- Email: [email protected]
Don't let them hurt me
Don‘t let them hurt me Caryl P Griffin, RN Trude R Aufhauser, RM
All her short life, 22-month-old Kim had been free in the expression of her feelings, whether happy or unhappy. She had always exhibited a strong will power, and would pull out her hairclip, hair and all, if she could not get her own way. For this reason, I (her mother) was anxious when she was scheduled for a bilateral ureteral reimplant operation. I feared that she would tear out her catheter or her intravenous tubing. Since I am a professional nurse and my husband is a pediatrician, I was afraid that my Caryl
P
G r i f f i n , RN, Kim’s mother, has been an
instructor i n staff
development
and
home
care
coordinator a t Children’s M e d i c a l Center, Dallas. She i s a graduate
of t h e University of Tennessee
C o l l e g e o f Nursing, Memphis. Trude
R Aufhauser, RN, BS, MPH, i s d i r e c t o r o f
nursing a t Children’s M e d i c a l C e n t e r and professor
of
nursing a t Texas Women’s University i n Dallas.
She i s a graduate of Johns Hopkins H o s p i t a l School o f Nursing i n Baltimore: Teachers C o l l e g e , C o l u m b i a University, N e w York C i t y ; and Yale University School of Medicine, N e w Haven, Conn.
May 1973
professional colleagues at the hospital would scrutinize my daughter’s behavior and that I would be labeled a mother unable to control her child.
To deal with my own rising anxiety, I began to prepare myself and Kim for the ordeal ahead. Behavioral scientists point out that man needs an outlet when faced with traumatic, anxiety producing experiences. For an adult, speech usually acts as a release for fear. In Wa7. ctnd Children, Anna Freud recalls: Whenever, during the time of “blitz,” mothers came to the Children’s Center after a bad night’s bombing, the best we could do for them would be to provide an interested audience for their tales. The kitchen in Wedderburn Road would reverberate with descriptions of neighbors who had been killed, possessions which had been destroyed, and miraculous rescues from burning shelters. . . . If they repeated
59
Kim ponders non-threatening toys. She i s faced with making her own decision while her mother keeps herself uninvolved.
the description often enough their excitement would subside visibly.’ Children who cannot ventilate their feelings in conscious thought and speech can find an outlet in play. Anna Freud relates how children a t the Center “bombed” houses built of blocks. After the raids in 1941, the youngsters would use the climbing frame in the garden to repeat in play what they had heard or seen. “One child climbed to the highest bar and threw heavy objects on the children underneath,” Miss Freud recalls.2 Therapeutic play, introduced in many hospitals in the past few years, helps children cope with traumatic experience by encouraging them to play out painful and fear-provoking procedures. When hospital equipment is available in playrooms on pediatric units, young patients have an opportunity to repeat in play painful experiences to which they have been subjected until their fear and excitement subside noticeably. This type of play helped Kim to cope with a hospital experience that
60
could have left a permanent emotional scar if it had not been managed wisely by her mother and the hospital staff involved. There are two aspects t o be considered when preparing a child for surgery. One is to allow time for nondirective play providing hospital equipment which is likely to be used on the child during his hospital stay, and a t the same time making available non-threatening toys such as blocks, pounding board, crayons, paper and a telephone. It is up to the child to decide what he wants to play with; he makes his own choice and directs his play. Demonstration and explanation of equipment is given only if the childs asks for this help. The adult is present only to prevent the child from harming himself. The second aspect of preparation deals with telling a story of a child who goes to the hospital and experiences a situation similar t o that which is anticipated for the patient. No details are omitted, painful or otherwise, including recovery and
AORN Journal
discharge. A description of procedures occurring while under anesthesia is, of course, not necessary or desirable. The story can also be acted out with use of hand puppets. This gives the child valuable information which enables him to anticipate what will be happening; yet it is nonthreatening since it occurs to the youngster in the story. Fear of the unknown is often worse than fear of the known, especially in children, since they normally fantasize and thus have difficulty sorting out reality from fantasy. These two preparatory techniques should be used separately. This is important since the story is giving information which often produces anxiety, and it should be told in as non-threatening a situation as possible. The play sessions, on the other hand, are work periods for the child and allow him to act out his fantasies and anxieties. This is true whether he is using the hospital toys or the non-threatening toys. In fact, a child may be too anxious to play with the
Kim
doll play
prepares
to
give
threatening needles and hospital equipment, especially if he has had many previous hospital experiences. Some of his anger may be released by beating on the pounding board or life-sized Bobo clown. For Kim, the play sessions seemed t o be intriguing. She was familiar with the catheter and the rectal thermometer from previous encounters. Other equipment available besides the non-threatening toys mentioned above were an intravenous set-up with needle, rubber tubing simulating catheter and drainage tubing, tape, bandages, stethoscope, syringe with needle, play doctor kit, and her life-sized baby doll complete with crayoned pink scar and stitches (done by Mom the night before). When time permits, the child should be allowed t o play a t his request and until he finishes. Kim used four onehour sessions the first day a t home, which was three days prior t o admission. The child is told the play session is a time to play when he decides
her
an injection. Therapeutic helps
Kim
cope
with
her hospital experience.
