Instructions on use of this template: Please remove this slide (slide 1) prior to use. This PowerPoint was created by child life specialists on the Child Life Council’s Professional Resources Committee as a resource for use by professionals in the field. It may be used to educate multidisciplinary team members and students in your practice. You may use it “as is,” or you may customize it by adding graphics or photos, selecting only a subset of slides, or integrating some of the slides into your own presentation, as appropriate for your audience. Please include the next slide (slide 2) in your presentation, either at the beginning, or end. Please refer to the speaker notes included with each slide, these are rich in detail!

Our Thanks to: The Child Life Council’s Professional Resources Committee, who provided the template to help in the creation of this presentation for our audience.

Communicating with Patients and Families in the Medical Setting

Communication: Why is it Important? Communicating with children can present significant challenges. It is always important to be honest with children and provide accurate information, but health care workers need to remember that children’s cognitive abilities and communication skills are developing. Gaynard, L., Wolfer, J., Golberger, J., Thompson, R., Redburn, L., & Laidley, L. (1998) Psychosocial Care of Children In Hospitals: a Clinical Practice Manual from the ACCH Child Life Research Project. Rockville, MD: Child Life Council.

It Takes Two to Communicate Communication is an interaction between at least two people. Both verbal and nonverbal cues can contribute to the overall understanding of the message. Context, symbolic language, and confusion can also affect understanding. Klinzing, D. G., & Klinzing, D. R. (2009) Communication and Child Life. In Thompson, R. H. (E.D.) The handbook of child life: A guide for pediatric psychosocial care (pp 80-84). Springfield, Ill: Charles C. Thomas.

“Health team members need to take the time , and have the skills, to talk with children and family members in an effective and supportive manner. They need to try to understand how children are receiving, interpreting, and applying new information.” Gaynard, L., Wolfer, J., Golberger, J., Thompson, R., Redburn, L., & Laidley, L. (1998) Psychosocial Care of Children In Hospitals: a Clinical Practice Manual from the ACCH Child Life Research Project. Rockville, MD: Child Life Council.

Important Factors for Communicating in the Health Care Setting Use language that conveys respect and enhances integrity and self-worth. Non-verbal communication can unintentionally alter the impact of the message. Offer a choice only when a choice is possible. Message delivery greatly impacts how it is received. Use pronouns accurately. This slide is meant to introduce the idea of communicating with children in the health care setting. This might be a good opportunity to encourage group participation in regards to definitions for the terms. While there is no right answer, it is important to emphasize development and how it can hinder or enhance communication. E.g. For rehab patient, consider the difference between: “I will feed you now” versus “I'm ready to help you eat your lunch” Aspects of non-verbal communication: physical appearance, clothing, facial expression, gaze, gestures, touch Delivery: tone, speed, eye level, space E.g. “It is time to take your medicine” rather than “Do you want to take your medicine now?” Avoid the use of “we,” “our” or “us” when the speaker actually means “you,” “I,” or “me” e.g. “It’s time for you to take your bath” rather than “It’s time for us to take our bath now” Gaynard, L., Wolfer, J., Golberger, J., Thompson, R., Redburn, L., & Laidley, L. (1998) Psychosocial Care of Children In Hospitals: a Clinical Practice Manual from the ACCH Child Life Research Project. Rockville, MD: Child Life Council. Klinzing, D. G., & Klinzing, D. R. (2009) Communication and Child Life. In Thompson, R. H. (E.D.) The handbook of child life: A guide for pediatric psychosocial care (pp. 85-93). Springfield, Ill: Charles C. Thomas.

Important Factors in Communicating in the Health Care Setting Be responsive and follow the lead of children and family members. Use positive directions whenever possible. Consider developmental level. Use minimally threatening language. This slide is meant to introduce the idea of communicating with children in the health care setting. This might be a good opportunity to encourage group participation in regards to definitions for the terms. While there is no right answer, it is important to emphasize development and how it can hinder or enhance communication. Ask questions to elicit their perceptions and understanding. Telling children what they can do rather than what they shouldn’t do gives them helpful information about the desired behaviors, while communicating respect. The use of “don’t” tends to convey a negative, punitive message. E.g. Consider “You can think of your favorite places and things to do, as you help keep your head still to get a good picture” vs “don’t move” 3. Consider what is relevant to the developmental level of the child. Is the child between 2-4 years old and determined to do things independently and in their own way? Offer that child as many available choices as possible. Is the child developmentally 8 years old and learning about following rules and problem solving? Give that child stress point preparation that follows the sequence of events and give the child a role or “job.” During a procedure or she might also like a challenge (e.g. You and the child alternate naming items from a category that go through the alphabet), as game playing with peers is relevant at this age. 4. Accurate sensory information should be given to children without increasing their stress level e.g. surgical incision can be described as “making as small opening” rather than “cut,” “hole,” or “slice”; avoid term “hurt” – you might say “some kids say it feels like a “pinch” or “sting” and some kids say they don’t feel it at all. Afterwards, will you tell us how it felt for you?” Gaynard, L., Wolfer, J., Golberger, J., Thompson, R., Redburn, L., & Laidley, L. (1998) Psychosocial Care of Children In Hospitals: a Clinical Practice Manual from the ACCH Child Life Research Project. Rockville, MD: Child Life Council.

