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The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.

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.Virtually all children undergo invasive medical procedures. Whereas some children only experience preventative immunizations, others require diagnostic tests and therapeutic treatments for serious illnesses. These experiences can provoke various levels of anxiety, fear, and pain in the child and a range of child behavioral responses from calm and controlled to panic and flailing. When a child is distressed, families and health care providers often experience anxiety, helplessness, and guilt. The procedure may then become technically more difficult (i.e., more attempts), further adding to everyone's discomfort. Experiencing stressful medical procedures in childhood can have long-term consequences, impacting the individuals' reaction to later painful events and acceptance of health care interventions in adulthood (von Baeyer, Marche, Rocha, & Salmon, 2004).Distraction is a cognitive-behavioral intervention that is effective in reducing pain and distress for many children undergoing painful medical procedures (Kleiber & Harper, 1999;Uman, Chambers, McGrath, & Kisely, 2008). Distraction diverts attention from an adverse stimulus by redirecting attention to something else such as a book, toy, or nonprocedural Correspondence should be addressed to Ann Marie McCarthy, College of Nursing, University of Iowa, NB 344, Iowa City, IA 52242. ann-mccarthy@uiowa.edu. NIH Public Access Author ManuscriptChild Health Care. Author manuscript; available in PMC 2011 June 2. talk. An effective distractor stimulates the senses, is developmentally appropriate, easily implemented, acutely engaging, and able to compete with negative stimuli to capture the child's attention (Cavender, Goff, Hollon, & Guzzetta, 2004). Evidence suggests that distraction may help the child to cope not only with the immediate medical procedure, but may also buffer memories of the experience so that the individual remembers less of the negative aspects, which may impact future responses to painful medical procedures (Cohen et al., 2001;Salmon, Price, & Pereira, 2002).Young children generally need help or "coaching" to use distraction effectively. Professionals such as child life specialists, nurses, and psychologists typically provide distraction coaching, but the availability of these professionals to provide the intervention is limited in most practice settings. At the same time, many...

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.

This is a descriptive study reporting normative salivary cortisol values and responsivity to a hospital clinic visit and IV procedure in children. The study presented is a sub-project of a primary research study that examined parents coaching their children in the use of distraction for children requiring an IV placement. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of children's physiologic response to stressful, painful stimuli. Salivary cortisol samples were obtained on 384 children, 4-10 years of age, on arrival to the clinic and 20 minutes after the IV insertion. Baseline samples were collected at home on a typical day for the child. Data from baseline samples were used to establish normative values between the hours of 8:00 am and 3:00 pm on a non-procedural day. Results demonstrated normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to midafternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than levels obtained during the day of the procedure and tapered over time as expected (−8.7% + 6.7%; p=0.43). Cortisol levels on the clinic day were increased from baseline and increased further in response to IV placement (15.7% +6.7%; p=0.023). A location by time interaction was significant (p= 0.019). Findings demonstrate salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

Purpose Assessment of children’s anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Children’s Anxiety Meter-State (CAM-S), a brief measure of state anxiety. Design and Methods Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure. Results Children’s (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings. Practice Implications Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

A strategic approach is crucial to eliminating SC and integrating EBP. This report calls nurses globally to action, to identify and abandon ineffective healthcare practices. Further research should compare and test the efficacy of implementation strategies, in particular how to sustain EBP in clinical settings.

Nurses need training and mentoring to lead evidence-based practice (EBP) improvements. An array of roles have been reported to have a positive impact on EBP adoption. A training program was created to assist point-of-care nurses and nurse leader partners in operationalizing the EBP Change Champion role to address priority quality indicators. The program, a case exemplar, and lessons learned are described with implications for leaders responsible for promoting EBP to improve quality care.