Paediatric Emergency Medicine
Practical communication guide for paediatric procedures
- Amanda Stock, MBBS, FRACP, Paediatric Emergency Consultant, Paediatric Emergency Physician; Amber Hill, BA, Play Therapist; Franz E Babl, MD, MPH, FRACP, FAAP, FACEP, Paediatric Emergency Consultant.
Correspondence: Dr Amanda Stock, Royal Children's Hospital, Melbourne, Vic. 3052, Australia. Email: email@example.com
Children undergo many diagnostic and therapeutic procedures in the ED. Although emergency staff can often intervene to reduce physical pain through topical anaesthesia, analgesia and sedation, much procedural distress can be addressed by better preparing patients and families for the procedures. A key to guiding children through procedures is the use of age-appropriate and non-threatening language by all clinicians involved. We present a practical language guide for procedures and equipment for use by clinicians in the ED before, during and after procedures. The language tables might be most usefully placed in the procedure rooms for easy reference or incorporated into clinical practice guidelines.
Visiting the healthcare environment is often a confronting experience for an adult. Children are faced with similar feelings of fear and anxiety and have fewer coping skills compared with adults. When stepping through the doors of the ED, children and families are met with unfamiliar surroundings, unfamiliar healthcare providers, and a lack of recognised items or resources that help them cope successfully. Distress levels can escalate when children undergo uncomfortable or painful procedures, which might have a flow on effect to parents. Ideally, a comprehensive procedural management approach involves not only analgesia and sedation, but use of non-pharmacological pain and distress management techniques. In some EDs such support is available through hospital play therapists. Hospital play therapy techniques have been demonstrated to reduce stress and anxiety for children and families in the ED.
A key to helping children and their families through procedures is the use of accurate, age-appropriate and non-threatening language by all clinicians involved. Hospital play therapists often help to model developmentally appropriate language for other emergency staff and parents. Yet, in most emergency or acute care settings where children are seen, they are either not available at all or only for limited time periods. The authors (a hospital play therapist and two ED physicians) have set out to develop a practical language guide for clinicians in acute care settings who conduct or assist with procedures in children. The term clinician in this article includes doctors, nurses and allied health staff. The term procedure in this context is used in a very broad sense, as even oxygen saturation measurements or the application of topical anaesthesia cream can provoke anxiety and confusion if not explained in age-appropriate terms. The child-friendly list of terms for procedures and equipment might be most usefully placed in the procedure rooms for easy reference or incorporated into clinical practice guidelines.
In the ED, health professionals might have as little as 5–10 min to build rapport with a child and their family. Having strategies to build rapport quickly is vital. Speaking at eye level is a good strategy to come across as less threatening when approaching a child. Use plain language with the child and family, providing clear explanations.
In stressful environments it is easy for details about the child's care to be misunderstood by the family. The medical jargon that healthcare providers use can frighten and intimidate families leading to communication failures. Using simple language appropriate to the child's developmental level is vital as children have a more concrete way of understanding the world. The commonly used phrases, such as ‘going to theatre’, ‘doing a dressing change’ and ‘flushing the iv’, can be very confusing as these phrases can be interpreted as having alternative meanings. This makes it fundamental for healthcare staff to pay close attention to the language used with children and their families. Tables 1 and 2 set out a list of child-friendly explanations for equipment and procedures. Every child and family is different and explanation will need to be tailored accordingly.
Table 1. Child-friendly explanations for medical equipment
|Topical anaesthetic cream||The cream on your skin helps to make your skin feel numb. Numb means that you can't feel that part as much or not at all.|
|Bandage||For a wound or fracture – this helps to keep your sore (name body part) nice and safe.|
|For an intravenous catheter – this helps keep the straw in your hand.|
|Blood pressure cuff||This goes around your arm and gets tight.|
|It doesn't stay tight for long.|
|It helps to know how strong your heart is pumping.|
|Cardiac monitor leads||These are the buttons on your tummy and chest – the long strings go to the monitor and help check how your heart is beating.|
|Monitor||Your body is drawing lines on the screen – this helps us look after you.|
|Electrocardiogram (ECG)|| |
These stickers on your chest, arms and legs connect to the ECG machine and give a picture of how your heart is beating.
