PREPARATION OF CHILDREN FOR HOSPITALISATION AT THE JOHANNESBURG HOSPITAL

’n Voorbereidingsprogram om aan die kind se sielkundige behoeftes te voldoen is by Johannesburg-hospitaal ontwikkel. Algemene programm e word aangebicd vir kleuterskoolgroepe en kinders wat chirugie moet ondergaan word genooi om spesiale programm e by te woon. Die programme bestaan uit ’n toer, poppeteater en spel met hospitaalklere en apparaat. Kinders word met opname en na chirurgie verder ondersteun.


Children are like wet cement.
Whatever touches them makes an impression.

Author Unknown
The hospital is a strange envi ronment When a child enters hospital, he enters an alien environment.He is leaving the security o f home and fam ily and entering a world that is not only foreign, but intrusive.(Klein and Satterthwaite, 1980;p.60)Research has shown that one quarter of our population consists of children, and that almost half of them will spend at least one night in hospital before reaching the age of seven.A child is confronted by as many as fifty-two unknown faces during his first day in hospital.In past years the concern in the care of the hospitalised child was mainly disease orientated.This approach ignored the child's normal psycho social developm ent, which was re stricted during the treatm ent of his physical illness.As a result of re search, it was recognised that a child would be more responsive to physical treatm ent, if his emotions and p sy cho-social d e v e lo p m e n t w e re d e a lt w ith c o n c u r r e n tl y (Kaplan; 1980).

Loss of security
Hospitalisation denies the child the sense of safety and security he has developed in his own environment.He is exposed to strange uniforms and rooms and is asked incompre hensible questions by unfamiliar people.He experiences pain and has little privacy, or control over his own body, in that he is told when to eat and when to urinate etc (Klein and Satterthwaite;1980).
He is often no longer accessible to his parents, which intensifies his sense of loss and fear.He under goes an experience fraught with traum a and filled with fantasies.Mutilation anxieties may result in common misconceptions such as the fear that cutting during an opera tion will lead to castration.The traumatic experience of hospitalisa tion may lead to destruction of his trusting relationship with loved ones and may also promote anxiety in similar situations later in life (Kaplan;1980).

Misconceptions
In a dissertation by Denise Kaplan, a social work student at the Univer CURATIONIS sity of the W itwatersrand, on the ef fectiveness of a pre-operative pre paration programme for the patient and his family, data obtained from her sample revealed that 40% of patients to undergo elective tonsilloadenoidectomy had no idea of the instruments used to remove their tonsils, 20% felt that the procedure was carried out with scissors, 13% with a knife, 7% with a spoon, 7% with forceps, 7% with a balloon and 7% with the doctor's hands.
Further misconceptions could result when explanations such as the dead bird on the lawn has gone to sleep, are offered to pre-school children.These little ones have begun to evoke a sense of life and death, and such misdirected expla nations could cause problems when the child has to undergo anaesthesia for a surgical procedure, and is told that he will go to sleep for a short while, and he therefore develops a fear of never waking up.If a child has enjoyed a stable re lationship with his parents, the ef fects of hospitalisation are likely to be less pervasive and severe, than on the child who has grown up in an emotionally deprived background.He is however, still likely to mani fest short-term effects of hospitali sation (Kaplan;1980).

Reactions
Robertson documented the re actions of six month to four year old children to their first hospitalisa tion, in three graphic stages: • The inital phase or phase of pro test During this phase the child is totally bewildered by the disap pearance of his m um m y and cries loudly and throws himself about.It may last from a few hours to a few days.
• The middle phase or phase of des pair is often mistaken as the settling-in period.The child with draws and is apathetic, and may cry intermittently, as he is in a state of mourning for the loss of his mother.During this phase the m other must be encouraged to visit frequently, as the child is only able to verbalise his grief in the presence of someone he loves.
• In the final phase or phase of denial the child shows more inte rest in his environment.The child may even appear to be happy, but is repressing his feel ings for his m other, and may openly reject her.
A fter discharge the child may progress through a period of quiet ness and may regress to enuresis and encopresis, either clinging to m other or showing aggression to wards her.
If children experience multiple separations due to hospitalisation, there is a risk of disturbed be haviour in later childhood and ado lescence, as shown by research done by Douglas, Quinton and Rutter.

PREPARATION ESSENTIAL
It therefore follows that children need pre-admission preparation at physical, intellectual and emotional levels for their individual hospital experiences and to be helped to work through their fears.(Taken from guidelines for To Prepare a Child -film produced by Washing ton Children's Hospital) Children should never be lured into hospital under false pretences.This would result in tremendous and perhaps perm anent loss of trust in adults.If the child is allowed to experience anticipatory anxiety he will be able to marshall his defences and master the event (Schreier; 1980).
Visentainer and Wolfer demon strated that systematic preparation and support increased patient co operation, decreased their upset be haviour, improved post-hospital ad justment and resulted in less anx iety, better information and im proved total patient care.
Parents play a vital role in the preparation process.M others can communicate their trust in the pre paration team and thus facilitate the process of preparation.The objec tives of a good preparation pro gramme should include: -assisting the child in the express ion of his feelings generated by hospitalisation whereby groups of nursery school children are invited, together with their teachers and supervisors, to attend the programme which is pre sented in a slightly different format.These children are taken on a short selective tour of the paediatric sec tion of the hospital.This is followed by attendance of the puppet show which initially was A prospective patient is show n a " p o p-up" theatre scene by a child care w orker.The m odel of a ward and a theatre can be seen in the background.

