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Objective: This study used a candidate gene approach to examine genomic variation associated with pain, anxiety, and distress in children undergoing a medical procedure. Study Design: Children aged 4–10 years having an IV catheter insertion were recruited from three Midwestern children’s hospitals. Self-report measures of pain, anxiety, and distress were obtained as well as an observed measure of distress. Samples were collected from children and biological parents for analysis of genomic variation. Genotyped variants had known or suspected association with phenotypes of interest. Analyses included child-only association and family-based transmission disequilibrium tests. Results: Genotype and phenotype data were available from 828 children and 376 family trios. Children were 50% male, had a mean age of 7.2 years, and were 84% White/non-Hispanic. In family-based analysis, one single-nucleotide polymorphism (SNP; rs1143629, interleukin ( IL1B) 1β) was associated with observed child distress at Bonferroni-corrected levels of significance ( p = .00013), while two approached significance for association with high state anxiety (rs6330 Nerve Growth Factor, Beta Subunit, [ NGFB]) and high trait anxiety (rs6265 brain-derived neurotrophic factor [ BDNF]). In the child-only analysis, multiple SNPs showed nominal evidence of relationships with phenotypes of interest. rs6265 BDNF and rs2941026 cholecystokinin B receptor had possible relationships with trait anxiety in child-only and family-based analyses. Conclusions: Exploring genomic variation furthers our understanding of pain, anxiety, and distress and facilitates genomic screening to identify children at high risk of procedural pain, anxiety, and distress. Combined with clinical observations and knowledge, such explorations could help guide tailoring of interventions to limit procedure-related distress and identify genes and pathways of interest for future genotype–phenotype studies.

Spinal fusion for idiopathic scoliosis is one of the most painful surgeries experienced by adolescents. Music therapy, utilizing music-assisted relaxation with controlled breathing and imagery, is a promising intervention for reducing pain and anxiety for these patients. It can be challenging to teach new coping strategies to post-operative patients who are already in pain. This study evaluated the effects of introducing music-assisted relaxation training to adolescents before surgery. Outcome measures were self-reported pain and anxiety, recorded on 0-10 numeric rating scale, and observed behavioral indicators of pain and relaxation. The training intervention was a 12-minute video about music-assisted relaxation with opportunities to practice before surgery. Forty-four participants between the ages of 10 and 19 were enrolled. Participants were randomly assigned to the experimental group that watched the video at the preoperative visit or to the control group that did not watch the video. All subjects received a music therapy session with a board certified music therapist on post-operative day 2 while out of bed for the first time. Pain and anxiety were significantly reduced from immediately pre-therapy to post-therapy (paired t-test; p).

Purpose Distraction is a relatively simple, evidence-based intervention to minimize child distress during medical procedures. Timely on-site interventions that instruct parents on distraction coaching are needed. The purpose of this study was to test the feasibility and usability of the Distraction in Action Tool© (DAT©), which 1) predicts child risk for distress with a needle stick and 2) provides individualized instructions for parents on how to be a distraction coach for their child in clinical settings. Design and Methods A mixed-methods descriptive design was used to test feasibility and usability of DAT in the Emergency Department and a Phlebotomy Lab at a large Midwest Academic Medical Center. Twenty parents of children ages 4–10 years requiring venipuncture and clinicians performing 13 of those procedures participated. Participants completed an evaluation and participated in a brief interview. Results The average age of the children was 6.8 years, and 80% of parent participants were mothers. Most parents reported the DAT was not difficult to use (84.2%), understandable (100%), and they had a positive experience (89.5%). Clinicians thought DAT was helpful (100%) and did not cause a meaningful delay in workflow (92%). Conclusion DAT can be used by parents and clinicians to assess their children's risk for procedure related distress and learn distraction techniques to help their children during needle stick procedures. Practice Implications DAT for parents is being disseminated via social media and an open-access website. Further research is needed to disseminate and implement DAT in community healthcare settings.

