Enhancing the efficacy of psychoeducational interventions for paediatric patients in a randomised controlled trial: methodological considerations

Effects of Virtual Reality on Pain and Anxiety During Children's Circumcision: A Systematic Review and Meta-Analysis

BACKGROUND

Circumcision-a common pediatric procedure-can cause significant pain and anxiety. Virtual reality has been proposed as a nonpharmacological intervention to alleviate these negative experiences.

OBJECTIVE

This systematic review and meta-analysis was conducted to evaluate the effects of virtual reality interventions on pain and anxiety in children undergoing circumcision.

METHODS

This study comprehensively searched PubMed, Embase, and Cochrane Library for articles published from database inception to October 2, 2023. Randomized controlled trials that investigated the effects of virtual reality interventions on pain and anxiety during circumcision in children were included. The Cochrane risk-of-bias tool was used to appraise the included studies. The primary outcomes were pain and anxiety scores.

RESULTS

Three randomized controlled trials and four data sets involving a total of 224 children were included in our meta-analysis. Virtual reality interventions significantly reduced children's pain and anxiety scores.

CONCLUSIONS

Virtual reality interventions are promising nonpharmacological strategies for alleviating children's pain and anxiety during circumcision. Pediatric healthcare professionals use virtual reality interventions to create a child-friendly and healthy healthcare environment.

The Perceptions of Children and Adolescents with Cancer Regarding Nurses' Communication Behaviors during Needle Procedures

Background: Communicating with children and adolescents with cancer during a needle procedure can prove challenging for healthcare professionals. Objective: Our aim was to explore the perceptions of children and adolescents with cancer regarding communication with nurses during needle procedures. Method: Thus was a qualitative phenomenological study. Data were gathered through seven in-depth interviews with a convenience sample of children and adolescents with cancer. Data were analyzed using a grounded theory approach to identify themes in the participants' narratives. Results: The analysis revealed three themes describing participants' experience: (1) nurses need to explain clearly what they are going to do while also allowing children to express their emotions without feeling coerced; (2) nurses need to be honest and approachable and relate to children as active participants in the treatment process; and (3) it is distressing to hear other children who are undergoing a needle procedure cry out in pain. Further application of the constant comparison method yielded a core theme: (4) the pressures faced by oncology nurses lead them to focus on the technical side of procedures at the expense of their young patients' communication needs. Conclusions: We suggest that hospital managers need to ensure that oncology nurses have sufficient training in communication skills and are confident in their ability to respect and respond to the communication preferences and needs of patients.

Virtual reality distraction for acute pain in children

BACKGROUND

Virtual reality (VR) computer technology creates a simulated environment, perceived as comparable to the real world, with which users can actively interact. The effectiveness of VR distraction on acute pain intensity in children is uncertain.

OBJECTIVES

To assess the effectiveness and adverse effects of virtual reality (VR) distraction interventions for children (0 to 18 years) with acute pain in any healthcare setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and four trial registries to October 2019. We also searched reference lists of eligible studies, handsearched relevant journals and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cross-over and cluster-RCTs, comparing VR distraction to no distraction, non-VR distraction or other VR distraction.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological processes. Two reviewers assessed risk of bias and extracted data independently. The primary outcome was acute pain intensity (during procedure, and up to one hour post-procedure). Secondary outcomes were adverse effects, child satisfaction with VR, pain-related distress, parent anxiety, rescue analgesia and cost. We used GRADE and created 'Summary of findings' tables.

