Background

Pain is a complicated, subjective and a multidimensional experience that involvesbiological, emotional, and behavioural and the sensory components. Although pain can be an unpleasant experience, but the presence of which indicates that tissue damage can occur and thus the protective responses has to be initiated (Wiederhold et al., 2014). However an extended exposure to pain can have delirious effect on the paediatric patients. Studies have found that prolonged pain can have negative effect on the neurological growth  of the children and those children whose pain has not been treated properly in childhood have complained to have lower threshold for the pain (Fein et al., 2012).

In this paragraph, the background of the issue has been discussed.  Children have to go through several medical procedures throughout their life time, such as needle related procedures at the time of the vaccinations or during the procedure of intravenous cannulations at the time of the medication or fluid administration (Koller& Goldman, 2012). Some of the common reactions displayed during the invasive procedure include varying levels of fear and anxiety, negative temperament and high levels of distress before the procedures and an avoidant coping styles.

This paragraph demonstrates the relevance of the research proposal. Several studies have reported that distraction techniques can shift the focus of children from pain stimuli and can help in coping up with the pain. Distraction is an  effective procedure that guides the attention of the child form noxious stimuli. Nowadays a large number of technologies are being used as distraction techniques (Sahiner&Bal, 2016). Although a large number of literature have agreed on the effectiveness of pharmacological interventions and topical cream for the reduction of the pain during the invasive literature but there are few literatures focussing on the alternative procedures. This gap provides the rationale for researching about the distraction techniques in mitigating procedural pain in children.

The significance of this research is, after conducting this research, we will be able to analyse and evaluate the impact of distraction techniques in reducing procedural pain in paediatrics patients. This in turn will help healthcare professionals to develop effective techniques to distract children more efficiently so that their pain gets mitigated.  

1. Does distraction techniques help in reducing pain in paediatrics undergoing invasive procedures, such as needle stick procedures in a clinical setting?
2. Do the parents perceive distraction techniques to be more effective than parental presence during painful procedures?

Several procedures in the emergency department such as intramuscular or subcutaneous injections, Intravenous (IV) insertions, and central venous port access can be the cause of pain and anxiety in children (Sadeghi et al., 2015). The use of the topical creams like prelocaine and lidocaine are normally used in the ED to mitigate pain in children(Koller& Goldman, 2012). However these topical crèmes can take up to 1 hour for providing subsequent dermal and epidermal anaesthesia.

Furthermore many paediatricians and doctors are hesitant to provide anaesthesia to the paediatrics and analgesics to the paediatrics. Sadeghi et al. (2015), have found that very few paediatric patients admitted in the ED have received pharmatherapeutical management of pain in procedures likeplacement of IV catheter and venepunctures. And even if the anaesthesia has been applied, the paediatric patients continue to report about the procedural pain and anxiety.

Relevance of the Research Proposal

Distraction methods are commonly used as the non-pharmacologic way of managing pain of the paediatric patients. Distraction techniques is based on the belief that deviatingthe focus of a child  in to something that is attractive and engaging can hinder the child’s response to painful stimuli and thereby mitigating the pain and anxiety in patients (Bagnasco et al., 2013). According to Wente, (2013), in paediatrics, distractioncan be defined as the strategy to draw the attention of the child from the noxious stimuli of pain. Various type of distraction has been found to be useful for reducing the pain in children.

The active distraction includes the direct involvement of the child in the distraction technique during the procedure and thereby involving multiple sensory components. Some of the most common form of distraction methods includes provision of interactive toys, guided imagery, controlled breathing and relaxation (Hillgrove-Stuart et al., 2015).

Interactive toys and video gaming are multisensory toys that involves kinaesthetic, audio-visual and tactile senses that requires active cognitive, motor and visual skills of the patients. In order to play successfully, avid devotion is required. Children might get so much engrossed in the activities that the surroundings might get non-existent (Riddell et al., 2015). Hence video games are often considered as distraction techniques for blocking multiple senses for reducing pain and anxiety.

Nilsson et al.(2013), have evaluated the effect of distraction in children receiving perioperativecare, venepuncture and the cancer treatment and the pre-school children receiving repeated injections. A study was conducted by Nilsson et al. (2013), with 110 childrenbetween the age group 5-12 years for determining the type of the distraction most effective decreasing the anxiety before the surgery and the group receiving interactive handheld device in addition to the presence of their parents have experience a significant decrease in the anxiety level.

