Communicating With Children

Communicating with Children: Age-Related Techniques Communicating with the child is essential for promoting effective coping and facilitating nursing care. Special sensitivity to the child's developmental needs and cognitive ability is necessary. Children are highly sensitive to both verbal and nonverbal means of communication and internalize their personal interpretations of communicated messages. They are normally not as likely to share their interpretations unless prompted by an adult, thus placing the bulk of the responsibility for effective communication on the nurse. Nursing Diagnoses Impaired verbal communication related to developmental level, language, physiologic or cultural barriers; Fear or anxiety related to unmet informational needs about or changes in health status, or threat to self-concept. Steps Assessment 1. Identify nature of the child's diagnosis and prognosis.

2. Determine the child's age and developmental level (see Table 1, Age-Related Communication Needs).

3. Determine presence of developmental or perceptual disorders (e.g., developmental delay, deafness). 4. Assess family's basic value system and other culturally prescribed determinants of communication (see Guidelines box, Culturally Sensitive Interactions, text p. 109).

5. Determine need for an interpreter (see Guidelines box, Using an Interpreter, text p. 111). 6. Consider readiness for communication, e.g., the ability to focus thoughts. 7. Determine past medical events and experiences with professionals. 8. Determine purpose of communication (e.g., to elicit information, to provide information, to offer psychosocial support, to prepare the child for an event, or to build rapport). 9. Assess personal feelings and attitudes about the child/family.

Rationale This information provides a basis for predicting feelings the child may be experiencing and the type of information that needs to be communicated. Age and developmental level influence factors such as word selection, complexity, and approach. Younger children are more concrete in their communication, whereas adolescents can think abstractly.

Developmental or perceptual disorders may influence or alter the communication process. The more the family's value orientation is understood, the greater the probability communication will be appropriate and responsive to the family's and child's needs. Culture can affect communication patterns and word meanings. For example, in Native American and some Asian cultures, direct eye-to-eye contact is considered disrespectful. When the nurse and child/family speak different languages, an interpreter facilitates communication. In a crisis situation or when in a state of fear or denial, the child may not be able to listen. Children’s past experiences with medical professionals may have an effect (either positively or negatively) on communication. Communication with the child is an ongoing process. Determining the purpose of each communicative encounter guides selection of techniques and choice of communication setting. Feelings and attitudes are easily communicated to the child and family nonverbally. The appropriate person to interact with the child is someone who is capable of communicating positive feelings and attitudes. If this is

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not possible for the caregiver, reassignment should be strongly considered. Planning and Goal Setting 1. Choose where communication will occur.

2. Select an appropriate time, considering factors such as timing, readiness, and the child's schedule. 3. Develop a nursing goal of care: To engage in an accurate and communicative exchange. To establish open communication. To establish a therapeutic relationship. Implementation 1. Communicate a caring attitude toward the child.

a. When speaking to the child, use his or her name. b. Speak directly to the child at eye level.

c. Touch the child (e.g., pat the child on the arm or hand, touch his or her shoulder, or hold the infant). d. Handle the child and speak in a gentle and loving manner. e. Attend to responses of the child, especially when performing procedures. Allow enough time for the child to complete a statement or ask a question. f. Convey the recognition of the uniqueness and individuality of the child, e.g., refer to a special endearing characteristic of the child. 2. Be an empathetic listener. a. Active listening (e.g., "It sounds like you are concerned that you won't be able to use your hand after

Much communication occurs during the routine course of the day. However, if the purpose of the communication demands privacy, a quiet room may be more appropriate. Special Considerations: If play materials are to be used, the playroom may be the most appropriate setting. A consideration of such factors offers the greatest possibility for successful communication.

