The specificities of communication in child nursing care

Abstracts

Objetiva-se, com esta investigação, identificar a forma do enfermeiro comunicar-se com a criança e analisar como a comunicação com a criança faz-se presente durante a assistência de enfermagem. Estudo descritivo, que utilizou conceitos vinculados às Representações Sociais. Foram entrevistados 49 enfermeiros que assistem a criança em tratamento e acompanhamento hospitalar, e a coleta de dados ocorreu mediante entrevista semiestruturada. Os resultados apontaram, após a análise temática, para a linguagem falada, linguagem comportamental e atitude profissional. Constata-se que a comunicação apresenta-se como fenômeno indissociável do cuidado à criança, transcendendo a transmissão de informações lineares. Conclui-se que, ao mapear a forma, como o fenômeno comunicação se concretiza na assistência à criança, coloca-se em relevo não apenas a comunicação, mas, principalmente, como ela se traduz, caracterizando a relevância das ações da enfermagem que apontam para uma perspectiva integral na assistência à criança.

Cuidados de enfermagem; Relações enfermeiro-paciente; Comunicação; Enfermagem pediátrica

ORIGINAL ARTICLE

The specificities of communication in child nursing care

Especificidades de la comunicación en atención de enfermería al niño

Elena Araujo Martinez^I; Florence Romijn Tocantins^II; Sônia Regina de Souza^III

^IRN, Doctoral student of the Anna Nery School of Nursing, Federal University of Rio de Janeiro - UFRJ, Master in nursing at Federal University of the State of Rio de Janeiro - UNIRIO; RN at Instituto Fernandes Figueira (IFF) – Pediatrics Department - FIOCRUZ. Rio de Janeiro - RJ - Brazil

^IIRN, Ph.D. in Nursing, Full Professor at the Public Health Nursing Department of the Alfredo Pinto School of Nursing - UNIRIO, Professor at the Nursing Graduate Program of UNIRIO. Rio de Janeiro - RJ - Brazil

^IIIRN, Ph.D. in Nursing, Adjunct Professor at the Medical-Surgical Nursing Department of the Alfredo Pinto School of Nursing- UNIRIO. Rio de Janeiro - RJ - Brazil

Author's address

ABSTRACT

This study aimed to identify the way nurses communicate with children and to analyze how this communication takes place during nursing care. It is a descriptive study that uses concepts associated with social representations. The authors interviewed 49 nurses who care for children in the hospital setting. Data collection occurred through semi-structured interviews. After thematic analysis, results emphasized the importance of spoken language, behavioral language and professional attitude. As evidenced, communication is presented as a phenomenon separate from child care, transcending the transmission of linear information. It is concluded that, in terms of understanding the communication phenomenon in child care, the way in which communication is presented and translated characterizes the relevance of nursing actions that point to a comprehensive perspective in child care.

Descriptors: Nursing care. Nurse-patient relationships. Communication. Pediatric nursing.

RESUMEN

Los objetivos de esta investigación: identificar la forma cómo la enfermera se comunica con el niño y examinar cómo la comunicación con el niño está presente durante la atención de enfermería. Estudio descriptivo que utiliza conceptos vinculados a de las Representaciones Sociales. Se entrevistaron a 49 enfermeros que asisten al niño en tratamiento y acompañamiento hospitalario y la recolección de datos se produjo por una entrevista semiestructurada. En el análisis temático de los datos se destacaron: lenguaje hablado, lenguaje comportamental y la actitud profesional. Toma nota de que la comunicación se presenta como un fenómeno integral, trascendiendo la transmisión lineal de información. Se concluye que mapear la forma cómo el fenómeno de la comunicación se concreta en la atención al niño, pone de relieve no sólo la comunicación, sino sobre todo cómo se traduce, caracterizando la pertinencia de las acciones de atención de enfermería la salud del niño.

Descriptores: Atención de enfermería. Relaciones enfermero-paciente. Comunicación. Enfermería pediátrica.

INTRODUCTION

In child care facilities, it is recognized that nursing professionals deal with several challenging situations in their daily routine, including meeting the health needs of patients and their families with responsibility and resolvability, which implicates the development of care management activities⁽¹⁾.

