IMMUNIZING CHILDREN IMMUNIZING CHILDREN WHO FEAR NEEDLESWHO FEAR NEEDLES

By Mary IvesBy Mary IvesRN, BSN, MHSRN, BSN, MHS

Chilliwack, BCChilliwack, BC

Goal:Goal: To prepare nurses to immunize To prepare nurses to immunize children who fear needles.children who fear needles.

Learning objectives:Learning objectives:

1.1. To identify practice issues when To identify practice issues when immunizing children who fear needles.immunizing children who fear needles.

22. To explore ethical actions to guide the . To explore ethical actions to guide the process and facilitate child cooperation.process and facilitate child cooperation.

AgendaAgenda

Problem definitionProblem definition

Stress responseStress response

Problem solving processProblem solving process

Guiding principles and interventionsGuiding principles and interventions

EvaluationEvaluation

Problem BackgroundProblem Background

Fear of needles is one of children's’ top 3 fears. Fear of needles is one of children's’ top 3 fears. Up to 10% of children feel anxious and helpless Up to 10% of children feel anxious and helpless before immunization. before immunization. (Bowen & Dammeyer, 1999)(Bowen & Dammeyer, 1999)

Actual pain appears to be less Actual pain appears to be less important than fear of pain.important than fear of pain.

Temperament, previous experience, environment Temperament, previous experience, environment and adult behaviour influence child coping and and adult behaviour influence child coping and distress behaviour distress behaviour (Cohen, Manimala, Blount, 2000)(Cohen, Manimala, Blount, 2000)

Background – from literatureBackground – from literature Much variability in effectiveness of Much variability in effectiveness of

interventions.interventions.

Distraction is a reliable toolDistraction is a reliable tool (Duff, 2003). (Duff, 2003).

Adult coaching can help children with Adult coaching can help children with painful medical procedures painful medical procedures (Cohen, 1997).(Cohen, 1997).

Topical anesthesia results are equivocal Topical anesthesia results are equivocal (Martin, Ramsay, Whiney, Fiset & Weinstein, 1994).(Martin, Ramsay, Whiney, Fiset & Weinstein, 1994).

Problem definition Problem definition (Ives, 2007)(Ives, 2007)

1.1. Immunizing resistant children is stressful for Immunizing resistant children is stressful for nurses.nurses.

2.2. Child resistance and certain adult behaviours Child resistance and certain adult behaviours create an ethical dilemma for nurses.create an ethical dilemma for nurses.

3.3. Adult behaviours can make the situation more Adult behaviours can make the situation more difficult and even unsafe.difficult and even unsafe.

4.4. Resources to support best practice are Resources to support best practice are needed.needed.

RelevanceRelevance

Best immunization practiceBest immunization practice

Stress ResponseStress Response

Children under stress often react in Children under stress often react in an undisciplined way.an undisciplined way.

When a person is overstressed the brain When a person is overstressed the brain has limited ability to process information.has limited ability to process information.

A person cannot be stressed and relaxed A person cannot be stressed and relaxed at the same time.at the same time.

PROBLEM SOLVINGPROBLEM SOLVING

Understand/define the problemUnderstand/define the problem Brainstorm possible solutionsBrainstorm possible solutions Choose and apply a solutionChoose and apply a solution EvaluateEvaluate Adapt as neededAdapt as needed Understand the problem may not be Understand the problem may not be

solvable at this timesolvable at this time

Guiding Principles/BeliefsGuiding Principles/Beliefs

Nurses respect the intrinsic dignity of Nurses respect the intrinsic dignity of each person each person (CNA code of ethics).(CNA code of ethics).

Nurses provide safe, compassionate, Nurses provide safe, compassionate, competent and ethical care competent and ethical care (CNA code of ethics).(CNA code of ethics).

Honest interactions foster trust.Honest interactions foster trust.

Guiding Principles/BeliefsGuiding Principles/Beliefs

Children do well if they can, not just if Children do well if they can, not just if they want to they want to (R.W. Greene).(R.W. Greene).

Children do better when they feel Children do better when they feel better, not when they feel worse better, not when they feel worse (Jane (Jane

Nelsen).Nelsen).

