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IJHCQA 32,6
1034
Received 26 July 2018 Revised 26 July 2018 Accepted 6 February 2019
Improving pediatric experience of
pain during vaccinations:
a quality improvement project
Terri MacDougall
North Bay Nurse Practitioner-Led Clinic, North Bay, Canada
Shawna Cunningham
Health Quality Ontario, Toronto, Canada
Leeann Whitney
North Bay Nurse Practitioner-Led Clinic, North Bay, Canada, and
International Journal of Health Care Quality Assurance
Vol. 32 No. 6, 2019
pp. 1034-1040
© Emerald Publishing Limited 0952-6862
DOI 10.1108/IJHCQA-07-2018-0185
Purpose – The purpose of this paper is to share lessons learned from a quality improvement (QI) project that studied pediatric pain assessment scores after implementing additional evidence-based pain mitigation strategies into practice. Most nurses will acknowledge they implement some practices to mitigate pain during injections. Addressing pain during vaccination is important to prevent needle fear, vaccine hesitancy and health care avoidance. The aim of this project was to reduce pain as evidenced by pain scores at the time of vaccination at the North Bay Nurse Practitioner-Led Clinic (NBNPLC).
Design/methodology/approach – The design for this study was quasi-experimental utilizing descriptive statistics and QI tools. The NBNPLC utilized the model for improvement to test change ideas. A validated observation tool to assess pain during vaccination with the pediatric population (revised Face Legs Activity Cry and Consolability) was used to test changes. The team deliberately planned improvements according to best practice guidelines to optimize use of strategies to mitigate pain during injections. QI tools and leadership skills were utilized to improve the pediatric experience of pain during vaccinations. Parents and clinicians provided qualitative and quantitative feedback to the project.
Findings – Nurses tested pain assessment tools and agreed to use a validated tool to assess pain during vaccinations. Parents agreed to use of topical anesthetic during vaccinations. Improved pain scores during vaccinations were demonstrated with the use of topical anesthetic. Parents agreed to use of standardized sucrose solution during vaccination. Reduced pain scores were observed with the use of standardized sucrose water. To sustain implementation of the guideline, a nursing documentation form was devised with nurses agreeing to ongoing use of the form.
Research limitations/implications – This is a QI project that examined the intricacies of moving clinical practice guidelines into clinical practice. The project validates guidelines for pain management during vaccinations. Leaders within clinics who want to improve pediatric pain during vaccinations will find this paper helpful as a guide.
Practical implications – Pain management in the pediatric population will be touched on in the context of parental expectations of pain. QI tools, lessons learned and suggestions for nurses will be outlined. Leadership plays an influential role in translating practice guidelines into practice.
Originality/value – This paper outlines how organizational supports were instrumental to give clinicians time to deliberately challenge practice to improve quality of care of children during vaccinations.
Keywords Quality improvement, Nurse practitioner, Injection pain, Pain assessment, Pain mitigation Paper type Research paper
Introduction
Immunizations given by injection are painful. The experience of having a painful injection can cause a life-long fear of needles, which can lead to potential avoidance of health care, including vaccine hesitancy (Taddio et al., 2015). There are techniques that can be implemented by health care providers to minimize pain during injections. However, these techniques are underutilized. Therefore, improving pain management during vaccinations
Abstract
Monakshi Sawhney
School of Nursing, Queen’s Univesity, Kingston, Canada
is an opportunity for improvement in the quality of care delivered to children (Taddio and Rogers, 2015).
In Ontario, Canada, immunizations begin at two months of age and continue throughout infancy, childhood and adolescence. In Ontario, a toddler will receive ten injectable immunizations by 18 months of age (MOHLTC, 2016). Clinical practice guidelines to reduce vaccine injection pain are available. However, there is low uptake of pain mitigation interventions in clinical practice resulting in potentially unnecessary pain and suffering (Chambers et al., 2009; Taddio et al., 2015).
