Preventing Stress during Medical Procedures

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Child Life Services in the Hospital Setting

• Preventing Stress during Medical Procedures

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Child Life Services

• Child life specialists address the psychosocial
  concerns that accompany health care experiences
  by promoting optimal child development and
  minimizing adverse effects.
• Using play and psychological preparation as
  primary tools, child life interventions
  facilitate coping and adjustment under
  circumstances that might otherwise be
  overwhelming.

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Child Life Services

• Basic Tenants of Child Life
• Play and Normalcy
• Psychological Preparation
• Education
• Expressive Activities
• Emotional Support/Family Support

4
Child Life Services

• Professional Standards of Practice
• Minimum bachelors degree or masters degree in
  human growth and development, education,
  psychology or related field
• Certified child life specialists
• Internship
• Certification examination
• Certification maintenance through professional
  development
• Adhere to code of ethics and standards
  established by the Child Life Council

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Psychological Preparation

• Communication of accurate, developmentally
  appropriate information in advance of an
  experience
• Includes
• reason for the procedure
• anticipated sequence of events
• sensations that accompany the experiences

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Psychological Preparation

• Summary of Literature
• Children psychologically prepared
• experience lower levels of fear and anxiety in
  comparison to those not prepared
• display long term coping and adjustment to future
  medical challenges
• express significantly greater satisfaction with
  their hospital experience than those who are not
  given this type of support
• show greater cooperation during stressful
  procedures and are more willing to return to the
  hospital for further treatment
• Pediatric patients who have not been effectively
  prepared for a medical experience display long
  term effects including post-traumatic stress,
  increased fears, and decreased cooperative
  behavior.

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Psychological Preparation

• Benefits for Provider and Child
• Predictability decreases stress and anxiety
• Expected stress is less upsetting than unexpected
  stress
• Fosters trusting relationships
• Increases accuracy of childs expectations
• Identifies potential stress points
• Allows for learning and rehearsal of coping
  strategies
• Increases confidence and cooperation

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Psychological Preparation

• Developmentally Appropriate Preparation Tools
• Medical Play Kits
• Medical Play Dolls
• Preparation Books
• Blueberry Eyes by Monica Driscoll Beaty
• Chris Gets Ear Tubes by Betty Pace
• Good-Bye Tonsils by Juliana Lee Hatkoff and Craig
  Hatkoff
• Rita Goes to the Hospital by Martine Davison.
  ISBN 0679818200
• Videos and Virtual Tours
• www.oumedicine.com

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Procedural Support

• Non-Pharm Pain Management
• Sensory
• Positioning, holding, pressure, motion, rocking
• Cognitive/Behavioral
• Thought stopping, guided imagery, distraction
• Relaxation, deep breathing

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Procedural Support

• Infant Stressors
• Birth to 1 year
• Separation from parents/stranger anxiety
• Under or overstimulation
• Impaired basic needs
• Loss of comfort items
• Pain
• Parent anxiety

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Procedural Support

• Infant Interventions
• Calm soothing voice
• Avoid bright lights, loud noise
• Parental presence/participation
• Holding, patting, rocking, stroking
• Singing, playing music
• Rattles, grasping toys
• Bubble blowing by adult
• Comfort positions
• Objects that change position, color, or shape
  (mobiles)
• Pacifier/Sweet ease 

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Procedural Support

• Toddler Stressors
• 1-3 years
• Separation/Stranger Anxiety
• Unable to fully comprehend purpose of procedure
• Loss physical and emotional control
• Bodily injury and pain/needles
• Unfamiliar environment

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Procedural Support

• Toddler Interventions
• Calm soothing voice
• Limit separation from parents
• Comfort Positions
• Simple explanation and reassurance/praise
• Playing Music
• Holding, Patting, Stroking
• Nursery and Action Rhymes (pat-a-cake)
• Books (pop-up and sound books)
• Puppets
• Breathing/Relaxation (Bubble Blowing, Pinwheel
  Blowing)
• Singing Songs, Counting and Story Telling 

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Procedural Support

• Preschool Stressors
• 3-5 years
• Fear of the unknown
• Loss of body function
• Pain/needles
• Misconceptions common (fantasy vs. reality)
• Believe procedure is a result of wrongdoing

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Procedural Support

• Preschool Interventions
• Reassure procedure is not a form of punishment
• Praise and reinforce positive coping
• Encourage participation
• Comfort Positions
• Bubble Blowing, Pinwheel Blowing
• Music/Singing
• Storytelling, Counting
• Books (Pop-up, I Spy, Play-a-Sound)
• Puppets, Squeezy Balls
• Breathing/Relaxation
• Guided Imagery

