Consent and prepare a child for a procedure — OSCE

Candidate instructions

You are the paediatric registrar on the ward. A 4-year-old child needs an intravenous cannula for antibiotic therapy. The bedside team has suggested holding the child down. You have 8 minutes to take valid consent and assent, deliver the preparation conversation, outline the comfort bundle, and explain your approach to restraint and the documentation. [1]

The four tasks are: take valid consent and developmentally appropriate assent from the parent and child and explain the framework you are using; deliver the preparation conversation for this preschool child and her anxious parent, including what to say, what to avoid, and how you will brief the parent; outline the bedside comfort bundle you will assemble; and explain your approach to restraint versus a comfort position and the documentation you will complete. [1] [3]

You may use the parent as the simulated participant. You do not need to perform the cannulation. [6]

Encounter script (examiner / simulated parent)

Simulated parent (opening): "She had a needle once before and it was awful, she screamed the whole time. The nurse said we should just hold her down this time so it's over quickly. Is that okay?" [3]

If the candidate proposes restraint without exploring alternatives: "Are you sure? Won't it be traumatic? She's already scared." [6]

If the candidate says it won't hurt: "You promise it won't hurt? She won't believe me if you say that and then it does." [3]

If the candidate gives a developmentally matched, honest plan with a comfort position and a briefed parent role: "Okay, that makes sense. What do you want me to do?" [1]

Model answer and marking domains

Domain 1 — Consent and assent (3 marks). The candidate identifies the parent as the holder of parental responsibility and takes parental permission, layered with developmentally appropriate assent from the four-year-old, using the AAP framework that distinguishes informed consent (for those with capacity), parental permission (for the young child) and affirmative child assent. The candidate avoids treating silence as agreement, asks open questions, watches behaviour, and records any dissent. The candidate names the procedure, the material risks, the alternatives and what happens if nothing is done, in language the parent and child can both use, and states the basis on which they are acting. [1] [2]

Domain 2 — Preparation conversation (3 marks). The candidate prepares the preschool child 30 to 60 minutes before using play and a simple, honest, concrete sequence: showing the equipment on a doll first, using short concrete words (squeeze, cold, push), and explicitly avoiding the false promise that it will not hurt (recognising that betrayal destroys trust for this and future procedures). The candidate offers a real choice only where one genuinely exists (which arm, watch or look away) and does not offer a false choice about whether the procedure will happen. The candidate briefs the parent on the helpful role (a calm, matter-of-fact tone, a single honest statement, a chosen coping task such as a comfort hold or distraction toy) and on the behaviours to avoid (excessive reassurance, apologising, criticism, promising a reward for no tears). [1] [6]

Domain 3 — Bedside comfort bundle (3 marks). The candidate assembles a layered bundle: topical anaesthesia on intact skin 30 to 60 minutes before; comfort positioning (chest-to-chest on the parent or hugging a wrapped toy); distraction and coping coaching, ideally with a child-life specialist using medical play; and a calm, briefed parent with a specific task. The candidate correctly notes that the infant sucrose dose (typically 0.1 to 2 mL of 24% to 33% solution as an absolute volume, maximum about 2 mL per dose) and breastfeeding for procedural pain are infant measures that do not apply to this four-year-old, and cites the Cochrane review (bundle over any single component) and the Taddio additive-effect analysis. [3] [4] [5]

Domain 4 — Restraint versus comfort position and documentation (3 marks). The candidate distinguishes restraint (the use of force to overcome active resistance) from a comfort position (a supported, child-accepting posture that reduces fear and improves access), and states that for this non-emergency procedure restraint is not the right approach: the least-restrictive alternative — enhanced preparation, child-life referral, comfort positioning, rescheduling with a more experienced operator, or procedural sedation — should be used. Restraint is reserved for a genuine, proportionate, least-restrictive emergency and must be documented. The candidate completes a defensible consent record naming the procedure, the person who gave permission and assent, the material information disclosed, the capacity findings, any dissent and how it was weighed, and the time and clinician. [1] [3]

Examiner global rating anchors

• Pass (clear): Frames consent as parental permission plus assent using the AAP framework; delivers an honest, developmentally matched preschool preparation; assembles a layered comfort bundle; explicitly rejects routine restraint in favour of a comfort position and the least-restrictive alternative; documents the encounter. Cites at least the consent framework and the comfort-bundle evidence. [1] [3]
• Borderline: Names consent and preparation but conflates assent with consent, or proposes restraint for the non-emergency cannula, or omits the comfort bundle or the parent briefing. Some key citations missing. [6]
• Fail: Plans to restrain the child without considering alternatives; tells the child it will not hurt; cannot describe the consent framework or the comfort bundle; does not document. [1]

High-yield pitfalls for the candidate

• Saying "it won't hurt" — betrays trust and is an immediate fail on this station. [1]
• Proposing restraint for an elective cannula without first exhausting the least-restrictive alternatives. [3]
• Conflating assent with consent, or treating a quiet, frozen child as having assented. [1] [2]
• Omitting the parent briefing — an unbriefed, anxious parent amplifies distress. [3]
• Forgetting to document the consent and the dissent, which makes the encounter indefensible. [1] [3]