The North Bay Nurse Practitioner-Led Clinic (NBNPLC) is one of the 25 NPLCs providing comprehensive primary care to people of all ages in Ontario. The clinic is staffed by a multidisciplinary team of four nurse practitioners (NP), a registered nurse, a registered practical nurse, a registered dietitian, a social worker, a physician and a pharmacist. In 2012, the NBNPLC partnered with the Registered Nurses Association of Ontario (RNAO), with funding from the Ministry of Health and Long Term Care to become a Best Practice Spotlight Organization (BPSO) over a three-year period of time.
The NBNPLC committed to implement the Assessment and Management of Pain Best Practice Guideline (RNAO, 2013) into their primary care practice. An identified area for improvement was assessment and management of pediatric pain during vaccinations. Routine assessment of pain utilizing a standardized tool is recommended prior to, during and after painful procedures. Assessment tools must be reliable, valid and feasible for use in practice (RNAO, 2013). Clinical practice guidelines describe how to mitigate pain during vaccinations according to age. The five Ps of pain management that can be used with children during vaccinations or other painful procedures are: psychological techniques such as honest, neutral communication and distraction; procedural techniques before and during vaccination, such as no aspiration (drawing back on tissue prior to injecting); process strategies such as educating parents how they can help to reduce their child’s pain; physical measures such as breastfeeding and holding child during the procedure; and pharmacological strategies such as the use of topical anaesthetics and sucrose solution (Taddio et al., 2015).
The clinical director, a NP, led the quality improvement (QI) project during participation in an RNAO Advanced Clinical Practice Fellowship. An acute pain specialty NP mentored the clinical director through the project. In addition, the clinical director participated in the Improving and Driving Excellence across Sectors (IDEAS) program. This is a QI learning program supported by Health Quality Ontario, University of Toronto and the Institute for Clinical Evaluative Sciences to gain knowledge and support on the implementation and evaluation of a QI project in the clinical setting (HQO, 2017).
The aim statement of the NBNPLC’s QI project was: to reduce vaccine injection pain in children aged 0-16 years attending the NBNPLC by 50 percent (pain score) at 0 min (at vaccination).
Methods
Ethics approval to collect patient-related data for this QI initiative was obtained through Research Ethics Board at Queen’s University, Kingston, Ontario. The model for improvement is the framework that was used to guide this project. It is considered to be useful for guiding QI projects within a limited timeframe. The model focuses on answering three main questions: what are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Benefits of utilizing the model for improvement for projects with a limited timeframe include the improvement of processes, facilitation of teamwork and it provides a framework to make improvements with the application of statistical tools and methods, encourages planning based on evidence, emphasizes iterative learning and provides a way of empowering people in organizations to take action (API, 2017; Provost and Murray, 2011).
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IJHCQA 32,6
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What are we trying to accomplish?
As stated earlier, the aim of the NBNPLC’s QI project was: to reduce vaccine injection pain in children aged 0-16 years attending the NBNPLC by 50 percent (pain score) at vaccination (0 min). Improving the pediatric experience of pain during vaccinations required deliberate planned action within a social setting of a team providing care to children and their families. Initially, the NBNPLC team felt that they were doing everything that they could to make vaccination as painless as possible. During a six-month period of time prior to this project, the NBNPLC administered ten injections per week. The average age of child receiving an injection was 26 months. A chart audit found that nursing staff inconsistently documented the assessment of pain and the use of evidence-based pain mitigation strategies.
The project leader engaged staff during scheduled team meetings to review the evidence regarding pain mitigation during immunization by injection, share information about prevention of needle fear, vaccine hesitancy and health care avoidance. The team agreed to the adoption of evidence-based pain mitigation strategies according to the five Ps of pain management routinely into practice.
How will we know that a change is an improvement?
From the outset, it was important to establish a practice of pain assessment during injections to assess if changes implemented resulted in improvement. Pain scores were documented along with the age of child and the routine mitigation strategies used. Data were prospectively collected on a weekly basis. While the culture of pain assessment was being established by the nurses, it was imperative for the project leader to ensure that appropriate resources were in place for additional change ideas and to continually engage with staff regarding the QI project.