Person First Language Person first language stresses the importance of not using a diagnosis to define a person, as a diagnosis is just one characteristic of his or her identity. It is important, as professionals, to show patients and families that we value them, not the diagnosis. Missouri Department of Mental Health. (2007, June 1). Philosophy & values: People first language – disability etiquette. Retrieved from http://dmh.mo.gov/docs/dd/A05PeopleFirstLang.pdf. The citation above does an excellent job explaining person first language if you need a better understanding.

Examples of Person First Language Say… Rather than… “The girl has diabetes” “The diabetic girl” “The boy has down syndrome” “The down syndrome boy” “The child who uses a wheelchair” “The handicapped child”

Choosing Words for Effective Communication Many words can have different meanings. This is especially true of medical jargon. Most patients and families are not “fluent” in hospital speak. Words that the patient and/or family might understand differently should be explained. Dye (contrast) or Die Stool collection CAT scan Be sure to add some examples of easily misunderstood language to help your participants gain a better understanding of how to think through language choices. Additional examples: Potentially ambiguous  clearer Dressing or dressing change  bandages; clean, new bandages Urine  pee Put you to sleep  give medicine that will help you go into a very deep sleep; you won’t feel anything until the operation is over; then the doctor will stop giving you the medicine, so you can wake up. Special or funny  odd; different; strange; unusual

Terminology to be mindful of… “Red Blood Count” “Benign” The next two slides you can have fun with and customize to your audience. What every 8 year old wants to be… Count Dracula

Terminology to be mindful of… “CAT Scan” “Stool Sample”

Developmental Considerations for Effective Communication

Infants in the Hospital Birth – 12months In the hospital environment, infant patients might experience: Some responses infants might display are: Failure to bond Separation Distrust Anxiety Lack of stimulation Delayed skill development Pain Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Communicating with Infants & Parents Maximize parental involvement and information. Speak directly facing, and close to, infant. Respond to infant’s non-verbal and verbal cues. Additional key points to speak to: Continuously assess parental understanding and coping. Lower parental anxiety will allow for a more optimal healing environment for the patient and family. Minimize number of caregivers and attempt to have consistent primary caregivers, whenever possible. Use simple sensory language during interactions. Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Toddlers in the Hospital 12 months – 36 months Toddler patients might experience: Separation Forced regression Loss of routine and rituals Some reposes toddlers might display are: Uncooperativeness Protest Despair Additional key points to address to keep the audience engaged (and not just reading everything from the slides): In the hospital environment, toddler patients might experience: Fear of bodily injury, pain Some reposes toddlers might display are: Negativism Tantrums Resistance Regression Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Communicating with Toddlers Use simple, concrete language. Use sensory information the child can relate to. Preparation should be hands on, including play and medical equipment. Provide choices whenever possible. Remember to use specific examples of procedures from your unit when addressing these slides. Tell, show, do Tell the child who you are and what you are going to do Show the child using a doll, stuffed animal or a caregiver Finally do exactly what you said you were going to do Concept of Time Concept of time is abstract Time is understood in terms of before and after Allow toddler time to move from one task to the next, lowering desire to resist Script examples: “This will take less time than singing the ABCs” or “This will take about as long as one episode of Dora” Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Preschoolers in the Hospital 3 years – 5 years Preschool patients might experience: Separation Fear of loss of control, sense of own power Dependency Some responses preschoolers might display are: Regression Despair and detachment Physical and verbal aggression Additional key points to address to keep the audience engaged (and not just reading everything from the slides): In the hospital setting, preschool patients might experience: Fear of bodily mutilation or penetration by surgery or injections, castrations Withdrawal Some responses preschoolers might display are: Acting out Protest Anger toward primary caregiver Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Communicating with Preschoolers Use the “tell, show, do” bedside approach. Recognize understanding of time is still developing. Sequence of events Model honest communication “Magical thinking”- e.g. thoughts caused illness Remember to use specific examples of procedures from your unit when addressing these slides. Use simple, concrete language Concept of time is gradually progressing. Use appropriate time descriptors (e.g. before, after; if, then; first, second). Time is defined by recognizable events and symbols. Words to describe time are often still mixed up at this stage. 3-4 year olds learn time through normal routines and have typically mastered before and after concept. 5-6 year olds are beginning to understand that certain events happen at defined times each day. While these kindergarteners understand before and after, they don’t completely understand length or quantity of time (e.g. they may honestly ask if people really live to be 60 years old). Sensory Information Review information related to all five sensory systems when providing preparation. Sequence of events Breaking down the medical experience (or requirements for getting them home) in steps. Predictability gives children a greater sense of control over their situation. Allows children to gage progress of the experience. Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

