Introduce yourself, and ask the name of each family member who is present. Address parents or other adults by their appropriate titles, such as “Mr.” and “Mrs.,” unless they specify a preferred name. Record the preferred name on the medical record. Using formal address or their preferred names, rather than using first names or “mother” or “father,” conveys respect and regard for the parents or other caregivers (Seidel, Ball, Dains, et al., 2011).

At the beginning of the visit, include children in the interaction by asking them their name, age, and other information. Nurses often direct all questions to adults, even when children are old enough to speak for themselves. This only terminates one extremely valuable source of information: the patient. When including the child, follow the general rules for communicating with children given in the Guidelines box on p. 775.

Assurance of Privacy and Confidentiality

The place where the nurse conducts the interview is almost as important as the interview itself. The physical environment should allow for as much privacy as possible, with distractions, such as interruptions, noise, or other visible activity, kept to a minimum. At times it is necessary to turn off a television, radio, or cellular telephone. The environment should also have some play provision for young children to keep them occupied during the parent-nurse interview (Fig. 29-1). Parents who are constantly interrupted by their children are unable to concentrate fully and tend to give brief answers to finish the interview as quickly as possible.

Confidentiality is another essential component of the initial phase of the interview. Because the interview is usually shared with other members of the health care team or the teacher (in the case of students), be certain to inform the family of the limits regarding confidentiality. If confidentiality is a concern in a particular situation, such as when talking to a parent suspected of child abuse or a teenager contemplating suicide, deal with this directly and inform the person that in such instances confidentiality cannot be ensured. However, the nurse judiciously protects information of a confidential nature.

Computer Privacy and Applications in Nursing

The use of computer technology to store and retrieve health information has become widespread. The health care community is increasingly concerned about the privacy and security of this health information. Any person accessing confidential health information is charged with managing safeguards for disclosure, since violations might incur civil damages.

Many institutions use computer and information applications in nursing (nursing informatics), such as electronic medical records, to record care and access information. Two important health care applications are (1) record transmission, including online access, fax, and e-mail; and (2) telemedicine. The telemedicine application is capable of two-way video conferencing, transmission of radiographs, and clinical consultation between remote sites and centralized resources.*

Telephone Triage and Counseling

Nurses are increasingly responsible for assessing children’s symptoms and applying clinical judgment for further medical care (triage) via telephone report. Most often, health problems are assessed and prioritized according to urgency and nurses provide treatment via telephone services. A well-designed telephone triage program is essential for safe, prompt, and consistent quality health care (Beaulieu and Humphreys, 2008; Marklund, Ström, Månsson, et al., 2007). Telephone triage is more than “just a phone call,” since a child’s life is a high price to pay for poorly managed or incompetent telephone assessment skills. Typically, guidelines for telephone triage include asking screening questions; determining when to immediately refer to emergency medical services (dial 911); and determining when to refer to same-day appointments, appointments in 24 to 72 hours, appointments in 4 days or more, or home care (Box 29-1). Successful outcomes are based on the consistency and accuracy of the information provided. Telephone triage care management has increased access to high-quality health care services and empowered parents to participate in their child’s medical care. Consequently, patient satisfaction has significantly improved. Unnecessary emergency department and clinic visits have decreased, saving medical costs and time (with less absence from work) for families in need of health care.

Encouraging the Parents to Talk

Interviewing parents not only offers the opportunity to determine the child’s health and developmental status but also offers information about factors that influence the child’s life. Whatever the parent sees as a problem should be a concern of the nurse. These problems are not always easy to identify. Nurses need to be alert for clues and signals by which a parent communicates worries and anxieties. Careful phrasing with broad, open-ended questions such as “What is Jimmy eating now?” provides more information than several single-answer questions, such as “Is Jimmy eating what the rest of the family eats?”