Background The uptake of evidence in practice remains a challenge for healthcare professionals including nurses and providers. Increased use of evidence-based practices (EBPs) in healthcare settings may improve patient conditions such as pain and decrease the cost of health care. The relationship between context in the practice environment and uptake of EBP remains an understudied area. Aims This study explored the relationships of context including the elements of individual, unit, and hospital and the use of evidence-based nonpharmacological pediatric pain management practices (EBNPPs) using an existing data set of RNs and providers, defined as doctors of medicine and osteopathy, nurse practitioners, and physician assistants caring for children in the emergency department. Methods A secondary data analysis was conducted using correlation and regression. Results Initial analysis identified several significant positive correlations with individual, unit, and hospital context elements and EBNPP. A significant correlation was not found between evaluation and EBNPP and magnet status and EBNPP for RNs or providers. RN regression analyses found that knowledge and continuing education were significant predictors of EBNPP. Overall context was a significant predictor of EBNPP for both the RN and provider models. A pooled regression analysis with RNs and providers found that RNs had a significant increased use of EBNPP when compared to providers. Conclusions Regression analyses found that overall context significantly predicted the use of EBPPM for RNs and providers although no one element—individual, unit, or hospital—was identified as more important. The effect of context on EBNPP did not differ by profession in this sample. Future research should focus on the overall influence of context on EBP and consider other factors that may play a role in the uptake of EBP.

Hospitals and other medical settings often involve situations that are distressing to children, including intrusive procedures, therapeutic interventions, limited or restricted activity, separation from the familiar, and an unfamiliar environment (Bossert, 1994). In particular, painful medical procedures, such as injections or intravenous (IV) line insertion, may lead to high levels of distress (Bossert, 1994; Claar, Walker, & Smith, 2002; Cohen et al., 2001; Smalley, 1999). Higher levels of distress have shortand long-term effects; extreme distress can jeopardize successful completion of a required procedure, and long-term effects include difficulty with future medical procedures and avoidance of medical care (Du, Jaaniste, Champion, & Yap, 2008; Kennedy, Luhmann, & Zempsky, 2008; Matthews, 2011; Noel, McMurtry, Chambers, & McGrath, 2010). Variability in causes of children’s distress, levels of anxiety, and responses to interventions designed to lower anxiety and reduce distress highlight the need for tools facilitating rapid clinical evaluation of each child. Such tools are readily available for assessment of pain (von Baeyer, 2009), but not for anxiety. Validated measures of child anxiety are typically lengthy and designed for use in research, limiting their utility in busy clinical settings. A brief measure of child self-reported state anxiety will facilitate identification of children with high anxiety levels, as well as development of interventions to lower anxiety in clinical settings, helping clinicians provide individualized care. The purpose of this article is to describe the construct validity of the Child Anxiety Meter-State (CAM-S) as a brief measure of child state anxiety appropriate for use in a clinical setting.

Evidence-based pediatric pain management (EBPPM) has been identified as a practice too often overlooked in Emergency Departments (EDs). Studies show EBPPM is practiced inconsistently in urban EDs, and even less is known about the practice in rural EDs. The objectives of this study were: A) Determine the frequencies with which specific EBPPM practices are used in EDs of a primarily rural state; and B) Explore the differences in EBPPM practice in Critical Access, rural, and urban hospital EDs. A web-based survey, measuring the use of 14 EBPPM practices, was offered to all licensed independent providers (Medical Doctors, Doctors of Osteopathy, Physicians’ Assistants, and Advanced Registered Nurse Practitioners) and nurses from the 118 hospital EDs in a rural state. Responses from 259 providers and 1,177 nurses revealed that the majority of respondents infrequently used any type of topical analgesic before venipuncture or IV insertion in children, or oral sucrose for infant procedures. Tests for group differences show that providers from urban EDs more frequently used a topical analgesic for suturing lacerations, provided analgesics for blood draws, and gave pain medication to children with abdominal pain. Nurses from urban hospitals used significantly more EBPPM practices than nurses from Critical Access and rural hospitals (P Perspective In hospitals of all types, ED providers and nurses fail to take advantage of EBPPM practices. This study reveals that health professionals in rural settings are particularly in need of improving the use of recommended pediatric pain management practices.

