| | The Effect of Programmed Distraction on the Pain Caused by Venipuncture among Adolescents on HemodialysisReceived 22 November 2008; received in revised form 22 February 2009; accepted 19 March 2009. Abstract Pain is described as the fifth vital sign, and inadequate pain management is linked to numerous immediate and long-term negative outcomes. Venipuncture is one of the most painful medical procedures and one of the most frequently performed ones, and children and adolescents on hemodialysis are anxious about repeated venipunctures. Distraction is one of the most effective ways to relieve pain, and nurses are responsible for pain control. The purpose of this quasi-experimental study was to test the effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis. All of the pediatric hemodialysis centers in Tehran (three centers) were assigned to case group (one center with 21 patients) and control groups (two centers with a total of 21 patients) randomly. The Wong-Baker face pain scale was used to assess pain caused by venipuncture. Assessing of pain was done in 12 sessions in both case and control groups. Three first sessions were held without intervention (pretest) and the next nine sessions were held with distraction intervention (posttest). To cause distraction, the adolescents were asked to look at two similar pictures and tell the number of differences between them during venipuncture. Results showed that case and control groups matched in demographic variables and pain intensity. After distraction, pain intensity during venipuncture significantly decreased (p =.003); but this decrease began from the sixth session; at the five first sessions, pain intensity had not changed. This study shows the effect of distraction with a simple, inexpensive, and quick way for decreasing the pain caused by venipuncture. We recommend that the reasons of the intervention's delay in effect be assessed in future studies. Pain assessment is a critical component of the nursing process (Wong & Hockenberry, 2003) and the American Pain Society created the phrase “pain: the fifth vital sign” to increase awareness about pain assessment among health care professionals (Loeser, 2003). The rationale is that if pain was assessed with the same seriousness as other vital signs, it would more likely be treated properly (Wong & Hockenberry, 2003). Inadequate pediatric pain management is linked to numerous other immediate and long-term negative outcomes. In the short term, poor pain control is associated with negative psychologic outcomes for the child patient, parent, and staff. Specifically, inadequate pain relief is associated with heightened child reports of anxiety during the medical procedure (De More & Cohen, 2005). Unrelieved pain is stressful and has many undesirable physiologic consequences (Ball & Bindler, 2003). Early painful experiences have been linked to poorer health care attitudes and elevated fear and avoidance of medical procedures in adulthood (De More & Cohen, 2005). The long-term effects of pain on the child's physical or psychologic condition are unknown (Ball & Bindler, 2003). Some studies suggest that there could be impairment in physiologic, behavioral, and cognitive areas of functioning (De More & Cohen, 2005). Pain, when it is ongoing and uncontrolled, has a detrimental and deteriorative effect on virtually every aspect of a patient's life. It produces anxiety and emotional distress, undermines well-being, interferes with functional capacity, and hinders the ability to fulfill family, social, and vocational roles (Katz, 2002). Venipuncture is one of the most painful medical procedures for a child, and it is one of the most frequently performed ones (Rogers & Ostrow, 2004). Many children view receiving needles as one of the most traumatic aspects of being in the hospital (Ellis, Sharp, Newbook, & Coben, et al., 2004). Many children with chronic illnesses require repeated invasive medical procedures (Slifer, Tucker, & Dahlquist, 2002). Children who receive long-term dialysis usually receive treatments three times per week for 3-4hours each time (James, Ashwill, & Droske, 2002). They are anxious about repeated venipunctures (Wong & Hockenberry, 2003). Initiating aggressive pain prevention and control before, during, and after medical procedures, therefore, will yield both short- and long-term physical and psychologic benefits (Whetsell et al., 2000). Various pain relief methods are often categorized as pharmacologic or nonpharmacologic (Jakobsson, 2004). For those procedures that are considered less painful, such as venipunctures, nonpharmacologic strategies can be used alone (Whetsell et al., 2000). Distraction from needle-related pain has been researched and is an empirically supported form of nonpharmacologic pain management (Gold et al., 2005). A variety of different distracters have been used in the management of children's pain. Typically, these distracter