- Email: [email protected]
Family-centred services within Accident and Emergency Departments
International Emergency Nursing (2008) 16, 175–179
www.elsevierhealth.com/journals/aaen
Family-centred services within Accident and Emergency Departments Polly Lee Msc BA (Hons) RSCN RGN (Lecturer in child health)
*
City University, Philpot Street, Whitechapel, London, E1 ZEA, United Kingdom Received 12 July 2007; received in revised form 1 April 2008; accepted 21 April 2008
KEYWORDS
Abstract The concept of children and their families receiving family-centred care when the child is unwell is not new. Family-centred care has been examined extensively within children’s nursing curricula. However, recent policy documents have suggested that all child health services, not just children’s nursing, should be family-centred. The subtle differences between family-centred care and family– friendly care are identified. The skills for working with children are also examined in turn for all ED nurses. Whilst many ideas may not initially appear to be new or therefore innovative, a careful evaluation encourages individuals to rethink the services that they currently offer to children and their families. c 2008 Elsevier Ltd. All rights reserved.
Children; Family-centred; Family friendly; NSF
Introduction The care of children and their families in Emergency Departments has been influenced by recent policy reports and documents. Some of these documents relate specifically to Accident and Emergency services and include the Services for Children in Emergency Department (RCPCH, 2007) and for those in Scotland the Emergency Care Framework (Scottish Executive (2007). Other documents relate to child health care more generally and include the National Service Framework [NSF] for Children, Young People and Maternity services (DoH, 2004). Although published for England,
* Tel.: +44 207 040 5766. E-mail address: [email protected]
[Wales has its own children’s NSF (Welsh Assembly, 2005), and there is a similar document for Scotland (Scottish Executive, 2007)], one common theme within these child health strategy documents is that of ‘child centred care and family–friendly care’ (RCPCH 2007 Section 4). Standard 3 of the NSF states that ‘Children and young people and families receive high quality services which are co-ordinated around their individual and family needs and take account of their views’ (DoH, 2004, p. 87), and although published in England the principles are nevertheless applicable to all UK nurses who work with children in whatever health care setting the child is in. Indeed this approach would also have relevance to the wider international community. This article will critique the need for child and family friendly/centred care as identified within the policy documents stated
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.04.005
176 above and then examine how it may be implemented within the environment of the Emergency Department [ED]. The article will focus on the role of the clinical ED nurse.
What is child and family friendly/familycentred care? The Royal College of Paediatrics and Child Health (RCPCH, 2007) outlines child and family–friendly care in EDs though it fails to define child and family–friendly care. The NSF (DoH 2004) however, states how child, young person and family-centred services should be delivered. Additionally, within children’s nursing there is the concept of familycentred care that has been discussed within the literature for several years. It is important therefore, to gain an understanding of the similarities and differences between these differing terminologies. In order for ED nurses to understand the differences in these terms, they will now be examined in a historical chronological order. Family-centred care has been practiced in children’s nursing in the UK for some years. There are many definitions that have been debated within the literature. Ahmann (1988) and Hutchfield (1999) are some of those who have offered definitions, but more recently most children’s nurses within the UK have followed the continuum outlined by Smith et al. (2002). All of these definitions involve putting the child and family at the centre of the child’s care, as parents not only have a caring role, but unlike other patient and carer situations, parents have legal responsibilities associated with parenthood. The NSF (DoH 2004), in giving direction for all who come into contact with children in health services, likewise implies that firstly, all services for children are co-ordinated around individual and family needs, and secondly, services take account of children and their families’ views. Standard 3 therefore affects any manager who makes decisions on health services and not just health care professionals. However the RCPCH (2007 p27) only suggests that ‘EDs must accommodate the needs of children and accompanying families as far as is reasonably practical’ (Recommendation 1). Sadly, the RCPCH (2007) does not define reasonably practical, and it would therefore be easy for EDs to state that they had done everything that they considered to be reasonably practical. However, when considering the child and parent perspective, they may consider that more could be done. In this situation the NSF (DoH 2004) should be viewed as the more important document as the RCPCH (2007) report is just that – a re-
P. Lee port with recommendations, whereas the NSF (DoH 2004) is a policy document with standards that the government expects to be implemented within a 10 year time span of publication and affects all child health services. The implementation of the NSF standards will also be monitored.