Background: Previous research shows that numerous child, parent, and procedural variables affect children's distress responses to procedures. Cognitive-behavioral interventions such as distraction are effective in reducing pain and distress for many children undergoing these procedures. Objectives: The purpose of this report was to examine child, parent, and procedural variables that explain child distress during a scheduled intravenous insertion when parents are distraction coaches for their children. Methods: A total of 542 children, between 4 and 10 years of age, and their parents participated. Child age, gender, diagnosis, and ethnicity were measured by questions developed for this study. Standardized instruments were used to measure child experience with procedures, temperament, ability to attend, anxiety, coping style, and pain sensitivity. Questions were developed to measure parent variables, including ethnicity, gender, previous experiences, and expectations, and procedural variables, including use of topical anesthetics and difficulty of procedure. Standardized instruments were used to measure parenting style and parent anxiety, whereas a new instrument was developed to measure parent performance of distraction. Children's distress responses were measured with the Observation Scale of Behavioral Distress-Revised (behavioral), salivary cortisol (biological), Oucher Pain Scale (self-report), and parent report of child distress (parent report). Regression methods were used for data analyses. Results: Variables explaining behavioral, child-report and parent-report measures include child age, typical coping response, and parent expectation of distress (p < .01 Level of parents' distraction coaching explained a significant portion of behavioral, biological, and parent-report distress measures (p < .05). Child impulsivity and special assistance at school also significantly explained child self-report of pain (p < .05). Additional variables explaining cortisol response were child's distress in the morning before clinic, diagnoses of attention deficit hyperactivity disorder or anxiety disorder, and timing of preparation for the clinic visit. Discussion: The findings can be used to identify children at risk for high distress during procedures. This is the first study to find a relationship between child behavioral distress and level of parent distraction coaching.

Children's distress during medical procedures can be decreased when professionals or parents provide distraction coaching, but the quality of distraction may contribute to the variation in the results. This article describes the development of the Distraction Coaching Index (DCI), a tool for measuring the quality and frequency of distraction coaching. Nominal group technique and consensus agreement were used for concept clarification and development of behavioral indicators and descriptors. Videotapes of untrained parents, trained parents, and expert professional coaches, who provided distraction to children (4–10 years old) undergoing peripheral intravenous catheter insertion, were used to assess interrater reliability and construct validity. DCI scores were significantly higher for the experts versus untrained parents and trained parents versus untrained parents. The DCI can be used by researchers to evaluate treatment fidelity of distraction coaching and by clinicians for teaching health professionals ...

Some children report significant pain with peripheral intravenous catheter (IV) insertion, despite the appropriate use of topical lidocaine anesthetics. This analysis of data from an existing study identified factors related to variation in topical anesthetic effectiveness used for IV insertion. The children (n = 218) in this investigation were 4 to 10 years old and undergoing a scheduled IV insertion. Inclusion criteria were (1) topical anesthetic was used according to manufacturer's recommendations, (2) DNA material was available, and (3) child completed a self-report measure of pain intensity (Oucher scale). Low pain phenotype was defined as a pain intensity score of 0 to 3, and high pain phenotype was an intensity score of 4 to 10. Potential predictor variables included child age, gender, number of previous painful procedures, state and trait anxiety, temperament characteristics, and alleles in 3 candidate genes in a pain pathway influenced by topical anesthetics (endothelin-1 [ EDN1 ], endothelin receptor A [ EDNRA ], endothelin receptor B [ EDNRB ]). All subjects were genotyped for a single-nucleotide polymorphism in each gene. Children in the high pain group (n = 89) were significantly younger ( P P = .0029), scored higher for trait ( P = .0009) and state anxiety ( P = .0312), and had the EDNRA TT genotype (high pain group, TT 67.35%; low pain group, TT 39.47%; P = .026). Perspective The identification of factors that influence peripheral pain sensation aids in selecting the most appropriate pharmacologic and nonpharmacologic interventions. Until genotyping is available at a clinically prescriptive level, other predictors (eg, age and activity level) can be used to tailor pain-relieving strategies for children undergoing needle sticks.

