Caring for the child comes first for child wound care specialist Sharon Cassidy. FIONA CASSIE profiles the Christchurch-based nurse who works with burns, pressure ulcers, abscesses, and the super-sensitive skin of ‘butterfly’ children.
Sharon Cassidy has an early memory of her three-year-old sister standing up, crying in her hospital cot. She was only five and the pair was in hospital having their tonsils removed. No sleepovers by mothers in those days or in the early days of Cassidy’s nursing career as an enrolled nurse at Burwood Hospital. So it’s not unexpected that as a young nurse she was drawn to looking after children waking up alone in Burwood’s ENT ward. “I’d be picking them up and cuddling them, singing to them, making them feel safe and secure, and ensuring they had pain relief so they could get back to sleep.”
For Cassidy, the nurturing side of nursing came first but the desire to build the technical side of her clinical skills soon followed. In October, the clinical nurse specialist is heading off to the inaugural International Paediatric Wound Care Symposium in Rome (thanks to support from Canterbury DHB and NZNO). Cassidy is a member of the Australian New Zealand Burn Association, New Zealand Wound Care Society, Paediatric Society, and Nurses for Children and Young People of Aotearoa.
Less is best
Working with children’s wounds takes specialist care but also needs your heart in the right place, believes Cassidy, whose numerous roles include wound resource nurse for Christchurch Hospital’s paediatric department. “I think you have to have a love of children.” Her aim at all times is to look at ways of reducing distress, anxiety and pain for a child.
An important aspect of this is planning ahead. “It’s thinking about the opportune time (for wound dressing). Sometimes you only have a small window of opportunity.” So you need to make sure – whether the child is at home or in hospital – that they have pain relief before arriving to get a wound dressed. And to think about whether they need distraction or play therapy to permit as stress-free a wound dressing as possible.
“I like the motto of working with children that ‘less is best’,” Cassidy says. “So that’s less time, less dressing changes, less product used and above all, less anxiety for the child and family.” But there are some occasions when “less is more”, like decorating a plain crepe bandage protecting a wound with something colourful and appealing. “So they don’t want to take it off, instead they want to show everybody how pretty it is.”
The wounds she treats and advises others on can vary from skateboarding injuries to abscesses and from pressure ulcers to burns. “Whatever the wound, you use the same principles.” And the key principle of wound healing, she reiterates, is to keep the wound moist to alleviate pain, prevent infection and reduce the risk of scarring.
Merging her skills and passion
Cassidy’s health career began as a 14-year-old schoolgirl working part-time as a hospital cleaner, then came nurse aiding and in 1981 she trained as an enrolled nurse at Burwood.
Before becoming a mother herself, Cassidy was drawn to caring for children, whether they were in the ENT ward or her base at the burns and plastics surgery unit, where children and adults were nursed together.
In 1996 she completed her bridging course from enrolled to registered nursing and around the same time the burns and plastic surgery unit shifted to Christchurch Hospital. The newly qualified RN followed, successfully applying to work in the paediatric department. Her RN badge might have been newly won, but her wound expertise soon surfaced in a ward new to treating serious burn wounds. By 2001 she had completed several postgraduate papers, which also gave her the confidence to initiate changes. “Some (burn victim) children need sedation for wound-dressing changes and we used to take them back to the plastics and burns unit to do that.” But Cassidy was uncomfortable with what she saw as the unsafe practice of moving children around under sedation and treating them in an adult ward with no time for staff to establish a rapport or offer play therapy.
She helped develop standards and guidelines for nurses on sedation and wound dressing that saw sedated dressing changes happen on the paediatric ward from 2002.
Paediatric specialist – pamphlets and website
Cassidy’s enthusiasm for building and sharing her skills with colleagues and patients’ families has been unabated ever since.
Early projects included compiling a pamphlet, Understanding your child’s burn injury and a step-by-step form covering initial treatment of paediatric burns.
It might be that childhood memory of her distressed sister, but Cassidy remains very conscious that coming to hospital can be a scary experience for children, so she worked with others nurses and a play therapist to develop a book on Going to Hospital and a story called Having an operation at Christchurch Hospital complete with video and photo board. The project won her a quality and innovation award in 2003 and she used her prize money for further postgraduate study that helped her complete her postgraduate diploma.
The next push in making hospital a less scary place for children and their families has been working with a colleague on a child health website for the DHB, with sections aimed at taking the fear out of having your plaster cast sawn off or having an IV line put in.
She also removed the risk of accidental burns from hot drinks by introducing a ‘no hot drinks’ policy into the paediatric department despite some initial resistance. Only hot drinks with lids are now allowed and she believes the move should go hospital wide. So far she has not been successful in that wish, but her work in paediatrics was rewarded in 2008 with the Flora Cameron Award for excellence in practice for Canterbury.
Wounds – butterflies to burns
It was in 2006 that Cassidy first came across her first ‘butterfly’ child (a child with the rare skin blistering condition, Epidermolysis Bullosa (EB) that in severe cases can leave a child’s skin as “fragile as a butterfly’s wing”. The child was admitted to the ward with badly infected wounds and Cassidy was brought in to help advise on her wound-care regime.
