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PEDIATRIC HEALTH NURSING UNIT IV : COMMUNICATION/ THERAPEUTIC PLAY WHILE CARING FOR CHILDREN WITH VARIOUS DISEASE PROCESS

MUHAMMAD SULIMANPost RN BSc.N

ROYAL COLLEGE OF NURSING SWAT

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INTRODUCTIONCommunicating with children and family caregivers is a primary source of data collection during a well-child visit or in any health crisis situation. Communication occurs in all settings and focuses on data collection as well as information related to immunizations, developmental assessment, teaching, and anticipatory guidance. Information about the child is derived from the child, the caregivers, and the nurse’s observations of the child and family. Understanding the developmental level of the child and influences on the child’s and caregiver’s communication (e.g., family, culture, community, age, & personality) are critical for communicating affectively.

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PURPOSE

Sometimes it is just about talking to and interacting with children

Establishing a therapeutic relationship Supporting children Eliciting and giving information Explaining procedures Listening to what they want to tell us Obtaining information about how they ‘are

feeling’ to help with diagnosis

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GENERAL MEASURES CONSIDERING DURING COMMUNICATION

Be aware of children’s inability to communicate verbally because of disabilities, developmental delays or traumatic scenarios and adjust your approach to meet their needs.

Children may change their style of interaction, being passive or active, which the nurse needs to be aware of when communicating.

Adopting the SOLER approach (face people Squarely; Open body shape; Lean forward slightly; Eye contact; Relax).

Be prepared to come down to the child’s level (e.g. sitting on the floor) when communicating directly with them.

Use different approaches such as play, humour or drawing to engage with children.

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COMMUNICATING WITH THE FAMILY■ Encourage parents to talk openly regarding their

concerns.

■ Use open-ended questions.

■ Use careful, nonjudgmental statements.

■ Men may prefer a focus on cognitive, problem-solving talk.

■ Females may prefer a focus on the process rather than the outcome.

■ Be aware and considerate of generational differences.

■ Incorporate active listening skills.

■ Be aware and considerate of cultural differences.

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Cont…

■ When communicating, use silence, empathy,

respect, genuineness, and trust as nursing

interventions.

■ Communication can be tricky with non traditional

and noncustodial parents. Follow the established

policies and procedures the hospital has in place.

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Cont… ■ Remember to observe and record nonverbal

communication factors, such as tone of voice, body

language, and facial expression. Be aware of your own

nonverbal communication factors and make sure you are

not communicating unintended messages.

■ Allow family members to voice their understanding of the

current situation.

■ Clarify or provide teaching points to decrease

misunderstandings.

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Communicating with children

■ The majority of the communication will take place between practitioners and parents. However, the child cannot and should not be excluded.

■ Make sure to incorporate active communication strategies with the paediatric patient as well. Incorporate an understanding of growth and development when communicating with the pediatric patient.

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Cont… ■ Observe body language, facial expressions, and other nonverbal gestures.

■ Incorporate play into nursing assessments and

interactions where appropriate.

■ Use special toys or games to assist with assessments.

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Methods of Communication with Children

■ Verbal—words, face-to-face interactions; infants cry, coo, and respond to their environment; parents and caregiver need to learn the cues of the infant or child

■ Be mindful of long pauses, rapid speech, and engaging the appropriate individuals in the communication process.

■ Gear communication to the cognitive and developmental level of the child.

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Methods of Communication with Children ■ Nonverbal—gestures, body language, posture, eye contact. Be aware of cultural factors

■ Visual—can include signs, photos, and illustrations.

■ Play—allows children to express feelings and concerns in a nonverbal manner.

o Children base their views on the relationships andexperiences within their daily lives.o Infants and children with altered hearing may havedelayed communication.

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Communicating with infants ■ Newborn to 12 months ■ This is a time of rapid physical and developmental growth. The body systems are maturing, and skill development is taking place. ■ Social development is influenced by the infant’s

environment and the attachment developed withtheir parents and caregivers.

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Cont…

■ Infants are unable to verbalize needs, concerns, anddiscomforts.

■ Nonverbal behaviors, such as smiling, promotesocialization.

■ Infants display crying and cooing. ■ Infants cry when they are hungry, when their diapers

need to be changed, when feeling pain or discomfort, and when feeling lonely or wanting to be held. ■ Infants coo when they are content or happy.

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Cont… ■ Infants are often quiet, observing the environment around

them. ■ Infants respond to the nonverbal behaviors of adults:

touch, sound, and tone of voice. ■ Observe parents and child caregivers’ interactions and

handling of the infant: ■ Separation anxiety ■ Fear of strangers ■ Temperament and disposition ■ If the child has attained understanding of object permanence, he or she will know when a parent is missing

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Quickly respond to the infant’s crying by feeding, diapering, or picking up the infant.

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Infants need to feel and touch the environment around them.