Continuous Lateral Rotation Therapy (CLRT) is a therapy used in ICUs for early mobilization of ventilated patients. CLRT is believed by some in health care to not be sufficient to allow for capillary re-perfusion, and may lead to tissue damage.To determine if there are differences in skin interface pressures, skin integrity, or perceived discomfort across three positioning scenarios.A Hill-Rom Total Care SpOrt(®) bed was equipped with a pressure mapping device. Ten healthy volunteers were placed in each positioning scenario for 30 minutes; interface pressures were recorded.CLRT alone demonstrated statistically lower interface pressures on ischial tuberosities (p0.05) as compared to the scenarios with static wedge. Higher pressures were noted on the heels in CLRT alone (p0.05). One subject noted pain with CLRT. No erythema or breakdown noted.This feasibility study supports the use of CLRT to decrease pressure on capillary beds and decrease patient discomfort.

arents of children in pediatric intensive care units (PICUs) place great importance on receiving information about their children’s condition, having their questions answered, and talking with the physicians in charge of their children’s care. 1 Although nurses often bridge the communication gap between parents and physicians, patients’ families understandably want the opportunity to speak directly with physicians about the medical plan of care. In the PICU at Children’s Hospital of Iowa in Iowa City, the family visiting policy was a major obstacle to sharing information between parents and the physicians in a timely manner. Because families were not allowed to stay in the unit during medical rounds, nurses often felt “caught in the middle” between parents and physicians. When parents were allowed to reenter the unit after rounds, the physicians were busy with procedures, admissions, or rounds with other patients until late in the afternoon. Although the nurses could answer some of the parents’ questions, they did not have all of the information and thought that it was inappropriate for them to discuss prognosis or specific medical treatment options with the parents. In order to meet the parents’ need for communication and to alleviate the nurses’ discomfort with feeling caught in the middle, a group of PICU staff

The integration of molecular genetics approaches into the study of complex health phenomena is an increasingly important and available strategy for researchers across the health science disciplines. Pain sensation and response to painful stimuli are examples of complex health phenomena that are particularly amenable to molecular genetics approaches. Both human and animal model research suggests that differences in these responses may be related, in part, to variation in the genes that modulate sensation and behavior. The authors are currently managing a large cross-disciplinary research effort to identify child characteristics, including genotypes, that predict the degree of distress displayed by children following a painful medical procedure (i.e., IV insertion). The purpose of this article is to describe the strategies used to integrate molecular genetics methods into this project. The authors discuss the steps needed to complete this process, including (a) establishing a collaboration with genetics researchers and laboratory facilities, (b) developing and implementing a plan to manage biologic samples, and (c) incorporating genetics into the informed consent process.

Salivary cortisol has emerged in pediatric research as an easy-to-collect, relatively inexpensive, biologic marker of stress. Cortisol is highly variable and is responsive to a wide range of factors that should be considered when incorporating this measure into research with children. Strategies for sample collection include: (1) standardizing the time for sample collection, including baseline samples; (2) using consistent collection materials and methods; (3) controlling for certain drinks, foods, medications, and diagnoses; and (4) establishing procedures and protocols. Other strategies for laboratory analyses include: (1) selecting the appropriate assay and laboratory; (2) identifying units of measure and norms; and (3) establishing quality controls. These strategies control extraneous variables and produce reliable and valid salivary cortisol results.

The purpose of this article is to present a model of factors that may influence a child's response to a painful procedure when parents are distraction coaches during the procedure. Nonpharmacological interventions, in particular, distraction, and parents as coaches for their children during procedures are discussed. A conceptual model is presented that illustrates the multiple factors and their possible relationships. A selected review of studies is provided that supports the inclusion of these factors in the model. The model and literature review focus on three major areas: characteristics of the child, characteristics of the parent, and procedural variables. The model presented is currently being tested in a large multisite study on the use of distraction during intravenous line insertion.

Many children with urinary tract infections and vesicoureteral reflux require catheterization. Catheterization can be a painful experience, and a desire to avoid this experience may affect patient care. We evaluated the effectiveness of lubricant containing lidocaine for minimizing patient pain and distress during catheterization.We conducted a prospective, double-blind, placebo controlled trial. Twenty children (16 girls and 4 boys, mean age 7.7 years) had urethral lubricant with or without lidocaine placed within 10 minutes before urethral catheterization. In all children pre-procedure anxiety, and pain and distress during catheterization were recorded. Pre-procedure anxiety was measured using a visual analog scale, pain was measured with the Oucher Pain Scale and distress was recorded by 2 independent observers with a simple 7-point Likert-type scale.There were no significant group differences for age, number of previous catheterizations or pre-procedure anxiety. The group receiving lubricant with lidocaine had significantly lower pain (21 +/- 19.69 versus 65.5 +/- 26.29) and distress (2.65 +/- 1.97 versus 4.7 +/- 2.07) (p = 0.001 and 0.007, respectively).The use of lubricant with lidocaine significantly decreases pain with pediatric urethral catheterization and is recommended with pediatric catheterizations.