May 1973
62
what he wants to play with and how. The adult present during the session does not direct the child nor does she make any comments. The point is to allow the child to become absorbed in his own world of play without interruption. Intervention occurs only when there is danger to the child or to another person. Assistance or explanation is given only a t the child’s request. The first play session for the child is often a test in which the child begins cautiously and looks to the grown-up for approval or disapproval. It is important that she show acceptance of the child without encouraging or discouraging the child’s play. Non-verbal clues are quickly picked up by the youngster. For example, a grimace when the child is particularly aggressive in beating Bob0 or stabbing a doll is a non-verbal sign of disapproval. The toys are considered destructable and are replaced if broken. In her preoperative play sessions, Kim ignored the non-threatening toys, and asked instead for an explanation of each piece of hospital equipment. My own anxiety regarding needles subconsciously prevented me from making needles available to Kim at this time. In fact, it was seven months after Kim’s surgery that I realized my fear and was able then to give Kim an opportunity for needle play. Kim acquainted herself with each piece of equipment before she was hospitalized. It is interesting to note that she used each item on the doll with the exception of the rectal therometer and the catheter. Both had been used on her numerous times in the past, and Kim had fought them with all her might. It seemed that her avoidance of these two items indicated her anxiety as-
62
sociated with them. She did, however, carry the catheter with her wherever she went both during preand post-hospitalization. It was not until six months after surgery that she finally was able to put the catheter along one of her playmate’s legs, apparently having worked through her anxiety about catheterization. Now she even tries to catheterize herself and our dog. The important point here is that a child will work through his anxiety at his own rate if he is allowed to do SO, and it seems fruitless, even dangerous, to direct the child before he is ready. The following experience illustrates what reaction can result from actually directing play. On Kim’s seventh postoperative day a student nurse invited her into the playroom for a family-style breakfast and play thereafter. The nurse attempted to direct Kim to the needle play three times. Each time Kim refused, and on the third approach she started crying and kicking and ran to play with the dollhouse. It would seem advisable to allow the child to make the crucial decision whether t o play with the hospital toys on his own, since directing him may increase his a m iety. It is impossible to predict when a child may be ready for this threatening type of play. If he is pushed into it, his reaction might be disastrous. Kim had the advantage of playing with the equipment at home several days before admission. This is not possible for the majority of pediatric patients scheduled for surgery. It might be advisable, however, to admit the patient a day earlier to allow the child time to familiarize himself with hospital equipment and
AORN Journal
play out his fears on the non-threatening toys in supervised sessions in the hospital playroom. The second part of the child’s preparation, which should be kept completely separate from the nondirective play, is the story of a child who goes to the hospital to have an experience similar to that of the child being prepared. The story can be read from a book, such as Bemelmans’ Madeline, or can be fabricated by the storyteller. I n either case it is well to include as many details as possible regarding the thoughts, feelings, and events the child might encounter. Often the child fears hospitalization is a punishment for some wrong he has done. It is beneficial to dispel this fear and reassure the youngster that the hospitalization is unrelated to his previous actions. For Kim, I fabricated ad lib the story of a girl who went to the hospital to have her tummy fixed. The tale included positive aspects such as making new friends with nurses, doctors, other children, and playing with toys; as well as negative experiences such as getting ”shots” and having a tummyache after surgery. Telling Kim these negative points was the most difficult part for me and I found myself time and again trying to paint a rosy picture. Being honest seems t o be the key to building a child’s trust. Telling him it won’t hurt when the procedure is painful may foster anger and distrust. In the story the little girl ate, slept, and “tee tee’d” in the hospital. Her Mommy and Daddy were there with her and even her doll was present. New experiences were related, such as blowing up a balloon
Mtry 7373