Why there is a need for such a standard and recommendations? Although it may seem apparent to many ED nurses that family-centred care is the best way to practice child health nursing, there may not always be a full understanding regarding the necessity for this. Until the 1950s, care for children in hospital reflected the then current child-rearing practices of society when everything was very ritualistic and there was little emotional attachment to children. However, society has changed and there is now a much greater knowledge and understanding of the emotional needs of children and the devastating consequences that separation can have on a child’s emotional development (Bowlby 1953; Robertson 1970; Darbyshire 1993; Smith et al. 2002). Parents not only visit their child in hospital but now participate in their child’s physical and emotional care in EDs, anaesthetic rooms, and more recently recovery rooms (Harris 2007). In all health care settings parents are involved in decision making but each family must be assessed individually and health care staff cannot assume that parents want to be involved or participate in their child’s care (Coyne 1996; Lee 2004). A majority of more recently qualified nurses may not be fully aware of these former issues unless they have had the opportunity to view such films as ‘A two year old goes to hospital’ (Robertson 1952). Policies for the health care of children today therefore not only reflect current thinking but also aim to minimise any emotional effects of health care (DoH 2004). Family-centred care is but one way to minimise the emotional affects of a child’s illness. As there is a need therefore to have standards and recommendations regarding family-centred and child and family friendly care, there should likewise be clear guidelines for how such standards and recommendations should be implemented within EDs and how their effectiveness should be evaluated.
How the standard can be implemented in the ED? All health care professionals feel that they provide a good standard of care to their patients and cli-
Family-centred services within Accident and Emergency Departments ents but it is difficult to justify this unless measured against some previously defined standards. The recent raft of policy documents within child health and child care more generally has suggested that all professionals (not just health care professionals) who work with children should have a common core of skills and knowledge (DfES 2005). The skills and knowledge are identified under six main headings in Box 1 below and are describe in full by the DfES (2005). Box. 1 Common core of skills and knowledge (DfES 2005)
Effective communication and engagement with children, young people and families. Child and young person development. Safeguarding and promoting the welfare of the child. Supporting transitions. Multi-agency working. Sharing information.
As an example, the core skill of child and young person development states that those who work with children should ‘know that development includes emotional, physical, intellectual, social, moral and character growth, and know that they can all affect one another’ (DfES 2005 p11). All ED nurses working with children therefore need to ensure that they understand the theories not only of physical development, but also those of emotional development (for example Bowlby 1953), social development (for example Erikson 1963) and moral development (for example Kohlberg 1969). These are only examples and a knowledge of linguistic development is also necessary. It may be worth ED nurses ensuring that they feel comfortable with such developmental theories and there are many useful websites that outline these theories. The preceding example is one small section on one common core and therefore careful attention should be given, as above, to ensuring that all points of all the common core skills have been met. Acquiring knowledge and skills cannot be developed quickly. However, the common core skills are only meant to demonstrate a basic level of competence, and ED nurses must decide how much more than a basic level of competence they should be aiming for, especially as children are so vulnerable within the ED environment and often arrive without their parents or carer and may be in a distressed state.
