issues of assent and consent, competency and dependency, privacy and
confidentiality and the potential power dynamics between the researcher and child (Graham et al.,
2013). It is argued that children/young people’s vulnerability and the need for protection should
inform methods of research that will promote inclusion, rather than limit their right to participate
(Powell et al., 2016).
In recent years, children/young people’s participation in research has been encouraged through
a diverse range of child-friendly methods used to collect data (Carter and Ford, 2013; Coad, 2007;
Epstein et al., 2006; Ford et al., 2017). Art-based methods are argued to be a way of minimizing the
reliance on verbal skills by giving children/young people time to reflect on the content they would
like to share. Furthermore, using art-based methods helps to minimize potential power imbalances
between researchers and children/young people and support children/young people to participate in
ways that are more fun (Carter and Ford, 2013). Methods, such as draw-and-tell have been sug-
gested to serve as a stimulus for children/young people to talk through their experiences and
provide researchers with greater insight into perspectives that may be inaccessible using other
methods (Carter and Ford, 2013). Undertaking research in the ‘unpredictable, messy, real world of
children/young people’s lives’ (Powell et al., 2016: 198) requires researchers to critically reflect on
research contexts during planning and implementation to ensure research is ethical, relevant and
respectful. Understandings gained may offer insights to other researchers working with children/
young people and reinforce the need for greater critical reflection and flexibility when engaging in
qualitative research.

Research design
The ethical and practical challenges described in this article arose within the context of a larger,
exploratory study titled ‘Better Health Through Design: Activating Interdisciplinary Perspectives
on Design’. The main study composed of four research teams, each looking specifically at one
aspect of the outpatient’s environment including the physical environment, wayfinding, sound,
food and uniforms. The current research team examined children’s perspectives on all five topics.
The topics were set in consultation and partnership with the hospital management team. The main
study was a collaboration between a paediatric outpatient service at a regional children/young
people’s hospital in New Zealand/Aotearoa and a university. The research team was a multi-
disciplinary, across-faculty group, that aimed to understand children/young people, parents/
guardians and hospital staff perceptions of the children/young people’s outpatient environment.
The sub-study reflected on in this article was focused on children/young people’s perceptions of
the outpatient’s environment. Overall, 175 children/young people between the ages of 5–16 years
were interviewed in the outpatient’s department during August 2015. Ethical approval was sought
and granted from the university ethics committee (Auckland University of Technology Ethics
Committee; 15/198).
Children/young people’s assent was obtained prior to the collection of data, and was ongoing
during the data collection period, along with guardian consent (primarily this included parents, but
in some cases other caregivers). No data were collected without the assent and consent of both
child and their parent/guardian. Assent is an agreement to participate in a study given by those who
can understand the research in general but are under the legally required age to give consent (i.e.
children). As such, consent from the children’s parents/guardians was sought in addition to chil-
dren’s assent to fulfil the legal and ethical requirements. This is consistent with ethical practice and
4 Journal of Child Health Care XX(X)

Figure 1. Example of draw-and-tell.

widespread recognition that children/young people have a legitimate role in the decision-making
process regarding their participation in research (Graham et al., 2013). Participants were not
offered incentives to participate nor were they compensated for having participated. However,
children/young people were offered their drawings/letters to keep acknowledging their role in the
generation and ownership of the data.
Data were collected using draw-and-tell and letter writing methods. The draw-and-tell tech-
nique used a method familiar to most children/young people, and drawing is often considered fun
and non-threatening (Driessnack, 2006). It is widely recognized as a useful tool for alleviating
anxiety at the start of an interview, setting a child at ease and providing a way into the topic of the
research (Driessnack, 2006; Irwin and Johnson, 2005; Kortesluoma et al., 2003). Letter writing is a
method that has been used in psychology by college students (Mosher and Danoof-Burg, 2006), by
nursing students (Kirkhorn and Airth-Kindree, 2010), teachers (Samaras and Sell, 2013) and as a
method of auto ethnography by researchers (Pithouse-Morgan et al., 2012). There is little docu-
mentation regarding the use of letter writing with children/young people. However, in a previous
workshop using draw-and-tell to find out what children/young people thought health was, one of
the researchers observed some of the younger children were not engaging with the draw-and-tell.
The researcher suggested that children might like to write a letter to someone, to tell them what
they thought about the topic. This approach seemed to give children more freedom to communicate
their thoughts. Letter writing was also popular with even younger children (i.e. five years old) who
may be only starting to read or write. As such, many younger children undertook a mixture of
writing and narrating their letter.
Children/young people were given a preprinted booklet in which they could draw a picture or
write a letter. When opened, the left-side of the booklet had room for their name and age in the top-
left corner. Most of the page was filled with an empty frame where a drawing could be added
(Figure 1). The right-side of the booklet was lined providing the option for participants to write a
letter (Figure 2), if they preferred.
Water et al. 5