stimuli are engaging and pleasant, and include interventions such as nonprocedural talk, toys, bubble-blowing, videos, music, imagery, humor, and virtual reality (Piira , Hoyes, Goodenough & Baeyer, 2006). Distraction is a nursing intervention focusing the patients' attention on other stimulants resulting in pain reduction and better pain control (Hasanpour Tootoonchi, Aein Yadegarfar, 2006). The mechanism by which distraction can produce pain reduction is not well understood (Slifer, Tucker, & Dahlquist, 2002). The principal physiologic rationale for distraction methods derives from the Gate Control Theory of pain. According to this theory, peripheral nerves become excited when cells are damaged. Impulses from these nerves are passed along to spinal cord systems and other neuroanatomic structures before they reach the cerebral cortex, where the pain experience is perceived. The substantia gelatinosa functions as a gate control system that moderates the afferent impulses (i.e., impulses traveling toward the brain) before they ascend to the cerebral cortex. External (e.g., skin stimulation therapies, such as massage) and internal forces (e.g., anxiety) can also influence the gate. Specifically, when the nonnociceptive input exceeds nociceptive (pain) input, the gate can be partially or entirely shut, blocking the pain signal (Melzack & Wall, 1965). Thus, a distraction intervention is thought to reduce pain via descending nonnociceptive signals that interfere with the nociceptive signal (De More & Cohen, 2005). Several studies have been done to assess the effect of different methods of distraction on reduction the pain caused by venipuncture. Windich-Biermeier et al. (2007) studied the effect of self-selected distracters (i.e., bubbles, I Spy, Super Challenger book, music table, virtual reality glasses, or hand-held video games) on the pain caused by venipuncture in 50 children and adolescents with cancer and showed that the pain was significantly lower in the intervention group. Caprilli et al. (2007) studied the effect of the presence of musicians who had attended specific training to work in medical settings on the pain caused by venipuncture in 108 children (4-13 years of age) undergoing blood tests and showed that pain intensity was significantly lower in the intervention group. Bellieni et al. (2006) showed the positive effect of watching TV on the pain in 69 children aged 7-12 years undergoing venipuncture, and Gupta et al. (2006) showed the positive effect of balloon inflation on the pain in 75 children aged 6-12 years undergoing venipuncture. Most of the distraction methods used in the above studies are expensive and time consuming and may not be attractive enough for adolescents with repeated venipunctures. Therefore, in the present study we selected a method that was inexpensive, quick, and attractive for adolescents. This method was two similar cartoon pictures with some differences that the adolescent must look at through the venipuncture and find the differences. In this method, the adolescent tries to focus on the picture and answer. This may cause the nurse to be able to create maximum distraction with minimum cost and time. Therefore, the purpose of this study was to determine the effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis. The hypothesis was that programmed distraction decreases the intensity of the pain caused by venipuncture among adolescents on hemodialysis. Materials and Methods  Design This study was quasiexperimental and was approved by the nursing board in winter 2007; the data were collected in spring 2007. Written informed consent was obtained from parents and oral consent from the adolescents. All of the the study population (42 persons) was recruited. Setting All the hemodialysis centers in the children's hospitals of Tehran were chosen (three centers). All of the patients totaled 50 individuals, and 42 of them possessed the characteristics needed for the study. Sample Thirty-six subjects were needed to detect difference in pain intensity, but due to the small size of study population (42 persons), we considered all of the population as sample. All of the hemodialysis centers (three centers) were assigned to case group (one center with 21 patients) and control group (two centers with a total of 21 patients) randomly. Adolescents were recruited if they met the following criteria: 10-21 years old, refer to dialysis wards for hemodialysis at least twice a week, be at least in the third month of their hemodialysis (because in the first 2 months, hemodialysis is done with a catheter without venipuncture), read and write Persian, and consent of patient and parent. Adolescents were not eligible if they had other acute or chronic diseases, had intent to exit, or applied any drug affecting their pain caused by venipuncture, or their parent was member of a health team. Conditions To cause distraction, two similar cartoon pictures