Objectives. Children view needle sticks as the worst source of pain and fear in the hospital setting. In an effort to minimize the pain of needle sticks, the use of eutectic mixture of lidocaine and prilocaine (EMLA) has become standard practice in many children’s hospitals. Unfortunately, EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction, leading to difficult vein cannulation. A newly available local anesthetic (ELA-Max) may require less time and cause less vasoconstriction. The purpose of this randomized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max. Methods. Thirty well children (14 girls and 16 boys) who were between the ages of 7 and 13 years volunteered to have EMLA applied to the dorsal aspect of 1 hand for 60 minutes and ELA-Max applied to the other hand for 30 minutes. Right and left hands were randomized to treatment type and order of intravenous (IV) insertion. Clinical Research Center nurses, blind to the anesthetic randomization, attempted to insert a 22-gauge Teflon IV catheter into a vein in each hand. The children rated pain during IV insertion on the Oucher scale, and the nurse rated the difficulty of the insertion. Results. There was no significant difference in pain ratings for hands that were treated with EMLA (mean: 20.5) or with ELA-Max (mean: 24), and there was no difference for the difficulty of vein cannulation. Children’s preprocedure state anxiety was positively associated with pain ratings. Conclusions. ELA-Max, applied for 30 minutes before IV cannulation, has an anesthetic effectiveness similar to EMLA applied for 60 minutes. Some children rated IV insertion pain fairly high for both hands (eg, 60 on a 0- to 100-point scale) despite anesthetic treatment. Preprocedural anxiety may affect the perception and/or rating of pain. There were no differences between hands that were treated with EMLA or with ELA-Max for success of IV insertion.

The purpose of this study was to provide a viable alternative to routine postpartum hematocrit measurement, by a determination of the clinical risk factors that identify patients with anemia and an examination of the resulting cost savings.In this retrospective review, cases (postpartum hematocrit level,26%; subgroup hematocrit level,23%) and control subjects were culled from the records of all vaginal deliveries from February 1997 to July 1998. Charts were reviewed for demographic characteristics, medical history, nursing assessments, and postpartum hematocrit measurements. Logistic regression modeling determined the best set of risk factors for the identification of low postpartum hematocrit levels.From 1484 vaginal deliveries, 117 of the women (8%) had postpartum hematocrit levels of26%. Estimated blood loss of500 mL, Hispanic ethnicity, dizziness, or third- or fourth-degree laceration were the factors that identified 82.9% of the women with hematocrit levels of26% and identified 97.4% of the women with hematocrit levels of23%. Only 39.3% of the women would have required postpartum hematocrit measurement to obtain these detection rates.Four risk factors (estimated blood loss of500 mL, Hispanic ethnicity, dizziness, and third- or fourth-degree laceration) can safely determine the necessity of a postpartum hematocrit measurement.

The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.

This study investigated the effectiveness of a brief Distraction Education intervention for parents prior to their preschool children's medical procedures. Forty-four preschool children with chronic non-life-threatening conditions were having intravenous catheters (IVs) placed for medical tests. Parent-child dyads were randomized into two groups. The experimental group received Distraction Education prior to IV insertion; the control group received standard care. Data were analyzed for two phases of the IV procedure. Phase 1 was the preparation for needle insertion; Phase 2 began with needle insertion. Experimental group parents used significantly more distraction than did control group parents during both phases (P < 0.001). There were no group differences for child behavioral distress or self-report of pain. There was a trend toward a group by phase interaction for behavioral distress (P = 0.07); more experimental group children showed decreased behavioral distress over time (from phase 1 to phase 2) than did control group children (P = 0.02).

issues and purpose. Researchers need a clear understanding of the natural behaviors parents use to help their children cope. This study describes the relationships between naturally occurring parent behaviors and child distress behaviors during urethral catheterization. design and methods. In this descriptive study, researchers videotaped the behaviors of parent-child interactions during urethral catheterization. results. Parents used distraction to maintain calm behavior during the first part of the procedure and used more reassurance when the children started to become distressed. Seven of the nine children displayed calm behavior at least half the time following distraction. Parental reassurance did not decrease distress behavior in most children. practice implications. Early implementation of developmentally appropriate nursing interventions to decrease child distress is imperative. Parents may need specific instruction and practice to continue the use of distraction throughout procedures, even when the child is upset.

