How to give great care to children in our ED

I was fortunate to attend a POEMS course recently. POEMS stands for Positive Outcomes and Experience Management Strategies and it is run by a group of anaesthetists from Great Ormond St Hospital. The theme is how to manage anxiety in children in healthcare settings. I can't recommend the course highly enough!

What is anxiety?
It is a psychological and physiological state characterised by somatic, cognitive and behavioural components.

And it is a BIG problem....

• 80% of all children admitted to hospital experience anxiety
• 75% of children having surgery experience anxiety in the anaesthetic room
• Up to 60% will display new dysfunctional behaviour within the 3 weeks following surgery
• Up to 12% still exhibit this behaviour 1 year after surgery

I suppose this is not surprising, and our Emergency Department is just as bad, if not worse, than an anaesthetic room: it is an alien environment, there is lots of frightening equipment stuff, and people rushing about! Children may be pushed beyond their capacity to cope.

Our job is to help children cope with anxiety and reframe it so that it does not become crippling. But how?

Communication is key.

Non verbal communication

• Body language
• Facial expression
• Height
• Positioning
• Proximity
• Mirroring
• Gestures
• Attentiveness

Which of these positions are most likely to put the child at ease?

Verbal communication

• Tone: Deeper & softer, communicate calm
• Timbre: Tends to be a natural vocal characteristic, not easy to alter
• Tempo: Slow & relaxed
• Text: Avoid frightening terms/use abstract alternatives​​
  • ​​Kiss your child goodbye --> "A kiss before you go"
    
  • It might be a bit painful --> "It might be a bit sore, we will make sure you are comfortable"
    
  • You won't feel sick --> "You will feel hungry"
    
  • It might smell --> "It might smell different"/"We are going to change the smell"
    
  • It might sting --> "It might tingle"/"It might sparkle"
    

Advanced communication

Advanced communication techniques fall into two groups

• Control attention: disrupt negative processes taking place, moving them from internal inaccessible state to external interactive state
• Coping strategies: help the child manage their anxiety

Not all techniques will work for all children, and as an individual you might prefer some to others. It is helpful to practice a few so you can try different approaches in different circumstances.

 
​Control attention
Overload
Example: "Hello James, come in. I love your shoes, reckon they'll fit me? I reckon they're too small but what's size between two friends? I'd probably bend them if I wore them, but not like Beckham though. He's a good player, better at United than Real, the real deal in red not white I think. Red devils are United, but they're heavenly players, making music on the pitch, perfect pitch but I'm tone deaf even though I love to sing in the shower. Not the rain shower, though Singing In the Rain is a great film, but water in the camera is bad news, it makes the colours run off the screen, right off track but listen to me I'm like a stuck record."

Accelerated rapport
Behaviour, non-verbal, verbal or tactile usually associated with having rapport where as yet that rapport does not exist.

Yes set

• Conversation intentionally structured such that the patient must respond with a 'yes', therefore obtaining a positive rather than a negative response.
• Momentum of the repetitive response to enable agreement without full consideration
• Experience dissonance if they break the yes pattern
• Example: Hello, you must be Charlotte? Are you're here with your mum? And you've hurt your arm? 

Bind of comparable alternatives
Free choice of two or more comparable alternatives, and whichever is chosen leads to behaviour in the chosen direction. Usually feel bound to accept one alternative.

• Would you like to go to sleep on the trolley or sitting in Mum's lap?
• Do you want me to examine your ear or nose first?
• Do you want me to measure your temperature or take your blood pressure first?
• Do you want four stitches or three really good ones?

Coping strategies
Humour
Use with caution and be inclusive and appropriate

• Hello Bob, can you tell me your name?
• Who is old, you or your Dad?
• Do your Mum and Dad have any children?
• Do you go to school? Oh really, what subject do you teach?

Successive approximation

• Now, George, I don't want you to get on the bed just yet, but could you just help me move it into position, and now help me put on the draw sheet
• Could you just hold the mask, while I tie up my shoelaces? Could you hold the mask up?
• Would you like to have a look around the ward before we go into the treatment room?

Distraction therapy
Methods to reduce anxiety and pain by focusing on something else

• Preparation: child and parents
• Choice: cuddles, bubbles, toys, books, music, games
• Allocate distraction to one person - avoid over distraction!!

Want to know more?
Please consider going on the course - see their website

C Bosanko