Toni is 6 years old. She has a chronic renal condition whereby she has only recently started gaining bladder control and, even now, when she needs to pass urine, she has to go straight away. As a result of this, Toni has had many hospital admissions with urinary tract infections (UTIs). Her perineal area is also prone to becoming very sore when she has little ‘accidents’ and has to wear slightly wet underwear.

Toni’s school were reluctant to take her at the outset, believing that she could and should be dry at the age she started with them. Her parents were forced to get medical evidence before the school would take her in and, even now, some staff refuse to allow her to leave the classroom to go to the toilet, resulting in soreness and embarrassment as well as frequent UTIs.

In hospital, Toni is very clingy to whichever parent is present. Although she is generally a very bubbly and confident little girl, when she enters any healthcare environment she changes and becomes very quiet. When asked what makes a good nurse, Toni gave two answers – ‘the one who hasn’t got a needle in her hand’ and ‘the one who plays with me and doesn’t just talk to mummy or daddy’.

• Why do you think Toni changes so much when she enters hospital?
• How could nurses improve Toni’s experience of healthcare through effective communication?

Answers: Reasons why her behaviour changes when going into hospital:

• Bad experiences in the past, particularly associated with needles (injections/medications) and nurses who ignore her, only speaking to her parents

Ways of overcoming these:

• Focus on Toni
• Using age-appropriate language, communicate with her alongside her parents
• Play – allow her to play with hospital equipment (ensure her safety at all times) and use books, videos, etc. to explain what is going to happen

Having explained what is going to happen, use distraction when Toni undergoes procedures, etc.

Josh is a 2-year old boy. He lives with his mother Kelly, older sister Jemma and baby sister Jasmine. Josh has recently started attending a local nursery. Four weeks ago Kelly noticed that Josh’s left leg seemed very swollen and he was not putting any weight on it. The local hospital said that there was no fracture, but the leg remains swollen and painful, so Kelly took him back to the Children’s Emergency Department (CED). The first nurse they encountered was very abrupt, but reluctantly agreed to book them into the department. Another nurse came into the cubicle and told Kelly that she had to take the bandage off. Josh immediately started to cry and became more and more distressed as the nurse cut away the bandage and pulled it off his leg. She told him to be quiet and made Kelly hold onto his toy rabbit as it was getting in her way.

Kelly and Josh were then left alone in the cubicle until another nurse (Melanie) arrived to take them off to x-ray. Seeing Josh on the trolley, she very gently picked him up and put him in his mother’s arms. Seeing how upset both Kelly and Josh were, she stayed with them throughout the x-ray, gently stroking Josh’s hair and putting a comforting arm around Kelly’s shoulders. When the x-ray was completed, Melanie stayed with Kelly and Josh while the doctor gave them the news that Josh’s leg was, in fact, fractured and that the initial diagnosis had been wrong.

• Which nurse demonstrated more effective communication skills? 

Answer: The nurse who enabled Josh’s mother to hold him, communicated with both him and his mother and stayed with them throughout the x-ray and until they got the results.

ANSWERS TO WHAT’S THE EVIDENCE? 2.1

By knowing the child’s perspective, the nurse can gain understanding of

• Their likes and dislikes
• What they know and understand about their health problem/need
• How the health problem/need affects them and their lifestyle
• Their perception and explanation of pain and other symptoms
• Who they consider to be important to them (this may include pets and friends as well as family members)
• How much they want to be involved in decision-making and their care
• Capacity/competence to give consent

This is not an exhaustive list!

‘I was on a long placement on a children’s ward. I got to know a young man with a rare progressive genetic condition very well and his family always said that the best days on the ward were when I was looking after him. On this admission he had come in with a chest infection, but, despite several changes of antibiotics, he wasn’t getting any better. The doctors told us (the nurses) that it was likely that he was going to die and asked who would accompany them when they told his parents. My mentor immediately said that I should be there, as I had a good relationship with them, and she would go with me. I wasn’t so sure as I was only in my second year, but she persuaded me. It was really, really hard and I couldn’t hold back the tears at one point, but I was glad I was there. His mother kept looking at me and, in the end, I just took hold of her hand, just to reassure like….. Once the meeting was over, I wanted to run away, but my mentor said to me “Stay with them for a while. Don’t worry if you don’t talk, just be there for them”, so I sat with them for about 15 minutes until they decided they could face going back into the ward. I didn’t want to be in that meeting, but I am so glad my mentor changed my mind.’

 Children’s Nursing Student  

‘Our son Mikey has a very rare condition and the children’s ward is his second home. We got to know a student nurse (Asha) very well over his last 3 admissions. Kept telling us that she was only in her second year, but you would not have thought it. She just seemed to know what Mikey needed and how to make me feel better too. I remember the day we were told that he was going to die. Although we always knew it would happen, we were not ready for it yet. It was a great relief to have Asha there when the doctor told us. I don’t remember much of what was said, but I did feel that the doctors and nurses there really cared, not just about Mikey, but about us too. When Asha cried I just knew how much she cared about my son and then she just reached across and took my hand – I’m not usually a great one for touch, but that just felt right. I expected the nurses to leave when the doctor had finished talking to us, but Asha stayed, in silence and somehow, her presence gave me the courage to go back to see Mikey. Thank you Asha!’

Parent

Read carefully both voices above. Why do you think Mikey’s parents valued Asha and the care she provided so highly?

Answer: Through the way in which she both cared for Mikey and communicated with his parents, Asha indicated that she was competent to care for their son every time they met her. At the time when the news that he was going to die was broken to the family, Asha may not have said much (in fact, she probably did not know what to say), but she was there with them. Remember silence and simply ‘being there’ are powerful communication tools that cannot be underestimated, particularly in difficult situations like this one. While Asha might have felt it was wrong to cry (it is not!!), Mikey’s parents really appreciated it as they perceived it as a sign of how much Asha cared for their son. Asha was also clearly very much ‘in tune’ with Mikey’s mother’s emotions as she used touch so effectively in this situation.

All these skills are difficult to quantify, but this scenario demonstrates how important they are.