with some differences were provided. For nine sessions of distraction, we provided nine different pictures. These pictures were given to the patient before venipuncture, they had to look at them through venipuncture, and after venipuncture they had to tell the differences. Outcome Variable Pain was defined as the variable of the study and was measured by the Wong-Baker scale immediately after venipuncture. Instruments The instrument used to measure the pain was the Wong-Baker face pain measurement. This instrument was invented by Wong and Baker in 1988 and contains six cartoon pictures that change from a laughing face for no pain and to a crying face for the most possible pain. Under each picture there is a number (0-10) and a word suitable for that intensity of pain (Wong & Baker, 1988). The patient chooses the picture, number, and word that matches his feeling and the researcher records this number. This scale has been studied for validity and reliability (Wong & Hockenberry, 2003). Construct and discriminant (Keck et al., 1996) and concurrent validity (Luffy & Grove, 2003) and test-retest reliability (Keck et al., 1996; Luffy & Grove, 2003) have been established for this scale and shown the faces scale to be a valid and reliable instrument to measure procedural pain intensity. In the present study, content validity and test-retest method with a minimum of 15minutes between the test and retest (r=1) were used. Procedure Venipuncture procedure in each session was done before connecting the patient to the dialysis set. The pain caused by venipuncture in each patient was investigated in 12 sessions. Three sessions were assigned for pretest, because venipuncture was being done with three nurses with different skill levels. The mean of pain intensity in three sessions was assigned for pretest. We did a pilot study with five adolescents, and because of its results nine sessions were assigned for posttest. In both groups, in three first sessions, the Wong-Baker scale was given to the patient immediately after venipuncture, and they were asked to express their pain level by choosing a number. The mean of the numbers chosen in these three sessions was considered to be pretest pain. In the next nine sessions, in addition to measuring pain by the Wong-Baker scale, we used distraction in the case group whereas the control group received no intervention. Statistical Analysis The collected data were analyzed by SPSS version 13. Alpha was set at .05. To compare the pain of the two groups, we used repeated measurement test. Results Discussion The results of this study show that distraction by concentration on two similar pictures and finding their differences can significantly decrease the pain caused by venipuncture in adolescents. The intensity of the pain caused by venipuncture with distraction in the case group was lower than in the control group. Results of other studies related to the effect of different methods of distraction on the pain caused by venipuncture in children and adolescents confirm this study's result (Bellieni et al., 2006; Caprilli et al., 2007; Gold et al., 2005; Gupta et al., 2006; Hasanpour et al., 2006; Kim et al., 2005; Klassen et al., 2008; Windich-Biermeier et al., 2007). In those studies, different methods of distraction were used that are self-selected distracters: bubbles, I Spy, Super Challenger book, music table, virtual reality glasses, or hand-held video games (Windich-Biermeier et al., 2007); presence of musicians who had attended specific training to work in medical settings (Caprilli et al., 2007); watching TV (Bellieni et al., 2006); balloon inflation (Gupta et al., 2006); parallel mirror box with a small doll in the center, or singing or taking a deep breath (Hasanpour et al., 2006); virtual reality (Gold et al., 2005; Kim et al., 2005); and music (Klassen et al., 2008). Some of these, such as computer game and playing music by composer, consume a lot of money, and some others, such as making bubbles or other simple methods, may not be interesting enough for adolescents. In addition, using these methods repeatedly and for long times (2 or 3 times in a week) may decrease their primary effectiveness and attractiveness. To avoid these problems, we designed a method that, although simple and inexpensive, is interesting enough, will not be tedious by repetition, and will not take so much of a nurse's time. The results of this study showed the effect of programmed distraction method on decreasing the pain caused by venipuncture in hemodialysis adolescents in nine sessions; but there was no significant decrease of pain in first five sessions of intervention: The significant decrease began from the sixth session in the case group. In the study by Schiff et al. (2001) that was done to investigate the effect of a collection of interventions on the pain caused by venipuncture in 43 children aged 4-12 years with HIV, the result was the same as