Allowing the viewing of animated cartoons by the paediatric surgical patients can be very effective to alleviate perioperative anxiety. A study conducted by Lee et al., (2012) have found that allowing the patents to watch their selected cartoons until the induction of the anaesthesia has been found to be useful in reducing pain and anxiety in children prior to the invasive procedure. An RCT consisting of three groups- the distraction cards group, the kaleidoscope group, and the control group was conducted and distraction cards were found to be the best techniques to relieve procedural pain in children (Canbulat, Inal & Sönmezer, 2014).

Again virtual reality can provide atechnology based three dimensional ambience with a visual, auditory and the tactile components. According to AslAminabadi et al., (2012), VR provides the chance to the patient to escape into an alternative world that keeps the patient distracted from the hospital environment to something positive and entertaining. The benefits might be related to the provision of more peaceful images with occlusive headsets that projects picturesbefore the eyes of the user to block him/her from the outside world. Strazar, Leynes, &Lalonde (2013), have evaluated the efficacy of the distraction technique for the burn victims with the help of aunique software that creates an illusion of freezing ice. A study by Wiederhold et al., (2014), has compared the nonimmersive and immersive forms of VR, and as per the findings the non-immersive forms, such as without wearing any headset, has been found to be enjoyable by the patients, although none of the patients reported that these had decreased their pain.

Significance of the Research

Controlled breathing is a part of the cognitive behavioural distraction technique where patients are deliberately made to pace their breathing. This is an active diversiontechnique inducing relaxation in the preschool children. Controlled breathing can be studied by bubble blowing or breathing exercises. Inal, & Kelleci, (2012), have tested that use of the party blowers along with parental presence help to reduce pain and anxiety at the time of the venipucture for the invasive cancer treatment.

Guided imagery is considered as another cognitive behavioural technique to be used in case of the children to reach a relaxation state that can affect the pain perception of the body. The process is cost effective, simple, and non-invasive and is found to be suitable for the preschool children (Birnie et al., 2014). Distraction by the help of guided imagery can be provided in a variety of ways such as the relaxing music along with a relaxing video (McNair et al., 2013, Hartling et al., 2013). There are studies that have proven a significant decrease in the anxiety in children experiencing needle stick procedure.

Few studies have supported the procedure of passive distraction to be helpful in reducing pain inn children. In this procedure a child is required to remain calm and quiet during the procedure (Harrison et al., 2014). Auditory distraction can be caused by using music therapy, although passive distractions have been found to have a little effect on pre-school children. These interventions have been found to be effective for elderly patients. In a randomised control study comparing the efficiency of television watching vs. parental support, television watching has been found to be more effective; on the contrary there are several other studies that have proven that televisions or films are not effective to reduce procedural pain on children (Harrison et al., 2014).

All these evidences provided the rationale for carrying out a research in finding out the effectiveness of the distraction techniques in the reduction of the procedural pain in paediatrics patient.

The study will be conducted in the Kingsford hospital (hypothetical), paediatric ward, where they consider different distraction techniques.  The study population would consist of parents having children of 6-12 years of age, whose names has been obtained from the directory of this setting and four registered nurses from the clinical setting. The nurses will be having a minimum of five years’ experience in the field of paediatric patient care.

A mail stating the aims and the procedure of the research will be sent to the named chosen. They will also be approached via phone, where they would be requested for attending an interview as per their convenience. There would also be provisions for telephonic interviews in case the participants are unable to attend the face to face interview. An interview would be conducted where the participants will be asked to fill up questionnaire and will be asked for a structured interview. The overall research design should be authentic and should be suitable to the topic of the research.  The particular method and design is chosen keeping in mind the demand, scope and budget of the research. In order to conduct in-depth analysis of the data and to provide an conceptual presentation, the thematic data analysis method has been selected. The telephonic interview has been selected since it is most cost ad time efficient procedure that fits perfectly within the scope of the research.

Distraction Techniques as non-pharmacological pain management

A purposeful sampling will be done, where the participants will be selected based on preselected criteria. In this research, those parents, whose children have gone through at least one invasive procedure has been included in the study. 20 such parents have been selected.

A Thompson paediatric questionnaire will be used to assess the severity of the pain reduced by various distraction techniques (Kozlowski et al., 2014). A tape recorder will be used to record the data of the respondent.

Data collection is an important part of the research. As per Ellis & Levy (2012), two type of data collection are used in a research- qualitative and quantitative data collection method. In this research, qualitative data collected method will be used.

In this research process 10 questions will asked and a Thompson paediatric pain questionnaire should be used to assess the pain in the paediatrics. The overall duration of the interview should be about 45- 60 minutes. Before the starting of the interview, a detailed information about the aims and the procedures should be provided to the respondents. The response to each question should be recorded by an audio recording device. The interviewer will also take hand written notes apart from the recording.