In child care, an organized and systematic nursing care process allows the nurse to analyze and perceive the health needs of their patients. Obtaining information regarding these needs derives from communication, among other methods, such as the data obtained through direct nursing activities⁽²⁾.

Regarding the provision of nursing care to children, words and behavior have a significant value. Hence, both verbal and non-verbal communication influence the reality in which the child is inserted, changing the perception of others and allowing the establishment of effective communication⁽³⁾.

It is important to highlight that in any situation experienced by the child during health care, regardless of the place where this care is offered, he/she goes through multiple complex experiences that lead to changes in lifestyle, which consequently cause the child to act, react and interact differently.

Children have singular characteristics that are expressed both through spoken and behavioral language (non-verbal communication). The care offered in light of their unique natures demands complex and full nurse-child interactions so that there is an understanding of the unpredictability of the child's behavior, since "an appropriate communication is that which aims to decrease conflicts, misunderstandings and achieves objectives defined for the solution of problems detected in the interaction with patients"⁽⁴⁾.

Regarding the communication theme, growing scientific interest is evidenced at the national and international level in the main virtual databases used for publications in the area of health care.

In the area of child care, the literature indicates that communication is considered to be an essential element for quality in the provision of nursing care, viewed as being fundamental in the care process⁽⁵⁾. The literature also highlights the role of the nurse, who must promote a safe, constructive and understanding environment which allows the child to maintain the abilities inherent to his/her development stage and to engage in experiences that encourage his/her growth⁽⁶⁾.

In light of these facts, considering the care experience of the child, this study emerges from the results of a master's dissertation titled "Communication in child nursing care: methods, influences and strategies"⁽⁷⁾, the purpose of which is to aggregate knowledge regarding the characteristics of communication in child nursing care, providing insight into care practices in terms of communication.

The study was based on the following guiding question: how does the nurse communicate with the child during the provision of care? In light of this, the study objective was to explore communication methods during child nursing care practices.

Based on this information, this study aimed to identify how the nurse communicates with the child and to analyze how this communication is present in nursing care.

METHODOLOGY

This is a descriptive qualitative study, using concepts of Social Representations⁽⁸⁾. Developing the study through the concepts of Social Representations, in light of the processes of objectification and anchoring, allowed us to understand the communication with the child in nursing care from the perspective of the nursing practice.

Moscovici highlights that "familiarization is always a constructive process of anchoring and objectification, through which the unfamiliar is given a place within our familiar world" ⁽⁸⁾.

Standing methodologically on the concepts associated with the theory of the social representations means, from an interpretative framework, making the representations intelligible as forms of social practice, thus allowing knowledge to be built with the purpose of giving meaning to people, events or phenomena. In this study, the phenomenon comprises communication with the child in nursing care.

The present study was developed in a federal health care institution, located in the municipality of Rio de Janeiro, which specializes in the care of women, children and adolescents. The scenes of study consisted of nursing wards (pediatric, infection-parasitic diseases and pediatric surgery), a pediatric outpatient clinic and intermediate (semi-critical) and intensive care units.

Study subjects were nurses from the units caring for children undergoing hospital monitoring and treatment. Nurses were chosen due to the understanding that the communication phenomenon is present in their daily care practice.

Data collection took place through semi-structured interviews carried out between February and April of 2009. Information was obtained once each nurse was individually invited to participate and informed regarding the purpose of the developing study. Their participation as study subjects was then requested and was confirmed when they signed the Free and Informed Consent Form.

Among the total of 51 nurses working in the different pediatric units in the institution, 49 agreed to participate as study subjects, with most of them being women (93.9%), with an average age of 34 years and nine years of clinical experience in pediatrics.

All nurses had a date scheduled for the interview. The author, in the intervals between the invitation and the development of the interviews, was available to be contacted at the Severe Patients Unit and let some nurses available to contact her at their convenience. Data were collected in social rooms and outpatient clinics, which allowed a calm and reserved environment aimed at minimum external interference.

The study development was focused mainly on the analysis of the statements generated by the question: "How do you communicate with the child during nursing care?" The interviewed nurses were identified with the names of stars; their statements were recorded on MP3 devices and were later fully transcribed. The procedure used for data treatment was thematic analysis ⁽⁹⁾.