Sometimes the parent will take the lead without prompting. At other times it may be necessary to direct another question on the basis of an observation, such as “Connie seems unhappy today” or “How do you feel when David cries?” If the parent appears to be tired or distraught, consider asking “What do you do to relax?” or “What help do you have with the children?” A comment such as “You handle the baby very well. What kind of experience have you had with babies?” to new parents who appear comfortable with their first child gives positive reinforcement and provides an opening for questions they might have on the infant’s care. Often all that is required to keep parents talking is a nod or saying “yes” or “uh-huh.”

Directing the Focus

Directing the focus of the interview while allowing maximum freedom of expression is one of the most difficult goals in effective communication. One approach is the use of open-ended or broad questions, followed by guiding statements. For example, if the parent proceeds to list the other children by name, say, “Tell me their ages, too.” If the parent continues to describe each child in depth, which is not the purpose of the interview, redirect the focus by stating, “Let’s talk about the other children later. You were beginning to tell me about Paul’s activities at school.” This approach conveys interest in the other children but focuses the assessment on the patient.

Listening and Cultural Awareness

Listening is the most important component of effective communication. When the purpose of listening is to understand the person being interviewed, it is an active process that requires concentration and attention to all aspects of the conversation—verbal, nonverbal, and abstract. Major blocks to listening are environmental distraction and premature judgment.

Although it is necessary to make some preliminary judgments, listen with as much objectivity as possible by clarifying meanings and attempting to see the situation from the parent’s point of view. Effective interviewers consciously control their reactions, responses, and the techniques they use (see Cultural Competence box).

Careful listening relies on the use of clues, verbal leads, or signals from the interviewee to move the interview along. Frequent references to an area of concern, repetition of certain key words, or a special emphasis on something or someone serves as a cue to the interviewer for the direction of inquiry. Concerns and anxieties are often mentioned in a casual, offhand manner. Even though they are casual, they are important and deserve careful scrutiny to identify problem areas. For example, a parent who is concerned about a child’s habit of bed-wetting may casually mention that the child’s bed was “wet this morning.”

Using Silence

Silence as a response is often one of the most difficult interviewing techniques to learn. The interviewer requires a sense of confidence and comfort to allow the interviewee space in which to think without interruptions. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. Silence can also be a cue for the interviewer to go more slowly, reexamine the approach, and not push too hard (Seidel, Ball, Dains, et al., 2011).

Sometimes it is necessary to break the silence and reopen communication. Do this in a way that encourages the person to continue talking about what is considered important. Breaking a silence by introducing a new topic or by prolonged talking essentially terminates the interviewee’s opportunity to use the silence. Suggestions for breaking the silence include statements such as “Is there anything else you wish to say?” “I see you find it difficult to continue; how may I help?” or “I don’t know what this silence means. Perhaps there is something you would like to put into words but find difficult to say.”

Being Empathic

Empathy is the capacity to understand what another person is experiencing from within that person’s frame of reference; it is often described as the ability to put oneself in another’s shoes. The essence of empathic interaction is accurate understanding of another’s feelings (Mathiasen, 2006). Empathy differs from sympathy, which is having feelings or emotions similar to those of another person, rather than understanding those feelings (Mathiasen, 2006).

Providing Anticipatory Guidance

The ideal way to handle a situation is to deal with it before it becomes a problem. The best preventive measure is anticipatory guidance. Traditionally, anticipatory guidance focused on providing families information on normal growth and development and nurturing childrearing practices. For example, one of the most significant areas in pediatrics is injury prevention. Beginning prenatally, parents need specific instructions on home safety. Because of the child’s maturing developmental skills, parents must implement home safety changes early to minimize risks to the child.

Unprepared parents can be disturbed by many normal developmental changes, such as a toddler’s diminished appetite, negativism, altered sleeping patterns, and anxiety toward strangers. The chapters on health promotion provide the nurse information for counseling parents. However, anticipatory guidance should extend beyond giving general information during brief visits to empowering families to use the information as a means of building competence in their parenting abilities (Magar, Dabova-Missova, and Gjerdingen, 2006). To achieve this level of anticipatory guidance, the nurse should:

Avoiding Blocks to Communication

A number of blocks to communication can adversely affect the quality of the helping relationship. The interviewer introduces many of these blocks, such as giving unrestricted advice or forming prejudged conclusions. Another type of block occurs primarily with the interviewees and concerns information overload. When individuals receive too much information or information that is overwhelming, they often demonstrate signs of increasing anxiety or decreasing attention. Such signals should alert the interviewer to give less information or to clarify what has been said. Box 29-2 lists some of the more common blocks to communication, including signs of information overload.