with special air and going to sleep while the doctor fixed her tummy. A bandage on her tummy, a catheter that “tee tee’d” for her, an infusion that gave her lunch so that she did not have t o eat, waking up in a strange room-these were all important aspects of the little girl’s experience. This part of the preparation can be done at home by the parents with the help of available books telling the story of a child going t o the hospital and having surgery. The nurse can reinforce and add details specific to the child’s circumstances in story form after the child has been admitted t o the hospital. When first hearing the story of this little girl, Kim was nonchalant and acted a s if she wasn’t listening. She walked around the room and even left the room while the story was being told, which would seem to be an indication of her anxiety. The story was repeated several times a day for about four days before entering the hospital. Inadvertently I left out of Kim’s story the admission routine of temperature taking, weighing, and measuring. Consequently, during admission Kim threw herself on the floor screaming and writhing as the nurse approached her to measure her height. However, as soon as she was taken to her room, she seemed a t ease and even allowed the surgeon to examine her. An additional step toward familiarizing the child with the hospital environment and thus reducing his presurgical anxiety is to take him on a tour of the operating room and recovery room. This can be done prior t o the admission day if possible, o r
63
perhaps the afternoon before surgery. The experience of seeing other children in the recovery room playing with toys, breathing the special “wake-up air” (oxygen), and meeting the ladies in pink dresses (nurses), all seemed to be positive steps toward allaying Kim’s fears. The results of Kim’s preparation were gratifying. She was able to cope satisfactorily with the subsequent traumatic intrusive events of surgery and the recovery period. She required very little medication for pain (two aspirin suppositories and one belladonna and opium suppository). As she noticed her infusion the first postoperative day, she exclaimed, “Look, Mommy, my bottle!” Neither the infusion which she retained for two days nor the urethral catheter which she wore for seven days, seemed to bother her much. She rode two hours in the red wagon the first day and was ambulatory as soon as her infusion was discontinued the next. Non-directive play sessions were offered Kim a t home following discharge from the hospital. I arranged the first session, but after that she requested sessions by asking to play with her “doctors”-the equipment. The emphasis on the first two days was on taping her doll. This apparently was her paramount concern since she herself had suffered from tape burns caused by an allergic reaction to the paper tape. After a week of carrying the catheter around, Kim lost interest in the hospital toys. She requested no further play. The following two months only two catheterizations were necessary. Four months following surgery, Kim asked to go see
G4
“Uncle George” (the urologist). Since such a visit was not indicated, I inquired what happens when she visits the doctor. After a moment she replied, “He gives me a lollipop and looks a t my bottom.” She began t o verbalize about going t o the hospital and getting her tummy fixed but avoided relating any painful experiences. Six months after surgery she placed the catheter along her friend’s leg and the month following she could express that, when she had her tummy fixed, it did hurt. Seven months postoperatively Kim had a follow-up intravenous pyelogram and voiding cystogram. She was able to talk freely following these procedures and told about them repeatedly t o anyone who would listen, explaining that she had medicine in her arm and had her bottom “fixed,” both of which did hurt. When we arrived home she spontaneously dug her catheter out of the toy box and when I was out of the room she removed her clothes and appeared to be trying to catheterize herself. Any child who is hospitalized is anxious and should have the opportunity of being informed of what t o expect as well as of expressing his thoughts and feelings, especially anger, either verbally or through play. Play is a child’s important business and is used by the child to work through his anxiety. Whether he’s expressing his anger pounding on the peg board or stabbing a doll with a syringe, he should be allowed to become absorbed in his own world without having to follow instructions given by an adult. Little Kim’s hospital experience was guided by a mother who is a professional with a rich background in
AORN Journal
pediatric nursing, an acute sensitivity for children’s needs, and an unusual skill in handling youngsters. Not every pediatric patient is so fortunate. But the activities that have been described and carried out can and must be emphasized and incorporated in pediatric nursing if child care in the hospital is to reach a higher level from the point of view of nursing.