The study was approved by the Research Ethics Committee of the institution under protocol number 0052/08, complying with ethical principles and criteria regarding studies with human beings⁽¹⁰⁾.

RESULTS

Data were organized as per the purposes established for the study. Thematic analysis allowed the ability to capture a variety of topics that were carefully grouped, considering the information contained in the statements. The statements were then regrouped ⁽⁹⁾, yielding the central axis: the means of communication between the nurse and the hospitalized child. This central axis pointed to communication in the form of spoken language, behavioral language and professional attitude. The identification of this first axis led to a new reading of the statements and the posterior extraction of themes⁽⁹⁾.

From the central axis – the means of communication between the nurse and the hospitalized child – seven themes emerged: speech (information regarding care procedures, involving the child, family and multiprofessional team, as well as inherent difficulties); touch – physical contact (nurse's approach to the child, affection, holding, touching and the ways of touching); look (identification of health needs); gestures (exchange of feelings and ideas in a clearer way); recreation (toys, play time, games, music, sounds, reading, drawings and coloring); nurse's attitude (attention provided to the child and family; transmission of safety and respect); and care actions (care as a moment of interaction – spoken and non-spoken communication).

This analysis process also allowed the author to identify content that points both to elements that influence the nurse's communication with the child, and to strategies used in this communication.

As articulated axes – and in constant relationship with the central axis – it was possible to identify the following themes that influence communication: service dynamics; characteristics of the child; technology used by the child; behavior of the child; and family. Regarding the strategies used to communicate with the child, the themes were: companion as interlocutor; reliability of companions; being attentive; and relationship between professionals and services.

The identification of the structural units of each axis in the communication phenomenon allowed the author to elaborate an image regarding the specifics of communication in child nursing care (Figure 1), expressing the synthesis and orientation of the study object.

It is known that the term 'communication' is formalized as a basic nursing instrument. Nevertheless, the findings of this study allowed the author to identify it as a phenomenon necessarily present during child nursing care in the broader perspective⁽¹¹⁾.

Hence, a new point of view is configured in terms of the form of the phenomenon: communication is characterized primarily as being inseparable from child nursing care.

DISCUSSION

For the nurse, communication is not a linear phenomenon, since it consists of an articulated network of institutional, family and personal relationships and information providing feedback. Based on this perspective, the nurse uses several situations to communicate during child nursing care.

Communication is a fundamental link used by the nurse during the provision of care. In this sense, the study revealed communication as being an inseparable phenomenon from child nursing care, yielding three registration units: spoken language, behavioral language and professional attitude.

Spoken language: the nurse's verbal communication in the provision of child nursing care

This first unit reveals a paradox: faced with a child with compromised health, the nurse experiences difficulties in communicating with those who cannot express themselves. However, at the same time, they try to overcome this difficulty by establishing an effective means of communication that perceives the child as the subject of care despite his/her clinical condition.

It is evident that nurses strive to constantly communicate and interact with the child, who despite their physical or biological needs, wish "to be perceived based on their strengths rather than on their differences"⁽¹²⁾, as expressed in the following speech:

I try to talk to her all the time, even if she doesn't listen to me or doesn't answer, because most of them don't. They are children who are generally very ill.(Acrux)

On the other hand, when faced with a child who does not speak, the nurse experiences difficulties or restrictions in establishing communication:

When the child is neuropathic, which we see a lot around here, sometimes I just forget. I go there, do the procedure and don't talk to that child, as if that was the normal routine. (Mimosa)

Spoken language is extremely important in child care, mainly because the hospitalized child must usually undergo several technical procedures and has "the right to know what is being done to him/her, why and what for"⁽¹³⁾.

During the treatment, the child is asked for their consent and procedures are explained, according to his/her understanding:

[...] but we ask: can I do this? It is going to be like this. (Avior)

In the development of care, the nurse may use spoken language as a facilitating pathway towards communicating with the child, appreciating his/her health condition, emphasizing the importance of the clinical treatment and respecting his/her individuality.

Another aspect related to spoken language and the facilitating path of communication is the strengthening of the nurse-child bond from the establishment of a relationship of trust with the companion.

