1. Carlisle, Joan B. DSN, CRNP
  2. Cull, Vera V. DSN, RN


Are nurses avoiding the issue?


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Pediatric nurses often overlook a crucial aspect of caring for a child with an illness or injury-developmental care. It's well known that a long illness or hospitalization can lead to developmental delays. Although many nurses think it's enough to decorate a child's room or to have a child-life therapist available in the playroom, it isn't. Developmental care must be a priority, even on busy units. FIGURES 1-2

Figure 1 - Click to enlarge in new windowFigure 1. Joan B. Carlisle
Figure 2 - Click to enlarge in new windowFigure 2. Vera V. Cull

Many hospital pediatric units have closed as a result of institutional downsizing, so children are being treated on adult units. Nurses with limited experience in providing pediatric care are now struggling to provide therapeutic interventions to children of various ages. Some nurses may not have cared for children since their basic training and may have difficulty identifying developmental needs.


Because a formal developmental assessment is rarely feasible while a child is ill or hospitalized, nurses must rely on other tools. We have found useful Erik Erikson's description of eight stages of human psychosocial development; other theories may be helpful depending on the patient's condition. Once the patient's developmental stage is identified, nurses can plan appropriate interventions. But even when the care plan addresses developmental needs and the nurse makes the additional effort to ensure that they are met, most nursing taxonomies are not specific enough.


For example, suppose a two-year-old boy is hospitalized for osteomyelitis of the right femur. According to one classification system, a possible developmental diagnosis would be "altered growth and development." But this diagnosis is too broad-the child may not have any growth problems, but he will need developmental interventions because of the hospitalization. A diagnosis that is too general can be an impediment to making an appropriate plan of care.


The average two-year-old is at the stage Erikson calls "autonomy versus shame and doubt," in which the child gains a sense of independence and self-control. Hospitalization imposes restrictions on the child's routines and independence; all too often, the young patient is given few choices. A developmental diagnosis such as "loss of control" would guide nursing strategies toward allowing the child to decide when to play and which foods to eat.


Since mobility is crucial to the toddler's development and this child has a medical condition that inhibits it, a developmental diagnosis related to altered mobility is also necessary, even though it is generally considered to be a physiologic problem. Similarly, if a toddler doesn't drink from a cup, speak in short sentences, or respond to toilet training, specific diagnoses-"alteration in fine motor skills," "delay in development of speech," or "delay in control of bowel and bladder"-should be identified.


In the past 50 years, many nursing functions have been taken over by professionals such as nutritionists, pharmacists, and social workers. Or have nurses renounced them? If nurses have relinquished developmentally appropriate care to child-life therapists and behavioral specialists, it may be because they don't feel comfortable planning and implementing it-because so much time has elapsed since they completed their educational programs or because they lack experience in applying their pediatric training. Various developmental diagnoses exist for all ill or hospitalized children. Nurses who use their assessment and critical-thinking skills creatively to address specific problems and plan care that meets the particular developmental needs of each child will find the process richly rewarding.