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Summer 2008 Bulletin
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Comfort Measures for Invasive Procedures:
A Major Paradigm Shift in Pediatric Practice
Knowing how many children, families and healthcare providers have benefitted from “Comfort Measures,” we asked Mary Barkey to reflect on the history of the comfort positioning techniques that she pioneered in partnership with the late Barbara Stephens.
“We’ve been very fortunate,” she says. “If you’d told me 15 years ago that I’d be traveling around the country speaking [at conferences and grand rounds], I’d have told you you were crazy!”
The comfort measures/positioning model for children having stressful procedures was initially inspired by Mary’s observations in the treatment room during her first few years as a child life specialist at Rainbow Babies and Children’s Hospital in the early 1980s. A typical approach is described in an article she coauthored, entitled “Techniques to comfort children during stressful procedures” (Stephens, Barkey and Hall, 1999):
The child was taken into the treatment room while the parents waited outside the door. Often the child was not prepared in any way for the procedure other than being told the type of procedure to be performed—“You need an i.v.,” for example, or, “We are going to put a tube in your nose.” The child was forced to lie supine on the table with staff members pinning the child down. The number of staff were increased until the child was sufficiently immobilized to perform the procedure, at times requiring 4 to 5 adults. (p.49)
“I remember thinking, ‘Why are we traumatizing our children like this? Isn’t there a better way to do these procedures?’” Mary recalls. So she began talking to her colleague Barbara Stephens, a nurse, and they discussed their ideas for transitioning to a team approach for procedures, which would be child- and family-centered. Thus began a period of exploration, intervention, and change at Rainbow Babies and Children’s (RB&C) that resulted in the development of the Comfort Measures model.
Mary and Barbara identified doctors who they thought might be open to something new. With the support of these doctors, they involved parents, caregivers, and children in various procedures. “It quickly became clear that the children really wanted to have their parents [or caregivers] with them, and to be able to sit up.” Mary says, “It now seems to be such common sense, but back then it was a real paradigm shift.” The Comfort Measures model includes preparation for the child and family, providing a role for everyone, positioning the child (sitting up whenever possible), creating a calm environment, and having the child choose distraction techniques.
Although this model was now commonly used at RB&C and began to generate interest from nearby programs, it was still not widely accepted. Convinced that they were onto something unique that would be helpful to the pediatric healthcare community, Mary suggested to Barbara that they submit a proposal for the 1992 conference of the Association for the Care of Children’s Health (ACCH).
Not only was the proposal accepted; it was well-received at the conference by a room filled to capacity with healthcare professionals interested in hearing more about the Comfort Measures model. “We thought only a few people would be there, since we were presenting in one of the last sessions,” Mary laughs.
Mary recalls some of the lively discussions during that session about whether child life specialists belonged in the treatment room. Some attendees argued that the child life specialist should always be perceived as “the good guy,” and therefore should not be present in the treatment room during difficult procedures. “Our argument was that child life absolutely belonged there as part of an interdisciplinary team – that [child life specialists] were instrumental in helping to guide the parents/caregivers and children, and ensuring that the procedure is accomplished with the least amount of trauma to the child,” says Mary. “It was really helpful to have Barbara there to provide her perspective as a Registered Nurse. She would always say, ‘we do our job best when child life specialists are there to help us.’”
The previous thinking was that parents were the original “good guys” and should not participate in painful interventions, and that children were simply passive participants. Mary recalls that the medical staff felt that parents would be in the way or, even worse, faint. They also worried that the parents would be tainted by their association with the pain the child was experiencing. In a similar vein, children were seen as unable to actively cooperate.
Within a year, the pharmaceutical company AstraZeneca approached Mary and Barbara to collaborate on the development of educational materials about the Comfort Measures/Positioning model. Over the course of the next seven years, AstraZeneca also underwrote their travel costs to present the model at more than 100 physician and nursing grand rounds and medical and interdisciplinary conferences nationwide. Mary often used her personal vacation time to make these trips. “Helping children was important enough to me to take my own time to make sure the message got out there,” she says.
For Mary, convincing the skeptics has been one of the most rewarding aspects of her work over the years. She keeps letters from child life specialists around the country who have thanked her for bringing Comfort Measures to their hospitals. One of her favorites is from a child life specialist who describes a nurse that had been openly skeptical about the effectiveness of having children sit upright. The letter described the nurse as a “big woman, known for her ‘holding abilities.’” Once Mary and Barbara had presented to the staff, the same nurse ended up being one of the biggest advocates for using comfort positions. “It’s that kind of feedback that kept us going,” says Mary.
Mary and Barbara went on to co-author two internationally-recognized articles on the model. The materials they produced with photographs and suggestions of positions for children in the treatment room are still used in hospitals throughout the world.
According to CLC Executive Board member and international child life advocate Andrea Standish, CCLS, “One of the reasons the Comfort Measures are so successful throughout the world is that they require a big heart but not a big budget. Healthcare providers in countries with limited healthcare resources successfully use these child friendly techniques to improve the experience for the patient, parent and healthcare provider. I have seen excellent outcomes in Brazil, Nicaragua, China, Jordan and the Republic of Georgia.”
“In pediatrics, these techniques have been widely accepted, and they’ve had a huge impact wherever they have been implemented,” says Toni Millar, former director of the child life program at Rainbow Babies and Children’s Hospital. “More than 90% of the invitations to present on the model came from child life specialists throughout the country, and they are the ones who singlehandedly promoted Comfort Measures. The success of their [Mary and Barbara’s] collaborative effort has helped child life specialists continue to partner with other disciplines to provide comfort techniques that improve the patient experience.”
Andrea Standish adds that Mary Barkey has been influential in mentoring child life specialists so that they become adept at dealing with the skeptics and overcoming their objections. As a result, many more child life specialists are able to successfully integrate Comfort Measures into practice at their hospitals.
For Mary, interdisciplinary collaboration was a key factor in the development of the Comfort Measures model. “Child life specialists can’t make major changes alone,” she says, stressing the importance of Barbara’s participation, in addition to the physicians, nurses, and many other team members who were open to new ways of doing things. Embracing interdisciplinary collaboration in the implementation of Comfort Measures has always been equally important. After an initial learning curve, Mary and Barbara screened the requests for a presentation. “We would only present if there was an interdisciplinary team already in place [at the facility in question],” says Mary, “We knew that was the only way that there would be a chance for those changes [to be] put into practice.”
Mary considers the development of Comfort Measures to be more “a solution to a problem” than true research, but, “it gave us a great deal of satisfaction.” For child life specialists who aspire to follow Mary’s lead in developing practical approaches that will benefit children and families, she has a few pieces of concrete advice:
- If something isn’t appropriate for family-centered care and child development, look at options to approach it differently; then speak up.
- Reach out beyond your own discipline and collaborate with others; it will give your project added dimension and give it the potential to reach a wider audience.
- Making changes takes twice as long and costs twice as much as you think it will, but it’s worth it.
- When undertaking this kind of project, do research and collect hard data as you are trying out new techniques, so that you will have a basis of comparison to back up your findings.
The child life profession owes a great debt of gratitude to Mary, an innovative pioneer whose commitment to “making things better” has touched the work of so many child life specialists practicing today. We thank her not only for the enduring legacy of the Comfort Measures model, but also for setting an example of interdisciplinary collaboration that will continue to benefit children and families in ways yet to be realized.
References
Stephens, B., Barkey, M., & Hall, H. (1999). Techniques to comfort children during stressful procedures. Advances in Mind-Body Medicine, 15 (1), 49-60.