177
The RCPCH (2007) has similarly produced a list of skills for those working in ED. These naturally focus on the skills required of all ED staff (particularly those working in departments where paediatric on-site support has been lost) in relation to the care of acutely sick or seriously injured children. The RCPCH (2007) makes specific recommendations for resuscitation training, airway management and the establishment of high-dependency and intensive care prior to the arrival of a ‘children’s retrieval team’ for transfer to a Paediatric Intensive Care Unit. However, the above recommendations are skills and the acquisition of these does not mean that family-centred care will be implemented. Likewise, recommendation 7 (RCPCH 2007) regarding staffing and training issues does not stipulate that family-centred care or family–friendly care should be implemented, neither does it state the skills that should be developed to provide family-centred care as suggested by Smith et al. (2002). Returning to the RCPCH (2007) report, the major thrust of section 4 (family friendly care) relates to the environment of the ED for children and their families. This includes recent government documentation on the physical space that is required for children attending the ED. The ambiance of the children’s area has been regularly discussed previously and therefore should have already been addressed by EDs, but it is useful that it is outlined here for the benefit of all ED staff. The ambiance for teenagers attending hospital has similarly been discussed within the adolescent literature (Hutton 2005) although less has been published in relation to the ambiance for teenagers within the ED. However, recent research suggests that children in hospital do not like wards decorated with images of clowns (Curtis et al. 2007), so it is imperative to ensure that such research is considered for its appropriateness to EDs, and where necessary, acted upon. The RCPCH (2007) also outlines the need for both play and a play specialist within the ED facilities. Again this is not a new phenomenon, rather it is a reiteration of previously published recommended practice (DoH 2004). The report does, however, make some suggestions regarding the role of the play specialist within an ED. Little thought seems to have been given to outlining the role of the play specialist in preparing children for procedures. Although in the ED there is often little time for such preparation, nonetheless there are usually a few minutes between deciding to undertake a procedure and the procedure actually being undertaken. Likewise if a child needs to be admitted to a children’s ward the play specialist
178 could have a role in preparing the child and family for admission to the ward. As well as recommendation 5 (p27) suggesting that ‘EDs seeing more than 16,000 children per year should employ play specialists at peak times’ consideration also needs to be given to how a play specialist could be ‘borrowed’ from a children’s ward at other ‘critical’ times for example, when there is a sudden influx of children or when a child has additional play preparation needs. Although recommendation 6 (p27) suggests that ‘Comments should be sought from children to improve services or facilities’ there is little detail as to how this could be done. Although the report suggests that children could be surveyed at the end of their visit, by then many families are anxious to get home as there may be siblings to collect who are temporarily being cared for by family/colleagues/ neighbours. Additionally, some children may be near the maximum recommended 4 h stay within an ED and may therefore ‘breach’ if the child (and family) were to be asked questions verbally, or indeed asked to complete an age appropriate questionnaire. Indeed it is considered that eliciting views from patients on discharge may not always be the best time and so consideration should be given to when children’s views can be obtained. As suggested previously, the section of the RCPCH Report (RCPCH, 2007) that examines child and family–friendly care focuses on the environment and play within the ED. However, as outlined at the beginning of this article it is suggested that family-centred care embraces more components than that of child and family–friendly care within the RCPCH report. Standard 3 of the NSF (DoH 2004) suggests two factors in the delivery of child-centred services, and these will now be explored in relation to the ED. Firstly, although health professionals recognise that all children are individuals, it is all too easy within the ED setting, for example, to treat all wounds or sprains in the same way, and not to consider the impact of the injury on the child or family. A child’s ethnicity, race, culture, faith, disability, sexual orientation and geographical location may all unknowingly impact on the way a child is actually approached by health care professionals – although of course it should not. So although services should be inclusive for all children (DoH 2004), services should at the same time recognise a child’s uniqueness. Secondly, the above standard (3) states that services need to take account of children and families’ views. As an example, the United Nations [UN] Convention for the Rights of the Child, [Article 12] (UN, 1989) proposes that children have a right
P. Lee to involvement in decisions regarding their care. The UN convention has been ratified in the UK, and all governments are asked to provide updates to the UN with regard to progress in the implementation of the articles. Article 12 of the UN convention (UN, 1989) applies to decisions regarding a child’s health care as well as other factors such as education and welfare, and so has actually been expected practice in the UK for some years. Even young children can make decisions, such as a willingness to take medicine. And they can be given a choice regarding sitting on a trolley or carer’s lap for a nebuliser. In respecting the two aspects of standard 3 (UN 1989) above, children and their families who feel valued and listened to, are more likely to be concordant or even compliant regarding their treatment in the ED and their ongoing management, normally at home where the care is supervised by the child’s family. Such improvement in care will, of course, enhance the child’s recovery from illness or injury.