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Communicating with Toddlers and Preschoolers

■ Younger than 5 years old ■ This is a time of intense exploration of the child’s

environment. The young child learns more of his or her environment while also exhibiting some negative behaviors, including tantrums (emotional outburst). ■ This time can be overwhelming and challenging for

parents and caregivers but is an important period ofdevelopment for the child. Much cognitive, social,

psychosocial, and biological growth and development is occurring.

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A tantrum (or temper tantrum or tirade or hissy fit) is an emotional outburst, usually associated with children or those in emotional distress, that is typically characterized by stubbornness, crying, screaming, yelling, shrieking

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Cont… ■ Children of this age are typically egocentric, or unable to think from another person’s point of view. ■ Use statements such as “good job” instead of “good boy/girl.” ■ Children of this age need to feel and touch the things around them to gain knowledge of and experiment with unknown environments

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Cont… ■ Medical play may be useful in demonstrating how a procedure will take place. ■ The child may practice or pretend that a doll is having a procedure done. ■ If appropriate, allow the child to handle a stethoscope,

pulse oximeter, and blood pressure cuff and explore theseitems in a nonthreatening environment.

■ Children of this age are very concrete and literal, and areoften unable to conceptualize that one word may havemore than one meaning.

■ “IV” means “intravenous” to the nurse, but may be translated as “ivy,” a known plant, by the young patient

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Cont… ■ “Stick” or “poke” refers to a needle insertion for the nurse,

but the young patient views a stick as a small piece of wood found in the yard. ■ Bleeding may be perceived as a child’s “insides leaking out.” Young children are often comforted by an adhesive bandage used to cover an open area. ■ When having an x-ray procedure, the child may smile

when getting his or her “picture” taken. ■ Children assume that inanimate objects feel and act as

humans do. For example, they might think that somethinginanimate could bite them.

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A young child may take the expression “a little stick in thearm” literally.

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Cont… ■ The child may call an instrument “bad” if it has caused pain or discomfort to them. ■ They are fearful of unfamiliar objects and environments. ■ When possible, allow the child to tour a facility or treatment room prior to the actual treatment. ■ Preschoolers begin to develop skills in fantasy and pretend play. ■ This is a period of social, language, and behavioral development. ■ Children of this age are developing a sense of autonomy.

04/17/2023 26Developing a sense of autonomy.

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Communicating with School-Age Children ■ Ages 6 to 12 years ■ This period of physical and psychosocial development includes many milestones, such as entering school, communicating independently, and beginning to conceptualize the environment. ■ Communication directly with children of this age is equally important as communicating with their parents. ■ School-age children are energetic and want answers to the questions they have. They want to develop connections and ties with information learned and ask themselves and others why certain things occur and happen. The pediatric nurse must be aware of this in his or her communication with the school-age child.

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Cont… ■ Curious ■ Used to asking questions in school when they cannot understand ■ Want to know why or how things happen or occur ■ Gain knowledge by experience and by understanding what is occurring ■ Enjoy having a job or task to complete ■ Eager to please, and want to complete a task independently ■ Work well with positive feedback ■ Tell the child that he or she is part of the medical team that will help to get him or her well. ■ Assign daily jobs, such as an exercise or a task, so that the child can assist with care.

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Cont… ■ Concrete ■ Unable to think abstractly ■ Examples should be given in a physical context in which the child can see, feel, or hear a result. ■ May overreact if feeling threatened ■ Able to verbalize thoughts, feelings, or concerns ■ Encourage children to ask questions. ■ Older children may wish to journal their experiences. ■ Other children may serve as a support group. ■ Need play time ■ Playing will allow the child to communicate thoughts or feelings in a nonthreatening environment.

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Allow the school-age child to be an active participant in care.

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Communicating with Adolescent Children

■ Ages 13 to 18 ■ This is a time of developing independence and maturity. The adolescent child focuses more on social networks and friends. ■ The adolescent child may seek counsel and feedback from sources other than parents and caregivers. ■ Sexual development, including menstruation and emission, has already occurred. ■ Behavior may fluctuate between adult and childlike. ■ Adolescents are independent with activities of daily living, but still require adult supervision and input

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Adolescents are becoming more independent, but still require adult supervision and input.

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Nursing Care Guidelines

• Allow children time to feel comfortable.• Avoid sudden or rapid advances, broad smiles, extended eye contact, and other

gestures that may be seen as threatening.• Talk to the parent if the child is initially shy.• Communicate through transition objects such as dolls, puppets, and stuffed

animals before questioning a young child directly.• Give older children the opportunity to talk without the parents present.• Assume a position that is at eye level with the child (Fig. 6-2).• Speak in a quiet, unhurried, and confident voice.• Speak clearly, be specific, and use simple words and short sentences.• State directions and suggestions positively.• Offer a choice only when one exists.• Be honest with children.• Allow children to express their concerns and fears.• Use a variety of communication techniques.

Communicating with children

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FIG 6-2 Nurse assumes position at child’s level.