Figure 2. Example of letter writing.

A protocol was developed where children/young people were asked to draw or write about one
of five topics regarding their outpatient service experience: (1) the (physical) environment, (2)
navigation, (3) sound, (4) food and beverages and (5) uniforms. The five different topics were
rotated over the period of data collection. On completion of the drawing or letter, a brief semi-
structured interview was conducted that commenced with the request for the participant to tell a
research assistant about their drawing or letter. The interviews were audio-taped using a portable
digital recorder. On conclusion of the interviews, a digital photograph was taken of the partici-
pants’ drawing or letter for later analysis, so children/young people could keep their original.
During the period of data collection, it became apparent that there were differences between the
anticipated design of the study and the reality of the methods being implemented. This required the
research team to be flexible in finding different approaches and solutions to the challenges that arose.
During the data collection phase of the study, the research assistants, Payam and Tokolahi met daily
with the research team to discuss any issues or challenges that had arisen, and to explore potential
solutions, or different approaches to data collection in this environment. At the completion of the data
collection period, the research assistants were interviewed by the research team to capture their
insights and reflections on the challenges and opportunities that arose during the data collection
period. This interview was audio-taped and transcribed, and the main themes related to the chal-
lenges in data collection were identified. These insights were then synthesized with the under-
standings and insights from the primary investigators and research team. Challenges that arose during
the research included the recruitment processes, the physical environment and distractions, the social
environment and the influence of others, time restrictions and the interview process itself.

Challenges in researching with children/young people

Recruitment
Traditional views on society construct opportunities to participate in research as fair and equal.
However, recruiting children/young people for research studies may face additional challenges.
6 Journal of Child Health Care XX(X)

For example, gatekeeping by ethics committees and organizations is frequently encountered (out
of concern for children/young people’s vulnerability). Practical issues that arise during recruitment
can include factors that limit inclusion such as limited verbal skills, proficiency in English (or the
primary language of the country where research is undertaken) and a disability that limits par-
ticipation (Graham et al., 2013; Powell et al., 2012).
Alderson and Morrow (2011) suggest that selection and recruitment of participants needs to
consider the social, political and economic factors that may influence children/young people’s
inclusion. Research with children/young people takes place within a network of social relation-
ships that children/young people have with others. This includes parents/guardians and gate-
keepers (such as hospitals and schools) who have legal, social and ethical obligations to promote
the best interests of children/young people. Therefore, researchers need to work with parents/
guardians and gatekeepers to reassure them how the research will protect children/young people
from any potential harm, while also ensuring they have opportunities to participate. Initially, we
planned to post children/young people and parents/guardians a participant information sheet along
with the information about their clinic appointment. Concerns were expressed by hospital senior
management that this might overload children/young people and their parents/guardians with
information (to the detriment to their clinic appointment). Therefore, it was necessary to recruit
children/young people and their parent/guardian when they arrived for their outpatient appoint-
ment. This meant going back to the ethics committee to approve the change of recruitment strategy.
Posters were displayed in the outpatient’s department advising potential participants of the study.
However, these appeared to go largely unnoticed by the arriving families. Consequently, when the
research assistants approached parents/guardians this was viewed as a ‘surprise’, unless parents/
guardians had seen other participants being approached. This presented issues for the research
team around the time children/young people and parents/guardians had to consider their partici-
pation. The potential of a ‘surprise’ most likely impacted the processes of informed assent/consent
and made potential participants to feel ‘put on the spot’. The research team needed to be especially
mindful of potential participants’ verbal and non-verbal cues in response to being invited and
respectful of any hesitation that was observed. Although this method of recruitment did not appear
to impact negatively on the number of participants recruited, it did mean extra time was needed to
orientate participants to the study. This directly impacted on the already constrained time available
to conduct interviews.
In presenting children/young people and parents/guardians with the participant information
sheet, the researchers were mindful that all information related to potential participation in a study
needed to be presented in a way and form that potential participants could understand (Powell
et al., 2012). Informed consent and assent are based on a principle that participants have knowledge
of what the study is, what their participation would be, and be able to understand the potential
benefits or harm of being involved in a study (Graham et al., 2013). This required the use of age-
appropriate information sheets. Two age-appropriate assent/consent forms were used, one for
children/young people aged 5–12 years (more concrete concepts appropriate to the cognitive
development of this age group) and another for those 13–16 years (Graham et al., 2013). The
participant information sheets for both groups included pictures of the research assistants (Figure
3), as well as a place to indicate their potential interest in participating with a place to circle ‘yes’,
‘no’ or ‘maybe’ (Figure 3).
On several occasions, children/young people responded by circling ‘maybe’. This became
problematic as they would become ‘stuck’ or unsure what further information they wanted to know
to change their response to either a ‘yes’ or a ‘no’. Often these children/young people had appeared
Water et al. 7

