Ellen
05-21-2008, 11:20 AM
ADVANCE for Nurses | Editorial (http://nursing.advanceweb.com/editorial/content/editorial.aspx?cc=114285&CP=2)
Sticking Point
Nurse-led initiatives aim to manage pain for children during venous access procedures.
By Shelby Evans
Page 1
From IV placement to blood draws to injection of medication, millions of needlesticks are performed on children each year - and for the child, parents and healthcare providers alike, the experience frequently is an unpleasant one.
Although techniques and interventions are available to make the process easier, they often are not employed because of barriers such as lack of awareness, time limitations or availability of supplies.
Recognizing the importance of improving needle pain management in pediatrics, RN VOICE (Registered Nurses for Venipuncture Optimization through Increased Comfort and Education) was established to facilitate solutions.
"There's plenty of information available about the impact of needle pain on children, but there's a huge gap between knowledge and practice," explained Sarah Leahy, BA, RN, RSCN, manager of the Center for Pain Relief at Children's Healthcare of Atlanta and member of the RN VOICE steering committee. "You can give people the knowledge but they still don't actually change their practice; the change has to become institutionalized to really be successful."
To bridge the gap from information to implementation, RN VOICE assembled a community of practitioners - nurses, child life specialists, pharmacists and physicians - from across the nation to promote improved needle pain management strategies. The result is a network of experts and a new resource - ManageIVpain.com - through which healthcare providers can access the tools they need to systemize needle pain management measures in their workplaces.
Eyeing the Needle
"We are dedicated to improving the peripheral vascular access experience for children, mainly through education, advocacy and collaboration," Leahy said. "And the great thing about RN VOICE is it draws on the experience and expertise of people from all over the country who have already been down the path in their own hospitals and developed, in different ways, initiatives that have helped improve [comfort] for children."
Keys to success include involving multiple disciplines and departments as well as parents in the approach, as well as recognizing the impact on each child's care experience.
"I think people have become inured to what they do on a daily basis and that's why it's such an important thing to tackle; it literally affects thousands of children nationwide and we can make a difference," Leahy said. "It may be a small thing to a healthcare provider but it's not a small thing to a child. Even children who've been treated for cancer or who've had major surgery continue to report needlesticks as the very worst aspect of their healthcare encounter."
At speaking engagements on the subject, Leahy said she frequently sees the long-term impact of traumatic needle-related childhood experiences. "At almost every event someone will come up afterward and share with me - usually they are survivors of childhood cancer - and they'll say, 'I have to tell you how much I identify with everything you've said.' They can remember to this day the fear, distress and misery they experienced when they were being held down and stuck with needles.
"Overall, the impact of needles on children is very underappreciated."
It's in the Approach
Realizing nurses have the opportunity to influence how traumatic the needlestick experience is for kids, RN VOICE provides references and information about how children can be affected by needle pain, during the experience and down the road, as well as recommendations for putting together a multidisciplinary team to implement changes.
"The way to approach this is partly through pharmacologic measures - local anesthetic creams and devices - but also with cognitive-behavioral interventions and developmentally supportive care," Leahy explained. An infant, for example, can be comforted by dimming the lights, providing a pacifier and swaddling or even encouraging breastfeeding during a stick. "But as children get older, what's supportive and helpful changes. So if you had a 2- or a 3-year-old, you wouldn't want to be trying to wrap them up in a blanket. They would find that actually more distressing, so you would use more distraction with a child that age - you can engage their imagination and do a little bit of guided imagery, you can use something like a magic wand and tubes that have liquid and glittery stars inside them."
At age 5 and 6, imaginary stories and magic can help to take away the "ouch."
"There's a lot you can do, bearing in mind children's developmental stage, and also their temperament," Leahy said. "We know there are some children for whom it is helpful to be very involved in the procedure, to know what's happening, to watch, to be given a task to do; but there are other children for whom those things would make the procedure even more upsetting."
How the caregiver behaves can affect how the procedure goes as well. Looking back on her clinical experience in pediatric oncology, Leahy sees ways in which she could have improved her own approach.
"When I was doing a needlestick on a child, I would often apologize and say, 'I'm so so sorry we have to do this.' It was intuitive to me to do that and be very empathetic," she explained. "But actually, more recently, research has shown that sort of behavior tends to increase distress in children."
