Chapter 2 Communicating with children
INTRODUCTION
Communication is the giving or exchange of information, ideas, or feelings. It is a two-way process where one person sends a message to another who receives it. Since the skills of communication are acquired from early infancy onward, the practitioner may feel that they are competent in this area without studying the subject further. However, poor communication is the basis of many formal complaints about healthcare Healthcare Commission for Audit and Inspection (2007) (online) and working with the child often provides particular challenges related to the child’s ability to understand information and to verbalise their concerns. The practitioner is required to ensure that the language and communication needs of the children in their care are met in a way that the child can understand (NMC 2008). This requirement is a central feature of the ‘Essential Care Clusters’ (NMC 2007). Consequently, this chapter will focus upon the interpersonal skills needed for working effectively with children.
Effective interpersonal skills not only ensure that the practitioners meet their professional responsibilities; they ensure many benefits for the child. In any setting, a skilled communicator gives the child a role model which facilitates their socialisation, their ability to communicate with others and to work cooperatively in groups (Bellman & Peile 2006). Skilled communication should enable the practitioner to recognise at an early stage when the child is unwell, has a developmental delay or is developing a disability, and facilitate interventions to minimise severity and complications (Hall & Elliman 2007).
Where the child becomes unwell, the practitioner can help them to understand their illness, enabling them to cope with any resulting treatment (Scott et al 2007), adhere to a therapeutic regime (Wales & Crisp 2007) and where appropriate, assist early discharge and care delivery in the home setting (Department of Health 2003a, Scott et al 2007). In some instances, the practitioner can facilitate discussion about issues which affect the health of the young person or causes worry but cannot be discussed with parents or carers for some reason (Department of Health 2003b, Duderstadt 2006).
THE KEY ASPECTS OF COMMUNICATION
VERBAL COMMUNICATION
Verbal communication is the use of words, spoken or signed, to convey information.
Practitioners are much more likely to give information to parents than to children (Pantell et al 1982) but they need to bear in mind that the child is their patient. The child’s best interest must come first (Children’s Act 1989), so it is important that the practitioner establishes a comfortable working relationship with the child. Most children would find it distressing and anxiety provoking to be ignored by someone who may then subject them to embarrassing or physical intrusive care. Such distress may cause the child to resist care delivery and/or leave them with anxieties, phobias and behavioural problems (Platt Report 1959). It may reduce the child’s ability or desire to cooperate with healthcare providers in the future.
The effective practitioner needs to:
Begin the interaction
in a warm, comfortable environment which will let the child relax quickly into their surroundings. Giving age appropriate toys and games often help this process but avoid using electronic games, radio or television, as the child can become absorbed in such activities and will be difficult to engage. Where the practitioner is unknown to the child, she or he should introduce themselves and establish the child’s preferred name. The practitioner should always explain what is going to be talked about and/or will happen. Jamieson (2006) suggests that young children often have a greater understanding of what is said to them than is realised because language comprehension usually exceeds the ability to verbalise thoughts. However, children who are anxious, unwell or have a short concentration span can be difficult to engage in meaningful interaction. So, where the child’s communication abilities are unknown, it is better to use simple words and short sentences until it is certain the child can manage more complex information.
Initially, it can be helpful to focus on the parent, leaving the child to become relaxed and orientated. The watching child will usually find this interaction reassuring and a signal that they can safely join in when invited to do so (Hockenberry & Wilson 2007).
Once the practitioner begins to talk to the child, it is usually helpful to move from the least private or intrusive issue to more sensitive topics or intimate care giving (Duderstadt 2006). The practitioner needs to sound calm, confident and unhurried.
Gather information
using a number of techniques including measurement, and observation, but the spoken component should give the child the chance to give their opinion and make their expectations clear (Carter 2007).
The use of questions is a common method of showing interest, seeking consent for care delivery and extending or collecting information (Box 2.1). There are many types of questions but the practitioner working with children may find that there are three types which are most useful:
Gain a focus
which can be established using directional phrases. These comments highlight something the child has said and tells them more information would be beneficial (Schuster 2000), e.g. ‘You said that you don’t like using the school toilets, why is that?’ or ‘Can you tell me more about your school. What are the toilets like?’.
