Child Life in Action

in Sedation with Laura Mitchell, MS, CCLS

by Bea Wikander | June 25, 2018

LauraMitchell

Laura Mitchell, BS, CCLS, is a child life specialist at Nemours A.I. duPont Hospital for Children in Wilmington, Delaware. She has been certified for 18 years and started her career at Nemours in a role where she supported patients and their families on various inpatient units. During the course of her work, she would often accompany patients to medical imaging for sedated procedures. The value of her work was recognized, and she was recruited to be a full-time member of the Sedation team. Laura works with a multidisciplinary team to facilitate procedures requiring sedation; increase coping and patient- and family-satisfaction; and decrease stress, anxiety, pain, and other negative feelings or effects related to the hospital experience.

Children often wonder if they will experience pain and worry about being separated from parents or caregivers.

Laura believes that facilitating coping skills should be an integral part of all procedures, not just those requiring sedation. She and her team incorporate a structured, individualized approach to sedation and use both pharmacological and non-pharmacological methods to ensure that procedures are completed safely with minimal pain and anxiety. Assessing children and families and then creating and implementing individualized plans is key to a successful experience because each child and family is unique.  Some patients may only require pre-procedural preparation before induction while others may benefit from education, play and procedural support.  As many of the children Laura sees are outpatients, she is also able to educate parents on how to support children in the days and weeks following a procedure, including providing opportunities for medical play in the home. 

Some of the children Laura works with are inpatient while others visit the hospital for recurring procedures. Most often, Laura meets her patients the day of the scheduled procedure, and she has about an hour to introduce herself to the family, build rapport, and assess educational needs and preferred coping mechanisms. Many of her patients' concerns stem from a fear of the unknown. From a child's perspective, everything is unfamiliar and potentially threatening: the hospital environment, the healthcare team, and the procedure itself. Children often wonder if they will experience pain and worry about being separated from parents or caregivers.

Laura collaborates with the interdisciplinary healthcare team to determine optimal coping strategies and they will often seek her input in sedation planning. Laura will develop an individualized treatment plan, assessing how a patient's age, developmental level, emotional state, previous healthcare experiences, and family dynamics will inform their response to the experience. She also explains the unknowns to both the child and his or her family, providing information that is non-threatening, honest, and developmentally appropriate. Her education will often focus on sensory elements. For example, Laura and her team will speak with children about how a medication will be administered or how it might make them feel. Having this information in advance helps to reduce some of the anxiety associated with the experience.  Children are often tactile learners, and Laura likes patients “to explore the medical equipment on their own terms.” Touching a mask or catheter or offering developmentally appropriate medical play is a good way to build trust and get more information about a child's feelings and concerns.

  The sedation team is committed to the One VoiceTM Approach:

  • One voice should be heard during procedure
  • Need parental involvement
  • Educate patient before the procedure about what is going to happen
  • Validate child with words
  • Offer the most comfortable, non-threatening position
  • Individualize your game plan
  • Choose appropriate distraction to be used
  • Eliminate unnecessary people not actively involved with the procedure

This methodology is critical because it supports healthcare teams in creating an environment that is less threatening for patients and their families. 

Laura's goal is to give pediatric patients "as much autonomy and power as we can in a situation where they don’t have a lot. So we’re trying to help them navigate that experience so things make sense to them in an experience that is inherently overwhelming and very scary.” Educating and supporting parents is an important part of this process. Children look to their parents for reassurance and guidance, but parents are often just as scared and confused. With the support of her team, Laura educates and calms caregivers so they are better equipped to support their children.

Laura and the sedation team provide empathetic, personalized care to all patients and make additional efforts to accommodate those with special needs. She communicates with the medical team to make sure they are aware of triggers that may escalate a patient's anxiety and offers a variety of accommodations such as allowing the patient to arrive at the hospital from a different door or at a certain time of day to avoid crowded and overwhelming waiting areas. The team also considers whether changing the location for assessment and pre-medication appointments would be beneficial. They may even decide to gather patient information over the phone the day before the appointment to reduce the amount of time the patient spends in the hospital.

Seeing children successfully complete procedures and feel proud and of their coping skills is always gratifying for Laura. This is especially true of patients that she has seen often over the years for treatment of chronic illnesses like cystic fibrosis. Some of these patients need a peripherally inserted central catheter (PICC) line inserted once or twice a year for long-term antibiotics. Over time, Laura and her colleagues have been able to help these patients cope more positively, and require less or even no sedation. This progressive development of coping skills is a success in itself as well as an important step in the patient's evolving healthcare journey. Transitioning to adult care is challenging for many reasons. Young adult patients who have seen the same doctors, nurses, and child life specialists throughout their lives and who have become accustomed to a certain level of support and advocacy may find the transition to adult care challenging. At Nemours, there is Transition Program devoted to helping patients and their families navigate this process. However Laura and her team view this transition through a "procedural support lens," focusing on variations in procedures and sedation options. An advanced practice nurse Laura works with refers to the preparation before the transition as the “step up process,” and together they encourage and promote incremental changes into coping and sedation plans.  This approach helps the patient develop a sense of accomplishment and mastery.

Laura has been an active member of the Society for Pediatric Sedation (SPS) since 2016 and currently serves on the Nursing and Allied Health Committee where she advocates for collaboration among allied healthcare professionals and encourages her child life colleagues to take an active role in the society. The first SPS conference Laura attended was inspiring and eye opening because of how much respect child life received from the physicians and nurses in attendance. The Society for Pediatric Sedation has a long history of commitment to and respect for child life, partly because Kristine K. Murray, CCLS worked with the founding physicians. Kristine served on the SPS Board and used her role to advocate for child life in the pediatric sedation community. Created in her honor, the Kristine K. Murray Child Life Award and Scholarship "recognizes an exceptional child life specialist who demonstrates exemplary care and clinical skill with children in a procedural sedation environment and who actively contributes to the field of pediatric sedation through multidisciplinary collaboration.” Each year, this generous award allows a child life professional to attend the SPS Annual Conference, and Laura was the deserving award winner 2017.

Laura's involvement with SPS has led to many opportunities for personal and professional growth. Although some of the conference programming is outside her scope of work, increasing her knowledge about all aspects of sedation helps her better advocate for and educate patients and families. In addition to writing several essays for the SPS quarterly newsletter, her involvement with the society also led to the honor of being invited to speak at the annual SPS conference held just last month in Atlanta. She partnered with Jessica Brown, CCLS from Children's Healthcare of Atlanta to develop a presentation highlighting how utilizing non-pharmacologic techniques as an adjunct to sedation planning can reduce pain and anxiety for patients and their families in a procedural setting. She was also asked to contribute a chapter to The Pediatric Procedural Sedation Handbook which will be published by Oxford University Press in October 2018. Moving forward, Laura will be will be collaborating with fellow nursing and allied health committee members to develop web-based modules to support nursing continuing education opportunities.

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