On the other hand, commands to engage in coping behavior, distraction and praise have been shown to be helpful.
"For example, if you were a 5-year-old and I was about to give you a shot, instead of saying, 'I'm so sorry, I know it's going to hurt,' it would be more helpful for me to say, in a firm voice, 'I know you can handle this. Here's what I want you to do.'
"There's a lot of interesting psychological research now that we can take and transfer into the way we practice and the way we behave with our patients, as well as the different pharmacologic interventions," Leahy added.
Page 2
Change in Culture
Strategies can be as simple as coating a pacifier with a sugar solution for an infant right before the procedure or applying a local anesthetic cream. But, Leahy admitted, creating a change in culture where ameliorating pain and anxiety is a priority can be a challenge.
Parental involvement is one important piece of what RN VOICE suggests to help create the shift. "Parents can then become allies in changing attitudes and heightening awareness," Leahy emphasized. "It's something we hear from nurses, that they're more likely to incorporate it into what they're doing if the parent says, 'Are you going to put some cream on my child?' So the role of parents is very important."
At Leahy's facility, posters on the walls let parents know local anesthetic cream is available and the nurses and phlebotomists are trained in behavioral pain management techniques to use with children. And the results of their efforts are promising.
"We've had patients here who have undergone a number of different needlesticks when they've come in for major surgery and report at the end of their hospital stay that they've experienced no pain and distress," Leahy said. "That's because they've been cared for by nurses who have been educated and know how to perform needlesticks in a pain-free way.
"It's because those children have parents who are informed and are ready and willing to advocate for them. And it's also because the materials necessary to take the pain away from needlesticks are readily and easily available to healthcare providers."
Through RN VOICE, nurses have access to information and workbooks and other materials to walk them through implementing a needle-pain initiative in their own facilities.
"The exciting thing about it for nurses is there's so much we can do to make a difference," Leahy said. "Nurses can work within their institutions to bring about some institutional change - for example, maybe there are standing orders for local anesthetic cream so nurses don't have to jump through a lot of hoops to get them - and once the training and education are in place, then there's really a lot the nurse can do to make this a different experience for a child."
Shelby Evans is associate editor at ADVANCE.
Resources Available at www.ManageIVpain.com (http://www.manageivpain.com/)
Sticking Point
Nurse-led initiatives aim to manage pain for children during venous access procedures.
By Shelby Evans
Page 1
From IV placement to blood draws to injection of medication, millions of needlesticks are performed on children each year - and for the child, parents and healthcare providers alike, the experience frequently is an unpleasant one.
Although techniques and interventions are available to make the process easier, they often are not employed because of barriers such as lack of awareness, time limitations or availability of supplies.
Recognizing the importance of improving needle pain management in pediatrics, RN VOICE (Registered Nurses for Venipuncture Optimization through Increased Comfort and Education) was established to facilitate solutions.
"There's plenty of information available about the impact of needle pain on children, but there's a huge gap between knowledge and practice," explained Sarah Leahy, BA, RN, RSCN, manager of the Center for Pain Relief at Children's Healthcare of Atlanta and member of the RN VOICE steering committee. "You can give people the knowledge but they still don't actually change their practice; the change has to become institutionalized to really be successful."
To bridge the gap from information to implementation, RN VOICE assembled a community of practitioners - nurses, child life specialists, pharmacists and physicians - from across the nation to promote improved needle pain management strategies. The result is a network of experts and a new resource - ManageIVpain.com - through which healthcare providers can access the tools they need to systemize needle pain management measures in their workplaces.
Eyeing the Needle
"We are dedicated to improving the peripheral vascular access experience for children, mainly through education, advocacy and collaboration," Leahy said. "And the great thing about RN VOICE is it draws on the experience and expertise of people from all over the country who have already been down the path in their own hospitals and developed, in different ways, initiatives that have helped improve [comfort] for children."
Keys to success include involving multiple disciplines and departments as well as parents in the approach, as well as recognizing the impact on each child's care experience.
"I think people have become inured to what they do on a daily basis and that's why it's such an important thing to tackle; it literally affects thousands of children nationwide and we can make a difference," Leahy said. "It may be a small thing to a healthcare provider but it's not a small thing to a child. Even children who've been treated for cancer or who've had major surgery continue to report needlesticks as the very worst aspect of their healthcare encounter."