Key measures for this improvement initiative were categorized as outcome, process and balancing. Data and measurement play supportive roles in testing, adapting, implementing and spreading changes in QI projects (Provost and Murray, 2011). Outcome measures for this project were captured by pain scores. After a trial of multiple pain assessment tools including: Neonatal Infant Pain Scale, Faces Pain Scale and revised Face Legs Activity Cry and Consolability (rFLACC) (RNAO, 2013), the NBNPLC chose the rFLACC behavioral assessment tool. rFLACC was originally validated for the intended use to assess procedural pain with children aged two months to eight years but has been used with children 0-18 years of age and cognitively impaired children. Each category (FLACC) is scored on a 0-2 scale, which results in a total score between 0 and 10 (Malviya et al., 2006; RNAO, 2013).
Pain score data were plotted on run charts. Run charts are used to determine if changes yield improvement. Run charts are used to answer the second question in the model for improvement: “How will we know that a change is an improvement?” Run charts are also known as trend charts (Provost and Murray, 2011). Pain scores were stratified according to age and pain mitigation strategy being tested. Patient/parent experience feedback was sought as an outcome measure. Process measures included the number of patients agreeing to use evidence-based pain mitigation strategies and duration of visit. Balancing measures included staff satisfaction during and at the end of the study. As part of morning huddle, the pain project was discussed with the opportunity to solve any immediate technical problems. Clinician satisfaction is important to address as close to the flow of care as possible.
What changes can we make that would result in improvement?
The team considered several change ideas to test in Plan-Do-Study-Act (PDSA) cycles. To determine which changes to test, a diagnostic journey to identify factors impacting the pediatric experience of pain was undertaken. Process flow mapping was used to review the current visit flow specifically what can be done before, during and after vaccination appointments, by whom, when, where, why and how (Provost and Murray, 2011). The team discussed the use of sucrose water and topical anaesthetic and identified these two pain mitigation modalities as rarely used
in practice. PDSAs were implemented on pain assessment tools, pharmacologic pain mitigation strategies (use of topical anaesthetic, sucrose) and a trial of a nursing documentation tool. The team agreed to enhance the types of distractions (bubbles, toys and videos) currently available; however, these enhancements were not measured in a PDSA cycle.
Table I outlines the steps taken at each PDSA cycle, the timeframe and lessons learned. During the second cycle of the topical anaesthetic PDSA, the team gathered parent feedback through interviews and surveys. To facilitate sustained evidence-based implementation of the guideline an easy to use nursing documentation form was designed and tested.
Results
Children 0-36 months of age, who, in addition to routine physical, procedural, process and psychological pain mitigation strategies, had topical anaesthetic applied prior to injection, rFLACC scores indicate an improvement in observed pain. Sustained improvement in rFLACC scores was demonstrated using QI Macros for Excel XmR individuals run chart. Mean score for all data was 5.1 (n 1⁄4 36), represented by the center line on the run chart. Mean score prior to use of topical anesthetic was 5.5 (n1⁄419). Mean score after topical anesthetic used during injections was 3.8 (n 1⁄4 17). Figure 1 contains the topical anaesthetic run chart. Staff expressed that the use of topical anaesthetic increased their firsthand knowledge of the benefits.
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1037
Pain assessment tool
Cycle 1 – will nursing staff utilize standardized tools to assess pain? Yes
Cycle 2 – pain tool
Will nursing staff find the use of one tool easier to implement?
Pain mitigation strategies
Cycle 1: topical anaesthetic
Will parents take advantage of the use of free topical anaesthetic before injections to reduce pain?
Cycle 1: standardized sucrose water
Will parents agree to use sucrose water to mitigate pain?
Cycle 2: topical anaesthetic
Will parents purchase and apply topical anaesthetic patches, apply at home prior to appointment through enhanced education? Advise where to purchase and how to apply
Timeframe and lesson learned
Date started: September 1
Date ended: September 30 multiple tools in use. Messy Data Date started: October 1
Yes…. ongoing use of rFLACC
40 anaethetic patches used between November 2 to December 9 Great uptake, questionable sustainability due to cost and length of time needed before injection. Quicker onset products available. Control chart indicates special change in pain score with topical anaesthetic use
100 standardized doses ordered, in use by November 12
Yes, great uptake. Nurses observe sucrose water helps pain. Cost is sustainable. Timing of dose is important, can repeat dose if needed. Will continue to stock after project
Date started: December 10
Difficult to track number of parents who purchase. Very few. Product insert for store bought anaesthetic patch is inadequate to prepare parents for routine vaccine injections sites. Handout depicting where and how to apply topical anaesthetic patches. End of project: Unethical not to stock topical anaesthetic, present case to board of directors for ongoing funding
Documentation form for pain score and mitigation strategies
Will use of evidence-based documentation formcapturemorecompletedataandassist nurses to implement pain mitigation guidelines?
