273CHAPTER 23
Developmental Assessment and Communication With Pediatric Patients and Their Families
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Pediatric clinical experiences can cause considerable anxiety for the undergraduate nursing student, primarily because of fear of making a mistake that could harm a child (Oermann & Lukomski, 2001). The lack of confidence in developing relationships with families is common, especially in situations in which families observe student assessments and interactions with their children. Students have concerns about including parents in the assessment process and doubt their ability to answer parent questions. Earlier experience with children does little to minimize the insecurity surrounding the examination of and communication with a sick child as their response is often unpredictable.
Simulation can help to decrease students’ anxiety and provide them with the opportunity to gain the clinical knowledge and skill required to confidently enter the clinical setting (Megel et al., 2012). In order to support our students learning, we developed three pediatric clinical scenarios using children of different stages of growth and development and used this simulated experience to replace a 7.5-hour clinical day.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The School of Health Studies at the University of the Fraser Valley (UFV) houses four dedicated medium- and high-fidelity simulation rooms, three single suites, and one two-bed suite. An advanced software program provides live viewing of the simulated learning event to the debriefing room. This software is equipped with annotated playback capabilities to highlight key learning opportunities during the simulated event. The human patient simulators (HPSs) include one high-fidelity adult, two medium-fidelity adults, one medium-fidelity child, and one medium-fidelity baby.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Learning Objectives
The objectives of this learning activity are to incorporate developmentally appropriate care into the assessment of children; to understand the unique communication needs of each age group; and to engage with family members to provide safe, atraumatic care to children.
274The simulation day was designed for students in the second year of the BSN program as an orientation to the clinical experience. Many of these students have very little experience with children and no experience in caring for the hospitalized child.
Student Learning Activities
1. Review assessment and communication strategies for:
an infant presenting with poor feeding
a preschooler admitted with dehydration
an adolescent with type 1 diabetes
2. Review communication strategies with different family forms in the acute care setting
D. INTRODUCTION OF SCENARIO
Setting the Scene
All three scenarios occur in the acute pediatric care setting of a regional hospital. Each child requires hospitalization but none are acutely ill; each has family members at the bedside.
Technology Used
Medium-fidelity human patient simulators are used for all three scenarios. The simulators include an infant simulator (for the infant scenario), a child (for the preschool child), and an adult (for the adolescent patient). Live-feed equipment for video-recording is helpful but not necessary.
The focus of the three scenarios is communication, so standardized patients could be used for both the patient and the family member.
Objectives
1. Discuss the role of the family when caring for an infant, preschool child, and adolescent.
2. Discuss developmentally appropriate strategies when communicating with an infant, preschool child, and adolescent in a health care setting.
3. Demonstrate communication with the family during infant, preschool child, and adolescent assessment using relational nursing practice.
4. Demonstrate a head-to-toe assessment of an infant, preschool child, and adolescent using atraumatic care and developmentally appropriate communication and assessment strategies.
E. RUNNING OF THE SCENARIO
Students have reviewed the learning activities before arrival. The briefing session includes a review of the objectives, the student confidentiality agreement, the expectation of professionalism, and the use of constructive feedback. It should last about 30 minutes. The challenges of realism in the simulated environment, as opposed to a real-life, active, verbal child, should be discussed. Time should also be provided for an orientation to the simulation suite, patient-care planning, questions, and a description of participant roles (Exhibits 23.1 and 23.2).
Exhibit 23.1 Description of Participants
Infant | Emily Sarah Smith is 2 months old. She was brought to the hospital because her mother felt that she was not her usual self; she had been lethargic and was not feeding well. Emily’s mother is in a common-law relationship with Emily’s father. Both have very busy careers and rely on Emily’s grandmother to provide care. |
Preschool child | Noah Eric Jones is age 5 years. He was admitted because of moderate dehydration following a tonsillectomy 5 days earlier. Before the procedure, he had recurrent tonsillitis, but according to his aunt was otherwise healthy. Noah has lived with his aunt since he was 2 years old, as neither parent could care for him. There are five other children in the household and the aunt is single. |
Adolescent | Melissa Jane Steward, age 14 years, was admitted 2 days ago because of hyperglycemia and ketonuria. She was first diagnosed with type 1 diabetes when she was 6 years old and her condition has been managed well until 6 months ago. This is her second admission in 6 months for the same condition. Melissa’s blood sugars are now stable and she is preparing for discharge. Her parents, who separated recently, are both present. |
Exhibit 23.2 Outline of Scenarios