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CHARACTERISTICS OF COMMUNICATIVE DEVELOPMENT IN YOUNG CHILDREN

Perlocutionary Stage (0 to 8–9 Months)Child is reflexive to stimuli.Child shows increasing purpose in action.Emerging Illocutionary Stage (8–9 to 12–15 Months)Child communicates intentionally with signals and

gestures.Conventional Illocutionary–Emerging Locutionary Stage(12–15 to 18–24 Months)Child communicates intentionally with gestures,

vocalizations, and verbalizations.Modified from Hoge DR, Parette HP: Facilitating communicativedevelopment in young children with disabilities, Transdisc J 5(2):113–130, 1995.

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Locutionary, illocutionary, perlocutionary

For example, my saying to you "Don't go into the water" (a locutionary act with distinct phonetic, syntactic and semantic features) counts as warning you not to go into the water (an illocutionary act), and if you heed my warning I have thereby succeeded in persuading you not to go into the water (a perlocutionary act). This taxonomy of speech acts was inherited by John R. Searle, Austin's pupil at Oxford and subsequently an influential exponent of speech act theory.

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Nursing Care Guidelines

Build a FoundationSpend time together.Encourage expression of ideas and feelings.Respect their views.Tolerate differences.Praise good points.Respect their privacy.Set a good example.

Communicating with Adolescents

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Cont…Communicate EffectivelyGive undivided attention.Listen, listen, listen.Be courteous, calm, and open minded.Try not to overreact. If you do, take a break.Avoid judging or criticizing.Avoid the “third degree” of continuous questioning.Choose important issues when taking a stand.After taking a stand:• Think through all options.• Make expectations clear.

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PLAYPlay is a universal language of children. It is one of the

most important forms of communication and can be an effective technique in relating to them. The nurse can often pick up on clues about physical, intellectual, and social developmental progress from the form and complexity of a child’s play behaviors. Play requires minimum equipment or none at all. Many providers use therapeutic play to reduce the trauma of illness and hospitalization and to prepare children for therapeutic procedures

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CONT…• Because their ability to perceive precedes their ability

to transmit, infants respond to activities that register on their physical senses. Patting, stroking, and other skin play convey messages. Repetitive actions, such as stretching infants’ arms out to the side while they are lying on their back and then folding the arms across the chest or raising and revolving the legs in a bicycling motion, will elicit pleasurable sounds. Colorful items to catch the eye or interesting sounds, such as a ticking clock, chimes, bells, or singing, can be used to attract children’s attention.

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CONT…Older infants respond to simple games. After this

intermittent eye contact, the nurse is no longer viewed as a stranger but as a friend. Much of the nursing assessment can be carried out with the use of games and simple play equipment while the infant remains in the safety of the parent’s arms or lap. The nurse can capitalize on the natural curiosity of small children by playing games such as “Which hand do you take?” and “Guess what I have in my hand” or by manipulating items such as a flashlight or stethoscope.

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Use of Play in ProceduresThe use of play is an integral part of relationships with children.

Many institutions have elaborate and well-organized play areas and programs under the direction of child life specialists. Other institutions have limited facilities. No matter what the institution provides for children, nurses can include play activities as part of nursing care. Play can be used to teach, express feelings, or achieve a therapeutic goal. Consequently, it should be included in preparing children for and encouraging their cooperation during procedures. Play sessions after procedures can be structured, such as directed toward needle play, or general, with a wide variety of equipment available for children to play with. Routine procedures such as measuring blood pressure and oral administration of medication may be of concern to children. Some suggestions for procedures are:

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SELECTING NONTHREATENING WORDS OR PHRASESWORDS AND PHRASES TO AVOID SUGGESTED SUBSTITUTIONS

Shot, bee sting, stick Medicine under the skinOrgan Special place in bodyTest To see how (specify body part) is workingIncision, cut Special openingEdema PuffinessStretcher, gurney Rolling bed, bed on wheelsPain Hurt, discomfort, “owie,” “boo-boo,” achy,Deaden Numb, make sleepyFix Make betterTake (as in “take your temperature”) See how warm you areTake (as in “take your blood pressure”) Check your pressure; hug your armPut to sleep, anesthesia Special sleep so you won’t feel anythingMonitor Television screenElectrodes StickersSpecimen Sample

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Playing with medical objects provides children with the opportunity to play out fears and concerns with supervision by a nurse or child life specialist.

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Nursing TipPrepare a basket, toy chest, or cart to keep near the treatment

area. Items ideal for the basket include a Slinky; a sparkling “magic” wand (sealed, acrylic tube partially filled with liquid and suspended metallic confetti); a soft foam ball; bubble solution; party blowers; pop-up books with foldout, three-dimensional scenes; real medical equipment, such as a syringe, adhesive bandages, and alcohol packets; toy medical supplies or a toy medical kit; marking pens; a note pad; and stickers. Have the child choose an item to help distract and relax during the procedure. After the procedure, allow the child to choose a small gift, such as a sticker, or to play with items, such as medical equipment.

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