Establish Trust and Provide Support.

The nurse who has spent time with and established a positive relationship with a child usually finds it easier to gain cooperation. If the relationship is based on trust, the child associates the nurse with caregiving activities that give comfort and pleasure most of the time rather than discomfort and stress. If the nurse does not know the child, it is best for he or she to be introduced by another staff person whom the child trusts. The first visit with the child should not include any painful procedure and ideally should focus on the child first and then on an explanation of the procedure.

Parental Presence and Support.

Children need support during procedures, and for young children the greatest source of support is the parents. They represent security, protection, safety, and comfort. Several studies have reported a positive impact on parental distress and satisfaction and no difference in technical complications when parents remain with children (Piira, Sugiura, Champion, et al., 2005). Controversy exists regarding the role parents should assume during the procedure, especially if discomfort is involved. Several professional associations support the option of family presence during invasive procedures (American Association of Critical Care Nurses, 2006; Emergency Nurses Association, 2005). The nurse should assess the parents’ preferences for assisting, observing, or waiting outside the room and the child’s preference for parental presence. Respect the child’s and parents’ choices. Give parents who wish to stay appropriate explanation about the procedure and coach them about where to sit or stand and what to say or do to help the child through it. Support parents who do not want to be present in their decision and encourage them to remain close by so they can be available to support the child immediately after the procedure. Parents should also know that someone will be with their child to provide support. Ideally this person should inform the parents after the procedure about how the child did.

Provide an Explanation.

Age-appropriate explanations are one of the most widely used interventions for reducing anxiety in children undergoing procedures. Before performing a procedure, explain what is to be done and what is expected of the child. The explanation should be short, simple, and appropriate to the child’s level of comprehension. Long explanations may increase anxiety in a young child. When explaining the procedure to parents with the child present, the nurse uses language appropriate to the child because unfamiliar words can be misunderstood (Table 39-1). If the parents need additional preparation, it is done in an area away from the child. Teaching sessions are planned at times most conducive to the child’s learning (e.g., after a rest period) and for the usual span of attention.

Special equipment is not necessary for preparing a child; but for young children who cannot yet think conceptually, using objects to supplement verbal explanation is important. Allowing children to handle actual items that will be used in their care such as a stethoscope, sphygmomanometer, or oxygen mask helps them develop familiarity with these items and reduces the fear often associated with their use. Miniature versions of hospital items such as gurneys and x-ray and intravenous (IV) equipment can be used to explain what the children can expect and permit them to safely experience situations that are unfamiliar and potentially frightening. Use photographs of children in different areas of the hospital (e.g., radiology department, operating room) to give children a more realistic idea of equipment they may encounter. Written and illustrated materials are also valuable aids to preparation.*

Expect Success.

Nurses who approach children with confidence and convey the impression that they expect to be successful are less likely to encounter difficulty. It is best to approach a child as though cooperation is expected. Children sense anxiety and uncertainty in an adult and respond by striking out or actively resisting. Although it is not possible to eliminate such behavior in every child, a firm approach with a positive attitude tends to convey a feeling of security to most children.

Involve the Child.

Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. However, a choice is given only in situations in which one is available. Asking children, “Do you want to take your medicine now?” leads them to believe that they have an option and provides them the opportunity to legitimately refuse or delay the medication. This places the nurse in an awkward, if not impossible, position. It is much better to state firmly, “It’s time to drink your medicine now.” Children usually like to make choices, but the choice must be one that they do indeed have (e.g., “It’s time for your medicine. Do you want to drink it plain or with a little water?”).

Many children respond to tactics that appeal to their maturity or courage. This also gives them a sense of participation and achievement. For example, preschool children are proud that they can hold the dressing during the procedure or remove the tape. The same is true for school-age children, who often cooperate with minimal resistance.

Provide Distraction.

Distraction is a powerful coping strategy during painful procedures (Uman, Chambers, McGrath, et al., 2006). It is accomplished by focusing the child’s attention on something other than the procedure. Singing favorite songs, listening to music with a headset, counting aloud, or blowing bubbles to “blow the hurt away” are effective techniques. (For other nonpharmacologic interventions, see Chapter 30.)

Allow Expression of Feelings.

The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. It is natural for children to strike out in frustration or try to avoid stress-provoking situations. The child needs to know that it is all right to cry. Behavior is children’s primary means of communication, and coping and should be permitted unless it inflicts harm on them or those caring for them.

Encourage Expression of Feelings.

Planned activity after the procedure is helpful in encouraging constructive expression of feelings. For verbal children reviewing the details of the procedure can clarify misconceptions and garner feedback for improving the nurse’s preparatory strategies. Play is an excellent activity for all children. Infants and young children should have the opportunity for gross motor movement. Older children are able to vent their anger and frustration in acceptable pounding or throwing activities. Play-Doh is a remarkably versatile medium for pounding and shaping. Dramatic play provides an outlet for anger and places the child in a position of control in contrast to the position of helplessness in the real situation. Puppets also allow the child to communicate feelings in a nonthreatening way. One of the most effective interventions is therapeutic play, which includes well-supervised activities such as permitting the child to give an injection to a doll or stuffed toy to reduce the stress of injections (Fig. 39-1).

Positive Reinforcement.

Children need to hear from adults that they did the best they could in the situation, no matter how they behaved. It is important for them to know that their worth is not being judged on the basis of their behavior in a stressful situation. Reward systems such as earning stars, stickers, or a badge of courage are appealing to children.

Returning to the child a short while after the procedure helps the nurse strengthen a supportive relationship. Relating with the child in a relaxed and nonstressful period allows him or her to see the nurse not only as someone associated with stressful situations but also as someone with whom to share pleasurable experiences.