Try to ensure a common understanding
about the purpose of any interaction. Children and practitioners have been shown to have differing conclusions about the role of communication and a satisfactory resolution to discussion. Practitioners often consider emotional support and therapeutic intervention to be the most important element of their role while the child places importance on practical support and expects the professional to ensure that their wishes are met (Macleod 2006). Ignoring these differing expectations can adversely affect the child/practitioner relationship.
Use supportive comments and compliments
to which children often respond and give constructive feedback. Information given in this way lets them know when they are doing well (Csoti 2001). This technique lets them feel a sense of approval and validation for appropriate actions, e.g. ‘It’s really good to see you choosing the healthy food option on the menu.’ It is often more effective than being critical (Green 2000).
Emphasise important points,
as children often lack the experience to know what is most relevant and appropriate. When something is important, they should be told (Green 2001). Use expressions such as ‘this is really important’; ‘you must always remember to …’.
Tangible rewards
reinforce positive feedback, rewarding effort and commitment. Bravery certificates, badges and fridge magnets might be offered (Green 2000).
Use silence,
Use silence sparingly because it can give the child time to organise their thoughts, describe their feelings and/or formulate questions (Hockenberry & Wilson 2007). The practitioner needs to sit quietly letting the child take the lead. However, the silence should not be allowed to become oppressive or threatening (Stanton 2004). The practitioner needs to recognise when the child’s silence is a sign that they do not want to talk at all. Children may find it hard to explain their discomfort or feel it is impolite to voice their preference. Generally, children are expected to respond to adult priorities. Signs that the silence is counterproductive may include the child fidgeting, changing the topic or introducing a distraction. They may look bored. Older children might look at their watch or at a clock (Hockenberry & Wilson 2007).
Finish the interaction clearly
to tell the child the discussion is complete. But ensure that the child’s questions have been answered; repeat anything that they are unsure about, recap any decisions made and actions to be taken (Thomas & Monaghan 2007).
NON-VERBAL COMMUNICATION
This is a form of communication without words although it does include vocal expression such as tone, pitch and pace of speech (Stanton 2004). Facial expression, hand gestures, body position and movement contribute to this aspect of communication (Hogg & Vaughen 2008). Bruce (2004) suggests that these non-verbal actions convey about 80% of any message.
Children learn non-verbal techniques more quickly than speech (Bruce 2006). Small children may use non-verbal signals to demonstrate many of their needs and to interpret the intentions and behaviours of others. This discussion introduces some of the main features of non-verbal techniques but further reading will be needed for expert practice, particularly when working with children from ethnic minority backgrounds. Some non-verbal signals vary in their meaning between cultures (Csoti 2001).
The practitioner needs to consider these aspects of their communication technique carefully to ensure that the non-verbal message conveyed is consistent with their speech and with what is happening to the child (Hockenberry & Wilson 2007).
Facial expression
enables most individuals to monitor the feelings and moods of others. It probably conveys to the child the most non-verbal information (Schuster 2000). Therefore, it is important that the practitioner looks calm, approachable and relaxed. They should try to ensure that expressions of shock, worry and discomfort are not evident even in difficult or challenging situations.
Gaze –
generally we look at the person talking to us, look away when we start to speak and then look back again when we are about to stop talking (Wainwright 2003). This signals to the other person that we are ready to listen to them. This pattern regulates social interaction, signifying interest and friendliness. Even young babies will show this pattern of eye contact (Bruce 2006). However, children may avoid eye contact if they are shy or uncomfortable. The practitioner should try to delay conversation until the child has relaxed.
Active listening
demonstrates that the practitioner is interested in what the child is saying. It requires concentration on the verbal and non-verbal messages the child is giving (Carter 2007). The practitioner may demonstrate they are listening by maintaining eye contact and nodding. They may use brief prompts, e.g. ‘mmm’ and ‘uh-huh’ (Hogg & Vaughen 2008) or reflective comment (Thomas & Monaghan 2007). This involves repeating a few words of the child’s, e.g. ‘my tummy hurts and I want some medicine’ becomes ‘some medicine?’
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