The nurse can correct communication blocks by careful analysis of the interview process. One of the best methods for improving interviewing skills is audiotape or videotape feedback. With supervision and guidance, the interviewer can recognize the blocks and consciously avoid them.

Communicating with Families Through an Interpreter

Sometimes communication is impossible because two people speak different languages. In this case it is necessary to obtain information through a third party, the interpreter. When using an interpreter, the nurse follows the same interviewing guidelines. Specific guidelines for using an adult interpreter are given in the Guidelines box.

Communicating with families through an interpreter requires sensitivity to cultural, legal, and ethical considerations (see Cultural Competence box). For example, in some cultures, using a child as an interpreter is considered an insult to an adult because children are expected to show respect by not questioning their elders. In some cultures, class differences between the interpreter and the family may cause the family to feel intimidated and less inclined to offer information. Therefore it is important to choose the translator carefully and provide time for the interpreter and family to establish rapport.

Legal and ethical concerns may also arise. For example, in obtaining informed consent through an interpreter, the nurse should fully inform the family of all aspects of the particular procedure to which they are consenting. Issues of confidentiality may arise when family members related to another patient are asked to interpret for the family, thus revealing sensitive information that may be shared with other families on the unit. With increased sensitivity toward patient rights and confidentiality, many institutions now require consent forms produced in the patient’s primary language.

Communicating with Children

Although the greatest amount of verbal communication is usually carried out with the parent, do not exclude the child during the interview. Pay attention to infants and younger children through play or by occasionally directing questions or remarks to them. Include older children as active participants.

In communication with children of all ages, the nonverbal components of the communication process convey the most significant messages. It is difficult to disguise feelings, attitudes, and anxiety when relating to children. They are alert to surroundings and attach meaning to every gesture and move that is made; this is particularly true of very young children.

Active attempts to make friends with children before they have had an opportunity to evaluate an unfamiliar person tend to increase their anxiety. Continue to talk to the child and parent but go about activities that do not involve the child directly, thus allowing the child to observe from a safe position. If the child has a special toy or doll, “talk” to the doll first. Ask simple questions such as “Does your teddy bear have a name?” to ease the child into conversation. Other guidelines for communicating with children are in the Guidelines box. Specific guidelines for preparing children for procedures, a common nursing function, are in Chapter 39.

 Guidelines

Communicating with Children

• Allow children time to feel comfortable.

• Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as threatening.

• Talk to the parent if child is initially shy.

• Communicate through transition objects such as dolls, puppets, and stuffed animals before questioning a young child directly.

• Give older children the opportunity to talk without the parents present.

• Assume a position that is at eye level with child (Fig. 29-2).

• Speak in a quiet, unhurried, and confident voice.

• Speak clearly, be specific, and use simple words and short sentences.

• State directions and suggestions positively.

• Offer a choice only when one exists.

• Be honest with children.

• Allow them to express their concerns and fears.

• Use a variety of communication techniques.

Communication Related to Development of Thought Processes

The normal development of language and thought offers a frame of reference for communicating with children. Thought processes progress from sensorimotor to perceptual to concrete and finally to abstract, formal operations. An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication (Box 29-3).

Box 29-3

Characteristics of Communicative Development in Young Children

Perlocutionary Stage (0 to 8-9 Months)

• Child is reflexive to stimuli.

• Child shows increasing purpose in action.

Emerging Illocutionary Stage (8-9 to 12-15 Months)

• Child communicates intentionally with signals and gestures.

Conventional Illocutionary–Emerging Locutionary Stage (12-15 to 18-24 Months)

• Child communicates intentionally with gestures, vocalizations, and verbalizations.