MAIN RESULTS

We included 17 RCTs (1008 participants aged four to 18 years) undergoing various procedures in healthcare settings. We did not pool data because the heterogeneity in population (i.e. diverse ages and developmental stages of children and their different perceptions and reactions to pain) and variations in procedural conditions (e.g. phlebotomy, burn wound dressings, physical therapy sessions), and consequent level of pain experienced, made statistical pooling of data impossible. We narratively describe results. We judged most studies to be at unclear risk of selection bias, high risk of performance and detection bias, and high risk of bias for small sample sizes. Across all comparisons and outcomes, we downgraded the certainty of evidence to low or very low due to serious study limitations and serious or very serious indirectness. We also downgraded some of the evidence for very serious imprecision. 1: VR distraction versus no distraction Acute pain intensity: during procedure Self-report: one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Observer-report: no data. Behavioural measurements (observer-report): two studies, 62 participants; low-certainty evidence. One study (n = 42) found no beneficial effect of non-immersive VR. One study (n = 20) found a beneficial effect favouring immersive VR. Acute pain intensity: post-procedure Self-report: 10 studies, 461 participants; very low-certainty evidence. Four studies (n = 95) found no beneficial effect of immersive and semi-immersive or non-immersive VR. Five studies (n = 357) found a beneficial effect favouring immersive VR. Another study (n = 9) reported less pain in the VR group. Observer-report: two studies (216 participants; low-certainty evidence) found a beneficial effect of immersive VR, as reported by primary caregiver/parents or nurses. One study (n = 80) found a beneficial effect of immersive VR, as reported by researchers. Behavioural measurements (observer-report): one study (42 participants) found no beneficial effect of non-immersive VR (very low-certainty evidence). Adverse effects: five studies, 154 participants; very low-certainty evidence. Three studies (n = 53) reported no adverse effects. Two studies (n = 101) reported mild adverse effects (e.g. nausea) in the VR group. 2: VR distraction versus other non-VR distraction Acute pain intensity: during procedure Self-report, observer-report and behavioural measurements (observer-report): two studies, 106 participants: Self-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (very low-certainty evidence). Observer-report: one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) found no evidence of a difference in mean pain change scores (low-certainty evidence). Behavioural measurements (observer-report): one study (n = 65) found a beneficial effect favouring immersive VR and one (n = 41) reported a difference in mean pain change scores with fewer pain behaviours in VR group (low-certainty evidence). Acute pain intensity: post-procedure Self-report: eight studies, 575 participants; very low-certainty evidence. Two studies (n = 146) found a beneficial effect favouring immersive VR. Two studies (n = 252) reported a between-group difference favouring immersive VR. One study (n = 59) found no beneficial effect of immersive VR versus television and Child Life non-VR distraction. One study (n = 18) found no beneficial effect of semi-immersive VR. Two studies (n = 100) reported no between-group difference. Observer-report: three studies, 187 participants; low-certainty evidence. One study (n = 81) found a beneficial effect favouring immersive VR for parent, nurse and researcher reports. One study (n = 65) found a beneficial effect favouring immersive VR for caregiver reports. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Behavioural measurements (observer-report): two studies, 106 participants; low-certainty evidence. One study (n = 65) found a beneficial effect favouring immersive VR. Another study (n = 41) reported no evidence of a difference in mean pain change scores. Adverse effects: six studies, 429 participants; very low-certainty evidence. Three studies (n = 229) found no evidence of a difference between groups. Two studies (n = 141) reported no adverse effects in VR group. One study (n = 59) reported no beneficial effect in reducing estimated cyber-sickness before and after VR immersion. 3: VR distraction versus other VR distraction We did not identify any studies for this comparison.

AUTHORS' CONCLUSIONS

We found low-certainty and very low-certainty evidence of the effectiveness of VR distraction compared to no distraction or other non-VR distraction in reducing acute pain intensity in children in any healthcare setting. This level of uncertainty makes it difficult to interpret the benefits or lack of benefits of VR distraction for acute pain in children. Most of the review primary outcomes were assessed by only two or three small studies. We found limited data for adverse effects and other secondary outcomes. Future well-designed, large, high-quality trials may have an important impact on our confidence in the results.

Influence of preoperative information support on anxiety, pain and satisfaction with postoperative analgesia in children and adolescents after thoracic surgery: A randomized double blind study

AIMS/BACKGROUND

The proportion of patients who experience anxiety prior to planned surgery, even a minimally invasive one, is estimated at 50-70%. Thoracic surgery, causes significant preoperative anxiety, especially in children. The aim of this study was to determine the effect of an important component of psychological preparation for a surgery as information support on levels of anxiety, pain and satisfaction with postoperative analgesia.

