Edge Runners. 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 Ford-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."
When her youngest son was about two years old, recalls Charmaine Kleiber, PhD, RN, FAAN, he fell and needed stitches in his forehead. "When I took him to the ED, I really didn't want to stay with him during the stitching. I had worked in a children's hospital ED, and I knew what was coming-the restraint, the screaming, the tears." She told the physician she wasn't going to stay and he agreed, but then her son didn't let go of her hand. "So I stayed," she says, "and talked to him and sang to him. And he actually did really well, with very little restraint or crying. I was amazed and so glad that he had insisted on my staying."
Kleiber had engaged in a practice that has become the focus of much recent nursing research: the distraction of pediatric patients to minimize discomfort during painful medical procedures.
Focusing on distraction. In the early 1990s, Ann Marie McCarthy, PhD, RN, FAAN, finished her postdoctoral work in pediatric psychology and joined the nursing faculty at the University of Iowa, where she began to research cognitive-behavioral interventions for pain control. Working with pediatric oncology patients who had to undergo painful procedures, such as lumbar puncture and bone marrow aspiration, she and her colleagues developed pain-reducing interventions that included medical play, guided imagery, distraction, and a reward system, among others.
"The nurses jumped on board," McCarthy says. "They loved it so much that I had to stop the study because my control group got contaminated. The nurses were using distraction on everyone. It was one of those cases where you're excited that people are using the technique, but the scientist in you is going 'Whoa!!'"
As her worked progressed, McCarthy found that the intervention package was effective but too time consuming for day-to-day use. She began to think that distraction was the element worth pursuing. "Distraction doesn't require a huge amount of training," she points out, "and the equipment-books and bubbles and things like that-isn't terribly expensive. Also, it was something parents could do, because it was like play."
Collaboration. Kleiber, as part of her doctoral studies, was at that time conducting research on pain medications at the Children's Hospital of Iowa at the University of Iowa Hospitals and Clinics, and the two colleagues often discussed their concerns about pain management in children. Both were getting interested in pain control during other painful procedures that young oncology patients frequently endure, like iv starts, blood sample collection, and urethral catheterization. Kleiber's office was next to a treatment room where such procedures were performed routinely. "It wasn't unusual to see a parent waiting outside the room, listening to the child crying inside and looking just awful," she says. "I thought, why doesn't someone invite the parents to be with their child and tell them how to distract their child?"
Kleiber and McCarthy began working together in the mid-1990s, and they conducted a series of studies on the use of distraction in pediatric patients and their family members. Together and with other colleagues, McCarthy and Kleiber have published more than a dozen research articles and given many more presentations.
In 2002 McCarthy and Kleiber received funding from the National Institute of Nursing Research to continue their investigations. More than 500 children and their families were enrolled in a study in which parents were trained in distraction techniques prior to iv starts in their children, all of whom had chronic conditions. The parent-child interactions were videotaped and analyzed. "We started by counting how many times [parents performed a distracting behavior]," McCarthy says, "and we realized we had no way of measuring the quality of the distraction, so we developed a distraction coaching index to determine whether our subjects were doing what we say they're doing."
Their hope is that this work will eventually help clinicians identify ahead of time which parents will be able to learn and perform the distraction techniques. But what about variability in the kids? Children don't necessarily respond to painful stimuli in the same way, so some may be more receptive to distraction than others.
A genetic component. Several years ago, Kleiber led a study on the effectiveness of two different lidocaine-based topical analgesics in minimizing pain during needlesticks in school-age children. Each analgesic cream was applied to the back of the hand, and then ivs were inserted. Two of the volunteers were identical twin boys. Although the experimental procedure was performed in separate rooms, so that the boys couldn't see or hear each other, both boys complained of considerable pain with both creams-which stood in contrast to almost all of the other children in the study, who experienced little or no pain. Kleiber was struck by these results. "Why was it," she says, "that these twin boys were so different? Could it be related to their genetic makeup?"
Another study followed from that observation. Led by Kleiber and nurse geneticist Debra L. Schutte, PhD, RN, the study examined the relationship between children's pain reports on iv insertion after pretreatment with a lidocaine topical analgesic and their genotypes for three genes associated with pain sensitivity. They found that a significant percentage of children who reported a high level of pain carried a variant of one of the genes.
"It was exciting to see a genetic contributor to this response," McCarthy says of her colleagues' work.
The next step for McCarthy and Kleiber is translational research that will help point the way toward putting their distraction intervention into a useable form for the practicing nurse in clinical settings. There are still many questions to answer: What level of distraction will help a particular child and how can that be predicted? Does a particular child need the help of a professional or will parents' coaching be sufficient?
"Distraction works," says McCarthy, "but it doesn't work for everybody, so we're trying to sort out which children it works for and which children it doesn't help. We're trying to help clinicians predict that, so they can use their resources in the best way."
And what does it mean to the researchers to be selected as Edge Runners? Kleiber says, "What I appreciate most is the publicity it generates for our research. Children's issues are often left behind. Children can't be their own advocates, so it's up to all of us to speak up for them."
James M. Stubenrauch, senior editor