purpose. To determine, the effects of saline, heparin 2 units (U) per ml saline, and heparin 10 U/ml saline flush solutions on the duration of intravenous (IV) locks and the incidence of IV infiltration in neonates. design. Randomized double-blind experiment. setting. Tertiary-care nursery. participants. Neonates (N = 90) hospitalized at birth in the intensive, intermediate care, or newborn units. main outcome measures. Total hours from the time the IV was inserted to the time the IV was removed; hours from the time the IV was first flushed to the time the IV was removed; number of IVs removed because of infiltration. results. No statistical or clinical differences between the three groups for duration of IV nor for incidence of complications. conclusions. The use of heparin in IV lock flush solution did not affect the duration of IV locks nor the incidence of infiltration in neonates.

This secondary data analysis used data mining methods to develop predictive models of child risk for distress during a healthcare procedure. Data used came from a study that predicted factors associated with children’s responses to an intravenous catheter insertion while parents provided distraction coaching. From the 255 items used in the primary study, 44 predictive items were identified through automatic feature selection and used to build support vector machine regression models. Models were validated using multiple cross-validation tests and by comparing variables identified as explanatory in the traditional versus support vector machine regression. Rule-based approaches were applied to the model outputs to identify overall risk for distress. A decision tree was then applied to evidence-based instructions for tailoring distraction to characteristics and preferences of the parent and child. The resulting decision support computer application, the Children, Parents and Distraction (CPaD), is being used in research. Future use will support practitioners in deciding the level and type of distraction intervention needed by a child undergoing a healthcare procedure.

To explore adolescents' memories about music therapy after spinal fusion surgery and their recommendations for future patients.Spinal fusion for adolescent idiopathic scoliosis is one of the most painful surgeries performed. Music therapy is shown to decrease postoperative pain in children after minor surgery. In preparation for developing a preoperative information program, we interviewed adolescents who had spinal fusion and postoperative music therapy to find out what they remembered and what they recommended for future patients.Eight adolescents who had spinal fusion for adolescent idiopathic scoliosis were interviewed about their experiences. For this qualitative study, the investigators independently used thematic analysis techniques to formulate interpretive themes. Together they discussed their ideas and assigned overall meanings to the information.The eight participants were 13-17 years of age and had surgery between 2-24 months previously. The overarching themes identified from the interviews were relaxation and pain perception, choice and control, therapist interaction and preoperative information. Participants stated that music therapy helped with mental relaxation and distraction from pain. It was important to be able to choose the type of music for the therapy and to use self-control to focus on the positive. Their recommendation was that future patients should be provided with information preoperatively about music therapy and pain management. Participants recommended a combination of auditory and visual information, especially the experiences of previous patients who had spinal fusion and music therapy.Music provided live at the bedside by a music therapist was remembered vividly and positively by most of the participants.The presence of a music therapist providing patient-selected music at the bedside is important. Methods to introduce adolescents to music therapy and how to use music for relaxation should be developed and tested.

Successful implementation of Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines must involve an institutional commitment and an interdisciplinary effort. This article describes how a pediatric nursing research committee took the leadership role in implementing the AHCPR acute pain guidelines for children. Steps toward implementation included assessment of current practice methods, nursing interventions, interdisciplinary interventions, and plans for evaluating the practice change through the institutional quality assessment and improvement program.

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Objective To compare salivary cortisol baseline levels and responsivity as well as behavioral distress to intravenous (IV) catheter insertions in 4- to 10-year-old children with (n = 29) and without (n = 339) attention-deficit/hyperactivity disorder (ADHD). Methods This is a secondary data analysis from a sample of 542 children who participated in a multisite study on distraction. Data included were demographic variables, Pediatric Behavior Scale-30, Observational Scale of Behavioral Distress-Revised, and four salivary cortisol samples. Results Home samples from the ADHD group revealed nonsignificant but higher cortisol levels than the non-ADHD group. However, on the clinic day, the ADHD group had significantly lower cortisol levels before (0.184 vs. 0.261, p = .040) and 20–30 min after IV insertion (0.186 vs. 0.299, p = .014) compared with the non-ADHD group. Conclusions Cortisol levels in children with and without ADHD differ in response to the stress of an IV insertion.