Skills for implementing family-centred care in the emergency department Although Smith et al. (2002) do not provide a toolkit for the development of the necessary skills for the implementation of family-centred care they do provide some indicators. It is surprising how much can be learnt from talking to parents and families as opposed to reading notes (Ford 2002) and this will help less experienced ED nurses develop the communication skills required (DfES 2005) by the former DfES. Reflection and critical thinking are also suggested by Ford (2002). Whilst these are higher level skills it would be worth an ED nurse seeking clinical supervision from an experienced registered children’s nurse within the ED for the development of this skill, and not necessarily their own preceptor/clinical supervisor. The first step is that some basic skills as identified above are developed and ED nurses are committed to the development and implementation of family-centred care within the ED. Then issues such as fast turnover of patients and lack of resources (often considered as obstacles to the successful implementation of family-centred care) can be considered. Finally, where necessary, a definition of family-centred care or partnership can be adapted for EDs. Likewise, systems and processes already established within the ED can, where necessary, be reviewed to ensure the maximum possible contact with one ED nurse. Therefore, a greater increase in the implementation of family-centred care is possible.
Family-centred services within Accident and Emergency Departments
Evaluating family-centered care in EDs Evaluating family-centred care within the ED can be undertaken against Standard 3 of the NSF (DoH 2004) and, more personally, by reflection and critical thinking, as identified in the skills section above. ED nurses should therefore ensure that they are critically reflective in relation to their understanding of and implementation of family-centred care. This will go some way towards the implementation of family-centred care within the ED. However, children and families would also need to be asked for their opinions as suggested by RCPCH (2007), and these people are in the best position to evaluate if family-centred care has been implemented.
Conclusion Many of the ideas contained within the concept of family-centred services for children and their families are not new, and many health care professionals consider that they already practice in such a way as described in this article. However, readers are encouraged to reflect on their attitudes and approaches to what is intended to be a truly familycentred service, from the perspective of children and young people. An evaluation of services by children and young people themselves may provide some interesting insights for health care professionals.
References Ahmann, E., 1988. Examining assumptions underlying nursing practice with children and families. Pediatric Nursing 23 (5), 467–469. Bowlby, J., 1953. Child Care and the Growth of Love. Penguin, Harmondsworth. Coyne, I., 1996. Parent participation: a concept analysis. Journal of Advanced Nursing 723, 733–740. Curtis, P., James, A., Birch, J., 2007. SPACE TO CARE: Children’s Perceptions of Spatial Aspects of Hospitals. (accessed 15/02/08).
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Darbyshire, P., 1993. Parents, nurses and paediatric nursing: a critical review. Journal of Advanced Nursing 18 (11), 1670– 1680. DoH, 2004. Core Document, National Service Framework for Children, Young People and Maternity Services, DoH, London. (accessed 29/03/07). DfES, 2005. Common Core of Skills and Knowledge for the Children’s Workforce, DfES, London. (accessed 29/ 03/07). Erikson, E.H., 1963. Childhood and Society. Norton, New York. Ford, S., 2002. Learning to practice family-centred care. In: Smith, L., Coleman, V., Bradshaw, M. (Eds.), Family-Centred Care Concept Theory and Practice. Palgrave Macmillan, London. Harris, S., 2007. Care of the child in the operating theatre. In: Chambers, M.A., Jones, S. (Eds.), Surgical Nursing of Children. Butterworth Heinemann Elsevier, London. Hutchfield, K., 1999. Family-centred care: a concept analysis. Journal of Advanced Nursing 29 (5), 1178–1187. Hutton, A., 2005. Consumer perspectives in adolescent ward design. Journal of Clinical Nursing 14 (5), 537–545. Kohlberg, L., 1969. Stage and sequence: the cognitive-development approach to socialization. In: Gaslin, D. (Ed.), Handbook of Socialization: Theory and Research. Houghton Mifflin. Lee, P., 2004. Family involvement: are we asking too much?. Paediatric Nursing 16 (10) 37–41. Robertson, J., 1952. A Two Year Old goes to Hospital Ipswich: Concord Films. New York Film Library. Robertson, J., 1970. Young Children in Hospital, second ed. Tavistock Publications, London. Royal College of Paediatrics and Child Health, 2007. Services for Children in Emergency Departments: Report of the Intercollegiate Committee for Services for Children in Emergency Departments, RCPCH, London. (accessed 10/07/07). Scottish Executive, 2007. Delivering a Healthy Future: An Action Framework for Children and Young People in Scotland, Scottish Executive, Edinburgh. (accessed 10/ 07/07). Smith, L., Coleman, V., Bradshaw, M. (Eds.), 2002. FamilyCentred Care Concept Theory and Practice. Palgrave Macmillan, London. UN Convention on the Rights of the Child, 1989. Convention on the Rights of the Child. (accessed 11/07/07). Welsh Assembly, 2005. National Service Framework for Children, Young People & Maternity Services in Wales Welsh Assembly. (accessed 10/07/07).
