The content,format and timing of a preparation for childhood hospitalization booklet

Introduction

Preparation for hospitalization is a right of all children and its practice requires improvement (Association for the Welfare of Child Health, 2005). Preparation benefits children and their families because it provides information and appropriate support which are known to be crucial for positive outcomes. Optimal preparation practice is both difficult to define and challenging to provide. The difficulty in definition is due to the range of approaches that may or may not be useful depending on the developmental stage of children and the content, format and timing of preparation. The challenges of the provision of preparation relate to the extent to which clinicians engage with the complexity of preparation and then seek to improve their practices. A working definition of optimal preparation for hospitalization is preparation using the most beneficial activities that prepare children before, during or after hospitalization.

Aim

As a way of mobilizing collective action for desired change in order to improve preparation for childhood hospitalization practices, a group of health-care professionals facilitated the reinstatement of a hospital-approved preparation for childhood hospitalization booklet (Salmon et al., 2006). Some of the reinstatement challenges included determining what constitutes appropriate preparation and what materials or approaches meet the needs of children and their families for a specific procedure preparation. The group of health-care professionals were aware that these materials were more likely to be used when clinicians were involved in their development and so clinician involvement was crucial to the success of the project.

Background

The systematic literature review of childhood hospitalization preparation was broadly based, and it was honed down to literature that was both relevant and rigorous. The keywords used in the search were children or paediatric, hospitalization, preparation, surgery, preoperative information, control, coping, resilience, temperament, illness concepts, intervention and strategies. The review period covered the years from 1990 to 2013, and the categories shown in Figure 1 were added to and reviewed over that period of time.

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Figure 1.

Selection process of literature on preparation for childhood hospitalization (adapted from Jeon et al., 2010: 56).

The literature developed in response to an awareness that hospitalization is an event that has unpredictable and often negative outcomes for children and their families (Platt, 1959). Interest in childhood hospitalization started in the middle of the 20th century and slowly developed up until the 1990s when many theorists and researchers were involved in seeking to develop simple ‘recipes’ to prepare children for hospitalization, using a wide range of approaches. Since the mid-1990s, researchers have been addressing specific kinds of hospitalization using preparation approaches that are tailored to them.

Childhood hospitalization is a significant and potentially anxiety-provoking and distressing event in the lives of children and their families that seems to have inconsistent outcomes depending on many variables (Caldas et al., 2004; Haslum, 1988; Platt, 1959; Thompson, 1986; Vernon et al., 1966). Nevertheless, a common outcome of hospitalization for children and their families is that anxiety and distress before, during and after the hospitalization are routine (Melnyk, 2000; Wray et al., 2011).

Information provision for childhood hospitalization that considers the recipient’s cognitive development and the content of the information, its format and language and its timing will potentially lessen the negative impact of hospitalization (Jaaniste et al., 2007). Lambert et al. (2013) conducted a study into the transmission of information to parents and children by health-care professionals. The researchers found that each individual had a wide range of needs and desires for information and recommended that information provision should be tailored to individual children and their parents (Lambert et al., 2013). The majority of approaches provide information either generically or in relation to a health-care procedure (Clough, 2005; Kain et al., 2007; Keller, 2001; McEwen et al., 2007; O’Shea et al., 2010; Rassin et al., 2004).

One of the challenges to improving childhood hospitalization preparation has been engaging clinicians in researching and improving practice because they express their ‘busyness’ and the existence of a workplace environment that does not support or recognize their input and suggestions regarding improvements in patient care (Hockenberry et al., 2006). As a way to involve clinicians in both the research and the improvement in practice, an action research approach was taken. The action group used one of several action cycles to investigate a pre-existing booklet to determine whether it could be reinstated for use in improving the experience of the micturating cystourethrogram (MCU) procedure for children and their parents through information provision (Figure 2).

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Figure 2.

Components of the action cycles including the place of the cycle involving the procedure information booklet.

Method

Investigation of the MCU booklet utilized one cycle of action research. This cyclical approach has been used successfully in acute children’s nursing to improve clinical practice, for example, in the suite of action research projects related to care coordination in a children’s hospital in the United Kingdom (Beringer and Fletcher, 2011) as well as improving discharge preparation of children and their families in Canada (Suderman et al., 2000) and improving paediatric pain management in the United States (Ely, 2001).

Investigation of the booklet

Issues relating to content, format and timing (see Table 1) formed the basis of the investigation of the booklet, and questions related to these were asked to the group members during group interviews at each of the four subsequent meetings.

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Table 1.

Group interview issues.

Group interview review of the MCU booklet		Check
Content	Quality characteristics of written literature in hospital preparation strategies
	Simplicity/complexity of booklet messages
	Authenticity of booklet
Format	Quality characteristics of written literature in hospital preparation strategies
	Words
	Photographs
Timing	Review of literature about timing of information provision for this age group
	Timing of information provision for this booklet
	Review of literature about who should or could provide information

MCU: micturating cystourethrogram.

Each member of the multidisciplinary group read through the booklet, applying his/her disciplinary and individual expertise and highlighting any sections of the booklet that he/she considered required discussion. Each member of the group also consulted with colleagues who were experts in their own areas of practice to gain feedback regarding the usefulness of the booklet as a preparation strategy for the MCU procedure for children between 18 months and 6 years and their parents.