our study. They used a collection of interventions along with venipuncture: EMLA cream, preparing the patient and explaining the procedure by a psychologist, doing the procedure on a doll, relaxation, and distraction (bubbles, pinwheel, toys, books, and music of their choice). They used these interventions in three sessions along with venipuncture, and comparing venipuncture pain before and after intervention showed that at first session, there was no significant difference in pain, in the second session the pain decreased significantly, and in the third session this significant decrease was kept (Schiff et al., 2001). Schiff et al. did not mention any reason for the delay of intervention effect on the pain decrease. To find reasons of the delay of intervention effect on the pain decrease, further research is required. In recent years, considerable progress has been made in the development of effective distraction interventions for children experiencing medical procedure–related pain, but research identifying the mechanisms of therapeutic change and the moderators of treatment effectiveness is lacking. In a review of the pediatric distraction literature, we found only a few studies that discussed treatment failures, including inconsistent parental prompting to use the distracter, autocratic parenting attitudes, anxious-appearing parent behavior, and traumatic medical experiences (e.g., multiple unsuccessful attempts to start an intravenous line or an especially frightening or painful procedure) during intervention. Children with higher baseline distress also have been found to respond less favorably to distraction. Taken together, the limited information available suggests that the age of the child, traumatic experiences, and parental variables, such as anxiety, prompting to use distraction, and parenting style, may play an important role in the success or failure of distraction intervention (Dahlquist & Pendley, 2005). Maybe we can mention these as probable reasons of the delay of beginning intervention effect on the pain decrease that for investigating it we need some other studies. Limitations and Future Study One of the limitations of this study is variation of samples' interest and their psychologic condition during measuring of the pain which can affect study results, because hemodialysis patients have many different problems related to their disease which can affect their psychologic condition. It was not possible for one person to do all of the venipunctures; therefore, another intervening variable is using different personnel with varying skill in venipuncture, so we suggest that other researchers plan their research in a way that one person do all the venipunctures. Clinical Applications Results of this study show that distraction program can decrease the pain caused by venipuncture in adolescents undergoing hemodialysis. Hospitals and clinical centers can use distraction program and decrease the pain of the patients. We recommend that use of this intervention begin in the first procedure, because a possible reason for its delayed effect is the preceding painful experiences. References Ball and Bindler, 2003. 1.Ball JW, Bindler RC. Pediatric nursing: Caring for children. 3rd ed. New Jersey: Prentice Hall; 2003;. Bellieni et al., 2006. 2.Bellieni CV, Cordelli DM, Raffaelli M, Ricci B, Morgese G, Buonocore G. Analgesic effect of watching TV during venipuncture. Archives of Disease in Childhood. 2006;91(12):1015–1017. Caprilli et al., 2007. 3.Caprilli S, Anastasi F, Grotto RP, Abeti MS, Messeri A. Interactive music as a treatment for pain and stress in children during venipuncture: A randomized prospective study. Journal of Developmental and Behavioral Pediatrics. 2007;28(5):399–403.
CrossRef
Dahlquist and Pendley, 2005. 4.Dahlquist LM, Pendley JS. When distraction fails: Parental anxiety and children's responses to distraction during cancer procedures. Journal of Pediatric Psychology. 2005;30(7):623–628. MEDLINE |
CrossRef
De More and Cohen, 2005. 5.De More M, Cohen LL. Distraction for pediatric immunization pain: A critical review. Journal of Clinical Psychology in Medical Settings. 2005;12(4):281–291. Ellis et al., 2004. 6.Ellis JA, Sharp D, Newbook K, Coben J. Selling comfort: A survey of interventions for needle procedures in a pediatric hospital. Pain Management Nursing. 2004;5(4):144–152. Abstract | Full Text |
Full-Text PDF (130 KB)
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CrossRef
Gold et al., 2005. 7.Gold J, Reger G, Rizzo A, Buckwalter G, Kim S, Joseph M. Virtual reality in outpatient phlebotomy: Evaluating pediatric pain distraction during blood draw. Pain. 2005;6(3):S57. Gupta et al., 2006. 8.Gupta D, Agarwal A, Dhiraaj S, Tandon M, Kumar M, Singh RS. An evaluation of efficacy of balloon inflation on venous cannulation pain in children: A prospective, randomized, controlled study. Anesthesia and Analgesia. 2006;102(5):1372–1375.