Nursery school children
The programme is aimed at patients who are to undergo elective sur gery, which obviously results in ca tering to a small percentage of cur rently hospitalised children.In order to overcome this, an outreach programme has been instituted

Photographs by courtesy of "The Star"
display -right down to the pat terned curtains in current use in the hospital.
The suggestion that a Hospital Corner be organised at the nursery school is put to the teachers.This would enable them to facilitate feedback on the children's feelings of the programme and to indicate any residual anxieties, which could then be dealt with.

Child to undergo elective surgery
The child for elective admission is introduced to the programme on a date prior to admission.He is wel comed by the child care worker on duty, who gives him a name tag, while mother fills in an attendance register.The patient, where poss ible, is to other patients who are to undergo similar proce dures.The child care worker, by means of models, demonstrates who doctors and nurses are and shows that mom can be in the ward too.The children are then shown the puppet show where procedures such as taking of blood and anaes thesia are emphasised.They are also shown slides and flipcharts of hospital situations and encouraged to dress up in gowns, masks and caps.The children are encouraged to talk to each other.Parents have the opportunity to ask nursing staff and the child care workers ques tions.Siblings are allowed to attend this part of the programme, but only patients and parents are per mitted to attend a tour of the wards to which they are to be admitted.
On return from the tour, and before leaving, each patient is given a specially designed colouring-in book of hospital scenes, a syringe, mask and threatre cap to take home.This enables the effective ness of the programme to be taken into the home.

Follow-up
After eventual admission and sur gery the children are visited postoperatively, wherever possible, by the child care worker who ran their particular preparation programme.She also offers support to the parents at the time of the surgical procedure as they wait in the specially allocated waiting area ad jacent to the theatres.Due to tne design of the theatres it is not poss ible to allow parents into the induc tion and recovery areas.This would have been ideal to facilitate the child going to sleep and waking up in the presence of loved and fami liar faces.
Anaesthetists are now specialis ing in paediatric anaesthesia, which has resulted in less traumatic induc tions and has minimised adverse psychological problems.Relatively open visiting hours and rooming-in facilities for mothers of long term cases, have also contributed to im proved quality of management of hospitalised children.Although sib lings are allowed to visit in some areas, this is a field which requires some consideration, especially for children who spend long periods in hospital.
D enise K a p la n 's rec o m m e n dations made as a result of her re search study included: • that a special effort should be made to ensure that patients fro m lo w e r s o c io -e c o n o m ic levels, attend the programme.Not only does chronic family ad versity predispose to hospital ad mission, but there is some indica tion that it may render children more likely to be damaged by re peated admission (R utter; 1979; p. 150) • that patients should be tele phoned or invited to the pro gramme by means of a letter, which should state the value of the programme • that there is a need for an infor mation booklet which could be issued by the paediatric outpa tient clinic to parents of children undergoing surgery • that the programme should poss ibly be offered at a time over a weekend to accomodate children of working mothers.

CONCLUSION
Children are special, with special needs.The needs which occur as a result of hospitalisation can be ca tered for by a carefully thought out and well co-ordinated preparation programme.
The author would like to thank Denise Kaplan for the help she of fered for the compilation of this article.

Factors
that affect the child's re action to hospitalisation are: -his stage of development -his relationship with his parents and siblings Fun and gam es with strange but exciting pieces of m edical equipm ent -previous separations from his family -recent significant deaths -admission to hospital of other members of the family.

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increasing the child's knowledge of what is happening to him -making use of anticipatory anx iety -reducing complications -enabling the child to return home with a positive feeling to wards the hospital and his parents (Kaplan; 1980) PREPARATION PROGRAMME A little girl is introduced personally to Lindy the puppet by the social w o rker w ho co-ordinates the program m e.

BIBLIOGRAPHY 1 .
K ap lan D .(1980) W hen yo u n g children fa ce surgery: the effectiveness o f a pre-operative preparation p rogram m e, f o r the pa tien t an d his fa m ily U n p u b lish ed B .A .(Soc.W o rk ) d issertatio n .U n iv ersity o f th e W itw atersrand.2. K lein , C .B .; S atte rth w aite (1980) P re p ara tio n a n d the hospitalised child.J o u rn a l o f the A ssociation f o r the Care o f Children in H ospitals.V ol. 8, N o .3,p p 60-63.W inter. 3. R o b e rtso n J. (1970) Y o u n g children in hospital.L ondon.T avistock.4. R u tte r M .(1979) S e p a ra tio n exp erien ces: a new look at an old to p ic Paediatrics.V ol.95, N o .l, pp 147-154. 5. S chreier A .(1980) P rep arin g young c h ild ren for h o sp ital isation.U n p u b lish ed P a p e r a c ce p te d for p u b lication in P re-School Years.6. V isen tain er M .A .;W olfer (1975) Psychological p re p a ra tio n for surgical p ae d ia tric p a tie n ts.T h e effect on c h ild ren 's a n d p a re n t's stress resp o n ses a n d ad ju stm en ts.Paediatrics.V ol.56, N o. 2 p p 187-202, A u g .1975. 7. T o p rep a re a ch ild , (1975) Film P ro d u c ed by W ashington C h ild re n 's H ospital.