Adapted from Hoge DR, Parette HP: Facilitating communicative development in young children with disabilities, Transdisc J 5(2):113–130, 1995.

Infancy.

Because they are unable to use words, infants primarily use and understand nonverbal communication. Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Adults interpret this to mean that an infant needs something and consequently try to alleviate the discomfort and reduce tension. Crying (or the desire to cry) persists as a part of everyone’s communication repertoire.

Infants respond to adults’ nonverbal behaviors. They become quiet when they are cuddled, patted, or receive other forms of gentle physical contact. They receive comfort from the sound of a voice, even though they do not understand the words that are spoken. Until infants reach the age at which they experience stranger anxiety, they readily respond to any firm, gentle handling and quiet, calm speech. Loud, harsh sounds and sudden movements are frightening.

Early Childhood.

Children younger than 5 years are egocentric. They see things only in relation to themselves and from their point of view. Therefore focus communication on them. Tell them what they can do or how they will feel. Experiences of others are of no interest to them. It is futile to use another child’s experience in an attempt to gain the cooperation of small children. Allow them to touch and examine articles they will come in contact with. A stethoscope bell will feel cold; palpating a neck might tickle. Although they have not yet acquired sufficient language skills to express their feelings and wants, toddlers can effectively use their hands to communicate ideas without words. They push an unwanted object away, pull another person to show them something, point, and cover the mouth that is saying something they do not wish to hear.

Everything is direct and concrete to small children. They are unable to work with abstractions and interpret words literally. Analogies escape them because they are unable to separate fact from fantasy. For example, they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” or “coughing your head off.” Children who are told they will get “a little stick in the arm” may not be able to envision an injection (Fig. 29-3). Therefore avoid using a phrase that might be misinterpreted by a small child.

School-Age Years.

Younger school-age children rely less on what they see and more on what they know when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. For example, to explain a procedure such as taking blood pressure, show the child how squeezing the bulb pushes air into the cuff and makes the “silver” in the tube go up. Let the child operate the bulb. An explanation for the procedure might be as simple as “I want to see how far the silver goes up when the cuff squeezes your arm.” Consequently, the child becomes an enthusiastic participant.

School-age children have a heightened concern about body integrity. Because of the special importance they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of treasured objects. Helping children voice their concerns enables the nurse to provide reassurance and to implement activities that reduce their anxiety. For example, if a shy child dislikes being the center of attention, ignore that particular child by talking and relating to other children in the family or group. When children feel more comfortable, they will usually interject personal ideas, feelings, and interpretations of events.

Adolescence.

As children move into adolescence, they fluctuate between child and adult thinking and behavior. They are riding a current that is moving them rapidly toward a maturity that may be beyond their coping ability. Therefore when tensions rise, they may seek the security of the more familiar and comfortable expectations of childhood. Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently, and encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes is common. It is as much a mistake to regard the adolescent as an adult with an adult’s wisdom and control as it is to assume that the teenager has the concerns and expectations of a child.

Interviewing the adolescent presents some special issues. The first may be whether to talk with the adolescent alone or with the adolescent and parents together. Of course, if the parent is not there, the only question is whether to suggest to the teenager that the parents be interviewed at another time. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the interpersonal relationship. However, talking with the parents initially may provide insight into the family relationship. In either case, give both parties an opportunity to be included in the interview. If time is limited, such as during history taking, clarify this at the onset to avoid appearing to “take sides” by talking more with one person than with the other.

Confidentiality is of great importance when interviewing adolescents. Explain to parents and teenagers the limits of confidentiality, specifically that young persons’ disclosures will not be shared unless they indicate a need for intervention, as in the case of suicidal behavior.

Another dilemma in interviewing adolescents is that two views of a problem frequently exist—the teenager’s and the parents’. Clarification of the problem is a major task. However, providing both parties an opportunity to discuss their perceptions in an open and unbiased atmosphere can, by itself, be therapeutic. Demonstrating positive communication skills can help families communicate more effectively (see Guidelines box).