School-Aged Children in the Hospital 5 years – 12 years School-aged children might experience: Fear of loss of control Fear of loss of mastery Fear of bodily mutilation Some responses school-aged children might display are: Regression Withdrawal Depression Frustration Additional key points to address to keep the audience engaged (and not just reading everything from the slides): In the hospital environment, school-aged children might experience: separation Fear of bodily injury and pain, especially intrusive procedures in genital area Fear of illness itself, disability and death Some responses school-aged children might display are: Displaced anger and hostility Uncooperativeness Inability to complete some tasks Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Communication with School-Aged Children Ensure preparation for, and involvement in, procedures. Help children recognize aspects of their effective coping. Be sure to define unfamiliar hospital terminology. Additional key points: Offer appropriate choices when available. Continue to assess their understanding. School aged-children benefit from hands-on exploration and learning (e.g. loose parts medical play) in order to process their medical experience. Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc. (Chapter 1).

Adolescents in the Hospital 12 years – 18 years Adolescent patients might experience: Dependence on adults Separation from family and peers Fear of bodily injury and pain Some responses adolescent patients might display are: Uncooperativeness Withdrawal Anxiety Depression Additional key points to address to keep the audience engaged (and not just reading everything from the slides): In the hospital environment, adolescent patients might experience: Fear of loss of identity Concern about body imagine and sexuality Concern about peer group status after hospitalization Some responses adolescent patients might display are: Uncooperativeness Anger or frustration towards parents/caregivers Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc.

Communicating with Adolescents Communicate honestly. Provide privacy during intimate conversations. Involve patient in care and decisions. Address long-term issues. Additional Key Points: Respect independence (choices). Discuss potential psychological changes and physical responses. Provide opportunity for follow up discussion and guidance, as needed. Offer adolescent patients the opportunity to speak with health care providers without caregiver present. Rollins, J. A. (2005). Children’s Hospitalization and Other Health-Care Encounters. J. A. Rollins, R. Bolig, & C.C. Mahan (Eds.), Meeting Children’s Psychosocial Needs Across the Health Care Continuum. Austin, TX: Pro-Ed, Inc. (Chapter 1).

Communicating with Patients and Families During Health care Encounters

the provision of developmentally appropriate information; “More than 50 years of research and experience support 3 key elements of the preparation process: the provision of developmentally appropriate information; (2) the encouragement of questions and emotional expression; and (3) the formation of a trusting relationship with a health care professional.” American Academy of Pediatrics Committee on Hospital Care & Child Life Council. (2014). Child Life Services. Pediatrics, 133, e1471-e1478.

Language During Preparation Honesty Clarification of words that the child might not understand Appropriate Choices Adaptability Many of these points have already been made in the developmental slides. Adaptability within the realm of communication is important for all health care professionals, but especially when providing education and preparation to patients and families. Continuous assessment of whether the information being provided is beneficial or is heightening anxiety help the speaker in determining if modifications in language need to be made to match the patient or parent’s developmental level, abilities or sensitivities. For example, some teenagers might be receptive to learning about an upcoming procedure, but as you begin to provide stress-point preparation their affect changes and you see a shift in their coping. Rather than continuing on, consider asking the patient how they are feeling, taking a break, or changing the dialogue to focus solely on coping techniques. Klinzing, D. G., & Klinzing, D. R. (2009) Communication and Child Life. In Thompson, R. H. (E.D.) The handbook of child life: A guide for pediatric psychosocial care (pp 80). Springfield, Ill: Charles C. Thomas.

Language During Procedures Use behavior-specific verbal praise. Limit number of voices. Remember to offer appropriate choices. Avoid using the word “sorry.” It is important to highlight these important aspects of procedures. Staff should know that offering specific verbal praise is the most beneficial during procedures, but it always important to praise the effort that child puts forth. Examples of behavior-specific praise might include: “Good job keeping your arm still” or “Nice job trying to work on taking slow breaths.” Limiting the number of voices can help keep the room calm and avoid staff talking at the same time in an effort to calm a screaming child. As child life specialists, we know the power of appropriate choices. You might find it helpful to offer examples to your audience (ie: are you ready for the IV? vs. Would you like to take your pills with water or sprite). Another note, on saying sorry, we each have a job to do and we need to remember that the family has come to the hospital for help. You might want to facilitate a discussion on appropriate ways to say sorry.

Language Throughout the Day Be mindful to clarify words that the child might not understand. Always incorporate choices built into the day to empower the child. Continue to assess the child’s understanding. Clarification – (e.g. “taking vitals” is something the nurse or doctor will do every hour to check how your body is feeling. S/he will listen to your heart and give your arm a hug with this) Offer choices throughout the day (during exams; while encouraging PO intake, walks, medicine; activities) to offer child a sense of control. Assess the child’s understanding – (e.g. “can you tell me what the doctor is going to do to fix your arm?”)

Communicating Across Cultures It is imporant to remember that different cultures have different styles and norms around communication. Always remember when using an interpreter to look at the family. Siblings should not be expected to translate. Educate yourself on different cultures that are often served at your facility

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