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/aaen
Family-centred services within Accident and Emergency Departments Polly Lee Msc BA (Hons) RSCN RGN (Lecturer in child health)
*
City University, Philpot Street, Whitechapel, London, E1 ZEA, United Kingdom Received 12 July 2007; received in revised form 1 April 2008; accepted 21 April 2008
KEYWORDS
Abstract The concept of children and their families receiving family-centred care when the child is unwell is not new. Family-centred care has been examined extensively within children’s nursing curricula. However, recent policy documents have suggested that all child health services, not just children’s nursing, should be family-centred. The subtle differences between family-centred care and family– friendly care are identified. The skills for working with children are also examined in turn for all ED nurses. Whilst many ideas may not initially appear to be new or therefore innovative, a careful evaluation encourages individuals to rethink the services that they currently offer to children and their families. c 2008 Elsevier Ltd. All rights reserved.
Children; Family-centred; Family friendly; NSF
Introduction The care of children and their families in Emergency Departments has been influenced by recent policy reports and documents. Some of these documents relate specifically to Accident and Emergency services and include the Services for Children in Emergency Department (RCPCH, 2007) and for those in Scotland the Emergency Care Framework (Scottish Executive (2007). Other documents relate to child health care more generally and include the National Service Framework [NSF] for Children, Young People and Maternity services (DoH, 2004). Although published for England,
* Tel.: +44 207 040 5766. E-mail address: [email protected]
[Wales has its own children’s NSF (Welsh Assembly, 2005), and there is a similar document for Scotland (Scottish Executive, 2007)], one common theme within these child health strategy documents is that of ‘child centred care and family–friendly care’ (RCPCH 2007 Section 4). Standard 3 of the NSF states that ‘Children and young people and families receive high quality services which are co-ordinated around their individual and family needs and take account of their views’ (DoH, 2004, p. 87), and although published in England the principles are nevertheless applicable to all UK nurses who work with children in whatever health care setting the child is in. Indeed this approach would also have relevance to the wider international community. This article will critique the need for child and family friendly/centred care as identified within the policy documents stated
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2008.04.005
176 above and then examine how it may be implemented within the environment of the Emergency Department [ED]. The article will focus on the role of the clinical ED nurse.
