Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial.

BACKGROUND: Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training. OBJECTIVE: The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress. METHODS: Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress. RESULTS: A total of 574 children, ages 4-10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels. DISCUSSION: Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.

A comparison of student attitudes and perceptions before and after an introductory interprofessional education experience.

There is increasing acknowledgement that interprofessional education (IPE) holds promise for preparing health professionals as collaborative-ready practitioners. The effects of IPE on learning outcomes are critical in determining the value of such programs. Attitudes are recognized as a significant element in developing behaviors. This study was designed to determine attitudes and perceptions of students toward collaborative learning in an interprofessional context. Three hundred and five students completed a questionnaire regarding attitudes and perceptions toward interprofessional collaboration before and after an introductory IPE course. Also 202 graduating health professional students without IPE completed the same questionnaire. The questionnaire included questions from the University of West England Interprofessional Questionnaire (UWE IQ) and Readiness for Interprofessional Learning Scale (RIPLS). Independent samples t-tests revealed significant positive changes before and after the IPE course for UWEIQ IP-Learning subscale (p = 0.012) and RIPLS (p = 0.05). This study provides some evidence that students who participate in an introductory IPE course early in their professional preparation not only keep positive attitudes toward interprofessional learning, but improve them. As a result, they are expected to be more engaged in learning this important knowledge that should help them to become interprofessional collaborative-ready practitioners.

Factors explaining children's responses to intravenous needle insertions.

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.

"It's the little things that count": the value in receiving therapeutic letters.

The focus of this qualitative study was to explore patient's perceptions of having received a therapeutic letter (TL) from a nursing student. Patient feedback contributes to student learning and is especially salient when students are trying to understand complex relationships and to deliver care that is individualized and personalized. Four themes from recipient interviews were identified, which show the influence of TLs on the student-patient relationship and the benefits of TLs to patients who receive them. Strategies to promote relationship building, such as TL writing are needed, particularly when students are required to work with patients who have long-standing psychiatric and social disabilities and find these relationships challenging. Findings are discussed in light of the value of TLs to patients and as a powerful strategy for student learning.

Therapeutic letters in undergraduate nursing education: Ideas for clinical nurse educators.

Therapeutic letter writing (TLW) is a well-known intervention in family nursing practice but it has been overlooked as a strategy in nursing education to promote relationship-building. This article reviews what is known about TLW and presents what was learned by adding a TLW assignment to undergraduate clinical nursing courses. This paper adds to the evidence supporting TLW as an effective clinical teaching strategy to promote students relational skills and to recognize patients' strengths. TLW has benefits for students, patients and faculty.

Writing therapeutic letters in undergraduate nursing education: promoting relational skill development.

Although therapeutic letters (TLs) have been included in graduate nursing programs, studies have not examined the impact of TLs on the clinical learning of undergraduate students. This qualitative study was part of a larger project that introduced TLs into already established undergraduate clinical courses. Instructors prepared students for writing TLs by discussing their purpose and by providing a relevant article and examples. In all, 74 students participated in 12 focus group interviews. Interviews were audiotaped, professionally transcribed, and analyzed using qualitative description. Results suggest that TLs cultivate rapport building and the development of students' relational skills. Although the assignment promoted clinical learning and reflection on helping relationships for the vast majority of students, a few students treated TLs as an instrumental activity. Implications for educating health professionals are described.

Impact of Parent-Provided Distraction on Child Responses to 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.

The school nurse role in asthma management: can the action plan help?

Asthma is the most common chronic disorder in American schoolchildren, and school nurses play a valuable role in its management. A study was conducted in which school nurses were asked to describe their role in caring for students with asthma and their use of Asthma Action Plans (AAPs). The nurses indicated that they frequently provided direct care and education. They were comfortable with providing care to students with asthma and familiar with AAPs. Having an AAP increased their confidence in managing students with asthma. This emphasizes the need for continued education regarding the AAP and the development of policies that direct care and encourage use of an AAP at school.

Methods to test feeding tube placement in children.

PURPOSE: This replication study examined the extent to which feeding-tube aspirates (pH and enzyme content) are effective predictors of feeding tube location in acutely ill children. STUDY DESIGN AND METHODS: A convenience sample of 56 children was obtained at a metropolitan children's hospital. Approximately 2.5 ml of fluid were withdrawn from children's nasogastric, orogastric, or nasointestinal tubes within 30 minutes of radiographic examination. Fluid was tested for pH and enzymes, and results were compared with radiographic results of tube location. RESULTS: Mean gastric pH was significantly lower than mean intestinal pH. Mean fasting gastric pepsin level was significantly higher than mean fasting intestinal pepsin level. Usual intestinal constituent, trypsin, was significantly higher in the small bowel than in the stomach. Mean fasting trypsin level was 70 microg/ml in the intestine, and only 10 microg/ml in the gastric site. Predictive positive value was >90% for all tests; predictive negative value was < 65%. Colors of the gastric aspirates were distinctly different from those observed in intestinal aspirates. CLINICAL IMPLICATIONS: Methods of aspirating fluid from feeding tubes and testing visually or assaying for aspirate characteristics were found to be adaptable from adults to children. The clinical implications of being able to use a test as simple as pH of feeding aspirates means that nurses can easily test these aspirates in any clinical setting using reliable pH test strips, similar to what was done in this study. These data add evidence that suggests indicators of tube location effective in adults are also effective in children.