Lifelong Learning Programme

This project has been funded with support from the European Commission.
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Training for Paediatricians and Paediatric Students

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This training package is addressed to students and medical practitioners in paediatrics on how to autonomously learn, develop and consolidate their soft skills for improving the quality of paediatric services.

Communication with Children

Table of Content

1.5 Building Trust
One of the core competencies that a pediatrician must possess is the ability to successfully build rapport with a pediatric patient and family and interact with the patient in an age appropriate manner. We cannot build rapport and trust if we cannot communicate effectively with a child. The first aspect of building rapport is to get down to the child’s level, physically. Standing over a child conveys the message that you are in charge and have power over the child. Getting down to the patient’s level shows that you want to be an equal and engage with the child.

Once you are engaged with the child, ask questions and do not assume you know the answers. For example, if a patient is crying, instead of saying, “I know you are scared.” you could say “I see you are crying. Can you tell me why you are crying or how you are feeling right now?” Then make sure you validate the answer and feelings that the child expressed to you.

It is important to remember that however the child feels is considered normal. Do not tell a child, “Don’t be scared; it will be ok.” It is appropriate for the child to be scared. With pediatric patients, you cannot assume anything about their understanding of the hospitalization. Depending on developmental level and past experiences, the patient may have many misconceptions.

It is important when building rapport, not to use words the patient may not understand. For example, telling a four year old child, “You are going to have an IV placed in your arm by the VAT (Vascular Access Team).” could be interpreted as, “You are going to have a plant (ivy) put in your arm by a bat.” This misconception is due to a four year old child’s magical thinking. Instead you could say, “You are going to have a small tube, like a straw, put in your arm so that you can get some water and medicine through the tube. A nurse is going to come into your room to put that straw in your arm.” At that point the pediatrician can provide the patient with an opportunity for medical play to help familiarize the patient with the IV and associated medical equipment, as well as an opportunity to discuss and rehearse a coping plan.

Another component in successfully building rapport with a patient is to be honest and not make promises you cannot keep. If you tell a child, “I promise that your chest tube will be taken out by the end of the day.” and it does not get removed for two more days, that child may have a difficult time trusting you again. And the child could generalize the lack of trust to all or most medical team members since a medical professional “lied” to her. Be open and honest about what is going to happen. You could say, “I hope that we can take out your chest tube today, but I can’t make any promises. I know you are ready to get it out so we will take it out as soon as we are sure you don’t need it anymore.”

Small Talk. Don’t dive into the medical talk right away. Even with time constraints, taking a few minutes out to talk about the child’s school, interests or hobbies also helps strengthen the rapport.

Use of Toys. Some doctors may feel more comfortable with this technique than others, but the use of toys like stuffed animals, sock puppets or dolls can be a powerful tool for connecting with a child and making a scary situation less so. A child’s cooperation can be obtained through play. If the child appears shy, build trust by asking how his little animal toy is feeling today: ’How does Teddy feel today?’ Follow up on the child’s answer with: ’And how do you feel?’ Offering to tak the Teddy’s temperature first may alleviate fear of thermometer.

Prior Contact with Child (if possible). Seeing the same child for several visits or over some length of time, the child will be more likely to be more comfortable and familiar with you.

Friendliness. An open, friendly expression, smiles, and a likeable manner can also help to reassure children who may be feeling afraid or confused about what is happening to them. Keep your voice low-pitched and gentle.

Expression of Interest in the Child. For older children, asking about a child’s interests and actively listening can also build rapport. Children are responsive to eye-level contact. Either raise them to your height or lower yourself to theirs.

In building rapport, consider the developmental age of the patient.

In the age group of 1-3 years, a primary source of stress during hospitalization is restriction of ambulation and access to areas to explore. Being limited in ability to explore can cause regression in a child’s psychomotor, behavioral and social skills. Allowing the child to explore during the hospitalization and even during examinations (e.g., playing with the stethoscope) can help reduce this anxiety. Find ways to encourage mobility outside of the child’s hospital room if possible. Utilizing age appropriate activities such as giving the child stickers, blowing bubbles and playing with toys can be an effective way to build trust.

Age group 4 to 5 years. One of the preschool child’s main sources of stress is magical thinking. Children believe they have the ability to wish things to happen (Rollins et al., 2005). Children at this age may view the hospital as a form of punishment, thinking that it is their fault that they are hospitalized. If children of this age are not given the opportunity for practice and development of psychomotor, behavioral and social skills, they may experience regression in these skills. Using developmentally appropriate language and explaining what you are going to do before you do it can help mitigate fears and eliminate misconceptions. Explaining why the patient is having a procedure or receiving medicine so as to clarify any misconceptions is very important. If a patient requires a procedure, it can be effective to perform the procedure in a room other than the child’s hospital room (e.g., a treatment room). This helps to keep the child’s hospital room a relatively safe place.

Age group 6 to 12 years. Much of the school-age child’s stress in the hospital is centered on the lack of socialization and absence of a normal schedule. Contact with family and peers is very important. Implementing a schedule, including times when patients can interact with other patients their age (if appropriate) or communicate with their peers and families, is important.
Practical Applications
Scenario 9 – Building Trust The scenario describes an encounter between a pediatrician and Ilinca, a 5-year-old girl, who was admitted in the Pediatrics Clinic for fever and productive cough. Based on the clinical exam, laboratory tests, and chest X-ray, the pediatrician established the diagnosis of pneumonia, and decided to administer intravenous treatment. She is admitted with her mother. When the pediatrician enters the room and greets her, the girl is so afraid that she runs into her mother’s arms to hide. The scenario will underline the importance of building trust with small children through expression of friendliness and play.
Softskills in the video: explaining and clarifying misconceptions, building trust through expression of friendliness and play.
The Transcript in English is available
Scenario 10 – Building Trust The scenario describes an encounter between a pediatrician and Ilinca, a 10-year-old girl, admitted for a severe food allergy. She is admitted alone because her mother has to work. She feels very scared and alone. The pediatrician enters her room, and sits next to her on the bed. The scenario will underline the importance of building trust in treating pediatric patients.
Softskills in the video: sitting at the child’s level, friendliness, expression of interest in the child, assurance of contact with familiy members and play with other inpatients, asking questions.
The Transcript in English is available
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This project has been funded with support from the European Commission. This web site reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.