CrossRef
Hasanpour et al., 2006. 9.Hasanpour M, Tootoonchi M, Aein F, Yadegarfar G. The effects of two nonpharmacologic pain management methods for intramuscular injection pain in children. Acute Pain. 2006;8(1):7–12. Jakobsson, 2004. 10.Jakobsson ULF. Pain management among older people in need of help with activities of daily living. Pain Management Nursing. 2004;5(4):137–143. Abstract | Full Text |
Full-Text PDF (154 KB)
|
CrossRef
James et al., 2002. 11.James SR, Ashwill JW, Droske SC. Nursing care of children: Principles and practice. Philadelphia: W.B. Saunders Company; 2002;. Katz, 2002. 12.Katz N. The impact of pain management on quality of life. Pain and Symptom Management. 2002;24(Suppl 1):S38–S47. Keck et al., 1996. 13.Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. Pediatric Nursing. 1996;11(6):368–374. Kim et al., 2005. 14.Kim S, Gold J, Rizzo A, Kant A, Joseph M. Effectiveness of virtual reality for pediatric pain distraction during IV placement. Pain. 2005;6(3):S58. Klassen et al., 2008. 15.Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L. Music for pain and anxiety in children undergoing medical procedures: A systematic review of randomized controlled trials. Acute Pain. 2008;10(2):106. Loeser, 2003. 16.Loeser JD. Pain: The fifth vital sign. American Pain Society Bulletin. 2003;13(1):. Luffy and Grove, 2003. 17.Luffy R, Grove SK. Examining the validity, reliability, and preference of three pediatric pain measurement tools in African-American children. Pediatric Nursing. 2003;29(1):54–59. MEDLINE Melzack and Wall, 1965. 18.Melzack R, Wall PD. Pain mechanisms: A new theory. Science. 1965;150(699):971–979. MEDLINE Piira et al., 2006. 19.Piira T, Hoyes B, Goodenough B, Von Baeyer CL. Effects of attentional direction, age and coping style on cold-pressure pain in children. Behavior Research and Therapy. 2006;44(6):1–14. Rogers and Ostrow, 2004. 20.Rogers TL, Ostrow CL. The use of EMLA cream to decrease venipuncture pain in children. Pediatric Nursing. 2004;19(1):33–39. Schiff et al., 2001. 21.Schiff WB, Holtz KD, Peterson N, Rakusan T. Effect of an intervention to reduce procedural pain and distress for children with HIV infection. Journal of Pediatric Psychology. 2001;26(7):417–427. MEDLINE |
CrossRef
Slifer et al., 2002. 22.Slifer KJ, Tucker CL, Dahlquist LM. Helping children and caregivers cope with repeated invasive procedures: How are we doing?. Clinical Psychology in Medical Setting. 2002;9(2):131–152. Whetsell et al., 2000. 23.Velasco-Whetsell M, Coffin DA, Lizardo LM, Lizardo MV, Mac Dougall BJ, Madayag TM. Pediatric Nursing. New York: McGraw-Hill; 2000;. Windich-Biermeier et al., 2007. 24.Windich-Biermeier A, Sjoberg I, Dale JC, Eshelman D, Guzzetta CE. Effects of distraction on pain, fear and distress during venous port access and venipuncture in children and adolescents with cancer. Journal of Pediatric Oncology Nursing. 2007;24(1):8–19. MEDLINE |
CrossRef
Wong and Baker, 1988. 25.Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatric Nursing. 1988;14(1):9–17. MEDLINE Wong and Hockenberry, 2003. 26.Wong DL, Hockenberry MJ. Wong's nursing care of infants and children. St. Louis: Mosby; 2003;. Nursing Department, Tarbiat Modares University, Tehran, Iran  Address correspondence to: Dr. Fatemah Alhani, Nursing Department, Tarbiat Modares University, Tehran 0098, Iran.
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