When we are there we will ask you to draw some pictures Please circle if you would like to take part by
or do some writing about the Starship Outpatients drawing pictures or writing a letter.
Department. You will know that we are not any of your
nurses. You can talk to us and we can get to know each
Please circle if you do not want to do this.
other. You can ask us about our work whenever you want
to. Sometimes we might use a tape recorder. Let us know
how you feel about this by colouring in one of these words Please circle if you are not sure. If you
- cannot decide that is fine because you can come along
any time and tell us or one of your nurses or your
parents that you want to join in.

This is a photo of us both:

If you are not sure or worried come and talk to us about it

or ask one of your nurses or your parents about this.
We are finding out about the environment in Starship
Outpatients Department – you might like to find out about
this as well. We are not sure how to explain the word
environment to you. Environment might be regarded as the
surroundings or atmosphere of Outpatients. We will be
asking all of you at Starship Outpatients to draw pictures or
write a letter so that we can see what you mean by the word
environment. We will all work together on this.
Ema Shahin
We hope we can do this together. It will be great to meet
you and you will know who we are because of our
photographs. We will also wear a badge with our names
on, Ema Tokolahi or Shahin Payam, when we are in
Starship Outpatients.

Figure 3. Example of part of the participant information sheet for children/young people age 13–16.

to be enthusiastic initially, so the research assistants were keen to clarify their response rather than
to default to this being an indication of dissent. On most occasions, repeating the information was
enough for children/young people to be able to make a clear decision. At times, the research
assistants had to explain to the child/young person that by selecting ‘maybe’ they could not
progress with the interview (and that this was okay). However, typically the child would protest
and state that they wanted to take part. Although the three responses were intended to keep it open
for children/young people in deciding whether they wished to participate, this created ambiguity
for some children/young people. For the research team, this highlighted the importance of allowing
time and space for children/young people to consider their participation; reinforcing that saying
‘no’ was okay; and even if children/young people did agree to participate, assent/consent was
ongoing beyond signing an assent/consent form.
During the process of seeking assent/consent from children/young people for their participation
in the study, it also became apparent how children/young people could be influenced or potentially
coerced into participating by adults around them. The research assistants adopted an open manner
and reassured children/young people that saying no at any point was okay. Nonetheless, in some
cases, children/young people seemed hesitant or appeared to agree due to their guardians’ pressure
(e.g. ‘yes, sure you can do this’). The research assistants clarified in these situations that it was the
children/young people’s own decision whether they wanted to participate or not (e.g. ‘it’s up to
you’), which seemed to give them the freedom and power to refuse to take part. This reinforced
children/young people’s legitimate role in decision-making, but also minimized the power
inequalities between children/young people and adults (Coyne, 2010).
8 Journal of Child Health Care XX(X)

