ANÁLISIS ESTADÍSTICO

When providing explanation to the child/ caregiver(s) the nurse should use age appropriate language and/ or concepts and use culturally appropriate language. The nurse should assess if the child and caregiver(s) have understood the explanations by reframing their responses.

Children: This quality measure was observed during less than half of all the admissions of the

children. There was no significant association between the groups and meeting this QM -

p=.238. When the outlier was removed, the result was still not significant - p=.192.

More than half of the SPNs (55%) and 41% of the NSPNs met this QM. This was also a

surprising result because a crucial component of paediatrics is using age appropriate language and concepts to avoid misunderstandings or to prevent unnecessary fear in children (ACHS, 1998; Glasper & Richardson, 2011). For example, preschool children are often quite literal in their understanding of words and using phrases such as ―put to sleep‖, often used for being anaesthetised, may make them think of pets which have been euthanised. Similarly, using the word ―dye‖ for a diagnostic test may evoke fear that they are going to die (London, et al., 2007). Therefore, this QM is extremely important to help children become less anxious during the admission procedure. This was exemplified when an RN was observed telling a child that the cream on the hand was magic so that when the straw was put in the child‘s hand, he would not feel it going in. However, children often associate straws with drinks and may not understand this analogy.

The communication skills of the RNs varied during the admissions. A common phrase RNs used (n=11) was, ―I‘m going to put this in your ear‖ when using a tympanic thermometer. One RN did ask a child for permission to put it in his ear. When one considers the literal nature of toddlers and preschool children, these types of statements may evoke fear in children. Perhaps a more appropriate phrase would be something akin to ―I‘m going to touch your ear with this machine/ equipment.‖ The aforementioned RN who asked if the child had seen a thermometer,

147 explaining, ―It takes your temperature‖, may also have evoked fear as this may imply to the literal mind of a toddler that something is being removed. Very few of the RNs actually showed the equipment to the children before using it; one of the RNs asked a mother to hold her child‘s head before using the thermometer without any explanation. One of the RNs showed the child the thermometer, explaining that it made a ―... beeping noise when it is popped in your ear.‖ This seemed to engage the child and even if the explanation was interpreted literally, the use of other child friendly techniques may have helped overcome any misapprehension. This flexible

approach, when used in combination with knowledge about child development, may be more important than the actual phraseology employed.

One child who had had a nasogastric tube (NGT) inserted asked why it had been done to her and was told by the RN that ―she was lucky to have it in.‖ This was not followed with any other explanation and the RN left the room. It is unlikely that the child felt ―lucky‖ given that Crellin and Johnston (2005) had testified that children reported that NGT insertion as being severely

painful.

Another piece of equipment used frequently but not always explained was a blood pressure (BP) machine. One RN acknowledged that the BP cuff hurt which seemed to help the child whereas when other RNs told children that it did not hurt, the explanation did little to help as observed from the facial grimaces of some of the children. Another RN used age appropriate descriptor by saying the BP cuff gives ―a big hug.‖

An RN tried to explain what the SpO2 measured, starting to explain about blood haemoglobin levels. At the moment the nurse mentioned blood, the child became quite anxious about the SpO2 probe, as he immediately withdrawing his finger and asking, ―Am I going to bleed?‖

Techniques which appeared to help reduce anxiety included telling the children to watch the numbers on the machine (distraction) and using age-appropriate words such as ―squeeze‖ or ―tight.‖ One other effective technique in helping children visibly relax was the RNs thanking the children when they cooperated or, saying ―they were a good boy/ girl‖ reinforcing the importance of flexibility in the nurses‘ approaches, coupled with recognition of child developmental stages (Glasper & Richardson, 2011). Positive strategies such as these enabled children to relax more during the hospitalisation period.

148

Parents: More RNs in the study provided explanations to parents than they did to children

(n=57). There was no significant association between the two groups of RNs in meeting this QM (p=.195) although when the outlier was removed from the analysis, the p value indicated a trend towards significance - p=.079. This QM was not met by 8% of SPNs and 20% of the NSPNs. When waiting for their child to be admitted to the wards or departments, it was not uncommon to observe families becoming frustrated with the hospital processes. This frustration could have been lessened if more of the RNs apologised for the length of time the families had had to wait and gave approximate times for coming attention. Families are frequently told to arrive at the hospital by a certain time. This may be as early as 0630 hours but invariably the admission procedure is not completed until the next shift arrives, often around 0700 hours or, until a doctor arrives to either confirm or refute the need for an operation as was the case in some of

emergency admissions for trauma or abdominal pain. On one occasion, following a traumatic injury to a child‘s finger, the family were told to arrive at the hospital with the child fasted by 0800 hours only to be told the doctor would not be arriving until 1130 hours. There was no attempt made to explain to the family why the child had been asked to arrive early. For example, if the explanation was about operating theatre availability and its emergency use, the family may have been appeased. But, no explanation was offered and the family became increasingly frustrated.

One other aspect of this QM related to the language used by the RNs. The use of jargon is discouraged in all specialties within nursing. However, jargon was heard during 11 (16%) of the admissions. An RN asked a child‘s parents if he had ―... Panadol PRN ...‖ another nurse told a child‘s mother that the child needed ―a bolus of fluid.‖ Another RN explained to a child‘s father that she was checking the child‘s ―sats‖ (SpO2) but did not tell the father what this meant or the result. Another RN told the family that the child needed ―Emla for the GA‖ whilst another told a parent that their child was ―afebrile.‖ The use of jargon was observed many times despite it being a major barrier to effective communication (Farrell, Deuster, Donovan & Christopher, 2008). Perhaps the most ambiguous statement heard was an RN informing a child‘s parents that, ―His BP was # over # but the machine is not terribly accurate and I‘m sure his BP is okay‖. The RN‘s statement contained jargon and did nothing to explain the meaning of the result or that the machine may have been faulty. Nurses who clarify observations help forge trusting

149 It is not only medical jargon which can be confusing; hospital processes can be meaningless to families. For example, some of the children had red stickers on their charts and red name bands for their arms. One parent asked the reason for the red bands on his child and was told that the child must have an allergy and the stickers ―lessen the chance of their child being given the wrong medication.‖

The literature describes the anxieties of parents who have a hospitalised child (Glasper & Richardson, 2011; Hockenberry & Wilson, 2011). It includes not only fear for their child but such practicalities as getting home to collect other children from day care or schools. Some need explanations about visiting times and other facilities. Many of these are explained in the hospital handbook but, if the parent has not had the opportunity to read this, then they may want

answers about these practical matters sooner. For example, a parent asked about car parking but the RN said she did not know anything about this and did not offer to find out.

Nevertheless, there were many observed examples of RNs communicating effectively with families. The most effective styles observed seemed to be of the RNs who sat down in a

relaxed, professional style opposite the parents and child. They did not engage in the paperwork immediately but either examined the child or asked the parents questions prior to completing the forms. One RN completed the process then asked the family if they had any questions. This was reinforced by the RN informing the family to interrupt at any time if they had a question. This RN then reiterated the proposed plan of admission. This appeared to be an effective means of communicating with children and their families. Although there was not a statistically significant association between the groups and the meeting of this QM, 22 of the 24 SPNs and 35 of the 44 NSPNs met this quality measure.