Understanding the situation experienced by the child, based on communication with the child's companion, helps the nurse understand him/her better, especially when the professional has difficulties understanding the behavior of the child and when the latter cannot express his/her needs clearly, as exemplified in the following statement:

I talk to the mother, [...] without the mother we cannot win the child's heart. [...] without the caregiver it is more difficult, because he is a reference for the child, a support. If the caregiver is close, I notice some children will allow you to do the procedures more easily and are calmer. (Antares)

The establishment of a relationship of trust between nurse and caregiver helps the child to be calmer, which facilitates a better performance from the nurse⁽¹⁴⁾.

However, in the routine of the nurse's interaction with the child, the spoken language presents challenges and several factors may affect the communication process, including the condition of hospitalization itself.

Hospitalization is permeated with stressful events, and service dynamics are pointed out as being one of the elements influencing nurse-child communication:

In terms of mechanical care, sometimes you have something more urgent to do [...] so I act on the mechanical impulse and I often do not approach the child and talk to her. (Evanescence)

The complexity of child care often forces the nurse away from forming a closer bond, as illustrated in the following statement:

That would be time. I wish I had more time to prepare the environment for the child, so that I could do that procedure, but we don't always have time for that, it is just me in here. (Arrakis)

In addition to service dynamics, communication with the family during hospitalization is another challenge:

The child in the hospital context is not just a child alone- she has a family as well. So we have to integrate them. [...] Then I mention the verbal communication, because it is what we use to communicate with the family, but I think we don't communicate as we should [...] The family is not cared for, not assisted as well as they could be, both in terms of communication and in terms of care. (Evanescence)

The child must not be seen as an isolated being during hospitalization. He/she is part of a family nucleus and exists in a social context, which may directly and indirectly influence the period of hospitalization and the characteristics of care ⁽³⁾.

Therefore, it is understood that the spoken language – verbal communication- involves specific attention in the care provided to the hospitalized child. This specificity is appreciated, represented and, at the same time, distinguished in a context that comprises the assisted child, the family, the service and the nurse simultaneously.

Behavioral language: the nurse's non-verbal communication in child nursing care

Nurses point out that touching and physical contact are means of communication that are present in the interactions with the child, relating to the transmission of feelings of affection, safety and tranquility:

Touching, caressing and hugging are types of communication I use. (Achernar)

With touching, it involves holding her, getting close to her. (Maia)

Touching and physical contact are extremely important during nursing care, making the care provided to the child become more humanized. The nurse demonstrates involvement and tries to transmit calmness and tranquility even in the midst of a technical procedure⁽⁴⁾.

Another aspect of the nurse's non-verbal communication involves observing the child during care and communicating through eye contact. During hospitalization, the child has health needs that must be met, which are not always conveyed through speech. Through communication, the nurse identifies these needs in order to establish an appropriate plan of action ⁽⁴⁾.

In the statements, eye contact was identified as a way for the nurse to communicate with the child, who is capable of perceiving what happens around him/her. The nurse identifies his/her feelings, sensations and needs:

She is always demonstrating some need that I have to identify. And sometimes she does not even share this communication, this need, and I have to be attentive so that I can perceive the needs of this child, so that I can satisfy her. I think communication must be maintained with a recipient-messenger link, so that one demonstrates his expectations to the other. (Upisilon)

This ability to see the child beyond the health condition to establish an interactive relationship allows, through non-verbal communication, the development of genuine care and a true therapeutic relationship⁽⁴⁾.

During this therapeutic meeting, the nurse may also communicate with the child through gestures, demonstrating the care to be performed and facilitating understanding.

The child perceives and recognizes when the nurse communicates with him/her, demonstrating through gestures the activities to be performed, as identified in the following speech of a nurse:

But what it really important for the child is making gestures, showing them what you are going to do. Sometimes they don't understand it if you just explain what you are going to do. (Sirius)

Through the communication of gestures, the nurse demonstrates the care activities to the child, allowing him/her to understand more clearly and precisely the activities to be performed. Hence, in the hospital environment, the child feels safer and copes better with the period of hospitalization⁽⁴⁾.

Non-verbal communication in nursing care provided to the hospitalized child presents a specificity that must be appreciated and utilized by the nurse, since it provides a sensitive interaction and more humanized care through touch, physical contact, eye contact and gestures.

