Nursing Hospitalized Children: Barriers to Care

Hospitalized children often experience pain and anxiety, which can dramatically affect their well-being and often delay healing. This can result in long term effects such as post-traumatic stress disorder, often causing decreased intellectual and social capacities and decreased immune function (Zengerle-Levy, 2006).

Because hospitalization can cause substantial long term negative effect in children, both physically and psychologically, it is important for nurses to be knowledgeable of these effects, and be educated on techniques they can utilize to help ease the pain and anxiety children feel during hospitalization. Strategies nurses can use include teaching the child guided imagery techniques, establishing and maintaining a sense of trust with the child, and using specific therapeutic techniques to provide comfort and spiritual support to the child.
Acute pain causes a release of “fight or flight" stress hormones. These stress hormones cause a breakdown of body tissues, as well as an increase in heart rate and blood pressure. The end result is a strain on the immune system, which can complicate the effects of injury and slow down recovery (Zengerle-Levy, 2006). Most children do not become used to repeated painful procedures over time. In fact, their anxiety can increase and they may respond with much more negative behavior when faced with a repeated painful event. If procedural pain is not well managed during the first instance of a procedure, children can develop increased anxiety about the next time they face this or similar procedures. Such increased anxiety leads to greater pain intensity, which may make the management of pain relief medications more challenging (Zengerle-Levy, 2006).
Several studies have shown how nurses can utilize different techniques to improve a child’s experience while hospitalized. Guided imagery is a technique where the imagination is used to focus on an object or a scene in order to help relieve stress of pain, and promote relaxation. It is a way of communicating with the autonomic nervous system, the part of the nervous system that regulates many involuntary body functions, such as heart rate, blood pressure and digestion. A study conducted at Cincinnati Children’s Hospital Medical Center found that nurses who taught guided imagery techniques to hospitalized children significantly reduced postoperative pain and anxiety in children (Childers, 2004). Children can be very imaginative, which allows for this technique to be very successful. According to several of the nursing staff, the use of guided imagery with children increased the effectiveness of pain medications, elevated immune functioning and lessened anxiety and depression they were experiencing (Childers, 2004).
Another method nurses can use to help hospitalized children was discovered as the result of over 112 hours of interviews and 134 hours of observation with sixteen nurses in a pediatric burn intensive care unit (Zengerle-Levy, 2006). This data was grouped into four distinct categories. The first category involves being a “parent-minded nurse” (Zengerle-Levy, 2006). Nurses would care for the hospitalized child in the same way they would want their own child to be cared for. This involved providing unconditional love to the children and using storytelling techniques to explain procedures or answer questions. Another category was described as “sustaining human connections,” which involved establishing a relationship with the child (Zengerle-Levy, 2006). The nurses would use the power of touch, play music or videos to soothe the children. They would also talk to children that were unconscious to help them feel comforted and safe. The third category nurses used when caring for hospitalized children was described as “receiving the patient as a child” (Zengerle-Levy, 2006). Nurses would make sure to incorporate play and humor when interacting with children, which would lift their spirits and give them a way to express fear (Dowling, 2002). They also expressed the importance of realistic expectations when it came to caring for the children. The final category nurses described was “renewing the spirit of the child” (Zengerle-Levy, 2006). This involved providing spiritual support for the children who felt that God had abandoned them. The nurses would talk to the children and help them to find meaning or purpose in life, which would establish hope in their minds
A third strategy nurses can use when caring for hospitalized children involves establishing trust in a series of four distinct phases. Research conducted by the Tasmanian School of Nursing in Australia examined these phases and how they impacted the nurse-child relationship (Crole & Smith, 2002). The first phase is described as “the introduction phase” (Crole & Smith, 2002). This involves establishing initial contact with the child and his/her family by talking about favorite toys or television shows, which allowed the child to talk with the nurse about something other than their illness. The second phase is defined as “the building trusting relationships phase” (Crole & Smith, 2002). This is achieved by using child appropriate language and preparation for procedures. The nurses would also use games and play to help reduce stress the child may be feeling. The third phase is “the decision-making phase” (Crole & Smith, 2002). Nurses gave children some control over their care by allowing them to participate in making certain decisions. This is critical to maintaining trust between the nurse and child. The final phase is “the comfort and reassurance phase” (Crole & Smith, 2002). Children can often hold nurses responsible for pain and trauma they may be feeling. It is important for the nurse to re-establish trust with the child by praising and comforting him or her after a painful procedure. Providing comfort to the child has also been shown to improve health seeking behaviors and positive outcomes overall (Kolcaba & DiMarco, 2005).
In conclusion, pain and anxiety can cause many problems in hospitalized children, both short and long term. Acute pain can affect how quickly tissues heal, as well as impact a child’s long-term psychological health. Providing care to hospitalized children involves more than just implementing the medical aspect of nursing. It requires the nurse to play an active role in the psychological and emotional needs of the child, in order to promote holistic well-being and healing. Strategies such as guided imagery, establishing and maintaining trust and using specific therapeutic techniques to comfort and spiritually support the child have been shown to positively impact the outcome of the child’s experience, both physically and psychologically.