Providing communication with a caring attitude establishes a safe emotional environment in which trust can develop. Nonverbally, a statement is made that this child is lovable and that all children are worthy of being loved regardless of appearance, behavior, or life situation. If there is a conflict between verbal and nonverbal communication, the nonverbal communication will commonly be believed above the verbal. Using a child’s name demonstrates value for and appreciation of individual uniqueness. Special Considerations: Avoid extended eye contact, which can be uncomfortable to some children. Also a child may be distrustful of a new face with a too broad smile, or of an overly friendly manner.

Special Considerations: Touch must be used judiciously, considering readiness and cultural factors.

Empathetic listening facilitates establishment of a trusting relationship. An active listener demonstrates interest and concern about what the listener perceives is important to the

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the surgery"). b. Reflective listening (e.g., "Are you saying you think your blood might all come out if you have an IV?"). 3. Provide opportunity for ventilation of feelings and acknowledge feelings expressed. If the child is unable to express feelings verbally, use play to encourage selfexpression (see Skill, Therapeutic Play, Unit VIII).

4. Use silence when appropriate.

5. Communicate as honestly and as accurately as possible. a. Give accurate information. Tell the child if the information is a guess. b. Offer to get answers; locate information when necessary. c. Use terms the child understands; explain medical terms when used. d. Use visual aids, e.g., charts, drawings, or models to promote accuracy. 6. Observe for blocks to communication (see Box 6-2, Blocks to Communication, text p. 110). 7. Allow time for questions, both at the time and later. Provide paper and pen or pencil.

8. Convey sincerity. a. When choosing phrases of comfort or support.

b.

When sharing private information about self.

9. Use humor when appropriate.

10. Use a variety of communication methods (see Box 64, Creative Communication Techniques for Children, text pp. 115-116). Evaluation Outcomes 1. Communication is effective.

person. A reflective listener rephrases what was said for clarification. When the child ventilates feelings, he or she is able to cope more effectively. Young children especially have difficulty expressing feelings and need an adult to help name their feelings. A child learns it is acceptable to feel/express emotions when an adult acknowledges the feelings. A quiet presence can communicate caring and concern. A common misconception is that something needs to be said to be therapeutic. Honest, accurate communication facilitates trust and establishes safe parameters in which concerns and questions can be aired.

Blocks have an adverse effect on the communication process. Absorbing information is a process. Additional questions may surface after the passage of time and the opportunity for reflection. With paper and pen or pencil, questions can be written down in order to remember to ask them at a later time. Phrases such as "I understand" are of no value unless the person saying it has truly been in that situation. Furthermore, most situations are viewed as unique, and such a statement may provoke well-deserved anger. Special Considerations: Use of the third person could be more effective, e.g., "Other children in your situation have told me they felt very helpless. Is that how you're feeling right now?" Traditionally, personal disclosure was discouraged. A more open approach is advocated today. However, relating private information should have a purpose. Validation of feelings through personal experience can prove very supportive to the child. Sharing humor invites those present to come a little closer. Humor provides a common ground to soften cultural and economic barriers. Using a variety of communication techniques may elicit a more effective response. Observational Guidelines Techniques of therapeutic communication are employed. The child communicates and interacts in a comfortable manner. Needed information is exchanged.

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2. The child communicates needs and fears.

The child asks questions and expresses fears in a developmentally appropriate manner.

Documentation Document significant conversations with the child on his or her chart. Use direct quotes as much as possible. Describe the child's response to the use of specific techniques. TABLE 1 Age-Related Communication Needs Developmental Stage Developmental Communication Guidelines Infants Infants communicate primarily nonverbally and by vocalizing, e.g., crying. Parents are best able to discriminate differences in meaning of their infant’s cry. Sounds that were familiar in utero tend to calm the infant, e.g., music or singing. Gentle touching, cuddling, patting, and light bouncing are comforting to the infant, as well as a soft, low calm voice.