At speaking engagements on the subject, Leahy said she frequently sees the long-term impact of traumatic needle-related childhood experiences. "At almost every event someone will come up afterward and share with me - usually they are survivors of childhood cancer - and they'll say, 'I have to tell you how much I identify with everything you've said.' They can remember to this day the fear, distress and misery they experienced when they were being held down and stuck with needles.
"Overall, the impact of needles on children is very underappreciated."
It's in the Approach
Realizing nurses have the opportunity to influence how traumatic the needlestick experience is for kids, RN VOICE provides references and information about how children can be affected by needle pain, during the experience and down the road, as well as recommendations for putting together a multidisciplinary team to implement changes.
"The way to approach this is partly through pharmacologic measures - local anesthetic creams and devices - but also with cognitive-behavioral interventions and developmentally supportive care," Leahy explained. An infant, for example, can be comforted by dimming the lights, providing a pacifier and swaddling or even encouraging breastfeeding during a stick. "But as children get older, what's supportive and helpful changes. So if you had a 2- or a 3-year-old, you wouldn't want to be trying to wrap them up in a blanket. They would find that actually more distressing, so you would use more distraction with a child that age - you can engage their imagination and do a little bit of guided imagery, you can use something like a magic wand and tubes that have liquid and glittery stars inside them."
At age 5 and 6, imaginary stories and magic can help to take away the "ouch."
"There's a lot you can do, bearing in mind children's developmental stage, and also their temperament," Leahy said. "We know there are some children for whom it is helpful to be very involved in the procedure, to know what's happening, to watch, to be given a task to do; but there are other children for whom those things would make the procedure even more upsetting."
How the caregiver behaves can affect how the procedure goes as well. Looking back on her clinical experience in pediatric oncology, Leahy sees ways in which she could have improved her own approach.
"When I was doing a needlestick on a child, I would often apologize and say, 'I'm so so sorry we have to do this.' It was intuitive to me to do that and be very empathetic," she explained. "But actually, more recently, research has shown that sort of behavior tends to increase distress in children."
On the other hand, commands to engage in coping behavior, distraction and praise have been shown to be helpful.
"For example, if you were a 5-year-old and I was about to give you a shot, instead of saying, 'I'm so sorry, I know it's going to hurt,' it would be more helpful for me to say, in a firm voice, 'I know you can handle this. Here's what I want you to do.'
"There's a lot of interesting psychological research now that we can take and transfer into the way we practice and the way we behave with our patients, as well as the different pharmacologic interventions," Leahy added.
Page 2
Change in Culture
Strategies can be as simple as coating a pacifier with a sugar solution for an infant right before the procedure or applying a local anesthetic cream. But, Leahy admitted, creating a change in culture where ameliorating pain and anxiety is a priority can be a challenge.
Parental involvement is one important piece of what RN VOICE suggests to help create the shift. "Parents can then become allies in changing attitudes and heightening awareness," Leahy emphasized. "It's something we hear from nurses, that they're more likely to incorporate it into what they're doing if the parent says, 'Are you going to put some cream on my child?' So the role of parents is very important."
At Leahy's facility, posters on the walls let parents know local anesthetic cream is available and the nurses and phlebotomists are trained in behavioral pain management techniques to use with children. And the results of their efforts are promising.
"We've had patients here who have undergone a number of different needlesticks when they've come in for major surgery and report at the end of their hospital stay that they've experienced no pain and distress," Leahy said. "That's because they've been cared for by nurses who have been educated and know how to perform needlesticks in a pain-free way.
"It's because those children have parents who are informed and are ready and willing to advocate for them. And it's also because the materials necessary to take the pain away from needlesticks are readily and easily available to healthcare providers."
Through RN VOICE, nurses have access to information and workbooks and other materials to walk them through implementing a needle-pain initiative in their own facilities.
"The exciting thing about it for nurses is there's so much we can do to make a difference," Leahy said. "Nurses can work within their institutions to bring about some institutional change - for example, maybe there are standing orders for local anesthetic cream so nurses don't have to jump through a lot of hoops to get them - and once the training and education are in place, then there's really a lot the nurse can do to make this a different experience for a child."
Shelby Evans is associate editor at ADVANCE.
Resources Available at www.ManageIVpain.com (http://www.manageivpain.com/)