It’s a sensitive subject, emphasises Piet Leroy (1969), who has been affiliated with Maastricht University for about twenty years and has won numerous education prizes. It’s about children, fear and pain. “No one in health care wants to traumatise a patient, let alone a young patient. If you bring up the subject with a nurse or doctor, you hurt their heart, making them feel vulnerable. Caring is part of their identity. They all want the best for their patients. But it’s often taken for granted that the path to healing involves pain and fear. In some urgent cases, there’s simply no other way; doctors must take immediate action.”
But in all other cases, it’s important for health professionals to realise that any medical procedure – having blood drawn or an IV inserted, getting stitches or a thorough ear exam, anything involving needles – can quickly become a negative experience. “Imagine two parents bringing their toddler son into A&E. The doctor determines the child needs antibiotics, so you need to draw blood and insert an IV. These are routine procedures, but they can have a significant psychological impact. Unlike with adults, you can’t explain to the child why the needles are necessary; he only feels the pain or fear, and resists. His parents try their best but find themselves torn. They would normally comfort their son if he was in pain or distress, protect him from danger, but now they are worried and more likely to side with the doctor. This creates confusion in the relationship between parent and child.”
Earplugs
Leroy knows all too well that hospitals tend to focus on efficiency. “Children easily become victims of this sometimes industrial approach to health care.” In his inaugural lecture, he cited the example of a major Dutch hospital proudly reporting in its staff magazine on its solution to make blood draws on children more efficient. “Having staff wear earplugs to block out screaming children had significantly improved patient flow.”
Another example involved a junior doctor coming up to Leroy and asking, “How’s bed 4 doing?” “He had been sent by his supervisor and was copying his teachers’ behaviour. Behaviour that fits into a highly efficient system that tends to focus on disease and forget the person behind the patient.”
Attentive listening
Ever since his training as a paediatrician and paediatric intensivist, Leroy has focused on making health care for children more caring. In addition to prompt and proper treatment, communication is key. “Engaging in conversation, getting to know the child, being genuinely interested, listening attentively, not making assumptions. Children don’t care about what you know; they care about how you connect with them. You have to gain their trust.”
How do you go about building trust? There’s no one-size-fits-all approach – every child is different. During his lecture, Leroy showed photos of children lining up to be vaccinated. Some were relaxed, others hunched into themselves. “You always have to adjust your approach to the person and the situation. This can be challenging for health professionals who are used to protocols telling them exactly what, how and when to do things. But fear and anxiety require an individualised approach. That’s why you need to set aside plenty of time for the first meeting. Trust has to be earned, but once it has been established, future meetings will be easier – although it remains a process of trial and error.”
The first meeting often sets the tone. “How do you enter the room? What words do you use? Saying ‘You don’t have to be afraid of the needle, it will only hurt for a second’ only makes children more afraid.”
So what should you do instead? “To a child coming in for a blood draw, you could say, ‘If you keep your hand still, you’ll feel yourself relax, which will help me. You’ll see that we’ll be done faster.’ Sometimes it helps to apply numbing cream, which takes sixty to ninety minutes to take effect – this must be taken into account. Other young patients benefit from distraction, like reading a book or blowing bubbles. If none of this helps, we can use inhalation sedation, so they won’t feel the needle at all.”
Criticism
There has been criticism of Leroy’s approach, although it has diminished in recent years as more healthcare teams have adopted his methods. “You hear two lines of criticism. The first questions whether we coddle children too much – aren’t pain and fear part of life? My response: the pain a child feels when falling off the monkey bars is part of life. It’s a learning experience. But the only thing a young child can learn from a negative blood draw experience is to be afraid of needles.” The second line of criticism suggests Leroy’s approach is too expensive and time-consuming. “I actually believe it’s more time- and cost-effective in the long run. Children who have trust and feel understood in healthcare settings grow up to be adults who are more easy-going as patients, more likely to adhere to treatment and less likely to make a complaint if something goes wrong.”
Dream
In recent years, Leroy has not just conducted research on fear and trust in children in healthcare settings, but also co-organised biennial international PROSA conferences on the subject of “from fear to trust”, established a knowledge centre (www.PROSAnetwork.com), assembled a team of experts at MUMC+, and trained some thousand health professionals from the Netherlands and Belgium. “We always train people in teams. This is something you have to do together.”
His dream is that in a few years, the approach will be so common – in other words, part of the medical curriculum and standard procedure in all hospitals – that the knowledge centre has become redundant. But we’re not there yet. Leroy is currently working with municipal health services (GGD) and the National Institute for Public Health and the Environment (RIVM) to develop a more caring approach to childhood vaccinations. “I’m in favour of vaccination, protecting children from serious illness. We tell parents they’re good parents for vaccinating their children, but we don’t explain how to do it in a more caring way. For example, a jab is much less impactful if a baby is sitting on their parent’s lap, being fed. If the baby starts crying, you can immediately comfort them by cuddling them or changing position.”
Funding
Making children’s health care more caring won’t happen overnight; widespread change requires funding, which is currently lacking. “The Charlie Braveheart Foundation has helped us so much. I hope that health insurance companies, the government and hospitals will provide funding so that we can implement the approach more widely, starting with Maastricht University and MUMC+. My inaugural lecture received a lot of attention, which is great, but we’re almost drowning in our own success. We urgently need additional resources.”
Empathy
One last thing. In his lecture, he used the word “empathy” several times. “I struggled with that. We say it’s good for doctors to be empathetic. But what does that mean exactly? Judith Hall, an American colleague of mine, has done wonderful research on empathy through the patient’s eyes. She concluded that, to patients, empathy is mostly about active and non-judgemental listening. That’s what we need in health care.”