There were occasions where the child was eager to participate, however their parent/guardian
refused to consent to their participation. This was usually not due to the nature of the study but
because of concerns and anxieties around missing their clinic appointment, time constraints and
not being able to concentrate on reading the study information during busy clinic times. In
addition, some guardians expressed concern around having to pay for extra parking time if the
appointment or interview went over time. Although the research assistants were flexible and aware
in their approach of working around the constraints of appointments and time limits related to
parking, the stress of both these factors meant that parents/guardians often refused an initial
approach. The research assistants attempted to overcome this by reassuring parents/guardians that
the research would not remove them from the waiting area. Furthermore, if they were should they
be called for their appointment during the interview, they would simply go straight to their
appointment (and hopefully return to complete the interview afterwards). Some parents/guardians
refused participation on behalf of their child if cognitive impairments, high levels of emotional
distress or other significant limitations were present. It was not possible or appropriate to try and
overcome these limitations, and these were taken on a case by case basis. For example, a child who
was blind and a child with a broken arm were offered an alternative way of participating by having
their letters dictated. This ensured that children/young people had an opportunity to participate,
rather than being excluded based on not being able to complete an activity.
Careful consideration was given to who would interact with the children/young people and
undertake data collection. This included having a mix of gender and ethnicity of research assis-
tants, as well as a background in working with children/young people. This approach worked well,
as some participants gravitated more to one research assistant or the other. Payam and Tokolahi
were both PhD candidates and their professional area of practice as a child psychologist and
children/young people’s occupational therapist meant they were very experienced and comfortable
with interacting with children/young people. Consideration was also given to the communication
used (verbal and non-verbal), how a child/young person was approached (in a friendly open
manner and at the child/young person’s physical level) and dress (tidy but not formal). Phelan and
Kinsella (2013) describe all these details as impacting on perceptions of power between
researchers and child/young person participants.

Physical environment
Researchers have discussed the importance of creating a safe and non-threatening environment
when conducting art-based interviews with children/young people (Driessnack, 2006; Horstman
et al., 2008; Irwin and Johnson, 2005). However, researchers are often limited to the environments
they find themselves in. The interviews were carried out in the public waiting areas. This posed
issues related to confidentiality yet overcame some of the legal tensions of children/young people
in the company of researchers. The introduction of the Vulnerable Children’s Act in 2014 in New
Zealand (Vulnerable Children’s Act, 2014) always meant any researcher or research assistant
needed to be in the presence of staff and/or guardians when interviewing children/young people.
Although both research assistants had police and hospital clearance in their respective areas of
clinical practice, which meant they could be alone with children/young people, this did not include
this research study context. It has been suggested that there are benefits to interviewing children/
young people alone, as children/young people are less influenced or directed by parent/guardian
responses and may feel free to be more open (Coyne, 2010). This needs to be balanced with the
acknowledgment of the role of parents/guardians in children/young people’s lives and obligation to
Water et al. 9

support the best interests of their child as noted by UNCRC Articles 3 and 18 (UNCRC, 1989).
Despite police checks and clearance for researchers, many parents/guardians will still be wary of
leaving their child alone with a ‘stranger’.
In this study, while younger children seemed less worried about the lack of privacy, older
children or young people were more aware of their surroundings and appeared to be self-conscious
when answering questions (as characterized by their hesitations and gazes around the room). This
was especially obvious when they occupied the centre space of the waiting area to do their
drawings/write their letter. In these cases, creating a more relaxed atmosphere was difficult. The
research assistants were equally aware of the possible confidentiality issues and tried to speak
quietly as a result, making it more difficult to focus on the interview itself. Although the topics for
the study appeared fairly ‘neutral’, in qualitative research there is always a chance that children/
young people could reveal something that was private to them or possibly of concern. Alongside
this, the research assistants were aware of other potential participants being present and listening
for possible replies they may adopt later in the belief that these were the ‘correct’ answers. This
problem diminished when two research assistants carried out interviews in the same area simul-
taneously, as the issue of being the ‘centre of attention’ was essentially removed. Children were
also easily distracted by the events in their environment. For example, they would run to the
window to watch a helicopter land. One girl was so distracted by the TV that neither the research
assistant nor the parent/guardian could get a coherent response from her.
The noise of televisions, children playing, crying, rescue helicopters landing and taking off,
casts being removed, phones and clowns meant the audio recording required some effort to
decipher. This was addressed by holding the recording device closer to the participant, which the
children/young people did not like. To put these children/young people at ease, the research
assistants would sometimes ‘play’ with and demonstrate the recorder in order to incorporate it as a
‘natural’ part of the conversation.