As in Kim’s case, each toddler and pre-schooler should have his mother (or a mother-substitute) with him while b e i n g hospitalized. Kim’s mother and father spelled each other out. Thus separation anxiety-the number one fear of the young rhildwas minimized. Rooming-in in pediatrics can no longer be considered a luxury; it is a young child’s right, and appropriate arrangements should be made any time a child is admitted to the hospital on an elective basis. Non-directive play sessions, as well as clear information on things to come, will have to be provided by the hospital staff if children and their parents are to receive effective emotional support during a period of crisis. At the Children’s Medical Center in Dallas a nurse clinician has been employed for the past year as 3 “parent teacher and counselor.” This professional nurse, Diane Lesh, is a free-floating agent who visits the child and his parents to give support and instructions. She has preoperntive teaching sessions for patients and parents during which she informs the
family in a story-like manner of the coming events in the hospital. She is in ever-increasing demand. In addition, the Nursing Staff Development Program at Children’s Medical Center has adapted the concept of non-directive play and its application. Under the direction of Mrs Diana Cunningham, RN, MS, several nursing staff members have been prepared to conduct play sessions. Thus, Mrs Lesh and Mrs Cunningham are preparing the nursing staff to carry out the techniques used so effectively by Kim’s mother. I n this way, preoperative teaching, as well as non-directive play, will become part and parcel of pediatric nursing practice. FOOTNOTES I. A Freud and D T Burlingham, War a n d Chi/dren ( N e w York: M e d i c a l W a r Books,
1943), p 65.
2. /bid. p 68.
REFERENCES M.
Axline. V
Books, 1~
-.
Dibs in
P i o y Therapy. New York: Ballantine
1969. Search of Self. N e w York: Ballantine
Books, Inc, 1967. Bemelmani, L. Madeline. N e w York: Shuster. Erickson,
Simon
and
1939.
F H. Ploy
Interviews for Four-Year-Old
Hospitolized Children. A monograph of the Society f o r Research in C h i l d Development. Lafayette, Ind: Pu:due
University
Press, 1958.
Petrillo, M and S Sanger. €motional Core of Hospitolized Children. a n Environmental Approach. Philadelphia, Toronto: J B Lippincott Whitsan,
B J.
Americon
Co, 1972.
“The Puppet Treatment in Pediatrics,” Journal
of
Nursing.
72 (September
19721, I61 2- 1614.
A M A adopts metric system A l l publications
of the American Medical Association have been using the metric system of
measurements since January. Previously bath metric and English systems were used.
I
I
65
All her short life, 22-month-old Kim had been free in the expression of her feelings, whether happy or unhappy. She had always exhibited a strong will power, and would pull out her hairclip, hair and all, if she could not get her own way. For this reason, I (her mother) was anxious when she was scheduled for a bilateral ureteral reimplant operation. I feared that she would tear out her catheter or her intravenous tubing. Since I am a professional nurse and my husband is a pediatrician, I was afraid that my Caryl
P
G r i f f i n , RN, Kim’s mother, has been an
instructor i n staff
development
and
home
care
coordinator a t Children’s M e d i c a l Center, Dallas. She i s a graduate
of t h e University of Tennessee
C o l l e g e o f Nursing, Memphis. Trude
R Aufhauser, RN, BS, MPH, i s d i r e c t o r o f
nursing a t Children’s M e d i c a l C e n t e r and professor
of
nursing a t Texas Women’s University i n Dallas.
She i s a graduate of Johns Hopkins H o s p i t a l School o f Nursing i n Baltimore: Teachers C o l l e g e , C o l u m b i a University, N e w York C i t y ; and Yale University School of Medicine, N e w Haven, Conn.
May 1973
professional colleagues at the hospital would scrutinize my daughter’s behavior and that I would be labeled a mother unable to control her child.
