The United Nations (UN) Convention on the Rights of the Child (UN, 1989) advocates the right of every child to self-determination, dignity, respect, non-interference and the right to make informed decisions. When children and young people (CYP) need hospitalisation or nursing care in the community, these fundamental rights may be tested. Therefore, developing an effective therapeutic relationship with good communication skills, is essential for nurses when caring for CYP.
Good nursing communication is also integral to family-centred care because this is the way nurses establish and build relationships with the CYP, their family/carer and other health professionals. In this relationship, families are considered full partners in the provision of health care to CYP (Harrison, 2010). The importance of providing understandable, unbiased and timely information in a supportive way is identified as essential in enhancing family-centred care (Coyne et al, 2011). Effective communication supports and encourages positive relationships between the family and the nurse, while poor communication can do the opposite and undo this relationship.
CYP and parents/carers are not the only stakeholders to benefit from improved communication; use of certain interviewing skills can improve diagnostic accuracy and increase disclosure of psychological problems, which can underline or exacerbate many paediatric problems (Howells and Lopez, 2008). Although CYP may be able to report the nature of symptoms, they may not be very good at reporting the timing and duration of their problems. They may also not report problems if they are embarrassing or show them in a bad light (Srinath et al, 2019). Effective nursing communication to elicit accurate information can aid the healthcare multidisciplinary team to optimise care and improve the experience of the CYP and their families/carers. Measuring patient experience is important, not only to guide service improvement, but also because people's experiences of care may be linked to clinical outcomes and costs (Riskind et al, 2011)
Nurses must develop the communication skills necessary to inspire trust and maintain a professional relationship with children of all ages and levels of emotional and psychological development (Roberts et al, 2015). Furthermore, Brady (2009) identified that children form opinions about nurses by integrating appearance and body language with the spoken word, such as their demeanour (face and body), hand position, body posture and gait. Therefore, it is important that nurses recognise the impact they have on the child and the family and the features of good verbal and non-verbal communication.
Research by Fletcher et al (2011) collated the views of CYP on what skills, knowledge and attitudes children's nurses of the future will need to care for sick children and their families, including essential fundamental verbal and non-verbal communication skills (Box 1)
Nurses who smile and are approachable, and who are able to talk and actively listen to children, giving reassuring expert explanations before any procedure, will be in a strong position to support children and their families through hospital admission and any interventions required (Fletcher et al, 2011)
The child or young person's developmental stage
Clearly, when a nurse is communicating with a child or young person, they need to consider the client's age and level of development (Dos Santos et al, 2016), to acknowledge levels of understanding or communication difficulties. This includes paying explicit attention to any learning disabilities and difficulties that may make effective communication and care delivery more complex. Young children are often reliant on adults to make decisions on their behalf as they may lack understanding of illness and treatments and this in turn creates challenges for nurses (Duderstadt, 2014). To consider how age and stage should influence practice, it is helpful to review the aspects of development that are most pertinent. Nurses must consider a child's cognitive, social, emotional and speech development. All these factors have a role in communicating effectively (Kolucki and Lemish, 2011). It is not possible to explore each fully in this article, therefore the following is a review of key points. It is also important to note that the following discussion relates to the theoretical stages of development. Therefore, nurses need to assess each client as an individual, as outlined in the code of conduct (Nursing and Midwifery Council, 2018). This is especially the case if a child or young person has an additional need.
Piaget's stages of cognitive development (Cherry, 2020) provides an overview in relation to how individuals relate to concepts. These are also set out in Table 1. There are numerous contexts where this should affect a nurse's approach to communication. Consider explaining an intervention or providing health education for a child or young person. For example, if a nurse needs to promote good inhaler technique to a 5-year-old, pictures may help or actively showing the correct method. The child is improving their language and thinking but they tend to understand things in concrete terms.
| Stage | Age range | What happens at this stage? |
|---|---|---|
| Sensorimotor | 0–2 years old | Co-ordination with motor responses, sensory curiosity about the world. Language used for demands and cataloguing. Object permanence is developed |
| Preoperational | 2–7 years old | Symbolic thinking, use of proper syntax and grammar to express concepts. Imagination and intuition are strong, but complex abstract thoughts are still difficult. Conservation is developed |
| Concrete operational | 7–11 years old | Concepts attached to concrete situations. Time, space and quantity are understood and can be applied, but not as independent concepts |
| Formal operational | 11 years old and older | Theoretical, hypothetical and counterfactual thinking. Abstract logic and reasoning. Strategy and planning become possible. Concepts learnt in one context can be applied to another |
Social and emotional development are closely connected to one another. Table 2 provides an overview of a child's social and emotional development. These developmental stages allow a nurse to consider the best manner in which to approach the forming of a therapeutic relationship. If a child is 18 months old and requires distraction through play, they could be facilitated to choose which toy they would like to interact with. It is also important to consider the importance of significant adults, such as parents and carers, and their level of understanding when communicating with children and young people. Developmentally they may be socially independent from a parent but still require their emotional support in times of difficulty.
| Age | Social and emotional stage |
|---|---|
| 0–3 months |
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| 3–6 months |
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| 6–9 months |
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| 9–12 months |
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| 1–2 years |
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| 2–3 years |
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| 3–4 years |
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| 3–7 years |
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| 7–11 years |
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| Adolescence |
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Speech development is also important. This is both a cognitive and a physical skill that requires confidence to achieve. In Table 3 the stages of speech development are outlined. When communicating with a child or young person, a nurse must assess their level of speech development and adapt their skills in response to this. For example, when asking a 3-year-old child a question, the vocabulary should be basic and should only require a two or three word response from the child.
| Age | Speech development |
|---|---|
| 0–3 months | Smiles and interacts with others. Cries to communicate needs. Tends to differentiate cries to a need |
| 4–7 months | Babbles and makes both short and long sounds to communicate |
| 7 months–2 years | Understands what others are saying and is able to follow simple instructions. They can also answer simple questions by 2 years old, with new words being added to their vocabulary every day |
| 2½–3 years | Uses two-to-three-word sentences to talk about and ask for things |
| 4–5 years | Can name letters and numbers. Is able to hold a longer conversation |
Children's nurses have a duty of care to address the needs of the child and the family/carers. The relationship and communication skills required by the nurse must address the needs and understanding of all ages and stages of development of the child (Roberts et al, 2015) to develop an effective therapeutic relationship with the CYP and their family.