METHODS

The randomized double blind study including patients aged 9-18 years qualified for lateral thoracotomy or Ravitch procedure. The subjects were randomized to the control group (n=56) provided with a routine preoperative information by a nurse, and the experimental group (n=56) offered additional psychological consultation. Data were collected via the State-Trait Anxiety Inventory.

RESULTS

In the experimental group, the level of state anxiety at 48 h post-surgery was significantly lower than prior to the procedure, but only in subjects with preoperative trait anxiety Conclusion: Information support from a psychologist offered prior to a thoracic surgery decrease the level of postoperative state anxiety solely in children with lower levels of trait anxiety. Higher level of postoperative state anxiety negatively affect patients' satisfaction with post-surgical analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov; Influence of Preoperative Support on Anxiety, Pain and Satisfaction With Postoperative Analgesia; NCT03488459, https://clinicaltrials.gov/ct2/show/record/NCT03488459?cntry=PL&city=Rabka-Zdr%C3%B3j&rank=1.

Therapeutic play to prepare children for invasive procedures: a systematic review

OBJECTIVE

To analyze the available evidence regarding the efficacy of using therapeutic play on behavior and anxiety in children undergoing invasive procedures.

DATA SOURCE

The systematic review search was performed in the MEDLINE, LILACS, CENTRAL and CINAHL databases. There was no limitation on the year or language.

SYNTHESIS OF DATA

The literature search found 1892 articles and selected 22 for full reading. Eight articles were excluded, as they did not address the objectives assessed in this review. Twelve studies, representing 14 articles, were included. The studies were conducted between 1983 and 2015, five in Brazil, one in the United States, five in China, one in Lebanon, one in Taiwan, and one in Iran. Most studies showed that intervention with therapeutic play promotes reduction in the level of anxiety and promotes collaborative behavior and acceptance of the invasive procedure.

CONCLUSIONS

Evidence related to the use of therapeutic play on anxiety and behavior of children undergoing invasive procedures is still questionable. The absence, in most studies, of the creation of a random sequence to assign the subjects to either the control or the experimental group, as well as allocation concealment, are factors that contribute to these questions. Another issue that characterizes an important source of bias is the absence of blinded evaluators. It is necessary to perform further studies that will take into account greater methodological stringency.

Psycho-educational preparation of children for anaesthesia: A review of intervention methods

OBJECTIVE

To systematically review the different methods available for the psycho-educational preparation of children for anaesthesia induction.

METHODS

Articles were searched in Academic Search Premier, OvidSP, Web of Science, and PsycINFO. Inclusion criteria were psychological and educational preparation of children for anaesthesia and anxiety reduction. The titles of papers and abstracts were reviewed and full copies of selected papers were scrutinized.

RESULTS

Forty-four empirical studies were identified. Twenty-one articles described preoperative preparation programmes, twelve examined the effects of distractive techniques and eleven reported the effect of parental presence during anaesthesia's induction. Some general characteristics of the different interventions are discussed together with some key psychological and educational factors mediating anxiety in children undergoing anaesthesia.

CONCLUSION

The effectiveness of interventions were linked to several factors. Psychological and contextual aspects are discussed. Psycho-educational activities should be better described when reporting their effectiveness in children's preparation for an anaesthesia.

PRACTICE IMPLICATIONS

Patient and family characteristics together with organizational and systemic aspects are described in order to guide the choice of the most appropriate preparation method for diverse health care setting.

Holistic care for pediatric organ transplant recipients and their families during their dark postoperative recovery stage in the hospital

INTRODUCTION

This study explored the difficulties in caring for pediatric organ transplant recipients (POTR) and their families during dark recovery experiences (DRE) in the hospital from the perspectives of Taiwan organ transplant health professionals (OTHP).

METHODS

A qualitative design was used, with a purposive sample of OTHP including OT surgeons (OTS) and nursing groups. Data were collected by thorough face-to-face interviews and were analyzed using content analysis.