To deal with my own rising anxiety, I began to prepare myself and Kim for the ordeal ahead. Behavioral scientists point out that man needs an outlet when faced with traumatic, anxiety producing experiences. For an adult, speech usually acts as a release for fear. In Wa7. ctnd Children, Anna Freud recalls: Whenever, during the time of “blitz,” mothers came to the Children’s Center after a bad night’s bombing, the best we could do for them would be to provide an interested audience for their tales. The kitchen in Wedderburn Road would reverberate with descriptions of neighbors who had been killed, possessions which had been destroyed, and miraculous rescues from burning shelters. . . . If they repeated
59
Kim ponders non-threatening toys. She i s faced with making her own decision while her mother keeps herself uninvolved.
the description often enough their excitement would subside visibly.’ Children who cannot ventilate their feelings in conscious thought and speech can find an outlet in play. Anna Freud relates how children a t the Center “bombed” houses built of blocks. After the raids in 1941, the youngsters would use the climbing frame in the garden to repeat in play what they had heard or seen. “One child climbed to the highest bar and threw heavy objects on the children underneath,” Miss Freud recalls.2 Therapeutic play, introduced in many hospitals in the past few years, helps children cope with traumatic experience by encouraging them to play out painful and fear-provoking procedures. When hospital equipment is available in playrooms on pediatric units, young patients have an opportunity to repeat in play painful experiences to which they have been subjected until their fear and excitement subside noticeably. This type of play helped Kim to cope with a hospital experience that
60
could have left a permanent emotional scar if it had not been managed wisely by her mother and the hospital staff involved. There are two aspects t o be considered when preparing a child for surgery. One is to allow time for nondirective play providing hospital equipment which is likely to be used on the child during his hospital stay, and a t the same time making available non-threatening toys such as blocks, pounding board, crayons, paper and a telephone. It is up to the child to decide what he wants to play with; he makes his own choice and directs his play. Demonstration and explanation of equipment is given only if the childs asks for this help. The adult is present only to prevent the child from harming himself. The second aspect of preparation deals with telling a story of a child who goes to the hospital and experiences a situation similar t o that which is anticipated for the patient. No details are omitted, painful or otherwise, including recovery and
AORN Journal
discharge. A description of procedures occurring while under anesthesia is, of course, not necessary or desirable. The story can also be acted out with use of hand puppets. This gives the child valuable information which enables him to anticipate what will be happening; yet it is nonthreatening since it occurs to the youngster in the story. Fear of the unknown is often worse than fear of the known, especially in children, since they normally fantasize and thus have difficulty sorting out reality from fantasy. These two preparatory techniques should be used separately. This is important since the story is giving information which often produces anxiety, and it should be told in as non-threatening a situation as possible. The play sessions, on the other hand, are work periods for the child and allow him to act out his fantasies and anxieties. This is true whether he is using the hospital toys or the non-threatening toys. In fact, a child may be too anxious to play with the
Kim
doll play
prepares
to
give
threatening needles and hospital equipment, especially if he has had many previous hospital experiences. Some of his anger may be released by beating on the pounding board or life-sized Bobo clown. For Kim, the play sessions seemed t o be intriguing. She was familiar with the catheter and the rectal thermometer from previous encounters. Other equipment available besides the non-threatening toys mentioned above were an intravenous set-up with needle, rubber tubing simulating catheter and drainage tubing, tape, bandages, stethoscope, syringe with needle, play doctor kit, and her life-sized baby doll complete with crayoned pink scar and stitches (done by Mom the night before). When time permits, the child should be allowed t o play a t his request and until he finishes. Kim used four onehour sessions the first day a t home, which was three days prior t o admission. The child is told the play session is a time to play when he decides
her
an injection. Therapeutic helps
Kim
cope
with
her hospital experience.