Infant scenario | The infant is lying quietly in her crib when the students enter the room. The students should communicate with the mother and grandmother and complete an across-the-room assessment of the child. Emily’s grandmother verbalizes that there is nothing wrong with the infant. Emily’s mother should look visibly upset, tired, and annoyed with the grandmother. The students will do a physiological assessment of the child and will find nothing abnormal. The students should try to get to the heart of the family conflict. If they do, they will discover that Emily’s mother feels guilty about not spending enough time with her child because of the necessity of full-time work and her inability to breastfeed. Emily’s mother is also concerned about her own mother’s health and ability to care for Emily. Emily’s grandmother thinks her daughter should resign from her job to care for her child. If the students cannot facilitate a family conversation they should ask about the grandma’s comfort level and find a seat for her in a different room. This will demonstrate their ability to prioritize whose concerns take precedence and give them an opportunity to listen to Emily’s mother’s story without interruption. |
Preschool child scenario | The preschool child is sitting in a hospital bed. His aunt is sitting in a chair at his bedside checking messages on her phone. Noah should have a teddy bear and a coloring book. The students should comment on the teddy bear after they have introduced themselves. The students should assess his pain choosing a developmentally appropriate scale, administer an analgesic, encourage fluid intake, and link poor oral intake and subsequent dehydration to painful tonsil beds. The aunt, who is very distracted by her phone, should be drawn into the conversation. Unknown to the students, the aunt is trying to arrange day care for her other children. She asks the students, several times, whether she can leave, and wants to know how long it will be before Noah is discharged. |
Adolescent scenario | The students should introduce themselves to the patient and then the family. They should start to establish a therapeutic relationship with the family and discuss the possibility of involving social work because of the frequency of hospitalizations in the past 6 months. When doing the assessment, they should ask the adolescent whether she would like the family to remain in the room. The students will need to consider the developmental needs of the adolescent and determine how to support her in her illness journey. The focus of this simulation is on listening and challenging stereotypes. |
276The students start with the adolescent scenario, followed by the preschool child scenario, and close the day with the infant scenario. If there is time, students can repeat the scenario of their choice.
F. PRESENTATION OF COMPLETED TEMPLATE
All scenarios should be used with second-year BSN students and all are focused on pediatrics and family care (Exhibit 23.3).
Exhibit 23.3 Scenario Template for All Three Pediatric Scenarios
Infant scenario | Preschool-Age Scenario | Adolescent Scenario |
Shift report: Patient woke every 4 to 5 hours for feeds. Tylenol was given at 6 a.m. for a temperature of 39.0°C. Mom and Grandma are at the bedside. Emily last fed at 6 a.m. | Shift report: Patient did not sleep well. Around-the-clock Tylenol was given for pain. The last dose was given at 4 a.m. Noah’s aunt is at the bedside. Encourage fluids today. | Shift report: Patient slept well. Mom spent the night. Patient ready to be discharged. Discuss social work referral with the patient and her family. |
Patient: Emily Sarah Smith Age: 2 months Allergies: No known allergies Weight: 5 kg Last vitals: BP: 75/45 mmHg, HR: 100 beats/minute, RR: 35 breaths/minute, Temp: 39.0°C, O2 saturation: 98% on room air | Patient: Noah Eric Jones Age: 5 years Allergies: No known allergies Weight: 15 kg Last vitals: BP: 90/55 mmHg, HR: 75 beats/minute, RR: 26 breaths/minute, Temp: 37.1°C, O2 saturation: 99% on room air, pain 5/10 | Patient: Melissa Jane Steward Age: 14 years Allergies: Penicillin and cats Weight: 45 kg Last vitals: BP: 105/60 mmHg, HR: 60 beats/minute, RR: 16 breaths/minute, Temp: 37.0°C, O2 saturation: 100% on room air |
Medical history: Previously healthy. Admitted because mother felt her infant was lethargic, had a decreased appetite, and was warm to touch. | Medical history: Dehydration following tonsillectomy. Before the removal of tonsils, Noah experienced frequent colds and would snore loudly at night. He appears to be small for his age. | Medical history: Diagnosed with type 1 diabetes at 6 years of age; has been admitted twice in the past 6 months for hyperglycemia and ketonuria. Before these admissions, she managed her chronic illness very well. She attends the diabetic outpatient clinic. |
Family/social history: Emily’s parents are in a common-law relationship. Both work shifts; her father is a paramedic and her mother is a police officer. Emily is their first child and was born just after her mother graduated from the police academy Emily’s mother did not qualify for maternity leave, so the couple relies heavily on Emily’s grandmother for child care. | Family/social history: Noah has lived with his aunt since he was 2 years old. His aunt is a single parent who has five of her own children. His mother is homeless and addicted to drugs and is only allowed to have supervised visits with him. The identity of his father is unknown. Noah loves to watch TV, has started kindergarten, and gets along very well with his cousins. He is enrolled in soccer this year. | Family/social history: Melissa’s parents have recently separated and do not get along. Her father has a new girlfriend and Melissa and her mother are struggling with this. She has two sisters, aged 10 and 12 years. She was an “A” student and a member of the school band, but since the separation of her parents her grades have started to slip and she has become moody. She is not managing her diabetes well. |
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