Date started: December 8
Yes, nurses love the form. Data are more complete – an electronicnotewascreatedthatreflectstheform.Willbeused during orientation of new staff and ongoing with current staff
Table I.
PDSA cycles
IJHCQA 32,6
1038
14.0 12.0 10.0
8.0
UCL 11.9
Results – ELMA®
Pain Score Ages 0 to 36 months
Start Emla
6.0 CL 5.1 4.0
2.0
0.0
Figure 1. -2.0 Pain scores with -4.0 the use of topical
local anesthetic
LCL -1.6
1 2 3 4 5 6 7 8 91011121314151617181920212223242526272829303132333435363738 Patient
Notes: Run chart: upper control limit = 11.6; lower control limit = 1.6; mean = 5.1
Mean pain scores when sucrose was initiated were lower (4.7, n 1⁄4 14) than baseline mean score of 5.3 (n 1⁄4 7). A significant run in improvement in pain scores was not observed using QI Macros for Excel software. We learned that it is important to note the timing of the dose of sucrose water. The dose should be given 2 min prior to the painful procedure. The dose can be repeated after the initial dose.
Parents who purchased topical anaesthetic reported that the instructions in the topical anaesthetic patch package were inadequate to prepare for routine childhood vaccinations. Age specific handouts that are easy to read and contain diagrams were created by the NBNPLC and were distributed to parents. The nursing documentation form PDSA resulted in creation of a favorite note in the electronic medical record to facilitate paperless documentation and reminders of mitigation strategies recommended for use during injection. A parent satisfaction survey was distributed to parents who agreed to implement pain mitigation strategies with their children’s immunization. Over a two-week period, ten parents participated in the survey. Results of the survey indicated that 30 percent of the parent respondents reported that the immunization experience had improved, compared to previous experiences.
The NBNPLC team evolved from the perception that current practice was sufficient to the identification of how to incorporate additional pain mitigation strategies into practice. At the end of this project, nursing staff expressed pride in the work done to improve the pediatric experience of pain. We continue to refine our distraction techniques and build trusting relationships to influence parental behavior. A cost-benefit analysis was presented to the board of directors at the NBNPLC. The cost of providing standardized sucrose and topical anaesthetic may be offset by avoiding the costs of subsequent harm from unmitigated pain and fear, including the negative impact on health outcomes due to vaccine hesitancy and non-compliance with other health care interventions. The board felt that it would be unethical to not offer children topical anesthetic and sucrose water. These two pain mitigation strategies have been integrated into the clinic as part of routine care.
When nurses discussed the project with parents to obtain consent to use as many pain mitigation strategies appropriate for their child, there were some parents who refused, as they felt that pain was just part of the experience. Conversely, the nurses reported that some parents wanted to know everything about pain management, especially those parents, who have needle phobias themselves, while other parents were more laissez faire, accepting of pain as part of the process of injections. The “pain accepting” parents posed a dilemma for the staff.
During the project, the team discussed an approach to “pain accepting” parents. The approach involved educating parents with information to fill a knowledge gap. Education strategies included sharing clinical observations of pain reduction while using evidence-based
Pain Score rFLACC
pain reducing strategies and referring parents to social media campaigns on the internet, such as “It doesn’t have to hurt” (Canadian Institutes of Health Research, 2016). Informing parents that needle phobia cannot be predicted that pain management is a value at the clinic. The NBNPLC team tries to ensure that all children in our practice have the best vaccine experience possible to prevent needle phobia. This approach reflects our culture of best practice at the NBNPLC.