May 1973
62
what he wants to play with and how. The adult present during the session does not direct the child nor does she make any comments. The point is to allow the child to become absorbed in his own world of play without interruption. Intervention occurs only when there is danger to the child or to another person. Assistance or explanation is given only a t the child’s request. The first play session for the child is often a test in which the child begins cautiously and looks to the grown-up for approval or disapproval. It is important that she show acceptance of the child without encouraging or discouraging the child’s play. Non-verbal clues are quickly picked up by the youngster. For example, a grimace when the child is particularly aggressive in beating Bob0 or stabbing a doll is a non-verbal sign of disapproval. The toys are considered destructable and are replaced if broken. In her preoperative play sessions, Kim ignored the non-threatening toys, and asked instead for an explanation of each piece of hospital equipment. My own anxiety regarding needles subconsciously prevented me from making needles available to Kim at this time. In fact, it was seven months after Kim’s surgery that I realized my fear and was able then to give Kim an opportunity for needle play. Kim acquainted herself with each piece of equipment before she was hospitalized. It is interesting to note that she used each item on the doll with the exception of the rectal therometer and the catheter. Both had been used on her numerous times in the past, and Kim had fought them with all her might. It seemed that her avoidance of these two items indicated her anxiety as-
62
sociated with them. She did, however, carry the catheter with her wherever she went both during preand post-hospitalization. It was not until six months after surgery that she finally was able to put the catheter along one of her playmate’s legs, apparently having worked through her anxiety about catheterization. Now she even tries to catheterize herself and our dog. The important point here is that a child will work through his anxiety at his own rate if he is allowed to do SO, and it seems fruitless, even dangerous, to direct the child before he is ready. The following experience illustrates what reaction can result from actually directing play. On Kim’s seventh postoperative day a student nurse invited her into the playroom for a family-style breakfast and play thereafter. The nurse attempted to direct Kim to the needle play three times. Each time Kim refused, and on the third approach she started crying and kicking and ran to play with the dollhouse. It would seem advisable to allow the child to make the crucial decision whether t o play with the hospital toys on his own, since directing him may increase his a m iety. It is impossible to predict when a child may be ready for this threatening type of play. If he is pushed into it, his reaction might be disastrous. Kim had the advantage of playing with the equipment at home several days before admission. This is not possible for the majority of pediatric patients scheduled for surgery. It might be advisable, however, to admit the patient a day earlier to allow the child time to familiarize himself with hospital equipment and
AORN Journal
play out his fears on the non-threatening toys in supervised sessions in the hospital playroom. The second part of the child’s preparation, which should be kept completely separate from the nondirective play, is the story of a child who goes to the hospital to have an experience similar to that of the child being prepared. The story can be read from a book, such as Bemelmans’ Madeline, or can be fabricated by the storyteller. I n either case it is well to include as many details as possible regarding the thoughts, feelings, and events the child might encounter. Often the child fears hospitalization is a punishment for some wrong he has done. It is beneficial to dispel this fear and reassure the youngster that the hospitalization is unrelated to his previous actions. For Kim, I fabricated ad lib the story of a girl who went to the hospital to have her tummy fixed. The tale included positive aspects such as making new friends with nurses, doctors, other children, and playing with toys; as well as negative experiences such as getting ”shots” and having a tummyache after surgery. Telling Kim these negative points was the most difficult part for me and I found myself time and again trying to paint a rosy picture. Being honest seems t o be the key to building a child’s trust. Telling him it won’t hurt when the procedure is painful may foster anger and distrust. In the story the little girl ate, slept, and “tee tee’d” in the hospital. Her Mommy and Daddy were there with her and even her doll was present. New experiences were related, such as blowing up a balloon
Mtry 7373
with special air and going to sleep while the doctor fixed her tummy. A bandage on her tummy, a catheter that “tee tee’d” for her, an infusion that gave her lunch so that she did not have t o eat, waking up in a strange room-these were all important aspects of the little girl’s experience. This part of the preparation can be done at home by the parents with the help of available books telling the story of a child going t o the hospital and having surgery. The nurse can reinforce and add details specific to the child’s circumstances in story form after the child has been admitted t o the hospital. When first hearing the story of this little girl, Kim was nonchalant and acted a s if she wasn’t listening. She walked around the room and even left the room while the story was being told, which would seem to be an indication of her anxiety. The story was repeated several times a day for about four days before entering the hospital. Inadvertently I left out of Kim’s story the admission routine of temperature taking, weighing, and measuring. Consequently, during admission Kim threw herself on the floor screaming and writhing as the nurse approached her to measure her height. However, as soon as she was taken to her room, she seemed a t ease and even allowed the surgeon to examine her. An additional step toward familiarizing the child with the hospital environment and thus reducing his presurgical anxiety is to take him on a tour of the operating room and recovery room. This can be done prior t o the admission day if possible, o r
