Studying Children's Experiences in Interactions With Clinicians: Identifying Methods Fit for Purpose

Increased emphasis on the child's voice and point of view in care and treatment has led to an expansion in the development of methods to access and identify their perspectives. Drawing on our experiences in a study of children with leukemia in hospital, this article explains the challenges and opportunities that arise in the use of five commonly used methods in a study of hospitalized children's experiences with health care professionals, including the "Draw and Write" technique, a sticker activity, a paper-person exercise, informal interviews, and participant observation. Each of these methods was examined with regard to ease of use, data generation, and utility of data for accessing children's perspectives and development of initial clinical guidance.

Behavioral Health Care for Children Who Are Medically Hospitalized

Youth admitted to pediatric hospitals face a variety of emotional challenges throughout their stay. In addition to feeling compromised by their acute medical condition, managing the requirements imposed by hospital care can intensify the potential for behavioral dysregulation. Even meeting basic behavioral expectations often requires children to be highly vulnerable, uncomfortable, and in pain, having to trust a parade of people routinely delivering aversive interventions, all in the context of overwhelmed caregivers. Behavioral medicine approaches are thus essential for supporting adaptive coping to optimize emotional and pathophysiological recovery. Clinical implementation requires integration of emotional and behavioral health initiatives into medical services across the broadest of disciplines with hospital-wide vigilance to safety risks. Providers can support behavioral resiliency by nurturing youth who are hospitalized to become increasingly active agents in their care while bolstering the consistency of their behavioral expectations through effective communication and an empathic treatment approach tailored to their socioemotional needs. [Pediatr Ann. 2018;47(8):e323-e327.].

Evaluation of patient-reported outcome measurements as a reliable tool to measure acceptability of the taste of paediatric medicines in an inpatient paediatric population

OBJECTIVE

To evaluate the age appropriateness and suitability of patient-reported outcome measures to assess the acceptability of the taste of oral liquid medicines in children.

DESIGN AND SETTING

An observational mixed-methods study involving children aged 2-16 years taking oral liquid medicine in paediatric inpatient wards across the West Midlands (UK). Assessment tools included patient-reported scores on the taste of medicines via a five-point Facial Hedonic Scale; a Visual Analogue Scale (VAS); a question, 'Did you think the medicine tasted OK?' and researcher observations of facial expressions and behaviours immediately before, during and after administration.

RESULTS

611 children participated. The percent unable to complete the scales was 7% (n=46) for the VAS; 2% (n=15) for the hedonic scale and 1% (n=7) for the question about taste. Significant correlations (Spearman's r) were observed between the patient-reported outcome measures: 0.80 and 0.78 for the taste question and hedonic and VAS, respectively, and 0.84 for the hedonic and VAS. Researcher observations demonstrated the ability of the patient to take the medicine as intended but did not provide sensitive measures of taste. 5% of administrations were not taken as intended by the children. Medicines known to have poor taste (clarithromycin and prednisolone) showed mean hedonic and VAS scores of ≥3.5 and >65 mm, respectively.

CONCLUSIONS

Patient-reported outcome measures correlate with each other and are a useful means to assess the taste (and acceptability) of medicines. Hedonic scales are better understood by children and should be the first choice tool in the assessment of medicines taste.

Is surgery a risk factor for separation anxiety in children?

OBJECTIVE

Postoperative anxiety symptoms are distressing for both family and child. The aim of this study was to examine the prevalence of postoperative anxiety symptoms in children.

METHODS

60 children aged 6-12 undergoing surgery were included in the study group. The study group was assessed three times in terms of separation anxiety disorder (SAD), at the time of presentation, 1 and 3 months postoperatively. A personal information form and the SAD section of the K-SADS-PL on the basis of DSM-IV diagnostic criteria for screening SAD symptoms were used.

RESULTS

Study group consisted of 19 girls (31.7%) and 41 boys (68.3%) (mean age 8.9 ± 2.3). Four (6.6%) of the cases at the time of presentation and 13 (21.6%) in the study group met SAD diagnostic criteria in 1 month and 21 (35.0%) in 3 months. Anxiety disorder symptoms were significantly higher in the study group at 3 months postoperatively (p < 0.05). There is significant correlation between both SAD symptoms and duration of hospitalization. There was also a positive correlation between duration of hospitalization and parental education and SAD symptoms.