It is important to keep still while we are taking the picture.
|Intravenous catheter (IVC)||A small straw or tube that goes into your vein to give your body a drink of medicine.|
|Plaster of paris||Protects your broken bone until it gets better.|
|Stethoscope||Helps to hear the sounds the inside of your body makes – how your heart is beating, how you are breathing.|
|Syringe||A tube with numbers on it – describe its purpose.|
|E.g. a helper to give medicine in your mouth.|
|Tape||Special hospital sticky tape to make sure the straw (IVC) stays in the your hand.|
|Tegaderm||Like big clear sticky tape.|
|Tourniquet||Looks like a belt that goes around your arm. It may feel tight – its job is to find the best veins.|
Table 2. Child-friendly explanations for medical procedures
|Anaesthetic||Medicine we give you through the straw in your hand or with a mask that makes you go to sleep so the doctor can (name procedure). You will not feel anything and when it is finished you will wake up.|
|Blood test||A needle that goes under the skin to take a very small amount of blood. Explain reason for blood test. Tells the doctor information about how to make you better.|
|Fasting||You cannot eat or drink anything. Explain reason why in developmentally appropriate terms.|
|Flush intravenous catheter (IVC)||Water goes into the straw with the syringe to make sure it is working.|
|Fracture reduction||Putting the broken bone back in the right spot so that it can get better.|
|Infusion||Medicine that takes a bit of time to go through the straw and into your body.|
|Injection||Medicine that we put into your body with a small needle.|
|Lumbar puncture||A needle that goes into your back to take a small amount of fluid.|
|Describe positioning during lumbar puncture.|
|Explanation of cerebrospinal fluid and purpose of test depends on age of child.|
|Magnetic resonance imaging (MRI)/computed tomography scan (CT)||Takes a picture of the inside of you. Describe what the child will see, sounds they will hear, how equipment will move, what the child's role is.|
|Nitrous oxide||Special medicine air that comes out through the mask. You can't see it.|
|It helps make the pain go away.|
|Some children say it makes them have funny dreams.|
|It is sometimes called laughing gas because it makes some people laugh a lot.|
|Observations ‘obs’||The nurses do ‘obs’ to see how your body is working. ‘Obs’ mean they find out how fast your heart is going and how quickly you are breathing.|
|Oxygen saturation (sats)||This machine is like a peg that sits on your finger.|
|It tells us how your lungs are working.|
|Ondansetron wafer||A medicine that helps to make your tummy better and stops the vomiting.|
|It is small and goes on your tongue.|
|You don't need to swallow it.|
|Procedure/treatment room||A different room to go to for your ‘name of procedure’. It has everything the doctors and nurses need. Mum and/or dad (caregiver) can come with you when you go there.|
|Sedation||Medicine that helps you to feel more relaxed. Explain sensations further depending on sedation agent.|
|Stool collection||Use familiar term, e.g. poo|
|Suture||Like a band aid made out of strings to hold your skin together so it can heal the best (explain steps of procedure if developmentally appropriate).|
|Going to theatre||Explain reasoning for operation on a developmentally appropriate level. Only use details relevant to child, what they will experience awake, pre- and postoperative care.|
|Urine collection/checking urine||Checking to see how healthy your wee/pee is.|
Preparing a child for a medical procedure significantly improves observed behavioural distress. Explaining the purpose of the procedure and its benefits reduces anxiety and prevents misconceptions, such as treatment being a form of punishment. Information about the procedure should be developmentally appropriate, honest and be as clear as possible without unnecessary details that can cause greater anxiety. Children understand information better if sensory details are used when procedures are explained. They can therefore anticipate what they will see, smell, hear and feel, lessening the fear of the unknown. It can also be helpful to explain how other children have experienced a procedure. The following is an example of preparing a preschool-aged child to receive nitrous oxide for sedation. ‘This soft mask goes on your face and special medicine air that makes you feel sleepy comes out of it. Some kids say it makes them have nice dreams and others say it makes them laugh a lot.’
The use of negative words during procedure preparation can be minimised without being dishonest to a child. Warning patients about painful sensations does not reduce pain and might increase anxiety. Patients who expect negative outcomes are more likely to have them – this is called ‘the nocebo effect’. Words like ‘hurt’, ‘burn’ and ‘sting’ even when used with a modifier, such as ‘little’, ‘barely’ and ‘not much’, are negatively loaded and set up an expectation for distress.
The use of affirmative or positive language is another helpful strategy that can be used during procedures. Instead of ‘don't tense your arm’, affirmative language would be ‘keep your arm nice and relaxed’. Instead of ‘this medicine is for your tummy pain’, positive language would be ‘this medicine will make your tummy feel more comfortable’; similarly, instead of ‘you will stay sick if you don't have this needle’, say ‘this needle will help your body get better/heal quickly’. Coercive language, such as ‘If you don't hold your arm still I will be very angry with you’ or ‘Get into that room (treatment room) right now!’, is distressing to the child and not usually conducive to cooperation.
Intravenous cannula (IVC) insertion is one of the most frequent procedures performed in the ED and regularly elicits high levels of anxiety. Commonly asked questions by young patients are ‘does it feel sharp?’, ‘will the needle hurt?’ The following is an example of how the use of anaesthesia cream and the process of IVC insertion can be explained: ‘I need to put a straw under your skin to help give your body a drink of medicine. The cream on your skin helps to make your skin feel numb. Numb means that you can't feel that part as much or not at all. Some kids say that when I put in the straw in your skin that they feel nothing, some kids say they feel a poke on their skin – everyone is different, you tell me how you think the cream worked.’