63
perhaps the afternoon before surgery. The experience of seeing other children in the recovery room playing with toys, breathing the special “wake-up air” (oxygen), and meeting the ladies in pink dresses (nurses), all seemed to be positive steps toward allaying Kim’s fears. The results of Kim’s preparation were gratifying. She was able to cope satisfactorily with the subsequent traumatic intrusive events of surgery and the recovery period. She required very little medication for pain (two aspirin suppositories and one belladonna and opium suppository). As she noticed her infusion the first postoperative day, she exclaimed, “Look, Mommy, my bottle!” Neither the infusion which she retained for two days nor the urethral catheter which she wore for seven days, seemed to bother her much. She rode two hours in the red wagon the first day and was ambulatory as soon as her infusion was discontinued the next. Non-directive play sessions were offered Kim a t home following discharge from the hospital. I arranged the first session, but after that she requested sessions by asking to play with her “doctors”-the equipment. The emphasis on the first two days was on taping her doll. This apparently was her paramount concern since she herself had suffered from tape burns caused by an allergic reaction to the paper tape. After a week of carrying the catheter around, Kim lost interest in the hospital toys. She requested no further play. The following two months only two catheterizations were necessary. Four months following surgery, Kim asked to go see
G4
“Uncle George” (the urologist). Since such a visit was not indicated, I inquired what happens when she visits the doctor. After a moment she replied, “He gives me a lollipop and looks a t my bottom.” She began t o verbalize about going t o the hospital and getting her tummy fixed but avoided relating any painful experiences. Six months after surgery she placed the catheter along her friend’s leg and the month following she could express that, when she had her tummy fixed, it did hurt. Seven months postoperatively Kim had a follow-up intravenous pyelogram and voiding cystogram. She was able to talk freely following these procedures and told about them repeatedly t o anyone who would listen, explaining that she had medicine in her arm and had her bottom “fixed,” both of which did hurt. When we arrived home she spontaneously dug her catheter out of the toy box and when I was out of the room she removed her clothes and appeared to be trying to catheterize herself. Any child who is hospitalized is anxious and should have the opportunity of being informed of what t o expect as well as of expressing his thoughts and feelings, especially anger, either verbally or through play. Play is a child’s important business and is used by the child to work through his anxiety. Whether he’s expressing his anger pounding on the peg board or stabbing a doll with a syringe, he should be allowed to become absorbed in his own world without having to follow instructions given by an adult. Little Kim’s hospital experience was guided by a mother who is a professional with a rich background in
AORN Journal
pediatric nursing, an acute sensitivity for children’s needs, and an unusual skill in handling youngsters. Not every pediatric patient is so fortunate. But the activities that have been described and carried out can and must be emphasized and incorporated in pediatric nursing if child care in the hospital is to reach a higher level from the point of view of nursing.
As in Kim’s case, each toddler and pre-schooler should have his mother (or a mother-substitute) with him while b e i n g hospitalized. Kim’s mother and father spelled each other out. Thus separation anxiety-the number one fear of the young rhildwas minimized. Rooming-in in pediatrics can no longer be considered a luxury; it is a young child’s right, and appropriate arrangements should be made any time a child is admitted to the hospital on an elective basis. Non-directive play sessions, as well as clear information on things to come, will have to be provided by the hospital staff if children and their parents are to receive effective emotional support during a period of crisis. At the Children’s Medical Center in Dallas a nurse clinician has been employed for the past year as 3 “parent teacher and counselor.” This professional nurse, Diane Lesh, is a free-floating agent who visits the child and his parents to give support and instructions. She has preoperntive teaching sessions for patients and parents during which she informs the
family in a story-like manner of the coming events in the hospital. She is in ever-increasing demand. In addition, the Nursing Staff Development Program at Children’s Medical Center has adapted the concept of non-directive play and its application. Under the direction of Mrs Diana Cunningham, RN, MS, several nursing staff members have been prepared to conduct play sessions. Thus, Mrs Lesh and Mrs Cunningham are preparing the nursing staff to carry out the techniques used so effectively by Kim’s mother. I n this way, preoperative teaching, as well as non-directive play, will become part and parcel of pediatric nursing practice. FOOTNOTES I. A Freud and D T Burlingham, War a n d Chi/dren ( N e w York: M e d i c a l W a r Books,
1943), p 65.
2. /bid. p 68.
REFERENCES M.
Axline. V
Books, 1~
-.
Dibs in
P i o y Therapy. New York: Ballantine
1969. Search of Self. N e w York: Ballantine
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A M A adopts metric system A l l publications
of the American Medical Association have been using the metric system of
measurements since January. Previously bath metric and English systems were used.
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