Supporting children through clinical procedures can be one of the most challenging aspects of pediatric nursing. Everyone knows how tricky it can be to hold a 2-year-old for cannula insertion or to persuade a savvy 6-year-old to let us needle that port. Parents, nurses and children can come out of the procedure feeling like they’ve gone into battle! But it doesn’t always have to be like that and it is so important that we try to get it right.
First things first – what clinical procedures do we carry out on the children in our care?
Obviously it depends on the nature of the setting. Children may require IV access, IM injections, NG insertion, cast applications and catheter insertion to name just a few. They may be acute patients with no experience of clinical procedures or they may be children with chronic illness that know exactly what to expect. They can be compliant and stoic, they may be terrified and fight you all the way or they may be too sick to protest much. Children may be alone, with a parent or with the entire family including the next door neighbour and friend from down the road! All of these factors need to be considered when preparing yourself and others for any procedure involving a child.
Are children just little adults? Can we just treat them the same as we do our adult patients?
The answer is no. Children are not just little adults. They are emotionally different, physiologically different and psychologically different. Each age group has its own unique stage of development and coming with its own set of challenges. A one-year-old may have limited language skills and so cannot be reasoned with. A four-year-old may be able to understand simple terminology, but may be afraid and have some pre-conceived ideas of the upcoming procedure. A 10-year-old may know exactly what is going to happen but cannot display the emotional maturity to allow the procedure in order to make them better.
They may have supportive adults with them, but can feed off the anxiety of worried/tired/frightened parents or carers. There is evidence to suggest that some parents find it hard to advocate for their children when faced with medical professionals. They may feel unable to speak up for their child as they are intimidated by the medical staff treating their child. The notion that the ‘doctor is always right’ still exists. As nurses, we may need to advocate for both the child and their family.
When my youngest son was 2 years old he had coxsackie disease (hand, foot and mouth). He was febrile and had a mouth full of ulcers. He was refusing to drink, so I took him to a GP who attempted to look in his mouth. He was so sore he jumped from my lap and hid in the corner. The GP berated me. My child was naughty and if he was willing to behave, she may be able to look in his mouth. I left the surgery feeling bereft. Of course he wasn’t naughty – he was sick and sore and afraid. I did not say that to the GP, although I wish I had, I just never took him back to see her again. For me, this really underlined the necessity of minimising the fear and discomfort of children receiving medical care for all involved.
Why should we try our very best?
What we do to childen now can affect them for their whole lives.
Lambrenos et al have noted that “young people reflecting back on their experiences have told of their lasting emotional scars” and according to Sparkes, “research has found long-term traumatic memories for some children receiving painful medical procedures”. Essentially, what we do to children now can affect them for their whole lives. We all know adults with needle phobia. We know patients terrified of going to the dentist. Some people avoid going to a hospital altogether – the smell brings back bad memories. They avoid tests and procedures, both curative or preventative, as they may have had a previous bad experience. These fears are passed on to their own children, leading to a repetitive cycle of hospital/procedure avoidance.
Why do we do what we do?
As a rule, nurses or doctors do not want to inflict pain or trauma on children. We do it because often there is no choice. Nurses reflecting back on how they feel about carrying out such procedures can often rationalise why it’s done and move on without too much drama. Of course, there’s always that one difficult experience or procedure that may be not so easy to leave behind. We are human after all and recognising our own vulnerabilities is important.
I had a difficult moment soon after my mother died. I got the call my dad had signed a DNR one day and booked my flights home. I couldn’t fly for two days, so I decided to keep busy and go to work. I thought it would help. After managing for a few hours, I witnessed a sick child with pneumonia having an IV inserted. He was held down, obviously distressed and a pillow was placed over his chest to restrain him. I was so angry and upset because I knew and had been teaching a better way. But my upset was out of proportion.
I recognised two things that day – one, I needed to go home and grieve and two, how important this topic of supporting children correctly through procedures actually is to me. I recognised that it is sometimes ok to opt out of a procedure or if you can’t, to have the time to reflect and seek support afterwards.
In my next article, I will discuss practical techniques that we can use to help children through medical procedures.
- Children’s Mercy Hospital, USA (http://www.childrensmercy.org[…]Comfort_Positions/) website accessed 31/10/2013
- Dartford and Gravesham NHS Trust (2007) ‘Guidelines for holding children during Clinical Procedures’
- Harrison D,M (2008) ‘Oral sucrose for pain management in infants: Myths and misconceptions’ Journal of Neonatal Nursing Volume 14, Issue 2, Pages 39–46
- Koller,D(2012) ‘Distraction Techniques for Children Undergoing Procedures: A Critical Review of Pediatric Research’ Journal of Paediatric Nursing Volume 27, Issue 6, Pages 652–681
- Lambrenos K McArthur K (2003) Introducing a clinical holding policy, Paediatric Nursing, 15(4) pp30-33
- Law Reform Commission (2004) ‘Minors’ Consent to medical treatment Issues 24 New South Wales
- Royal College of Nursing (2003) Restraining, holding still and containing children and young people: An RCN Guidance for Nursing Staff
- Royal Children’s Hospital ,Brisbane (2009) ‘Physical Restraint of Children’(policy)QHEPS no 23372
- Sparks,L.Setlik,J +Luhman,J (2007) ‘Parental Holding and Positioning to Decrease IV Distress in Young Children: A Randomized Controlled Trial’ Journal of Pediatric Nursing, Vol 22, No 6 pp440-447
- Pywell,A and Xyrichis,A (2015)’Does topical Amethocaine cream increase first-time successful cannulation in children compared with a eutectic mixture of local anaesthetics (EMLA) cream? A systematic review and meta-analysis of randomised controlled trials’ Emerg Med J2015;32:733-737