For the purpose of confidentiality the name of the case study, has been changed
(UKCC 1996) The aim of this essay was to select a client, the client in this
case being a ten-year-old boy with cystic fibrosis, in a hospital setting. To
assess the holistic needs of that client, using Beck, Williams and Rawlings

“The five dimensions of self”, (Beck 1993) Josh has lived with cystic
fibrosis for 7 years –People with CF suffer from chronic lung problems and
digestive disorders. The lungs of people with Cystic Fibrosis become covered
with sticky mucus, which is hard to remove and promotes infection by bacteria.

Many people with CF require frequent hospitalisations and continuous use of
antibiotics, enzyme supplements, and other medications. Born and living in hull

59 miles away, Josh has to be admitted to this ward every two months for
treatment, when admitted he generally remains in hospital for three weeks. Josh
has no father, but has a mother who is very protective and takes a keen interest
in his care. His mother who works as a sales assistant in a small shop in hull,
travels with Josh every two months and stays with him for the duration.

Intellectual Dimension Education has been provided in hospital for many years,
the 1944 education act stated that “all children should be educated according
to age, ability and aptitude” (Hull 1989). One of the problems with having to
attend the ward every few months is the lack of schooling Josh received, and
increased chance that he will get behind in his schoolwork. This is why it is
extremely important that education and homework should continue in hospital. The
teacher on the ward that I worked came to see the children at 9am until 12pm

Monday to Friday, spending around 15mins with each child. Having spoken to the
teacher she said that she has to find each child’s level, and work from that.

This has its benefits, giving the child the one to one tuition, however in

Josh’s situation, he wasn’t very well, and didn’t feel particularly
motivated. The last thing he felt like doing was schoolwork. The teacher did
nothing to motivate Josh, she would explain what he had to do, and then leave
him until the following day. As soon as the teacher had gone, he would put the
work down and do something else. It was left to the nurses on duty to motivate
him to do his work, which during busy periods was quite difficult, so regardless
of the teacher being employed by the hospital, I don’t believe in Josh’s
case it was very useful. Making it a little more interesting would have helped,
and spending more than fifteen minutes to actually sit and go through the work,
would not only ensure that he did the work but gave some contact with another
person Emotional The emotional state of the child is also a crucial element in
development and health. According The Department of Health, “We now have a far
greater knowledge of how children develop both emotionally and physically. With
that understanding has come an awareness of the emotion vulnerability of the
child and the effect which early experience can have on later development,” (DOH

1991) Josh’s mother was very anxious about Josh and about her job, she was
finding it incredibly difficult to hold onto jobs that allow her the time she
needs to spend with Josh every few months. To help with the accommodation aspect
of her living temporarily in Leeds, there is a building for families called

Ecclesley house, which is situated in the grounds of St James hospital. It
enabled parents to be close to there children and to have all the comforts of
home. This is not only hugely beneficial for the parent but also for the child.

It was especially advantageous for Josh and his mum, who came all the way from

Hull. It was important to allow mum to be able to ask any questions she wanted
and to have those questions answered in a clear legible way. It was important to
allow mum to have as much hands on care for Josh as possible, giving her some of
the responsibility of care for Josh. This is known as family centred care,

“Family centred care can be described as a multi-faceted concept incorporating
interaction between child, family and nurse, to provide holistic care,”
(Brunner and Studdarth 1991). “Providing an opportunity for the family to care
for their hospitalised child under nursing supervision,” (Brunner and

Studdarth 1991). Family centred care is a key factor in maintaining emotional
support for the child. Physical Josh had many physical needs whilst in hospital,
some that he needed to stay alive and some to keep a sense of normality. One of
the symptoms of Cystic Fibrosis is the prevention of ridding mucus from the
lungs; if this is not helped or assisted then it can lead to breathing
difficulties and infections, even death. The physiotherapists, who were based on
the ward essential part of Josh’s treatment, without them he would have most
certainly died. Josh required four sessions of physiotherapy a day. This was a
routine Josh had to get used to as part of his ongoing treatment. The
physiotherapy was very hard going and at times seemed quite ruthless, there were
a number of occasions when he fought against the treatment. “Often the child
will manifest anger, fear and other emotions by resistance to chest
physiotherapy. Allowing the child to engage in physical activities within his
physical tolerance could redirect these feelings as well as to improve
respiratory function.” (Harvey 1990). Unfortunately there were no activities

Josh could have taken part in that were of a physical nature within the ward.