What is child and family friendly/familycentred care? The Royal College of Paediatrics and Child Health (RCPCH, 2007) outlines child and family–friendly care in EDs though it fails to define child and family–friendly care. The NSF (DoH 2004) however, states how child, young person and family-centred services should be delivered. Additionally, within children’s nursing there is the concept of familycentred care that has been discussed within the literature for several years. It is important therefore, to gain an understanding of the similarities and differences between these differing terminologies. In order for ED nurses to understand the differences in these terms, they will now be examined in a historical chronological order. Family-centred care has been practiced in children’s nursing in the UK for some years. There are many definitions that have been debated within the literature. Ahmann (1988) and Hutchfield (1999) are some of those who have offered definitions, but more recently most children’s nurses within the UK have followed the continuum outlined by Smith et al. (2002). All of these definitions involve putting the child and family at the centre of the child’s care, as parents not only have a caring role, but unlike other patient and carer situations, parents have legal responsibilities associated with parenthood. The NSF (DoH 2004), in giving direction for all who come into contact with children in health services, likewise implies that firstly, all services for children are co-ordinated around individual and family needs, and secondly, services take account of children and their families’ views. Standard 3 therefore affects any manager who makes decisions on health services and not just health care professionals. However the RCPCH (2007 p27) only suggests that ‘EDs must accommodate the needs of children and accompanying families as far as is reasonably practical’ (Recommendation 1). Sadly, the RCPCH (2007) does not define reasonably practical, and it would therefore be easy for EDs to state that they had done everything that they considered to be reasonably practical. However, when considering the child and parent perspective, they may consider that more could be done. In this situation the NSF (DoH 2004) should be viewed as the more important document as the RCPCH (2007) report is just that – a re-
P. Lee port with recommendations, whereas the NSF (DoH 2004) is a policy document with standards that the government expects to be implemented within a 10 year time span of publication and affects all child health services. The implementation of the NSF standards will also be monitored.
Why there is a need for such a standard and recommendations? Although it may seem apparent to many ED nurses that family-centred care is the best way to practice child health nursing, there may not always be a full understanding regarding the necessity for this. Until the 1950s, care for children in hospital reflected the then current child-rearing practices of society when everything was very ritualistic and there was little emotional attachment to children. However, society has changed and there is now a much greater knowledge and understanding of the emotional needs of children and the devastating consequences that separation can have on a child’s emotional development (Bowlby 1953; Robertson 1970; Darbyshire 1993; Smith et al. 2002). Parents not only visit their child in hospital but now participate in their child’s physical and emotional care in EDs, anaesthetic rooms, and more recently recovery rooms (Harris 2007). In all health care settings parents are involved in decision making but each family must be assessed individually and health care staff cannot assume that parents want to be involved or participate in their child’s care (Coyne 1996; Lee 2004). A majority of more recently qualified nurses may not be fully aware of these former issues unless they have had the opportunity to view such films as ‘A two year old goes to hospital’ (Robertson 1952). Policies for the health care of children today therefore not only reflect current thinking but also aim to minimise any emotional effects of health care (DoH 2004). Family-centred care is but one way to minimise the emotional affects of a child’s illness. As there is a need therefore to have standards and recommendations regarding family-centred and child and family friendly care, there should likewise be clear guidelines for how such standards and recommendations should be implemented within EDs and how their effectiveness should be evaluated.
How the standard can be implemented in the ED? All health care professionals feel that they provide a good standard of care to their patients and cli-
Family-centred services within Accident and Emergency Departments ents but it is difficult to justify this unless measured against some previously defined standards. The recent raft of policy documents within child health and child care more generally has suggested that all professionals (not just health care professionals) who work with children should have a common core of skills and knowledge (DfES 2005). The skills and knowledge are identified under six main headings in Box 1 below and are describe in full by the DfES (2005). Box. 1 Common core of skills and knowledge (DfES 2005)
Effective communication and engagement with children, young people and families. Child and young person development. Safeguarding and promoting the welfare of the child. Supporting transitions. Multi-agency working. Sharing information.
As an example, the core skill of child and young person development states that those who work with children should ‘know that development includes emotional, physical, intellectual, social, moral and character growth, and know that they can all affect one another’ (DfES 2005 p11). All ED nurses working with children therefore need to ensure that they understand the theories not only of physical development, but also those of emotional development (for example Bowlby 1953), social development (for example Erikson 1963) and moral development (for example Kohlberg 1969). These are only examples and a knowledge of linguistic development is also necessary. It may be worth ED nurses ensuring that they feel comfortable with such developmental theories and there are many useful websites that outline these theories. The preceding example is one small section on one common core and therefore careful attention should be given, as above, to ensuring that all points of all the common core skills have been met. Acquiring knowledge and skills cannot be developed quickly. However, the common core skills are only meant to demonstrate a basic level of competence, and ED nurses must decide how much more than a basic level of competence they should be aiming for, especially as children are so vulnerable within the ED environment and often arrive without their parents or carer and may be in a distressed state.