Social environment
Due to the ethical, legislative and physical environment in which interviews were conducted, a
parent/guardian was always present. This is not unusual as children/young people are encour-
aged to have a support person with them at any time. However, having a parent/guardian present
may also change the focus of the interview where parent/guardians scaffold their children/young
people’s narratives or help in finding words. This may add another layer to the depth of children/
young people’s narratives (Irwin and Johnson, 2005), although the risk is that an adult voice can
become proxy for that of the child (Coyne, 2010). In this study, parents/guardians would often
lead children/young people in specific directions before or during the interview. For example,
when talking about the topic of ‘navigation’, they prompted about the lack of available parking
spaces or, having read the list of topics in the information sheet, they would prompt the child/
young person about other topics not allocated to that day’s data collection. On one occasion, a
stranger to the child and parent/guardian interjected with their own opinion on a topic. These
occasions required the research assistant to reiterate to both the child/young person and the
parent/guardian that the child/young person could draw or write whatever the child/young person
thought was important or relevant.
An unexpected distraction during the interviews was the presence of hospital clowns who would
perform for and entertain those in the waiting areas. Their presence was unpredictable and offered
mostly welcome comedic relief that was sometimes included in children/young people’s drawings/
10 Journal of Child Health Care XX(X)

letters. In one instance though, the ‘performance’ involved telling the research assistant to ‘shush’
for a prolonged period of time. There were different clowns on each occasion and most were
interested in the study, sometimes providing loud and dramatic comments about the study for the
benefit of children/young people and guardians in the vicinity. This helped to create a social
atmosphere that positively promoted recruitment and participation into the study.

Time restrictions
The lack of time impacted on establishing a deeper rapport with children/young people and
obtaining in-depth accounts. Irwin and Johnson (2005) emphasize the role of rapport building,
which can take longer with children than with adults, suggesting ‘we cannot expect that a first-time
meeting with a child is going to see the establishment of suitable rapport’ (p. 823). Furthermore,
research assistants experienced the additional task of needing to establish an understanding with
the parent/guardian to facilitate access to the child/young person participant. Stressed parents/
guardians during busy clinics led to more declines and children/young people tended to be more
distracted during those periods, resulting in an overall lower likelihood to participate.
The scheduled interview time was around 20 minutes. However, due to the limitations posed by
the setting, recruitment of children and family/guardian, engaging in the draw-and-tell activity
and subsequent interview took on average 10 minutes. Due to the shorter duration of the
interviews and the potential impact this may have on data saturation, a larger number of parti-
cipants were recruited (n ¼ 175) which was facilitated by high levels of patient traffic over a
relatively short period of time (one month). The team considered the issues of quantity of data
over quality and depth of data. Shorter interviews may contribute to data with less depth,
however, they may also fit better with some children/young people’s wishes not to be engaged
for longer periods (Lambert and Glacken, 2011). During the data analysis phase, it became
evident that there was enough data to carry out a thematic analysis and provide overall depth of
findings. To overcome the challenge of time restrictions, the process of data collection became
more efficient by multitasking such as engaging two to three participants simultaneously (i.e.
recruiting participants while another participant was drawing). This worked well, as it supported
children/young people in having time to draw or write a letter in relative privacy and not be
distracted by the interviewer during this activity.