CONCLUSION

Greater SAD was observed in children undergoing surgical procedures. It will be useful to physicians to consider SAD after surgery in pediatric patients especially when the level of parental education and duration of hospitalization increase. Since SAD may persist long after surgery, it may cause constant fear in personality disorders and lead to psychological problems by significantly lowering quality of life.

Anxiety, hospital fears and conduct and behavioral alterations during pediatric hospitalization

INTRODUCTION

A hospital admission is an experience capable of generating emotional and behavioral alterations at any age. This study pretends to analyze the response of anxiety, fears and/or behavioral alterations in pediatric patients exposed to a conventional non-surgical hospital admission and the existing relationship between these responses and certain modulating variables. Metodology. Design of cohorts. Data collection was carried out in three stages (M1: at admission; M2: at discharge; M3: 2 weeks after discharge), on a 30 patient sample between the ages of 6 to 15 years and 30 caregivers. A comparison was made on the mean of the repeated measurements (Student t) of the respond variables and their correlation (Pearson&#8217;s Coefficient Correlation) with modulating variables.

RESULTS

The results of the intra-subject analysis showed significance in terms of anxiety levels state in patients in M1 versus M3 (t=3.93, p<.0001, d=0.69) and the magnitude of the total behavioral alterations registered in M1 versus M3 (t=-5.02, p<.0001, d=0.60). It was observed that a significant relationship between modulating variables of patients (anxiety risk) and of the caregiver (anxiety character state, strategy of confrontation) and the variables of response of the anxiety and behavioral alterations of the patient.

CONCLUSIONS

Exposure of a conventional non-surgical hospital admission may have negative consequences at an emotional and behavioral level in children, present far beyond the hospital admission. Certain variables, from the patient and the caregiver, are psychological vulnerability factors before a hospitalization process.

Education creates comfort and challenges stigma towards children with intellectual disabilities

Children with intellectual disabilities (IDs) are frequent users of the healthcare system, yet nurses report they receive little education regarding specialized medical, social and relational needs of this population. Therefore, parents take on a greater burden of care while their child is in hospital than do parents of typically developing children. This article reports findings from a qualitative study that used feminist poststructuralism to examine the hospital experiences of eight children with IDs, 17 mothers and 12 nurses. Nurses and mothers reported a lack of knowledge and education regarding the healthcare of children with ID and identified a need for more education. Participants noted that physical care of children with ID was prioritized as more important than communication and relationships. This unintentional prioritization was socially and institutionally constructed through stigma and stereotypes about people with IDs. Nurses and parents offered suggestions to access and increase ID education for healthcare professionals.

Parent Coping Support Interventions During Acute Pediatric Hospitalizations: A Meta-Analysis

CONTEXT

Parents may experience psychological distress when a child is acutely hospitalized, which can negatively affect child outcomes. Interventions designed to support parents' coping have the potential to mitigate this distress.

OBJECTIVE

To describe interventions designed to provide coping support to parents of hospitalized children and conduct a meta-analysis of coping support intervention outcomes (parent anxiety, depression, and stress).

DATA SOURCES

We searched Pubmed, Embase, PsycINFO, Psychiatry Online, and Cumulative Index to Nursing and Allied Health Literature from 1985 to 2016 for English-language articles including the concepts "pediatric," "hospitalization," "parents," and "coping support intervention."

STUDY SELECTION

Two authors reviewed titles and abstracts to identify studies meeting inclusion criteria and reviewed full text if a determination was not possible using the title and abstract. References of studies meeting inclusion criteria were reviewed to identify additional articles for inclusion.

DATA EXTRACTION

Two authors abstracted data and assessed risk of bias by using a structured instrument.

RESULTS

Initial searches yielded 3450 abstracts for possible inclusion. Thirty-two studies met criteria for inclusion in the systematic review and 12 studies met criteria for inclusion in the meta-analysis. The most commonly measured outcomes were parent depression, anxiety, and stress symptoms. In meta-analysis, combined intervention effects significantly reduced parent anxiety and stress but not depression. Heterogeneity among included studies was high.

LIMITATIONS

Most included studies were conducted at single centers with small sample sizes.