177
The RCPCH (2007) has similarly produced a list of skills for those working in ED. These naturally focus on the skills required of all ED staff (particularly those working in departments where paediatric on-site support has been lost) in relation to the care of acutely sick or seriously injured children. The RCPCH (2007) makes specific recommendations for resuscitation training, airway management and the establishment of high-dependency and intensive care prior to the arrival of a ‘children’s retrieval team’ for transfer to a Paediatric Intensive Care Unit. However, the above recommendations are skills and the acquisition of these does not mean that family-centred care will be implemented. Likewise, recommendation 7 (RCPCH 2007) regarding staffing and training issues does not stipulate that family-centred care or family–friendly care should be implemented, neither does it state the skills that should be developed to provide family-centred care as suggested by Smith et al. (2002). Returning to the RCPCH (2007) report, the major thrust of section 4 (family friendly care) relates to the environment of the ED for children and their families. This includes recent government documentation on the physical space that is required for children attending the ED. The ambiance of the children’s area has been regularly discussed previously and therefore should have already been addressed by EDs, but it is useful that it is outlined here for the benefit of all ED staff. The ambiance for teenagers attending hospital has similarly been discussed within the adolescent literature (Hutton 2005) although less has been published in relation to the ambiance for teenagers within the ED. However, recent research suggests that children in hospital do not like wards decorated with images of clowns (Curtis et al. 2007), so it is imperative to ensure that such research is considered for its appropriateness to EDs, and where necessary, acted upon. The RCPCH (2007) also outlines the need for both play and a play specialist within the ED facilities. Again this is not a new phenomenon, rather it is a reiteration of previously published recommended practice (DoH 2004). The report does, however, make some suggestions regarding the role of the play specialist within an ED. Little thought seems to have been given to outlining the role of the play specialist in preparing children for procedures. Although in the ED there is often little time for such preparation, nonetheless there are usually a few minutes between deciding to undertake a procedure and the procedure actually being undertaken. Likewise if a child needs to be admitted to a children’s ward the play specialist
178 could have a role in preparing the child and family for admission to the ward. As well as recommendation 5 (p27) suggesting that ‘EDs seeing more than 16,000 children per year should employ play specialists at peak times’ consideration also needs to be given to how a play specialist could be ‘borrowed’ from a children’s ward at other ‘critical’ times for example, when there is a sudden influx of children or when a child has additional play preparation needs. Although recommendation 6 (p27) suggests that ‘Comments should be sought from children to improve services or facilities’ there is little detail as to how this could be done. Although the report suggests that children could be surveyed at the end of their visit, by then many families are anxious to get home as there may be siblings to collect who are temporarily being cared for by family/colleagues/ neighbours. Additionally, some children may be near the maximum recommended 4 h stay within an ED and may therefore ‘breach’ if the child (and family) were to be asked questions verbally, or indeed asked to complete an age appropriate questionnaire. Indeed it is considered that eliciting views from patients on discharge may not always be the best time and so consideration should be given to when children’s views can be obtained. As suggested previously, the section of the RCPCH Report (RCPCH, 2007) that examines child and family–friendly care focuses on the environment and play within the ED. However, as outlined at the beginning of this article it is suggested that family-centred care embraces more components than that of child and family–friendly care within the RCPCH report. Standard 3 of the NSF (DoH 2004) suggests two factors in the delivery of child-centred services, and these will now be explored in relation to the ED. Firstly, although health professionals recognise that all children are individuals, it is all too easy within the ED setting, for example, to treat all wounds or sprains in the same way, and not to consider the impact of the injury on the child or family. A child’s ethnicity, race, culture, faith, disability, sexual orientation and geographical location may all unknowingly impact on the way a child is actually approached by health care professionals – although of course it should not. So although services should be inclusive for all children (DoH 2004), services should at the same time recognise a child’s uniqueness. Secondly, the above standard (3) states that services need to take account of children and families’ views. As an example, the United Nations [UN] Convention for the Rights of the Child, [Article 12] (UN, 1989) proposes that children have a right