The group reviewed the quality characteristics of the written literature of hospital preparation strategies for children and their families (Clough, 2005; Stone and Glasper, 1997; Sutters et al., 2011). The MCU booklet conformed as it was illustrated by photographs of the actual equipment used in the procedure and personnel likely to be encountered during the procedure. Studies have shown that booklets are a useful form of information provision for children (Francis et al., 2008; Huth et al., 2003; Robbins et al., 2003), so the use of a booklet was another way in which our preparation strategy conformed.

The group reviewed the simplicity/complexity of the messages provided by the photographs and words, particularly taking into account the fact that children (aged 18 months to 6 years) and their parents should be able to use the resource. Figure 3 shows a photograph and advice drawn from the booklet.

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Figure 3.

Photograph and advice contained in the MCU booklet.

Content and format review included assessing the authenticity of the photographs in the booklet. The words used were scrutinized for logical sequencing of the events of the MCU procedure and for the applicability of the advice given to parents when preparing their children for the procedure (Deller and Walker, 1994). Words were arranged in simple sentences that were accessible to people who had reached a year 9 level of reading (Flesch, 1948). Advice was structured around the importance of preparation for procedures, the elements of the actual procedure itself and examples of ways that a parent could support his/her child before, during and after the procedure. For example, the MCU booklet advises parents to ‘Try to engage your child’s interest in the procedure by talking and asking 1 or 2 questions’. Timing of the information provision was also assessed by the multidisciplinary group, and reference was made to the recommendations of Blount et al. (2009) that information should be provided once the procedure is scheduled and in the lead up to the procedure. Furthermore, Jaaniste et al. (2007) postulated that the high level of cooperation required for the MCU probably requires more preparation and more advanced notice. Optimal timing of information provision has been shown to vary in this age group (Kain et al., 1996), that is, from weeks in advance of the procedure to immediately before the procedure. However, as the booklet was designed for repeated use over a period of time, the group felt that the booklet was appropriate for children of this age group and their parents.

With regard to who provided the information, the group found that the design of the booklet allowed it to be read by the parents as well as to be read to the children by their parent, as required, for up to one month prior to hospitalization. Preparation by parents has been shown to be worthwhile (Li et al., 2007), so the fact that the booklet could be read and reread as often as the children or their parents wished was seen as useful. The group agreed that the booklet allowed for a range of timing of information provision according to individual needs of children and their parents.

Feedback was recorded through audio recordings of each group meeting, which were transcribed and emailed to each member of the multidisciplinary group before the subsequent meeting. By the end of the fourth meeting, the group members were satisfied that they had addressed all the issues for review of the booklet, which are listed in Table 1.

Results

Through this evaluative process, the action group found that the booklet conformed to the requirements of children (aged 18 months to 6 years) and their parents for MCU procedure preparation. The conclusion that the group reached was that the booklet seemed to convey ideas clearly and simply, that the messages were realistic and age-appropriate and that the design of the booklet encouraged appropriate use.

The approach taken in this project enabled two outcomes, namely, the evaluation of the MCU booklet and collaboration between health-care professionals to improve hospitalization preparation practices for children and their families. By paying attention to the content, format and timing (Jaaniste et al., 2007) of the preparation strategy, the action group members were able to evaluate the booklet and give reasons why it met the preparation needs for this procedure.

The content of the booklet was developed with photographs that related to what both the children and their parents would encounter, thereby adding realism to the preparation. The format and language used in the booklet were age-appropriate for both the young children and their parents and, importantly, included advice to parents to guide them through the preparation of their children for the procedure. Finally, given that parents know their children better than anyone, the timing of the preparation and its provision by parents through the booklet (Stone and Glasper, 1997) was shown to be appropriate.

Discussion

Involvement of clinicians in evaluation of the booklet enabled collaboration among health-care professionals, which empowered them to engage with the complexity of preparation and seek to improve their practices. The action research approach ensured that clinicians were valued within the group for their input and suggestions to improve preparation practice. Formation of the group enabled sharing of knowledge, which meant that everyone in the group was able to enhance his/her understanding of preparation for childhood hospitalization at the hospital. This led to an improvement in practice because the group members were able to reinstate the MCU booklet.

The action group took a clear path to evaluation, with each member of the group following the described process, including being part of the monthly group interviews to share what had been identified as requiring discussion among the group. This process worked very well for this cycle of action research, and the multidisciplinary approach is to be recommended as a means to improve practice by providing inclusive models of collaboration and shared professional power and responsibility.

Conclusion

The investigation and reinstatement of the booklet involved an integration of evidence and practice, which was an important outcome for the action group and for the clinicians caring for children and their families. The literature provided the best evidence for the content, format and timing of the information provision booklet, and the process of utilizing the expertise of the multidisciplinary group enabled inclusion of the booklet into the practice of preparing children and their families for the MCU procedure. Dissemination of the important principles of the production and use of preparation for childhood hospitalization materials will enhance their continued use and ultimate effectiveness in improving the experience of childhood hospitalization.

Limitations

The MCU booklet was designed for one procedure and for children in a specific age group. After review, the group anticipated that the booklet would be successful in preparing these children and their families for the MCU procedure. Further work is required to individualize preparation materials for the range of medical procedures that may be undertaken in the hospital setting.