Professional attitude: the nurse's verbal and non-verbal interactions in child nursing care

Verbal and non-verbal communication are the elements that support care and care actions, allowing true exchanges between the caregiver (the nurse) and the one being cared for (the child), grounding relationships of interaction with sensitivity and affection.

In order to achieve effective communication, the nurse must use strategies aimed to facilitate the understanding of the child regarding the treatment and its purpose, supporting him/her so that he/she may feel safe according to his/her level of understanding⁽⁶⁾. Therefore, establishing communication with the child that transmits respect and safety during hospitalization is fundamental.

Nurses use their professional attitude as a resource to communicate with the child; among those resources, the recreational perspective stands out. This attitude involves toys, play, games and music, facilitating the approach of the nurse and allowing interaction.

By playing with the child, the nurse communicates with her during hospitalization^(6,15), creating bonds of trust and facilitating the understanding of the child regarding what might happen, thus allowing, a less traumatic hospital stay:

Playing, proposing a game, or participating in a game with her. It is different. You are building something that is going to be the base when it is time for you to act. (Pollux)

Sometimes I sing for children who are alone, without their mother, [...] I ask her to show me a toy, let them engage me. (Keid)

The communication established in the nurse-child relationship based on true speech, individual care, respecting the child and explaining the need for the treatment allows a more pleasant coping experience, generating the construction of a relationship of trust:

Calling them by their name, because if you do, they pay more attention. Speak more calmly. [...] because that is the way she feels better, calmer. (Bete-Hydi)

You should never lie to a child [...] look, it is just a little prick. For those who understand, I always try to keep contact, because the more you stay away the harder it is for you to win them over. (Acrux)

Another aspect that involves communication is the care actions performed during nursing care. Care actions permeate interpersonal relationships, and communication mediates and facilitates nurse-child exchanges⁽¹⁶⁾.

The activities developed with the child during care allow a closer and truer meeting. During these activities, the nurse communicates through both verbal and non-verbal language:

I think one of the ways is through the care provided to the child. I communicate through care. (Sargas)

The way you deliver care. [...]They way you touch the child with tenderness, you provide her with care, you interact with her, you talk. (Mirach)

Through communication with care actions the nurse aims at helping the child to recover and helps her face the disease and hospitalization, allowing the exchange of affection and experiences. At the same time, this specificity in communication allows the identification of the health needs of the hospitalized child, understanding him/her and communicating with him/her from a perspective of humanization.

FINAL CONSIDERATIONS

The communication of the nurse with the child takes place in the most singular and intimate moments in child care, in small expressions – verbal and non-verbal- as well as in all the things that somehow guide and permit care.

It was observed that communication does not occur in a linear way, but instead occurs through an articulated network of information that is present in the way the nurse communicates. Hence, it was possible to identify a new point of view: communication in its full meaning happens during the entire care context with the child, comprising spoken language, behavioral language and professional attitude.

This study allowed the unearthing of specifics of communication in child nursing care. Nursing communication implies a relationship that goes beyond the communication process itself. Communication is the conducting wire in meetings among human beings – care subjects and their families- recognized in those who think, feel, act and react within the whole care context.

It was evidenced that the nurse – child – family communication triad, in addition to its relevance, involves aspects influenced both by the institutional organization and the professional relationship established with the child as the subject of care. This evidence indicates the importance of the theme in question becoming the focus of future studies.

Therefore, it is concluded that this study has built new knowledge: spoken language, behavioral language and professional attitude are translated into elements constituting child nursing care. This partially reiterates the general findings broadly transmitted and integrated into nursing care. However, it is an advance in terms of mapping the way the communication phenomenon is developed in child care, emphasizing not only communication but also the way it is translated, characterizing the relevance of nursing care actions to the health of the child.

The authors recommend the development of new studies to broaden the specificity of communication in child nursing care, which will contribute to the establishment and strengthening of means of communication that promote coping mechanisms and well-being.

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Publication Dates

• Publication in this collection
  03 Apr 2013
• Date of issue
  Mar 2013

History

• Received
  29 Dec 2011
• Accepted
  18 Jan 2013