 Guidelines

Communicating with Adolescents

Build a Foundation	Communicate Effectively
• Spend time together. • Encourage expression of ideas and feelings. • Respect their views. • Tolerate differences. • Praise good points. • Respect their privacy. • Set a good example.	• Give undivided attention. • Listen, listen, listen. • Be courteous, calm, and open minded. • Try not to overreact. If you do, take a break. • Avoid judging or criticizing. • Avoid the “third degree” of continuous questioning. • Choose important issues when taking a stand. • After taking a stand: • Think through all options. • Make expectations clear.

Communication Techniques

Nurses use a variety of verbal techniques to encourage communication. Some of these techniques are useful to pose questions or explore concerns in a less threatening manner. Others can be presented as word games, which are often well received by children. However, for many children and adults, talking about feelings is difficult and verbal communication may be more stressful than supportive. In such instances, use several nonverbal techniques to encourage communication.

Box 29-4 describes both verbal and nonverbal techniques. Because of the importance of play in communicating with children, play is discussed more extensively in the section that follows. Any of the verbal or nonverbal techniques can give rise to strong feelings that surface unexpectedly. Be prepared to handle them or to recognize when issues go beyond your ability to deal with them. At that point, consider an appropriate referral.

Box 29-4   Creative Communication Techniques with Children

Verbal Techniques

“I” Messages

• Relate a feeling about a behavior in terms of “I.”

• Describe effect behavior had on the person.

• Avoid use of “you.”

• “You” messages are judgmental and provoke defensiveness.

Example—“You” message: “You are being uncooperative about doing your treatments.”

Example—“I” message: “I am concerned about how the treatments are going because I want to see you get better.”

Third-Person Technique

• Express a feeling in terms of a third person (“he,” “she,” “they”). This is less threatening than directly asking children how they feel because it gives them an opportunity to agree or disagree without being defensive.

Example—“Sometimes when a person is sick a lot, he feels angry and sad because he cannot do what others can.” Either wait silently for a response or encourage a reply with a statement such as “Did you ever feel that way?”

• This approach allows children three choices: (1) to agree and, one hopes, express how they feel; (2) to disagree; or (3) to remain silent, which means they probably have such feelings but are unable to express them at this time.

Facilitative Response

• Listen carefully and reflect back to patients the feelings and content of their statements.

• Responses are empathic and nonjudgmental and legitimize the person’s feelings.

• Formula for facilitative responses: “You feel ____________ because ____________.”

Example—If child states, “I hate coming to the hospital and getting needles,” a facilitative response is, “You feel unhappy because of all the things that are done to you.”

Storytelling

• Use the language of children to probe into areas of their thinking while bypassing conscious inhibitions or fears.

• The simplest technique is asking children to relate a story about an event, such as “being in the hospital.”

• Other approaches:

• Show children a picture of a particular event, such as a child in a hospital with other people in the room, and ask them to describe the scene.

• Cut out comic strips, remove words, and have child add statements for scenes.

Mutual Storytelling

• Reveal child’s thinking and attempt to change child’s perceptions or fears by retelling a somewhat different story (more therapeutic approach than storytelling).

• Begin by asking child to tell a story about something, and then tell another story that is similar to child’s tale but with differences that help child in problem areas.

Example—Child’s story is about going to the hospital and never seeing his or her parents again. Nurse’s story is also about a child (using different names but similar circumstances) in a hospital whose parents visit every day, but in the evening after work, until the child is better and goes home with them.

Bibliotherapy

• Use books in a therapeutic and supportive process.

• Provide children with an opportunity to explore an event that is similar to their own but sufficiently different to allow them to distance themselves from it and remain in control.

• General guidelines for using bibliotherapy are:

1. Assess child’s emotional and cognitive development in terms of readiness to understand the book’s message.

2. Be familiar with the book’s content (intended message or purpose) and the age for which it is written.

3. Read the book to the child if child is unable to read.

4. Explore the meaning of the book with the child by having child:

Retell the story

Read a special section with the nurse or parent

Draw a picture related to the story and discuss the drawing

Talk about the characters

Summarize the moral or meaning of the story

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