CONCLUSIONS

Coping support interventions can alleviate parents' psychological distress during children's hospitalization. More evidence is needed to determine if such interventions benefit children.

Clowning as a Complementary Approach for Reducing Iatrogenic Effects in Pediatrics

Hospitalized children who undergo painful procedures are more susceptible than others to experiencing iatrogenic effects, such as anxiety, pain, and severe stress. Clowns in clinical setting have been found to be effective in reducing children's experiences of these effects during hospitalization and before procedures. This article provides an overview of clowning in health care settings; reviews major studies conducted on clowning for hospitalized children, discussing evidence that clown interventions decrease pain and distress in pediatric patients; and concludes with a discussion of health care clowning as a profession.

Beyond Hospital Discharge Mechanics: Managing the Discharge Paradox and Bridging the Care Chasm

Hospital discharge processes are complex and confusing, and can detrimentally affect patients, families, and providers. This qualitative study investigated pediatric hospital discharge experiences from the perspectives of parents of children with acute and chronic health conditions, primary care providers, and hospitalists. Focus groups and interviews with parents, primary care providers, and hospitalists were used to explore discharge experiences and ideas for improvement offered by participants. Using an iterative approach to analyze data resulted in five major themes for discharge experiences: (a) discharge problems, (b) teamwork, (c) ideal discharge, (d) care chasm, and (e) discharge paradox. The first three themes concern practical issues, whereas the last two themes reflect negative emotional experiences as well as practical problems encountered in the discharge process. Improvements in communication were viewed as a primary strategy for improving the discharge process for better outcomes for patients, their families, and providers.

Best Practice in Provider/Parent Interaction

In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings

BACKGROUND

Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management.

METHODS

In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent's respective hospital.

RESULTS

Responses were obtained from 38 North American academic children's hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management.

CONCLUSION

Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Effects of a Humor Therapy Program on Stress Levels in Pediatric Inpatients

OBJECTIVE

Disease and hospitalization generate stress, which can affect the response to treatment. Humor has been used in many hospitals to decrease stress. The aim of this study was to evaluate the impact of a humor therapy program on stress levels in pediatric inpatients.

METHODS

In the first phase, an intervention and a control group were studied over 2 consecutive 3-month periods; the interventions were performed by a team of artists trained in humor therapy. Salivary cortisol levels were measured by enzyme-linked immunosorbent assay, and the Weisz test, a pictorial chart that determines subjective stress perception, and the Parker test, which assesses objective stress, were applied. In the second phase, salivary cortisol levels were measured and the Weisz test was administered before and after the interventions.

RESULTS

A total of 306 patients were recruited into this study: 198 in the first phase (94 in the intervention group and 104 in the nonintervention group) and 108 in the second phase. There were no differences between groups regarding age, sex, or medical diagnosis. The children in the intervention group presented lower cortisol levels, lower scores on the Parker test, and higher scores on the Weisz test than children in the nonintervention group. In the second phase, the children showed lower salivary cortisol levels and higher scores on the Weisz test after the intervention.

CONCLUSIONS

Humor therapy has beneficial effects on stress and cortisol levels in pediatric inpatients. This supports the implementation and reinforcement of these therapies in pediatric hospitals.

Pediatric Brain Tumor Patients: Their Parents’ Perceptions of the Hospital Experience

Studies have shown that admission to the hospital of a child can induce feelings of fear and helplessness in parents, challenging usual patterns of coping and parenting competence. Stress has been associated with parents’ need to establish effective communication with staff and their need for information, ready access to their children, and participation in decision making relating to their child’s care. This study of coping and adjustment was undertaken with the parents, including mothers and fathers, of children under 18 years of age diagnosed with a brain tumor, presenting at Royal Children’s Hospital, Melbourne, between 2001 and 2002 (N = 53). It was a prospective study using repeated measures over time. Participants in the study were involved in a questionnaire interview at 4 different points: at the time of diagnosis, 6 months postdiagnosis, 1 year postdiagnosis, and 2 years postdiagnosis, in which they were asked, among other things, about their experience of the hospital. The point of diagnosis was marked by a high level of dependence, with parents coping with rapid decision making and shock, and the surrender of care of their child. Parents identified high levels of information need but noted that they were often too stressed to take in information early on, and that this information need persisted up to the 2-year postdiagnosis point. More parents expressed dissatisfaction with the hospital and particularly with their interactions with the health care team at the 6-month post-diagnosis period, reflecting a possible reduction in attention given to families once they had settled into the treatment routine and the crisis of diagnosis had passed.