This study evaluates the impact of parent-provided distraction on children's responses (behavioral, physiological, parent, and self-report) during an IV insertion. Participants were 542 children, 4 to 10 years old, randomized to an experimental group that received a parent distraction coaching intervention or to routine care. Experimental group children had significantly less cortisol responsivity (p = .026). Children that received the highest level of distraction coaching had the lowest distress on behavioral, parent report, and cortisol measures. When parents provide a higher frequency and quality of distraction, children have lower distress responses on most measures.

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of children's physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

PURPOSE. To describe the relationship between pain-sensitive temperament and self-report of pain intensity following surgery. DESIGN AND METHODS. Fifty-nine adolescents and young adults (average age 14 years) undergoing spinal fusion for adolescent idiopathic scoliosis completed the Sensitivity Temperament Inventory for Pain–Child version (STIP-C). The Pearson correlation between STIP-C scores and the highest pain intensity for each of the first three postoperative days was investigated. RESULTS. There was a small but significant correlation between the Perceptual Sensitivity and Symptom Reporting subscales of the STIP-C and pain intensity measured on the third postoperative day. PRACTICE IMPLICATIONS. Aspects of the pain-sensitive temperament may be important in understanding the variability in postoperative pain. This is the first investigation of the relationship between pain-sensitive temperament and surgical pain. More research is needed in this area.

Existing research identifies numerous variables that may influence children's distress responses during medical procedures. In preparation for a large multisite study to test relationships among these numerous variables and parent distraction coaching, a pilot study of instruments was performed that measured the more complex constructs, namely anxiety, coping, temperament, attention, and parenting style. This article describes the benefits, process, and results of evaluating research instruments before initiating a large study on children's distress during ;medical procedures. A convenience sample of 68 children (4-12 years old) and their parents participated in this study. Children completed state and trait anxiety measures and a coping style scale. Parents completed questionnaires about their child's temperament, attention behavior, anxiety, and coping during a recent medical procedure, and about their own anxiety and parenting style. Coefficients of reliability of the measures were examined and understandability of the instruments was assessed. A forward regression showed that nurturing parenting style, parent's state anxiety, and child's state anxiety accounted for 32% of the variance in child distress during a recent medical procedure.

Pain experienced in infancy may have effects later in life. Neonatal circumcision is a common painful procedure. In addition to dorsal penile nerve block, interventions that may have a role in minimizing pain and distress in neonatal circumcision include use of a sucrose pacifier, buffered lidocaine, small needles, acetaminophen, swaddling, and environmental modification. The evidence for each intervention is presented and evaluated. Implementation of a comprehensive evidence-based circumcision pain control standard of practice is discussed.

Background It is difficult to determine the usefulness of distraction to decrease children's distress behavior and pain during medical procedures because many studies use very small samples and report inconsistent findings. Objectives To investigate the mean effect sizes across studies for the effects of distraction on young children's distress behavior and self-reported pain during medical procedures. Method Hunter and Schmidt's (1990) procedures were used to analyze 16 studies (total n = 491) on children's distress behavior and 10 studies (total n = 535) on children's pain. Results For distress behavior, the mean effect size was 0.33 (+/-0.17), with 74% of the variance accounted for by sampling and measurement error. For pain, the mean effect size was 0.62 (+/-0.42) with 35% of the variance accounted for. Analysis of studies on pain that limited the sample to children 7 years of age or younger (total n = 286) increased the amount of explained variance to 60%. Conclusions Distraction had a positive effect on children's distress behavior across the populations represented in this study. The effect of distraction on children's self-reported pain is influenced by moderator variables. Controlling for age and type of painful procedure significantly increased the amount of explained variance, but there are other unidentified moderators at work.

As part of its Raise the Voice campaign, in November 2006 the American Academy of Nursing (AAN) named Ann marie McCarthy and Charmaine Kleiber as "Edge Runners"--nurses who identify new models of care that integrate the physical and mental health of patients and who make a "clear connection between research and practical solutions." Pat Fort-Rogner, chief executive officer of the AAN, says "We hope patient-advocacy groups and federal agencies like the Agency for Healthcare Research and Quality will take note."