After the interview the recording will be transcribed with the help of a transcriptionist and the transcript will again be cross verified by the respective participants for ensuring the validity of the research. After the generation of the professional transcripts, they should be checked rigorously for accuracy by comparing those transcripts with the audio recordings taken at the time of the interview (Kallio et al. 2016).

10 questions that will be asked is given below-

• Have your children ever gone through any invasive procedure?
• How do your child cope up with the pain?
• Do you remain present at the time of the procedure?
• Do your presence or any of your family members help your child to cope up with the pain?
• Share your ideas about the types of distraction techniques that can be helpful for reducing the pain sensation in your child?
• Do the use of toys help your child to remain distracted during an invasive procedure?
• Do you consider music relaxation therapies to be useful in keeping your child distracted from noxious stimuli?
• Share your perception regarding the use of virtual reality techniques in case of paediatrics patient?
• Do you consider video-gaming to be more useful than parental presence for alleviating pain in children?
• Can you refer us with any techniques that can be used to distract children’s attention from the pain stimulus?

In this research process, a thematic data analysis will be performed. According to Tracy, (2013), a thematic data analysis can be normally used for all types of qualitative research and is a useful method for analysing patterns within the data collected. The thematic data analysis helps to maintain flexibility while analysing the data. The steps that will be followed for the primary data analysis include, compiling, disassembling, reassembling, interpreting and concluding. Compilation will involve the accumulation of the data in the form of writing. After the compilation the data has to be separated; disassembling and then grouping of the data. Codes against each of the mapped concepts will be then put under the context for generating the themes. The researcher will make an analytical conclusion from the data. The final part of the data analysis is the conclusion.

Ethical approval is an important part of the research and it aims to protect both the participants and the researchers (Ellis and Levy, 2012). The participants should have enough details for making autonomous decisions regarding the pros and the cons of the study.

Approval for this study will be taken from the local ethics committee and from the institution from where the participants will be chosen. The names of the participants will be obtained from the hospital directory under the supervision of the hospital staffs and an invitation email will be sent to them inviting them for the study. The participants will be contacted over phone if a reply of the invitation is got. The aim and the method of the study will be explained to the children and their parents and they will be informed that if they do not want to continue, they can withdraw themselves from the study, without stating the reason. A consent form will be made to sign before the conduction of the interview.

Active Distraction Techniques

The interview session will be conducted in a setting as per the time and the consequence of the participants. The interview should be held in private spaces in order to maintain the privacy and the confidentiality of the procedure. All the answers will be recorded electronically and should be saved for the analysis in encrypted computer desktops. All the hardcopies of the data will be enclosed in secured cabinet.

Conclusion:

In conclusion it can be said that that a qualitative research using thematic analysis will be appropriate for assessing the feedback of the participants;  the parents and the nurses, regarding the reduction  of  procedural pain by the use of distraction techniques. The data will be collected from the parents and the nurse working in “X’ clinical settings. The interview conducted will consist of structured interviews and a questionnaire and will take place for about 30 minutes. The data will be collected complying with the certified ethical guidelines.

One of the limitations of the research project is that the children will not be included in the study and the study and self-reported data of the parents and the nurses are subjective and might not tally with what is actually experienced by the children. Furthermore, the number small number of participants may lead to bias, like non-response or high variability that might cause bias. Voluntary response bias is other types of bias that can be caused due to small sample size.

The clinical implication of this research is that, understanding the perception of the nurses and the parents regarding the innovative distraction techniques would help hospitals to take children –specific interventions to reduce procedural pain. Thus would provide extensive scope for researches regarding the introduction of technology aided distraction techniques in clinical settings.

References:

AslAminabadi, N., Erfanparast, L., Sohrabi, A., GhertasiOskouei, S., &Naghili, A. (2012). The Impact of Virtual Reality Distraction on Pain and Anxiety during Dental Treatment in 4-6 Year-Old Children: a Randomized Controlled Clinical Trial. Journal of Dental Research, Dental Clinics, Dental Prospects, 6(4), 117–124. https://doi.org/10.5681/joddd.2012.025

Bagnasco, A., Pezzi, E., Rosa, F., Fornonil, L., &Sasso, L. (2012). Distraction techniques in children during venipuncture: an Italian experience. Journal of preventive medicine and hygiene, 53(1).

Bergh, D., and Ketchen, D. J., 2011. Research methodology in Strategy and Management, 1^st ed. Bingley: Emerald Group Publishing Ltd

Birnie, K. A., Noel, M., Parker, J. A., Chambers, C. T., Uman, L. S., Kisely, S. R., & McGrath, P. J. (2014). Systematic review and meta-analysis of distraction and hypnosis for needle-related pain and distress in children and adolescents. Journal of pediatric psychology, 39(8), 783-808.