Variations in Pain, Sleep, and Activity During Hospitalization in Children With Cancer

This study examines the pain experiences of children with cancer during hospitalization. A descriptive design with repeated measures was used to describe the location, intensity, and quality of pain, pain medications, amount of pain relief, and perceptions of sleep and activity during hospitalization. Data were collected once daily from the day of admission for up to a maximum of 5 consecutive days during hospitalization. Results show that more than half of the patients (27 of 49 patients) indicated they were having pain. Eleven patients (22.4%) had mild pain (mean = 2.3 ± 0.9 SD; range, 0.3-3.6), 10 (20.4%) had moderate pain (mean = 5.3 ± 0.2 SD; range, 5.0-5.5), and 6 (12.2%) had severe pain (mean = 7.6 ± 1.3 SD; range, 6.5-10.0). The highest pain intensity ratings occurred on day 1. Overall, most patients reported good relief after pain medications during hospitalization. Consistent assessment and implementation of pain interventions within the 24 hours of admission is recommended, with particular attention to persistent pain after painful procedures.

Critical Analysis of Interventional Research Designs to Promote Coping in Pediatric Patients

PURPOSE

The purpose of this article is to analyze the strengths and limitations of research designs of studies implementing coping based training interventions in adolescents.

METHODS

Quantitative and mixed methods studies were selected and reviewed for critical analysis of strengths, limitations, and validity concerns.

RESULTS

Methodological strengths and weaknesses were assessed. The major limitation to the studies reviewed is selection bias in both quasi-experimental studies and randomized controlled trials.

PRACTICE IMPLICATIONS

Improved coping strategies and skills were found in participants of coping skill training intervention programs. Decreased depressive symptoms and less impact of individual disease burden was found in the treatment intervention groups.

Human Dignity in Paediatrics: The Effects of Health Care

Human dignity is grounded in basic human attributes such as life and self-respect. When people cannot stand up for themselves they may lose their dignity towards themselves and others. The aim of this study was to elucidate if dignity remains intact for family members during care procedures in a children’s hospital. A qualitative approach was adopted, using open non-participation observation. The findings indicate that dignity remains intact in family-centred care where all concerned parties encourage each other in a collaborative relationship. Dignity is shattered when practitioners care from their own perspective without seeing the individual in front of them. When there is a break in care, family members can restore their dignity because the interruption helps them to master their emotions. Family members’ dignity is shattered and remains damaged when they are emotionally overwhelmed; they surrender themselves to practitioners’ care, losing their self-esteem and self-respect.

Needs of Young Children With Cancer During Their Initial Hospitalization: An Observational Study

The aim of this study was to describe young (under the age of 7) children’s needs as expressed by their behavior, body language and verbal expression through observations during their initial hospitalization after being diagnosed with cancer. Twelve children under the age of seven were followed during 26 hours with non-participant unstructured observations. Field notes were written after each observation and transcribed into a narrative text, which was analyzed by content analysis at both manifest and latent level. Five themes were identified, of which “need to have the parent close by” was the most prominent. The other themes were “need to play and feel joy,” “need for participation in care and treatment,” “need for a good relationship with the staff,” and “need for physical and emotional satisfaction.” The results indicate that the children needed their parents and the parents’ presence helped the children to express other needs. Professionals need to support the child and his or her parents so that the parents in their turn can support and alleviate their child’s hospitalization and cancer treatment.

Parental Involvement and Family-Centered Care in the Diagnostic and Treatment Phases of Childhood Cancer: Results from a Qualitative Study

Few research studies have addressed the ways parents participate in their childs medical care, particularly in relation to the cancer experience. The purpose of this study was to explore parents descriptions of their participation in medical care for their children with cancer. For this study, seven focus groups were conducted with 45 parents of 26 children who had completed cancer treatment at least one year prior, and who were still alive. Data were coded using thematic analysis procedures. It was found that parents emphasized their role as advocates during the diagnosis and treatment phases, by informing themselves about their childrens medical conditions, making medical care decisions, limiting the actions of medical professionals, and affirming and supporting medical professionals. These results emphasize the need to employ a family-centered approach in cancer care medical settings, by fostering and supporting the active inclusion of parents in their child’s treatment and management.