People need encouragement People need encouragement like plants need water like plants need water (Rudolf Dreikurs).(Rudolf Dreikurs).

Approach and InterventionsApproach and Interventions

1.1. Model empathy and respect.Model empathy and respect.

2.2. Structure the environment.Structure the environment.

3.3. Use distraction and calming tools.Use distraction and calming tools.

1. Model Empathy and Respect1. Model Empathy and RespectAcknowledge feelingsAcknowledge feelingsAsk about previous experiencesAsk about previous experiencesGive permission to cryGive permission to cryUse fantasy to acknowledge wishesUse fantasy to acknowledge wishesDo not give false reassuranceDo not give false reassuranceDo not tolerate threats, shaming or Do not tolerate threats, shaming or

manipulation from adultsmanipulation from adultsEncourage effortEncourage effortRemain firm and respectfulRemain firm and respectful

2. Structure the environment2. Structure the environment

Generally, start with the most anxious firstGenerally, start with the most anxious first

Prepare the immunization out of sightPrepare the immunization out of sight

Give information about what you plan to doGive information about what you plan to do

Involve the parents and the childInvolve the parents and the child

Provide limited choicesProvide limited choices

Manage the time and set limitsManage the time and set limits

Provide an option to rest or deferProvide an option to rest or defer

3. Use calming and distraction 3. Use calming and distraction

Promote slow deep breathingPromote slow deep breathing

I think I canI think I can

I think I canI think I can

Encourage positive self-talk Encourage positive self-talk

Use bubbles for distraction Use bubbles for distraction

Allow opportunity for nurses to debrief Allow opportunity for nurses to debrief after challenging situationsafter challenging situations

Communicate policy of least restraintCommunicate policy of least restraint

Develop resources for parentsDevelop resources for parents

Access presentation and materials at:Access presentation and materials at:

http://immunizingchildren.wordpress.com/

ReferencesBowen, A., & Dammeyer, M. (1999, October). Reducing Children’s Immunization Distress in a Primary Care Setting. Journal of Pediatric Nursing, 14(5), 296-303.Cohen, L., Blount, R., & Panopoulos, G. (1997). Nurse Coaching and Cartoon Distraction: An Effective and Practical Intervention to Reduce Child, Parent and Nurse Distress During Immunizations. Journal of Pediatric Psychology, 22(3), 355-370.Cohen, L., Manimiala, R., & Blount, R. (2000, Spring). Easier Said Than Done: What Parents Say They Do and What They Do During Children’s Immunizations. Children’s Health Care, 29 (2), 79-87.Dreikurs, R. cited by Dinkmeyer, D. & McKay, G. (1997) in Systematic Training for Effective Parenting. www.Steppublishers.comDuff, A. (2003). Incorporating psychological approaches into routine paediatric venipuncture. Archives of disease in Childhood. 88:931-937.Greene, R.W. & Ablon, S. (2006) Treating Explosive Kids: The Collaborative Problem Solving Approach. New York: Guildford Press.Hodges, F. M., Svoboda, J. S., & Van Howe, R. S. (2002). Prophylactic Interventions on Children: Balancing Human Rights With Public Health. Journal of Medical Ethics, 28, 10-16. Ives, M. (2007). Model Empathy and Respect When Immunizing Children Who Fear Needles. Canadian Nurse. Apr. p.6-7.Lott, L. & Nelsen, J. (1998). Teaching parenting the Positive Discipline Way (5th Ed.). Orem, Utah: Empowering People.Martin, M., Ramsay, D., Whitney, C., Fiset, L., & Weinstein, P. (1994). Topical Anesthesia: Differentiating the Pharmacological and Psychological Contributions to Efficacy. Anesth Prog, 41: 40-47.O’Laughlin, E. & Ridley-Johnson, R. (1995). Maternal Presence During Children's Routine Immunizations: The Effect of Mother as Observer in Reducing Child Distress. Children’s Health Care, 24(3), 175-191.McVittie, J. (2009). Positive Discipline Facilitator Training Manual. Sect. 8. p. 40.