Caregivers are a vital member of the team performing the procedure and should be consulted as part of a patient- and family-centred care model. They understand their child's needs, fears, familiar comforts and previous positive or negative hospital experiences. Research with school-aged children has found that having a parent present during the procedure was the most important way to help during the emergency visit. However, caregivers understandably can become distressed when their child undergoes a painful procedure. Giving parents a task to focus on can assist in reducing their anxiety and help comfort the child. For example, caregivers can assist in providing an alternative focus, engaging their child's attention towards a compelling distraction tool, such as an interactive book or bubbles.
Pain management interventions are most effective when the child, family and health professionals work together. This can be achieved when caregivers have a clear understanding of the procedure and its benefits, and their role during the procedure.
Despite research showing that caregiver presence is beneficial during procedures, there might be some situations where it is not in the child's best interests. A caregiver's anxiety about their child's procedure and their unresolved experiences of pain in childhood can interfere with the procedure and cause distress. It is important to provide complete and unbiased information regarding procedures to families, so that they can make an informed decision whether to be present during a procedure.
Development and language
The communication and language needs for children and young people in the ED are closely related to their developmental level. As a child or young person experiences each new stage of development, different hospital stressors will be prominent and can be addressed through developmentally targeted content, topics and strategies. Appreciating the different developmental needs of children can assist in making procedures run more smoothly for the patient, caregiver and health professional. An explanation regarding the normal developmental response to stress in an unfamiliar environment can help caregivers understand their child's behaviour during procedures.
For toddlers it is helpful to explain to caregivers that kicking and screaming during a procedure is a common response because of loss of their mobility and not because of pain or bad behaviour. Without such explanation, caregivers might perceive that unnecessary distress is being caused to their child or alternatively that their child is behaving badly. Procedural restraint use in preverbal and early-verbal children in the ED is often extensive and significant amounts of force are used. Procedures or examinations can often be performed more easily while the toddler sits on the caregiver's knee and might result in less distress for the child and family. Resources explaining the concept of positioning for comfort are available online.[15, 16]
Beginning in the preschool years, because of an increased mastery of skills, children can begin to feel an increased loss of control. Offering appropriate choices when possible is an important way to empower the child in a hectic acute care environment in which many choices are taken away. It is helpful to have two practical well-defined options available. An example might illustrate this concept: ‘Would you like chocolate or strawberry flavour on your breathing mask [for nitrous oxide administration]?’ or ‘Would you like to sit on mum's lap or on the bed when we do the blood test?’ On the other hand, do not give a choice when there is not one available or when the answer will most likely be no. If the tegaderm needs to be removed, rather than asking ‘Can I take the tape of now?’, it is better to ask ‘Which hand first?’ Giving helping tasks is another way to give control back. Helping tasks can also involve caregivers. For example: ‘Mum's job is to give you a big cuddle and your job is to keep your leg as still as a statue while we help make your cut better.’
Preschool-aged children, because of magical thinking, can have blurred boundaries between fantasy and reality. Allowing a child to play with medical equipment that they can touch can reduce anxiety by providing an active role in learning and desensitisation to the procedure. Examples of this are letting a child put a pulse oximeter on a teddy, or play with a stethoscope and other safe medical items before an examination or procedure. It is important to use concrete, sensory language during medical explanations using descriptive words the child can relate to when possible to further enhance understanding. An example of this: ‘The blood pressure cuff goes around your arm and feels like a tight hug around your arm; your job is to hold your arm still until it is not tight anymore. It helps tell how strong your heart is.’
School-aged children are characterised by concrete understanding and an intense interest in their body and how it functions. This will surface by the common fear of blood tests or ‘taking blood’. Some children might believe that all their blood is being taken from them and that there will be none remaining. They might also perceive that treatment is a form of punishment. Clear and simple explanations and confirming that the child understands ensure that it is less likely for the school-aged child to develop these misconceptions.
Adolescents are able to engage in higher reasoning and are increasingly aware of their identity and impact on the world. It is important to respect the privacy and independence of adolescents. Simple interventions that can be used in acute care settings include closing curtains when examining the adolescent patient and allowing time for them to ask questions about their own care. Respect the adolescent as an individual, ensuring that not only parents are provided information about illness and treatment, but the adolescent has this information as well. Ask if the adolescent would like their caregiver as a support person during procedures.
Clinicians can prepare and guide children and families through procedures. Key is the use of developmentally appropriate and non-threatening language. This practical language guide can help clinicians find child-friendly terms for procedures and equipment.
We acknowledge grant support from the Murdoch Children's Research Institute, Melbourne, Australia and the Victorian Government's Operational Infrastructure Support Program.
All authors contributed to the design, methodology, ethics application, data interpretation and drafting of the study. All authors have read and approved the final manuscript. AS and FEB conceived the idea of the article. All authors contributed to the writing of the article. All authors approved the final version submitted. AS takes responsibility for the paper as a whole.