Toddler to 5 years

Smile at the infant and respond to his or her cues. Approach the infant slowly because sudden movements may be frightening. Play pat-a-cake, peek-a-boo, or “this little piggy” with the child. Duplicate the parental style of holding the child. If style is unknown, hold the child in an upright manner. Keep the mother in the infant’s view. Preschoolers have limited verbal communication, therefore they continue to rely heavily on nonverbal communication. Kneel to look at the child at eye level when speaking. Touch the child gently on the shoulder to gain attention. Introduce yourself in terms the child can understand. Show interest in the child, e.g., ask about a toy in the child’s hand or comment on his or her appearance. Speak to the child in familiar terms, e.g., use the family term for urination. Provide positive reinforcement through words and tangible objects, e.g., say “I like the way you are sitting in that chair,” or “Your mommy and I are talking right now. If you Copyright © 2006 by Elsevier, Inc.

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6 to 12 years

Adolescents

continue to play quietly until we are finished, you can play with my favorite puppet.” Use short, concrete descriptions and terms. If it is essential to communicate more than one statement at a time, pause briefly between sentences or at the end of phrases to allow time for the child to grasp the information. Avoid words/phrases with literal and figurative meaning, e.g., “coughing your head off” or “a little stick in the arm.” Respect the child’s ability to animate inanimate objects, taking care not to dehumanize toys. Use play to project feelings and gain information. Use communication techniques of third person, therapeutic responding, storytelling, bibliotherapy, “what if” questions, and three wishes. Allow the child to sit on the lap of the parent or nurse or beside him or her, if the child desires. Repeat explanations several times if the child has not grasped the content. When possible, couple explanations of objects with a child-sized replica of the object or with simple fantasy play. Answer persistent “why” questions with pleasant but short answers. Explain how things might feel in simple terms. Give the child a name for what he or she seems to be feeling, e.g., “You look upset right now.” Use humor. Laugh when the child sees humor in a situation; make funny faces, imitate, or tickle the child in an appropriate manner. Set limits firmly, but gently, in a nonaccusatory manner. Reward acceptable behavior, e.g., “The toys are not to be thrown. Sit here beside me right now. When you are calm, you may play with the toys again.” Younger school-age children desire explanations. They are better able to grasp the information they seek. When providing answers to questions, give the how, when, where, and why as the child requests. Use humor by laughing at things the child finds humorous, telling simple jokes and riddles, making funny faces, and using dramatizations. Use simple role play, therapeutic play, three wishes, “what if” questions, bibliotherapy, and storytelling. Allow fearful children to sit with parents. If the parents desire, ask them to perform the activity/explanation. Allow the child to participate at his or her own pace. Adolescents communicate most often in verbal form and develop a “language” that is shared by their peers; ask for clarification of terms, if needed. Use adolescent terms in moderation. Because of the adolescent’s fluctuating emotions and behavior, communication may be adult-like one moment and childlike the next. Anticipate shifts in communication by using a variety of techniques: third person technique, bibliotherapy, storytelling, “what if” questions, three wishes, rating game, word association game, sentence completion, pros and cons, writing, and drawing. Use humor by taking advantage of funny events that happen, telling jokes and riddles, listening to the adolescent’s jokes, or watching a funny video. Play a board game or card game with an adolescent to facilitate discussion. Express a nonjudgmental attitude by not reacting to issues that differ with personal values. Adolescents may at one time reveal feelings and at another be silent. Attend to conversations without interruption and avoid comments that are value-laden. Remain aware of developmental issues that the adolescent may wish to talk about, e.g., peer relationships, sexuality, parental relationships, and identity concerns. Decide whether to talk with the adolescent and parents together or separately; when possible, communicate directly with the adolescent and retain confidentiality. Inform the adolescent of limits to confidentiality, e.g., if the adolescent would have suicidal or homicidal ideations. Assist with resolution of conflicts with parents by role playing assertive communication, arbitrating a family meeting, or brainstorming solutions. Copyright © 2006 by Elsevier, Inc.

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From Smith D et al: Comprehensive child and family nursing skills, St Louis, 1991, Mosby. Modified from Wong D, Whaley L: Clinical manual of pediatric nursing, ed 3, St Louis, 1990, Mosby.

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