Patient-centered care when the patient is a child Martha Driessnack - PDF document

9/18/2015 Patient-centered care when the patient is a child Martha Driessnack PhD, PPCNP-BC Patient-centered Care? Crossing the Quality Chasm • In 2001, the IOM named “patient-centered care” as one of the 6 fundamental aims of the U.S. health care system. • Why? – Orienting health care around the preferences/needs of patients has the potential to improve patients: • satisfaction with their care • clinical outcomes • The challenge arises when the “patient” is a child. – Is ‘family-centered’ care enough? – How can we ensure children’s voices are heard? • It turns out that children are perfectly equipped and totally capable of communicating with us, using art. 1

9/18/2015 Integrating ‘art’ into your practice with children What are we going to talk about? • Introduce NPs to: – the use of art to communicate with children – an overview of different forms of art – evidence to support its use, and – how to integrate art into your practice. • Emphasis is on … – increasing the quality of communication with children – the actionable information that results, and – the re-discovery of the artist that lies within all of us. A little background • To date, children have typically been viewed: – Using a deficit-based lens • Human ‘becomings’ vs human beings – Adult proxy & observation • Parents, teachers, health care professionals … – Little agreement between adult/child • Traditional methods of self-report are adult- centered, -directed, and dominated 2

9/18/2015 Because of this… • Current approaches to self-report are: o Adult-centered, -developed, and -directed o With “child-friendly” language/adaptations Current NIH Initiative No More Research http://www.nhlbi.nih.gov/childrenandclinicalstudies/index.php The challenge… Can we hear children’s voices without changing existing tools and methods? 3

9/18/2015 Children’s Drawings • Growing interest in the use of art – ‘Natural’ medium for children • Internal, sensory cues for retrieval • Opportunity to organize • However, drawings have typically been taken away from children (‘ectomized’) – interpreted by adult ‘experts’ – windows vs. doorways Historical perspective • The study of children’s art [drawings] has a long tradition in the fields of psychiatry • Early work with adults with mental illness, then children with mental illness • Measures of ‘mental’ age lead to measures of intelligence (cognitive development) • Insights into emotions & feelings gave rise to ‘emotional indicators’ Historical perspective of drawings • Psychiatry/Psychology – Mental health/illness • Cognitive development/Developmental Psychology – ‘Mental’ age – Developmental level – Intelligence • Emotional indicators 4

9/18/2015 Historical progression (Series of Assessment Tools) • Draw-A-Man (Goodenough, 1926) • House-Tree-Person (Buck, 1948) • Draw-A-Person (Machover, 1949) • Draw-A-Person (Harris, 1963) • Emotional indicators (Koppitz, 1968) • Squiggle (Winnicott, 1971) • Kinetic Family Drawing (Burns, 1972) • Draw-A-Story (Silver, 1978) Drawing progression • Stage I Scribbling • Stage II Basic forms • Stage III Beginning Schemata – Human forms* (~age 4-5 years) • Stage IV Visual schemata – Less egocentric • Stage V Realism • Stage VI Adolescence…. Fine motor skill progression…. • Scribbling – eye follows hand – hand in mouth to grasp progression – hand to paper, hand leads, mark + feedback • Shapes – eye & hand work together – mastering form & basic design – line, circle, box, cross • Pictures – mind guides hand – Combining shapes – Depicting reality 5

9/18/2015 Human forms (4-12 yrs) • Tadpoles – Head, legs • Facial features – Eyes, nose, mouth, hair • Arms • Body/neck • Feet • 2-D, naturalistic placement of arms/legs 6

9/18/2015 7

9/18/2015 “Draw a person” • Any person you want • 8 x 11 paper & pencil • No time limit (~10min) • No clinician guidance/probing • Assessment – Cognitive/intellectual development – Emotional indicators Emotional indicators • 30 specific characteristics (Koppitz, 1968) (DiLeo, 1970; 1973; 1983) • Quality signs – Shading, transparencies, lack of integration – Asymmetry, slant • Omissions • Special features – Tiny head, crossed eyes, teeth!, emphasis on hands, legs/arms pressed together, genitals, clouds/rain/snow 8