P. Lee to involvement in decisions regarding their care. The UN convention has been ratified in the UK, and all governments are asked to provide updates to the UN with regard to progress in the implementation of the articles. Article 12 of the UN convention (UN, 1989) applies to decisions regarding a child’s health care as well as other factors such as education and welfare, and so has actually been expected practice in the UK for some years. Even young children can make decisions, such as a willingness to take medicine. And they can be given a choice regarding sitting on a trolley or carer’s lap for a nebuliser. In respecting the two aspects of standard 3 (UN 1989) above, children and their families who feel valued and listened to, are more likely to be concordant or even compliant regarding their treatment in the ED and their ongoing management, normally at home where the care is supervised by the child’s family. Such improvement in care will, of course, enhance the child’s recovery from illness or injury.
Skills for implementing family-centred care in the emergency department Although Smith et al. (2002) do not provide a toolkit for the development of the necessary skills for the implementation of family-centred care they do provide some indicators. It is surprising how much can be learnt from talking to parents and families as opposed to reading notes (Ford 2002) and this will help less experienced ED nurses develop the communication skills required (DfES 2005) by the former DfES. Reflection and critical thinking are also suggested by Ford (2002). Whilst these are higher level skills it would be worth an ED nurse seeking clinical supervision from an experienced registered children’s nurse within the ED for the development of this skill, and not necessarily their own preceptor/clinical supervisor. The first step is that some basic skills as identified above are developed and ED nurses are committed to the development and implementation of family-centred care within the ED. Then issues such as fast turnover of patients and lack of resources (often considered as obstacles to the successful implementation of family-centred care) can be considered. Finally, where necessary, a definition of family-centred care or partnership can be adapted for EDs. Likewise, systems and processes already established within the ED can, where necessary, be reviewed to ensure the maximum possible contact with one ED nurse. Therefore, a greater increase in the implementation of family-centred care is possible.
Family-centred services within Accident and Emergency Departments
Evaluating family-centered care in EDs Evaluating family-centred care within the ED can be undertaken against Standard 3 of the NSF (DoH 2004) and, more personally, by reflection and critical thinking, as identified in the skills section above. ED nurses should therefore ensure that they are critically reflective in relation to their understanding of and implementation of family-centred care. This will go some way towards the implementation of family-centred care within the ED. However, children and families would also need to be asked for their opinions as suggested by RCPCH (2007), and these people are in the best position to evaluate if family-centred care has been implemented.
Conclusion Many of the ideas contained within the concept of family-centred services for children and their families are not new, and many health care professionals consider that they already practice in such a way as described in this article. However, readers are encouraged to reflect on their attitudes and approaches to what is intended to be a truly familycentred service, from the perspective of children and young people. An evaluation of services by children and young people themselves may provide some interesting insights for health care professionals.
References Ahmann, E., 1988. Examining assumptions underlying nursing practice with children and families. Pediatric Nursing 23 (5), 467–469. Bowlby, J., 1953. Child Care and the Growth of Love. Penguin, Harmondsworth. Coyne, I., 1996. Parent participation: a concept analysis. Journal of Advanced Nursing 723, 733–740. Curtis, P., James, A., Birch, J., 2007. SPACE TO CARE: Children’s Perceptions of Spatial Aspects of Hospitals.
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Darbyshire, P., 1993. Parents, nurses and paediatric nursing: a critical review. Journal of Advanced Nursing 18 (11), 1670– 1680. DoH, 2004. Core Document, National Service Framework for Children, Young People and Maternity Services, DoH, London.
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