Perhaps this would have helped. Josh did take a liking to a fire engine that was
on the ward, which he used to race around the ward with and crash into
everything, quite violently. The only feedback at the time was “Stop It!!”,
he is very young for his age, certainly too young to be playing with fire
engines.” I believe the nursing staff failed to see the link between this and
the physiotherapy sessions. I believed Josh was very scared and frightened by
what was happening to him. His mum, was getting increasingly anxious, with
regard to Josh and her job in Hull. Josh would have easily picked up an
atmosphere, perhaps even felt guilty about his mum, and was finding no
reassurance from her. The team that should have intervened with this situation
was the nursing staff, who are a very important part of Josh’s physical well
being. It was essential for the nursing team, to explain treatment, give him
information, but not overwhelm him with facts. Sitting and listening to Josh,
was equally as important as talking to him. Listening to his fears and feelings.

Spending time one to one, was what Josh wanted a lot of the time, which was
difficult when the ward was busy, but this is one of the times when family
centred care was found to be useful. his mum spent a lot of time with Josh,
during the times she went for food or home for some rest we would step in and
spend that time with him. This worked well, however the problem was that there
wasn’t the time to spend with Josh’s mum, to explain and resolve her
anxieties. This was a problem because as much as the nursing staff were
reassuring Josh, his mum was inadvertently creating anxiety, stress and possibly
guilt. The one to one care the nursing staff were giving was wasted. If the
nursing team had allocated more time to spend with both Josh and his mum
together, then a lot of the anxieties and stresses of both mother and child
could have been alleviated. Social The social care of Josh was extremely
difficult; there were four other patients on the ward with Cystic fibrosis, all
around Josh’s age. Unfortunately because of the nature of CF, each had to be
isolated from other CF patients, because of the risk of cross infection. This
was very distressing for Josh, as he loved to play with friends, make friends,
and talk with friends. This made Josh very angry and frustrated with the Nurses,
and his mum. The hospital ward tried to create a state of relative normality for

Josh whilst on the ward, but according to the National Child development study”isolation from friends and peers has an important impact on future
relationships, and socialization,” (Hull 1990). This was a problem that
wasn’t raised as an issue within the ward. I suggested that they write to each
other, and that we would help with any reading and writing he needed, this
seemed to work, and was great fun. There was a strong onuses on play on the
ward. “Through play the child learns about his/her environment, through the
process of assimilation or through the practice of skills,” (Harvey 1990).

“Children develop, intellectually, emotionally, physically and socially
through a series of sequential stages” (Johnston 1988). The play requirements
vary according to their age and/or developmental level. Play helps form their
own identity, to exercise control, to adapt their particular culture and to
develop inter personal relationships. “Deprived from play a child is a
prisoner shut of from all that makes life meaningful, play is not merely a means
of learning the skill of daily living, but gives the impulse to create and
achieve”. (Harvey 1990). Children in isolation, such as Josh, have particular
difficulties. They are not only away from home, but also in an unnatural, lonely
and alarming situation with no opportunity to play with the other children. Play
programmes are essential to compensate for the loss of independence and
companionship. Play is also one of the ways in which a child may develop the
capacity to deal with the stresses and strains of life as they press upon him.

It acts also as a safety valve, allowing him to re-live and often come to terms
with fears and anxieties that become overwhelming. This failed Josh whilst he
was on the ward. The onuses on the ward were either the very young children or
the adolescents. So I believe this didn’t benefit Josh at all. The activity
specialists were only part time, and they didn’t work weekends. Maybe
employing them as full time and over the weekend with better funding would help
provide a suitable care programme for children Josh’s age. Spiritual One of
the noticeable problems with Josh was that he always behaved when with the
nurses, however as soon as his mum arrived he would throw tantrums. One of the
factors the nursing staff and all other agencies working on the ward should have
ensured was Josh’s self-esteem. Being isolated, Josh could have easily felt
rejected by his mum and by the ward. Children who experience repeated rejection
and other negative emotions “will eventually develop low self esteem and a
poor self image” (Hull 1990). Children with low self-esteem often behave badly
in front of the person they need reassurance from; in order to have it confirmed
that they really are bad. Perhaps this was the reason why he only behaved badly
with his mum, because he felt guilty and blamed himself for his mum’s
anxieties. Conclusion There were many agendas raised in the care of Josh, the
main aspect I believe to have been ignored was the communication between the
nursing staff and his mum. She showed a keen interest in his care yet was not
properly explained the facts by the nurses. If more care had been given in
explaining and listening to his mums worries and concerns, then a lot of

Josh’s emotional problems could have been helped and eased. There was enough
interaction between the nurses and Josh, but very limited interaction between
nurse and mother. There were also enough signs within his behaviour to indicate
him not being happy, and worried, which were never noticed. Fighting against the
physiotherapy, going over the top crashing the fire engine. I believe family
centred care to be extremely important in the care of paediatrics; however there
is a fear that the nursing profession can take for granted the role of the
family in the hospital. It is true that the parents are the best managers of
their child’s care, but it must be remembered that, the parents are not
professional nurses, and need the information from the professionals, who have
had the training, knowledge and the experience in dealing with diseases such as

Cystic fibrosis.


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