Recommendations for researchers

This study highlighted the many challenges of carrying out art-based research with children/young
people, alongside the importance of reflexivity for researchers. The experiences of our team
highlighted the ‘messy world’ of research and having to be reflexive, flexible and responsive to
deal with the many issues that arose ‘on the go’. The following recommendations are offered to
help address some of the issues our team faced, alongside suggesting areas of consideration for
other researchers when undertaking research with children/young people.

Recruitment
Where possible, patients and families should be informed in advance, so they can plan to come
earlier and not be surprised by researchers/research assistants approaching them. This would help
reduce children/young people and parents/guardians’ natural suspicion and researchers having to
Water et al. 11

quickly establish credibility and trust while also assessing children/young people and parents/
guardians’ willingness to participate in research. The use of postcards offering a brief overview of
the study could be a useful addition to appointment letters or be sent out separately and would alert
parents/guardians to the study taking place. Participation could be further encouraged by providing
an incentive, such as a parking voucher, to increase interview numbers and duration, particularly
since some parents/guardians were conscious that waiting any longer would increase their parking
costs. This would also acknowledge and help towards recompensing participants’ time and effort
when participating in research.

Recruitment and collecting data in public areas: What are the alternatives?
A central space with few distractions could improve the overall quality of interviews conducted,
although we acknowledge that this may not always be feasible. Additionally, piloting the interview
questions may have resulted in more specific approaches between the research assistants, regarding
particular topics to help ensure greater consistency in the quality of responses obtained. None-
theless, having two research assistants available at all times was advantageous to accommodate for
working with multiple participants simultaneously, especially during busy clinics. A clear indi-
cation of the type of clinics and their peak hours in advance would also enhance the efficiency of
the researchers’ time spent at the clinic.

Quantity over quality: Can researchers gather quality data in a short amount of time?
In this study, data saturation was achieved and the children/young people’s drawings and letters
revealed insightful perspectives into the healthcare environment (Water et al., 2017). Interview
duration was influenced by parent/guardian anxiety around missing their appointment and paying for
extra parking. We noticed that children/young people were not as talkative as in other studies we have
conducted, most likely due to the lack of time in getting to know the research assistant and children/
young people’s sensitivity to parental/guardian concerns around parking. Although this decreased the
interview time and potentially the quality of data, it also acknowledged the challenges and context of
attending an outpatient appointment for children/young people and their parents/guardians.

Participant information sheets and assent/consent

Regarding the challenges that arose in the assenting process from the ‘maybe’ option, substituting
it for a concrete alternative such as ‘I still have questions’ may address this issue. Offering an
alternative, rather than removing such an option, ensures the child is not limited to selecting the
binary ‘yes’ or ‘no’.

Limitations
On reflection, issues such as gatekeepers, the locale for interviews, noise, intrusions and limited
rapport impacted on the situational ethics in carrying out this study. However, more importantly as
researchers, we were also called to consider whether the design of the study best suited and served
the needs of children/young people and their families. Although on balance children and young
people appeared to enjoy taking part in this study, in the future we will consider approaches that
allow for more prolonged engagement with children/young people and art-based methods that
include a more participatory approach rather than become a primary vehicle for data collection.
12 Journal of Child Health Care XX(X)

Conclusion
In conclusion, eliciting children/young people’s perspectives is still an emerging component in
healthcare design. The approaches outlined in this research show how alternate approaches may
more deeply engage children/young people in research, to allow them the best opportunity for their
unique views and perspectives to be carried into practice. However, this research shows that even
when researchers do use more engaging and creative methods, functional constraints (i.e. institu-
tional barriers, environment and time) continue to restrict deep levels of participation by children/
young people in research. Other researchers may be able to draw on the experiences outlined here to
inform the challenges of undertaking art-based research in pragmatic contexts. Sharing the ‘mis
steps’ or ‘side steps’ along the way highlights the importance of researcher reflexivity and not of just
providing sanitized accounts of research. Although qualitative research may be challenging because
of its more fluid and contextual nature, it also offers opportunities to be reflexive and learn.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this
article.

ORCID iD
Tineke Water https://orcid.org/0000-0002-4438-6721
Ema Tokolahi https://orcid.org/0000-0002-0176-4876

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