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Procedural Support

• School Age Stressors
• 6-12 years
• Loss of body function
• Loss of control
• Pain
• Death
• Disappointing parents/caretakers

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Procedural Support

• School Age Interventions
• Allow participation
• Reassure that expressing emotion is okay
• Comfort Positions
• Listening to music
• Hand-held games/Videos
• I Spy Books
• Counting, Storytelling
• Breathing/Relaxation
• Guided Imagery
• Squeezy Balls

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Procedural Support

• Adolescent Stressors
• Body mutilation
• Loss of body function
• Change in physical appearance
• Loss of control
• Loss of independence
• Invasion of privacy
• Rebellion may be response to anger/fear

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Procedural Support

• Adolescent Interventions
• Build trust through mutual respect
• Allow active participation in care
• Encourage questions and open conversation
• Respect the need for privacy
• Guided imagery
• Listening to favorite music
• Hand held games/Videos
• Squeezy Ball
• Breathing/Relaxation

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Comfort Positions

• Promote close physical contact
• Caregiver participates in positive assistance,
  not negative restraint
• Sitting up promotes a sense of control for the
  child
• Immobility is extremely successful
• Fewer people are needed to perform the procedure
• Gives providers more room to work

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Comfort Positions

• Back to Chest
• Chest to Chest

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Comfort Positions

• Butterfly Position

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References

• Cassell S, Paul MH. The role of puppet therapy on
  the emotional responses of children hospitalized
  for cardiac catheterization. Journal of
  Pediatrics. 196771(2)233-239.
• Child Life Council and Committee on Hospital
  Care. American Academy of Pediatrics Policy
  Statement Child Life Services. Pediatrics.
  2006118(4) 1757-1763.
• Clatworthy S. Therapeutic play Effects on
  hospitalized children. Journal of Association for
  Care of Children's Health. 19819(4)108-113.
•  
• Edwinson M, Arnbjornsson E, Ekman R. Psychologic
  preparation program for children undergoing acute
  appendectomy. Pediatrics. 198882(1)30-36.
•  
• Ferguson BF. Preparing young children for
  hospitalization A comparison of two methods.
  Pediatrics. 197964(5)656-664
•  
• Johnson PA, Stockdale DF. Effects of puppet
  therapy on palmar sweating on hospitalized
  children. The Johns Hopkins Medical Journal.
  19751371-5.
•  
• Kleiber C, Harper, DC. Effects of distraction on
  childrens pain and distress during medical
  procedures A meta-analysis. Nursing Research.
  1999 48(1)44-49.
• Kurfis SB, Barkey ME, Hall HR. Techniques to
  comfort children during stressful procedures.
  Advances in Mind-Body Medicine. 19991549-60
• Lang EV, Hatsiopoulou O, Koch T, Berbaum K,
  Lutgendorf S, Kettenmann E. Can words hurt?
  Patient provider interactions during invasive
  procedures. Pain. 2005114303-309.

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References

• Margolis JO, Ginsberg B, Dear GdL, Ross AK, Goral
  JE, Bailey AG. Paediatric preoperative teaching
  Effects at induction and postoperatively.
  Paediatric Anaesthesia. 1998817-23.
•  
• Melamed BG, Ridley-Johnson R. Psychological
  preparation of families for hospitalization.
  Journal of Developmental Behavioral Pediatrics.
  19889(2)96-102.
•  
• Melamed BG, Siegel LJ. Reduction of anxiety in
  children facing hospitalization and surgery by
  use of filmed modeling. Journal of Consulting
  Clinical Psychology. 197543(4)511-521.
•  
• Rae WA, Worchel FF, Upchurch J, Sanner JH, Daniel
  CA. The psychosocial impact of play on
  hospitalized children. Journal of Pediatric
  Psychology. 198914(4)617-627.
•  
• Roberts MC, Wurtele SK, Boone RR, Ginther LJ,
  Elkins PD. Reduction of medical fears by use of
  modeling A preventive application in a general
  population of children. Journal of Pediatric
  Psychology. 19816(3)293-301.
•  
• Schulz JB, Raschke D, Dedrick C, Thompson M. The
  effects of a preoperational puppet show on
  anxiety levels of hospitalized children. Child
  Health Care. 19819(4)118-121.
•  
• Schwartz BH, Albino JE, Tedesco LA. Effects of
  psychological preparation on children
  hospitalized for dental operations. Journal of
  Pediatrics. 1983102(4)634-638.
•  
• Wolfer JA, Visintainer MA. Prehospital
  psychological preparation for tonsillectomy
  patients Effects on children's and parents'
  adjustment. Pediatrics. 1979 64(5)646-655.
•  
• Zahr LK. Therapeutic play for hospitalized
  preschoolers in Lebanon. Pediatric Nursing.
  199823(5)449-454.

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