Interventions to Improve Safe Sleep Among Hospitalized Infants at Eight Children's Hospitals

BACKGROUND AND OBJECTIVES

Within hospital pediatric units, there is a lack of consistent application or modeling of the American Academy of Pediatrics recommendations for safe infant sleep. The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

METHODS

This multi-institutional study was conducted by using baseline observations collected for sleep location, position, and environment (collectively, "safe sleep") of infants admitted to pediatric units. Interventions consisted of: (1) staff education, including a commitment to promote safe sleep; (2) implementing site-generated safe sleep policies; (3) designating supply storage in patient rooms; and/or (4) caregiver education. Postintervention observations of safe sleep were collected. Eight hospitals participated from the Inpatient FOCUS Group of the Children's Hospital Association. Each site received institutional review board approval/exemption.

RESULTS

Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

CONCLUSIONS

Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment. Moving forward, hospitals should evaluate their compliance with American Academy of Pediatrics recommendations and embrace initiatives to improve modeling of safe sleep.

Expressive Arts Therapy with Hospitalized Children: A Pilot Study of Co-Creating Healing Sock Creatures©

A novel form of expressive arts therapy was developed in a pediatric unit and received enthusiastic support from hospital staff and family members because of their impressions that the children were calmer following therapy, as well as throughout the remainder of the hospital stay. A pilot study was conducted to assess the feasibility of quantifying such impressions by measuring changes in the children's mood by self-report. Twenty-five children (mean age 8.34 years, SD 3.77) were recruited for the study, coming from diverse social-economic backgrounds, ethnicities, and an array of medical diagnoses. The results document improvements in mood for children following therapy sessions, compared to children in a wait-list control group. Additionally, a meta-analysis examining external influences and changes in salivary cortisol levels measured before and after therapy sessions illustrates the importance of considering aspects of the clinical setting when assessing the effectiveness of this and other expressive arts therapies for reducing stress during hospitalization.

Turkish Nurses' Use of Nonpharmacological Methods for Relieving Children's Postoperative Pain

CONTEXT

The experience of pain is frequently observed among children undergoing surgery. Hospitalization and surgery are stressful experiences for those children.

OBJECTIVE

The research was conducted to investigate and analyze Turkish nurses' use of nonpharmacological methods to relieve postoperative pain in children.

DESIGN

The study was cross-sectional and descriptive.

SETTING

The study took place at 2 hospitals in eastern Turkey.

PARTICIPANTS

Participants were 143 nurses whose patients had undergone surgical procedures at the 2 hospitals.

OUTCOME MEASURES

The researchers used a questionnaire, a checklist of nonpharmacological methods, and a visual analogue scale (VAS) to collect the data. To assess the data, descriptive statistics and the χ² test were used.

RESULTS

Of the 143 nurses, 73.4% initially had applied medication when the children had pain. Most of the nurses (58.7%) stated the children generally experienced a middle level of postoperative pain. The most frequent practices that the nurses applied after the children's surgery were (1) "providing verbal encouragement" (90.2%), a cognitive-behavioral method; (2) "a change in the child's position" (85.3%), a physical method; (3) "touch" (82.5%), a method of emotional support; and (4) "ventilation of the room" (79.7%), a regulation of the surroundings. Compared with participants with other educational levels, the cognitive-behavioral methods were the ones most commonly used by the more educated nurses (P < .05): (1) encouraging patients with rewards, (2) helping them think happy thoughts, (3) helping them use their imaginations, (4) providing music, and (5) reading books. Female nurses used the following methods more than the male nurses did (P < .05): (1) providing encouragement with rewards, (2) helping patients with deep breathing, (3) keeping a desired item beside them, (4) changing their positions, and (5) ventilating the room.

CONCLUSION

Undergoing surgery is generally a painful experience for children. Nurses most commonly use cognitive-behavioral methods in the postoperative care of their pediatric patients after surgery.