This study explored parental and sibling perceptions and feelings about sibling information needs during a pediatric admission to an intensive care unit (ICU). Using a qualitative research design, parents (n = 14) and school-age siblings (n = 12) of children who were patients in ICU were interviewed using open-ended questions. Themes of information that the parents report having given to the siblings were similar to the themes that siblings report having heard. However, parents reported that the siblings had numerous questions about the reasons for hospitalization and expectations for the future of the family. The findings indicate that parents may neither be aware of the effects of the ICU experience on the siblings nor have the knowledge and skill to assist them. Parents may need counseling to increase their awareness of the siblings' need for information and teaching to increase skill in providing the information.

An exploratory design was used to study the effects of critical care hospitalization on family roles and responsibilities of adult family members and how these effects changed over time. A convenience sample of 52 subjects from pediatric, neonatal, surgical, medical, and cardiovascular intensive care units was used. Data were collected using an open-ended question contained in the Iowa ICU Family Scale (IIFS). Using qualitative techniques, seven themes were identified: (a) Pulling together, (b) Fragmentation of families, (c) Increased dependence, (d) Increased independence, (e) Increased responsibilities, (f) Change in routine, and (g) Change in feelings. These findings indicate that nurses need to implement family-centered interventions such as role supplementation programs or identification of support systems to decrease role strain and role overload in families during a crisis.

We have developed a protocol to identify unnecessary days of hospitalisation in the Department of Neurology of the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Seventy-four parameters (medical, social, type of investigation and treatment, degree of disability and of dependence) potentially associated with the length of stay were studied prospectively in 511 nonselected patients consecutively admitted to the Department over a period of 5 months. Each day spent on the wards was analyzed on a day-to-day basis and was classified into one of two groups: those due to a medical reason (4,700 hospital days), and those due to a nonmedical reason (1,184 days). These delays resulted chiefly from difficulties in obtaining laboratory investigations, especially in patients who were not disabled and who had been admitted for investigations (3.8% of hospital days, compared to 1.5% for patients with severe or total dependence) or from awaiting transfer to either another department or a nursing home. This second cause of delay markedly increased the length of stay of patients with severe or total dependence and with limited mobility on the first day (26.0 days, compared with 7.4 days for nondisabled patients) and, above all, on the last day spent in our Department (27.0 days, compared with 8.0 days). The ongoing analysis of these data may provide information as to which parameters could be influenced by neurologists in order to reduce the length of stay in hospital.

Collaborative research teams are an attractive means of conducting nursing research in the clinical setting because of the many opportunities that collaboration can supply. These opportunities include a chance to: (1) network with other nurses who have similar interests, (2) share knowledge and expertise for designing clinical studies that directly affect daily practice, (3) develop instruments, (4) write grant proposals, (5) collect and analyze data, and (6) prepare manuscripts for publication. The effectiveness of research teams, however, is strongly influenced by group functioning. This article describes the functioning of a collaborative family interventions research team of nursing faculty members and CNSs at a large Midwestern university setting. The formation of the group and membership characteristics are described, along with strategies used to identify the research focus and individual and group goals. Aspects related to the influence of the group on members and the internal operations of the group are also addressed. Future strategies to be explored will focus on the size of the group and joint authorship issues. The authors also set forth a number of recommendations for development of collaborative research groups.

The purpose of this meta-analysis was to estimate the effects of heparin flush and saline flush solutions on maintaining patency, preventing phlebitis, and increasing duration in peripheral heparin locks. The average effect size (d value) across 15 studies with a total sample size of 3,490 was .0573 for patency (clotting). The 95% credibility interval ranged from -.2267 to .3413. The average effect size across 13 studies with a total sample size of 2,356 was -.0757 for phlebitis. The 95% credibility interval ranged from -.2497 to .0983. The average effect size for duration across six samples with a total sample size of 1,960 was -.0550. The 95% credibility interval ranged from -.2424 to .1324. It can be concluded that saline is as effective as heparin in maintaining patency, preventing phlebitis, and increasing duration in peripheral intravenous locks. Quality of care can be enhanced by using saline as the flush solution, thereby eliminating problems associated with anticoagulant effects and drug incompatibilities. In addition, an estimated yearly savings of $109,100,000 to $218,200,000 U.S. health care dollars could be attained.