The child had very severe EB, which meant that the gentlest friction of a hug, or clothes rubbing could cause blistering and shearing of the skin.
Cassidy brought in one of two nurses employed nationally by EB support organisation DEBRA to speak to the department so she and her colleagues could learn more. As it was obvious the child needed more regular care than the stretched DEBRA nurse could provide, Cassidy entered negotiations with the board to get a special outreach contract for her to spend four hours a week supervising her care.
In 2008, two babies were born at Christchurch Hospital with EB and Cassidy’s outreach nursing contract was stepped up to 12 hours a week. She supports and teaches the carers of EB children – there are now six diagnosed in Christchurch – with the wound dressing of the most severe cases taking up to three hours a day. Cassidy says the aim is to care for the children at home so they stay infection free and only come to hospital when needed.
In 2006 she also took on the role of DEBRA nurse for the 40 children and adults with EB in the South Island and lower North Island – a role that last year got dedicated government funding for the first time after being funded by DEBRA for eight years.
With only the minority needing the level of hands-on care of severe EB sufferers, a lot of her work is giving support and advice over the phone. But she also visits in person, meets with their local doctor, nurse and pharmacist to advise on their care and follows it up with written advice so people have something concrete to refer to.
Own business
The child-focused nurse also saw a gap in services for children being discharged from hospital with complex wounds to treat. “They would be referred out to district nursing services, but unfortunately in Christchurch we didn’t have any outreach paediatric nurses.”
A couple of her fellow paediatric nurses agreed it was a gap that should be filled. But an approach to the district health board failed to get funding backing, so Cassidy added another hat to her nursing outfit and in 2007 set up her own nursing business to help fill that gap: SOS Nursing. So now her working life is one day a week as paediatric department wound-resource nurse, 12 hours as Canterbury DHB EB outreach nurse, part-time EB nurse for DEBRA and nursing business manager.
Her ideal would still be for the DHB to fund its own paediatric outreach service for discharged children but meanwhile her business is an ACC provider of community nursing, specialising in wound care for children and young adults with burns and other wounds.
Working with the whole rather than the hole
Cassidy always sees her job as more than just caring for the child patient. “As a paediatric nurse, when I go into a home I’m not just looking at the child, I’m looking at the whole family.” The mum might need advice and reassurance not only about the child being visited but the sibling who might have started soiling themselves or having problems at school while their mum spent time at hospital.
With burns and wounds can also come scars both physical and psychological. “We try to normalise them as much as possible… but sometimes psychologically they need some support.” Also, the whole multidisciplinary team who work with the child have to remember “it’s not all about the wound”. It can also be about remembering the parent and siblings whether the child has EB or burns. Parents of the genetic disorder EB can feel guilty about passing it on and parents can feel guilt that they caused the burn or accident that injured their child.
Cassidy says there is a saying in wound care that you should be “thinking about the whole patient rather than the hole in the patient”. So it is not only using the right products in the right way but also the psychological aspects, nutrition and managing pain. “They are very important as they can delay wound healing if not addressed.”
Colourful and salty baths…
Cassidy says an example of keeping it normal for kids can be the retention of daily routines like having a bath. “If they want a bath they can have a bath – it may just be as simple as having a plastic bag over their wound.”
On the other hand, if the child is scared of having a bath because it might hurt – like for children with eczema or a burn – she shares a tip that DEBRA director Anna Kemble Welch first initiated in New Zealand for EB children – a saline bath. First developed for burns victims, a saline bath is made up with a salt concentration of 9gms of salt to a litre of water – so the water touching the outside of the skin has the same saline concentration as inside the skin. “You don’t get any movement of water between the cells, so there’s no pain, as the water is not moving and out (of the skin).” If a child has bad memories of their last painful bath, you can bring in a little play therapy or distraction by adding food colouring to the bath. “So you can ask ‘what colour would you like today’. That’s the kind of troubleshooting you do to make it easier for children.”
Making it easier for children is what Sharon Cassidy’s work is all about. ✚
What is EB?
Epidermolysis Bullosa is medical Latin for skin that blisters and tears easily. Epidermal describes ‘outer skin layers’; lysis means ‘tearing and shearing’; and bulla are the ‘blisters’ that develop. The genetic condition means the skin blisters or tears more easily than normal skin. In severe EB the slightest touch can cause skin to blister or come off and leave wounds like burns, leading to people talking about “butterfly children”. More than 150 children and adults have this disorder in New Zealand – the majority experience mild to moderate symptoms, but there are currently 11 New Zealanders with severe EB, which has an incidence of one in 300,000.
*Source: The EB support group DEBRA
New Zealand’s website: www.debra.org.nz
Advice for children’s wound care
Think and plan ahead as often you only have a small window of opportunity
Ensure child has had some pain relief in advanced of planned dressing changes
Use appropriate language and distractions or play therapy to keep anxiety levels down
Remember the rule that less is best – less time, less dressing changes, less products and less anxiety
Also keep wound moist to alleviate pain, prevent infection and speed up healing with less chance of scarring.