RESULTS

Fifty-five subjects (39 female, 16 male) participated in this project. They included 15 OTS and 40 nurses. The nurses included registered nurses (n = 27), nurse practitioners (n = 5), and assistant or head nurses (n = 8). Their ages ranged from 25 to 66 (mean = 38.4) years old. Thirty-eight (69%) had college education, and 17 (31%) had graduate education. Their OT careers ranged from between 3 to 40 (mean = 23.8) years for OTS, and 0.5 to 15 (mean = 4.10) years for the OT nursing group. Five types of caring difficulties were reported: (1) threat of OT failure, (2) work overload, (3) insufficient collaboration within interdisciplinary teams due to incongruent surgical and nursing opinions, (4) poor communication between OTHP and POTR, and (5) lack of competent professional OT care.

CONCLUSIONS

The following suggestions were made to help relieve the OTHPs' stress in providing holistic care for POTR and their families during DRE: (1) increasing the amount of experienced OT manpower and professional communication liaisons, (2) providing systematic on-the-job interdisciplinary case seminars and OT workshops, and (3) enhancing the POTR's mental health care and helping manage their distress of DRE.

Psychometric validation of Emotional Reaction Instrument-English to measure American children's emotional responses to hospitalisation

AIMS AND OBJECTIVES

The aim of this study was to test the initial psychometric properties of the Emotional Reactions Instrument-English with hospitalised American children, ages 7-12 years, in the USA.

BACKGROUND

Children's negative emotional responses have been a subject of concern for paediatric clinicians and researchers, especially because negative emotional responses following or during hospitalisation are associated with adverse patient outcomes. Existing self-report paediatric instruments have a number of limitations including lack of clinical feasibility and psychometric evidence.

DESIGN

A survey and psychometric approach was used to test initial reliability and validity of the Emotional Reactions Instrument-ENGLISH.

METHODS

Two hundred hospitalised American children, 7-12 years of age, who were admitted to a Children's Hospital in the USA were recruited for this study. The children were administered the Emotional Reactions Instrument-English, the Facial Affective Scale, and a demographic form.

RESULTS

Internal consistency was supported by a Cronbach's alpha of 0·83 for the total scale. Alpha coefficients for subscales ranged from 0·59-0·82. Construct validity was tested with exploratory factor analysis. Through principal component analysis, four factors were identified that explained 64% of the variance. Concurrent validity was supported by most items in the Emotional Reactions Instrument-English being significantly correlated with the Facial Affective Scale (r = 0·18-0·59). The instrument can be administered to hospitalised children in 5-10 minutes.

CONCLUSIONS

The results of this exploratory study provide initial support for the psychometric adequacy of the Emotional Reactions Instrument-English with hospitalised American children ages 7-12 years. Further testing of the Emotional Reactions Instrument-English is required to validate the subscales and evaluate the instrument's use with children of different ages, race and ethnicity.

RELEVANCE TO CLINICAL PRACTICE

This study introduces a new, clinically feasible instrument to measure children's diverse emotional responses to hospitalisation.

An integrative review of literature examining psychometric properties of instruments measuring anxiety or fear in hospitalized children

Anxiety and fear are among the most frequently reported emotional responses to hospitalization and are known to be contributing factors to pain and other negative patient outcomes. The first step in confronting unnecessary anxiety and fear is to identify valid and clinically feasible assessment instruments. The purpose of this paper is to review and evaluate instruments that measure children's fear or anxiety associated with hospitalization or painful procedures. A search was conducted of published English-language literature from 1980 through 2010 with the use of Ovid Health and Psychosocial Instruments, Medline, Nursing/Academic Edition, Cinahl, and Google Scholar. Inclusion criteria specified that the self-report instrument: 1) was developed in English; 2) was developed for and/or widely used with hospitalized children or children undergoing medical procedures or treatment; and 3) had research evidence of psychometric properties from at least five different studies. A comprehensive review of the literature revealed only five fear or anxiety instruments with adequate testing for evaluation of reliability and validity. Although all instruments have beginning psychometric adequacy, no one tool stands out as superior to the others. Therefore, we recommend that researchers and clinicians exercise caution in choosing assessment instruments, balancing potential strengths with reported limitations. Using more than one tool (triangulating) may be one way to achieve more credible results. Knowledge of credible existing instruments alerts us to what is possible today and to the imperative for research that will improve communication with children tomorrow.