Introduction
Working as a nurse in paediatrics entails much patience and understanding of the young patients who have limited language skills to express how they feel. It is quite a challenge to determine how I can help a child in intense pain when I do not know the nature of his or her pain and the parent is likewise frantic and helpless and they are just looking at me to provide them with the much-needed relief.
This paper will deal with my own experience in helping a child in pain manage her situation. I would like to share my own reflective journey through my experience to serve as a lesson to readers who might undergo the same dilemma in their future nursing practice. To organize my reflection, I shall follow Gibbs’ Reflective Cycle (Jasper, 2003) so that readers can fully understand what was going on inside of me as I dealt with a child in pain and the process I went through to resolve the problem situation.
Description
A three-year-old toddler was brought to the emergency room one day when I was the pediatric nurse on duty. She cried incessantly and kept mumbling the words “ouwieeee!”. Her mother was very anxious and kept giving information as to when the child began feeling pain. In addition, she informed that she initially gave the child the usual Paracetamol medicine, but it did not work. She rushed her daughter to the hospital because she had been crying for over an hour and complaining of severe pain, but she could not tell where it hurt.
Feelings
Since I have ample experience working with sick children, I felt confident that I would be able to handle the situation. However, I remember that most of the child patients I had were older and could verbally communicate well. I realized that it was my first time handling a frantic toddler who had limited verbal skills and I needed to ease her pain as soon as possible because I could tell she was suffering so much.
My heart went out to the beautiful crying child, whose hair was all wet from sweat and tears. I also pitied her mother who looked so helpless in the situation as her child clung desperately to her. Looking at the mother and child, I felt I had to take charge and do something to provide immediate relief to the child.
Evaluation
In evaluating the situation, I knew that the pain in the child was prolonged and the agitation it caused the child were negative factors I had to contend with. To make matters worse, the child was unable to provide me with the necessary information I needed to give a preliminary diagnosis, due to the fact that her verbal skills were limited.
We had to wait for the paediatrician to come and the delay was caused by the large number of pediatric patients that came into the emergency room that day, therefore we were short of doctors. On the other hand, the fact that the mother was there with a child gave her the support she needed. It was really helpful that the mother was very cooperative and open to suggestions. Parents are usually the most affected when their children are in pain.
Walsh & Barfield (2006) found that parents were willing to shell out any amount of money just to see their child’s suffering from pain end. Their study focused on giving parents the choice of whether or not they would pay for a painless insertion of the IV catheter and their preference for the length of stay of their child in the medical facility. Most of the parents in the study, the majority were mothers, chose to stay longer and pay money to ensure a painless IV start for their child.
Observing how she tried to comfort her child was very helpful to me because I wanted to learn some strategies she used so I can apply them myself. I had to take the child’s temperature and blood pressure but needed her to be relaxed. I remembered that it was my duty to be a leader in such a situation (Swanwick & McKimm, 2011).
What comes to mind is my favorite leadership model by Kouzes and Posner (2007) who prescribed five effective leadership practices. These are to challenge, inspire, enable, model, and encourage their followers. What was needed in this situation was to inspire the child to calm down and envision that soon the pain would go away. I also needed to convince her that she was strong enough to do it. I should also have enabled her mother to help her child ease the pain and to let her know that she would survive this trying situation. I needed to enjoin her to be my co-model of calmness and relaxation so that the child herself would follow suit (Duffield et al., 2007).
Gauging from the number of patients in the emergency room, I knew that it would take more time until the doctor came to our aid. I needed to take her vital signs so that it is ready for assessment when the doctor arrived, but before I could do that, I needed to calm the patient down (Runciman, Merry & Walton, 2007). On feeling her forehead, she was very warm, but I needed to take her temperature to check if she was running a fever as well as check her blood pressure and other vital signs. From my experience, I thought the child was suffering from a middle ear infection which can be very painful, especially to a toddler.
The pediatric ward has several children’s books and toys to entertain children. I ran to get a toy that I believed would distract my patient and calm her down. I got a squeaky bunny and handed it to her, but she brushed it off. I made the bunny “talk” and asked the child what was wrong, using my high-pitched voice. That got the child’s attention. I signalled to the mother to help me out and she started asking questions to the bunny to which the bunny “answered”.
The child stopped crying and stared at the bunny. When I squeaked it and made a funny sound, she was surprised and she started smiling. The bunny told her he was in pain too and his long ears bothered him. I had to move his ears to show the child it needed attention. The bunny also told the child I could help him, so I took his temperature using the ear thermometer. Later on, the child also allowed me to take her temperature. After a few more minutes, she was engaged with playing with the toy. She was finally calm so I was able to take her vital signs.
