Nursing - Theses
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ItemClowns in the midst: understanding clown doctors at The Royal Children's Hospital Melbourne( 2018)Clown doctors are a feature in paediatric hospitals, visiting children and families, providing a welcome escape from the reality of hospitalisation. Though the use of humour to improve health and wellbeing has been widely researched, limited exploration of the clown doctors has occurred. This study aims to elucidate the work of clown doctors within a major paediatric hospital. This was an ethnographic study. Ethnography is an innovative approach to paediatric research, giving an intricate view that is otherwise difficult to attain. Participants for this study included the clown doctors employed at The Royal Children’s Hospital, and every person they had a meaningful encounter with during the course of their work, including patients, families, clinical and non-clinical staff. Data was collected via participant observation, with approximately 1,500 hours of ‘clown ward rounds’ documented over one year. Furthermore, 25 hour-long semi-structured interviews were conducted with a range of key informants. A constructivist framework was used to analyse emergent concepts. Constructivism explores how relationships and interactions create the individual’s understanding of the world. Furthermore, how different understanding, or meaning, can be derived from interactions based on individual context, background, culture and personal history. When asking people about the clown doctors, most ascribed a function, such as: distraction, anxiety reduction and procedural assistance; entertainment and making people laugh; emotional support and providing comfort; and communication, including translating clinical information to families. These functional elements of the clown doctors are the result of a more complex, intimate human connection that develops due to the nature of clown doctors being low-status, open, vulnerable and, in particular, existing as outsiders to the medical establishment. Clown doctors use humour to break down the emotional barriers created by illness, which they achieve through being person-centric and offsetting medically driven interactions the hospital often demands. They empower patients, returning a sense of control that is generally absent for hospitalised children. While almost universally acknowledged as a positive addition to the hospital, most people who encounter the clown doctors have little conception about the scope of their work. Although clown doctors are often described in concrete clinical terms, their real power lies in their ability to connect with people, and the psychosocial advantages that connection provides. The results of this descriptive study deliver valuable insight and a comprehensive understanding of clown doctors and the complexity of human relationships within a major paediatric hospital. Through this research we can identify what the clown doctors bring to the hospital environment, how paediatric staff can employ their unique skills more effectively, and finally give long-overdue credence to the notion that laughter, mirth, creativity and child-like wonder has as much place in a hospital as medicine.
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ItemProcedural pain assessment in infants and young children: identifying a suitable behavioural assessment scale( 2018)Infants and young children frequently experience pain as a consequence of medical procedures associated with their healthcare. Pain management is often suboptimal, and this is in part due to the difficulties associated with assessment of pain of infants and children too young to self-report pain intensity. Observable behaviours indicative of pain have long been considered a viable alternative and scales comprised of these behaviours have proliferated in the literature. However, it remains unclear which scales are best suited for procedural pain assessment and whether they are well supported by psychometric data. The aims of this project were to: identify behavioural observation scales potentially suitable for procedural pain assessment, summarise available psychometric data and prospectively test the psychometric properties of potentially suitable scales when used to assess procedural pain in infants and young children. These aims were addressed in three phases of work: i) a thorough interrogation of the literature to identify scales considered potentially suitable for assessing procedural pain in infants and children, ii) a series of systematic reviews to summarise the evidence supporting the psychometric properties of the identified scales and iii) a prospective observational study to test the psychometric properties of these scales used to assess procedural pain in infants and young children. Three scales, the Face, Legs, Activity, Cry and Consolability Scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs), met predefined criteria and were considered potentially suitable for inclusion in this project. The systematic reviews showed that available psychometric data was insufficient to recommend these scales for procedural pain assessment of infants and children. There was data to tentatively support the MBPS and to a lesser extent the VASobs for assessing immunisation related pain. The data regarding the FLACC scale was inconclusive. The results of the prospective study confirmed that all scales were sensitive to pain. The FLACC scale and MBPS scores were reliable (intraclass correlation (ICC) 0.92 and 0.87, respectively) but VASobs scores were less reliable (ICC 0.55). The FLACC scores showed the highest sensitivity (94.9%) and specificity (72.5%) for procedure type (painful vs non-painful) at the lowest cut-off score (pain score 2, area under the curve (AUC 0.83)). Similar results were achieved at a MBPS cut-off score of 4 (sensitivity 91.5%, specificity 77.5%, AUC 0.85). The FLACC scale resulted in more incomplete scores (p < 0.000) and was changed more often than other scale scores. Reviewers liked the VASobs most, considered it the quickest and easiest to apply, but judged the FLACC scale and MBPS to be more likely to be useful. In conclusion, three behavioural observational pain scales to assess procedural pain in infants and young children were identified and included in systematic reviews. This work culminated in a prospective study, the results of which support use of the FLACC scale, but not without reservation as there are practical limitations when used to assess procedural pain. These results build on promising existing evidence that suggests that the FLACC scale may currently be a suitable scale for procedural pain assessment in infants and young children.