Canbulat, N., Inal, S., &Sönmezer, H. (2014). Efficacy of distraction methods on procedural pain and anxiety by applying distraction cards and kaleidoscope in children. Asian Nursing Research, 8(1), 23-28.

Ellis, T., and Levy, Y., 2012. ‘Towards a guide for novice researchers on research methodology: Review and proposed methods’, Issues in Informing Science and Information Technology, 6, 323-337.

Fein, J. A., Zempsky, W. T., Cravero, J. P., & Committee on Pediatric Emergency Medicine. (2012). Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics, peds-2012.

Effectiveness of Distraction Techniques

Harrison, D., Elia, S., Royle, J., & Manias, E. (2013). Pain management strategies used during early childhood immunisation in V ictoria. Journal of paediatrics and child health, 49(4), 313-318.

Hartling, L., Newton, A. S., Liang, Y., Jou, H., Hewson, K., Klassen, T. P., & Curtis, S. (2013). Music to reduce pain and distress in the pediatric emergency department: a randomized clinical trial. JAMA pediatrics, 167(9), 826-835.

Hillgrove-Stuart, J., Pillai Riddell, R., Horton, R., & Greenberg, S. (2013). Toy-mediated distraction: Clarifying the role of distraction agent and preneedle distress in toddlers. Pain research and management, 18(4), 197-202.

Inal, S., &Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cards is effective in pain relief of children during blood draw. International Journal of Nursing Practice, 18(2), 210-219.

Kallio, H., Pietilä, A.M., Johnson, M. and Kangasniemi, M., 2016. Systematic methodological review: developing a framework for a qualitative semi?structured interview guide. Journal of advanced nursing, 72(12), pp.2954-2965.

Koller, D., & Goldman, R. D. (2012). Distraction techniques for children undergoing procedures: a critical review of pediatric research. Journal of pediatric nursing, 27(6), 652-681.

Kozlowski, L. J., Kost-Byerly, S., Colantuoni, E., Thompson, C. B., Vasquenza, K. J., Rothman, S. K., … &Monitto, C. L. (2014). Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing, 15(1), 22-35.

Lee, J., Lee, J., Lim, H., Son, J. S., Lee, J. R., Kim, D. C., &Ko, S. (2012). Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesthesia& Analgesia, 115(5), 1168-1173.

McNair, C., Yeo, M. C., Johnston, C., &Taddio, A. (2013). Nonpharmacological management of pain during common needle puncture procedures in infants: current research evidence and practical considerations. Clinics in perinatology, 40(3), 493-508.

Nilsson, S., Enskär, K., Hallqvist, C., &Kokinsky, E. (2013). Active and passive distraction in children undergoing wound dressings. Journal of pediatric nursing, 28(2), 158-166.

Riddell, R. R. P., Racine, N. M., Gennis, H. G., Turcotte, K., Uman, L. S., Horton, R. E., … &Lisi, D. M. (2015). Non?pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews, (12).

Sadeghi, T., Mohammadi, N., Shamshiri, M., Bagherzadeh, R., &Hossinkhani, N. (2013). Effect of distraction on children’s pain during intravenous catheter insertion. Journal for Specialists in Pediatric Nursing, 18(2), 109-114.

Sahiner, N. C., &Bal, M. D. (2016). The effects of three different distraction methods on pain and anxiety in children. Journal of Child Health Care, 20(3), 277-285.

Strazar, A. R., Leynes, P. G., &Lalonde, D. H. (2013). Minimizing the pain of local anesthesia injection. Plastic and reconstructive surgery, 132(3), 675-684.

Tracy, S. J. (2013). Qualitative research methods. UK: Wiley-Blackwell.

Uman, L. S., Birnie, K. A., Noel, M., Parker, J. A., Chambers, C. T., McGrath, P. J., &Kisely, S. R. (2013). Psychological interventions for needle?related procedural pain and distress in children and adolescents. Cochrane Database of Systematic Reviews, (10).

Wente, S. J. (2013). Nonpharmacologicpediatric pain management in emergency departments: a systematic review of the literature. Journal of Emergency Nursing, 39(2), 140-150.

Wiederhold, B. K., Gao, K., Sulea, C., &Wiederhold, M. D. (2014). Virtual reality as a distraction technique in chronic pain patients. Cyberpsychology, Behavior, and Social Networking, 17(6), 346-352.

Wiederhold, M. D., Gao, K., &Wiederhold, B. K. (2014). Clinical use of virtual reality distraction system to reduce anxiety and pain in dental procedures. Cyberpsychology, Behavior, and Social Networking, 17(6), 359-365.