Childers, L. (2004, November 24). Escape artists: Nurses help children relieve their pain, anxiety through guided imagery. Nurseweek. Retrieved April 10, 2007 from http://www.nurseweek.com/news/features/04-11/PediatricPain.asp
Crole, N. & Smith, L., (2002). Examining the phases of nursing care of the hospitalized child. Australian Nursing Journal, 9, 30-31. Retrieved March 26 from Proquest database.
Dowling, J. (2002). Humor: A coping strategy for pediatric patients. Pediatric Nursing, 28(9), 123. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Kolcaba, K. & DiMarco, A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursing, 31(3), 187-194. Retrieved May 2, 2007 from Proquest database.
Zengerle-Levy, K. (2005). Nursing the child who is alone in the hospital. Pediatric Nursing, 32(3), 226-231. Retrieved April 4, 2007 from Proquest database.
Intervention 1: Guided Imagery
Disadvantage 1: Knowledge Deficit
Although the use of guided imagery has been proven to decrease pain in hospitalized children, many nurses do not use it as a form of pain management because they are unaware of the technique or have not been educated in its use. According to a study recently published in Pediatric Nursing, only 14.3% of nurses routinely use guided imagery in addition to typical pharmacological methods for pain relief (Ely, 2001.) Because of the lack of knowledge in this form of therapy, there is often resistance in the nursing community on whether or not the technique works. Typically, nurses who have been in the profession for many years are most hesitant to try guided imagery, and often rely on medical management for pain relief. It is important for nurses to be open minded when considering all of the options for pediatric pain relief, whether it involves the use of medications or an alternative technique.
Disadvantage 2: Inadequate Insurance
Despite the vast and rising interest in this field, guided imagery and other alternative medical care remains untapped by hospitals. A major reason is the refusal of insurance companies to reimburse hospitals or physicians for the service. Hospitals want assurance that complementary medical services will be reimbursed. However, a crucial problem in reimbursement is the inconsistency in terminology usage among practitioners, sponsors, and consumers. Insurers or managed care providers that want to provide alternative medical coverage often do not because no “Current Procedure Terminology” codes represent alternative therapies on billing claims. Without uniform coding, insurers face the problem of providers misusing procedure codes to get reimbursed for alternative services; thus, widely implementing complementary alternative medicine such as guided imagery into hospital settings will be difficult.
Intervention 2: Spiritual Support for the Hospitalized Child
Disadvantage 1: Religion
Hospitalization can have many negative effects on a child. When children experience long term hospital stays as the result of a traumatic injury or chronic illness, they can often just “give up” and lose the will to live. Loss of their former self and excruciating pain could potentiate feelings of abandonment or punishment by God, which will ultimately affect their healing and outcome. A study conducted in a pediatric burn intensive care unit stated that nurses who nourished the spirit of the child helped them to find meaning and purpose in life in spite of their injuries (Zengerle-Levy, 2006.) Unfortunately, many nurses are uncomfortable incorporating spirituality in their nursing care. This lack of a spiritual component may be due to nurses' anxiety or confusion about introducing spirituality into what traditionally has been considered science-based nursing practice. Nurses may feel uncomfortable discussing spiritual issues with patients and may worry about boundaries or seeming "inappropriate." They also may feel ill equipped to implement spiritual aspects of care because they have not been formally trained or educated in this area. After all, asking patients about their spirituality and how they find meaning in their lives is very different from performing a physical assessment (Ameling & Povilinis, 2001.)
Disadvantage 2: Knowledge Deficit
Even though studies have shown that incorporating spirituality into nursing, it is not being included as part of the curriculum in many nursing programs. One hundred thirty-two randomly selected baccalaureate nursing programs in the United States responded to a survey exploring how the spiritual dimension of nursing care currently is being taught. The majority of programs included the concept of the spiritual dimension in curricula, but few programs had definitions of spirituality or spiritual nursing care. There appeared to be a lack of clarity in the understanding of the concept of spirituality, as well as uncertainty about levels of faculty knowledge and comfort with teaching this topic (Lemmer, 2002.) One factor that may affect the teaching of spiritual care is that faculty may be uncomfortable addressing the topic due to either their own lack of knowledge or discomfort.
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Lemmer, Corinne. (2002). Teaching the spiritual Dimension of Nursing Care: A Survey of U.S. Baccalaureate Nursing Programs. Journal of Nursing Education, 41(11), 482-491. Retrieved October 31, 2007 from Proquest database.
McEwan, William. (2004). Spirituality in Nursing: What are the Issues? Orthopaedic Nursing, 23(5), 321-322. Retrieved October 31, 2007 from Proquest database.
Santa Ana, Coleen F. (2001). The Adoption of Complementary and Alternative Medicine by Hospitals: A Framework for Decision Making. Journal of Healthcare Management, 46(4), 250-251. Retrieved October 25, 2007 from Proquest database.