Action Plan
My actions successfully helped calm down the patient enabling me to take her vital signs and get her ready for the doctor. Using the toy bunny helped a lot. I would do the same thing in a similar situation with another anxious pre-verbal child and engage the parent in interacting with the child. I would observe what the child may be interested in and use it to gain his or her trust and rapport. I need to brush up on my interactive skills with young children and read up on how to stimulate them.
Kenny (2001) explained that young children are disadvantaged in pain management due to their lack of verbal ability and personal power to demand appropriate pain management from health professionals. At a young age, they may not fully understand the reason for their suffering. Several factors influence children’s pain and behaviour. Some of these are environmental cues, situational factors, and familial factors (Rajasagaram, Taylor, Braitberg, Pearsall, & Capp, 2009).
Memories of poorly managed pain in certain medical procedures heighten children’s perception of pain, and so respond to even the slightest pain in a more exaggerated manner. These traumatized children present greater behavioural distress during the procedures. It follows that children’s memories of their previous experiences become important determinants of what they will expect in future pain experiences and anticipatory anxiety, which then increases their pain during the procedure (Chen, Bush & Zeltzer, 1997).
With preverbal children or those who have cognitive delays or disabilities, it may be worse due to a more difficult assessment of the pain experienced by the healthcare provider because of communication barriers. With these children, health providers resort to analgesic treatments and the engagement of parental support for more efficient pain assessment and management (Rajasagaram et al., 2009).
Getting the participation of the child’s mother was also very helpful, as the child needed someone she trusted to deal with the situation she was in. The report of O’Malley, Brown & Krug (2008) endorses the idea of family support, especially in the emergency department of a medical facility. They studied its adaptability incorporating family-centered approaches as opposed to strictly patient-centered care. There is much value in having the comforting presence of a parent throughout the chaotic process of emergency care for children.
Conclusion
Reflecting on a particular experience, event, or interaction from my own practice helps in clarifying my own philosophy and beliefs in good nursing practices (Chang & Daly, 2008). Gibbs’ model of reflection is a very useful method for doing that. Even if I may earn positive feedback on my performance from my supervisors and patients, I cannot be complacent knowing I still have a lot to learn. Knowing how I perform in certain tasks can help me gain more confidence that I am doing well, or make me realize my mistakes or the areas that I need improvement in.
The experience I had with the frantic toddler in the emergency room was new for me and I am grateful for such an experience even if it made me frantic as well deep inside. I know that my duty was to keep the patient calm and safe while providing relief and my priority was to help the patient become comfortable (Wolff & Taylor, 2009).
References
Chang, E., & Daly, J. (2008).Transitions in nursing: Preparing for professional practice (2nd ed.). Sydney: Elsevier.
Chen, E., Bush, J., & Zeltzer, L. (1997) Psychologic Issues in Pediatric Pain Management, Current Pain and Headache Reports 1(2):153-164.
Duffield C., Roche M., O’Brian-Pallas L., Diers, D., Aisbett, C.,… Hall, J. (2007). Getting it all together: Nurses their work environment and patient safety. Sydney: Centre for Health Services Management, University of Technology.
Jasper, M. (2003) Beginning Reflective Practice – Foundations in Nursing and Health Care. Nelson Thornes. Cheltenham.
Kenny, N. P. (2001). The politics of pediatric pain. In G. A. Finley & P. J. McGrath (Eds.), Acute and procedure pain in infants and children: Progress in pain research and management, Vol. 20 (pp. 147–158). Seattle: ISAP Press.
Kouzes, J., & Posner, B. (2007). The leadership challenge (4th ed.). San Francisco, Ca: Jossey- Bass.
O’Malley, P., Brown, K., & Krug, S. (2008). Patient and family-centered care of children in the Emergency Department. Journal of Pediatrics, 122(2): 511-521.
Rajasagaram, U., Taylor, D., Braitberg, G., Pearsall, J. P., & Capp, B. A. (2009) Paediatric pain assessment: Differences between triage nurse, child and parent. Journal of Paediatrics and Child Health, 45(4): 199–203.
Runciman, B., Merry, A., & Walton, M. (2007). Safety and ethics in healthcare – A guide to getting it right. Aldershot: Ashgate.
Swanwick, T., & McKimm, J. (2011). ABC of Clinical Leadership. BMJ Books, Willey- Blackwell.
Wolff, A., & Taylor, S. (2009). Enhancing patient care. A practical guide for improving quality and safety in hospitals. Strawberry Hills, N.S.W.: MJA books.