9/18/2015 NORMAL TINY FIGURE NO INTEGRATION Slant Slant Shading Transparency Moving away from… • Art as an ‘assessment’ tool • To art as a facilitation of communication – Encourage children to say something about their drawings (Naumburg, 1949) • Drawings ‘facilitate’ communication • Meta-analysis (Driessnack, 2005) – Amount of information • Mixed methods study (Driessnack, 2006) – Nature of information 9

9/18/2015 Draw-and-Tell Conversations Tools & Approaches need to be Child-sensitive • Child-directed – Least-adult role • Capitalize on children’s (not adults’) natural – Cognitive/developmental capabilities/strengths – Internal, sensory cues • not words = external semantic cues • When we do… – Elicit more information – Information is relevant, accurate, & actionable Listen… 10

9/18/2015 The stance of ‘not knowing’… • Never assume that any image always means something specific • Stay open to a variety of meanings • Being careful no to say too much • Looking for an uncensored view of children’s thoughts • Least adult role… Children’s interpretations often very different than ours Caution! You will be affected by children’s imagery in personal ways that may/may not be representative of what children are experiencing or trying to communicate 11

9/18/2015 I OFFER EVERY CHILD THE OPPORTUNITY TO DRAW… 12

9/18/2015 So… what does that mean? • What supplies do I need? • Do I need to be an artist? • Will it take too much time? • What is the value added? • What do I say? – Draw a picture of: • Yourself • Your family • You at home • You at school Children’s drawings • Drawings vs. drawing completion – Impromptu and/or spontaneous – Draw-and-Tell – Draw-and-Write • Self – Self-portrait • Family – Kinetic Family • Social network – Colored Eco-Genetic Relationship Map 13

9/18/2015 14

9/18/2015 15

9/18/2015 Draw your family? 16

9/18/2015 Draw your family doing something together? (KINETIC DRAWING) 17

9/18/2015 Draw your home? 18

9/18/2015 Here I am This is who I am avoiding 19

9/18/2015 My own exploration… of ‘fear’ 20

9/18/2015 21

9/18/2015 Meaning of the experience E Sequence of How the situation CA R events was solved Who, when, what, O C where? The end Primary Experience Social networks… … support, information, etc. 22

9/18/2015 23

9/18/2015 Often used following ‘trauma’ • 9-11 • Tsunami • Hurricane Katrina • Holocaust • Wars • Forensic/Abuse interviews …but that’s not the only time… 24

9/18/2015 25

9/18/2015 26

9/18/2015 27

9/18/2015 28

9/18/2015 Drawing completion • Inside the body 29

9/18/2015 ART is a powerful medium • Drawings* – Person, self, family, home, school • Sculptures – Tree vs forrest – Islands to worlds • Shoe box self • Collage • Masks • Life size tracing • Storybooks, photo-voice Most ‘young’ children never hesitate… 30

9/18/2015 But for those who do… we have collage! Visual ‘kaleidoscope’ of methods • Children’s drawings* – self, family, social networks • Photographs/Media – photo-elicitation – photo-voice – media diaries • Graphics – graphic-elicitation • Artifacts – masks 31

9/18/2015 Photographs/Media • Photographs – Can be made by child, found, or provided by researcher • Photo-elicitation – Photo-elicitation interview (PEI) – Photo diary/collage • Photo voice – Social justice/critical theory lens • Expanding media – Media/video diaries – Facebook/MySpace Graphics • Timelines – Life course timeline • Maps – Body/hand maps – Relational maps – Geographical maps 32

9/18/2015 33

9/18/2015 Artifacts • Masks • Shoebox self 34

9/18/2015 35

9/18/2015 Finding the ‘power’ of your own breath! 36

9/18/2015 37

9/18/2015 “There’s an ‘app’ for that!” “There’s an ‘app’ for that!” 38

9/18/2015 • Ready access at the point of care o Hard copy or digital o Easy upload o Easy retrieval • Ability to send in from home • Ability to capture/share child’s accompanying narrative or summary 39

9/18/2015 A ‘knot’ in my stomach 40

9/18/2015 Draw with provider Draw in waiting room Provider annotates and saves drawing Child talks about drawing Draw at home The importance of materials • Good quality materials (aka no broken crayons/used pencils) • Choices = control – Too many vs too little • Tools (active, continuum of control) • Materials (passive, receptive surface) • Familiarize yourself with both – Most adults draw, paint, and sculpt as if they were somewhere between age 4 & 12! 41