Discussion
This QI project addressed the interplay of clinician behavior, parental behavior and child behavior. Ultimately, improving pediatric experience of pain during injections is dependent on clinician and parent behavior. Pain accepting parents have been described in the literature and identified as a barrier to use of evidence-based pain mitigation strategies (Zhao et al., 2015). Clinician relationship with parents was important to influence parental behavior. Influencing behavior involves trust in the relationship, clear communication and deliberate dialogue centered on the desired change.
Adaptive leadership is emphasized by both the RNAO BPSO strategy and Health Quality Ontario’s IDEAS program. Leadership has been identified by best practice implementation scientists as a key ingredient to uptake of best practice guidelines (Gifford et al., 2017).
Conclusion
QI takes leadership and deliberate action to address barriers and challenge expectations. Utilizing implementation science clinician and parent behavior toward injection pain changed to improve the pediatric experience of pain during vaccinations. We have been able to sustain this change and implement pain mitigation strategies and pain assessment into the routine care of children undergoing vaccination at our clinic.
References
API (2017), “Associates in process improvement”, available at: www.apiweb.org/index.php (accessed June 28, 2017).
Canadian Institutes of Health Research (2016), “It doesn’t have to hurt”, available at: http://cihr-irsc.gc. ca/e/49821.html (accessed August 6, 2017).
Chambers, C., Taddio, A., Uman, L. and McMurtry, C.M. (2009), “Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review”, Clinical Therapeutics, Vol. 31 No. S2, pp. S77-s103, available at: https://doi.org/10.1016/j.clinthera. 2009.07.023
Gifford, W., Graham, I., Erhart, M., Davies, B. and Aarons, G. (2017), “Ottawa model of implementation leadership and implementation leadership scale: mapping concepts for developing and evaluating theory-based leadership interventions”, Journal of Health Care Leadership, Vol. 9, pp. 15-23.
HQO (2017), “IDEAS learning program”, Toronto, ON, available at: www.hqontario.ca/Quality- Improvement/E-Learning-and-Events/IDEAS (accessed August 22, 2017).
Malviya, S., Voepel-Lewis, T., Burke, C., Merkel, S. and Tait, A.R. (2006), “The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment”, Paediatric Anaesthesia, Vol. 16 No. 3, pp. 258-265, available at: https:// doi.org/10.1111/j.1460-9592.2005.01773.x
MOHLTC (2016), “Publicly funded immunization schedules for Ontario”, Ministry of Health & Long Term Care, Toronto, ON, December, p. 1, available at: www.ontario.ca/page/vaccines (accessed June 28, 2017).
Provost, L. and Murray, S. (2011), The Health Care Data Guide: Learning from Data for Improvement, Jossey-Bass Publishers, San Francisco, CA.
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RNAO (2013), “Assessment and management of pain”, Clinical Best Practice Guidelines, Toronto, ON, December, pp. 1-104, available at: https://rnao.ca/sites/rnao-ca/…/AssessAndManagementOFPain20 14.pd (accessed August 22, 2015).
Taddio, A. and Rogers, J.M. (2015), “Why are children still crying? Going beyond ‘evidence’ in guideline development to improve pain care for children: the HELPinKIDS experience”, Pain, Vol. 156 No. S4, pp. S127-S135, available at: https://doi.org/10.1097/j.pain.0000000000000090
Taddio, A., McMurtry, C.M., Shah, V., Riddell, R.P., Chambers, C.T., Noel, M., MacDonald, N., Rogers, J., Bucci, L.M., Mousmanis, P., Lang, E., Halperin, S.A., Bowles, S., Halpert, C., Ipp, M., Asmundson, G., Rieder, M.J., Robson, K., Uleryk, E., Antony, M., Dubey, V., Hanrahan, A., Lockett, D., Scott, J., Bleeker, E. and HELPinKids & Adults (2015), “Reducing pain during vaccine injections: clinical practice guideline”, Canadian Medical Association Journal (Journal de l’Association Medicale Canadienne), Vol. 187 No. 13, pp. 975-982, available at: https://doi.org/ 10.1503/cmaj.150391
Zhao, A., Leong, R. and Watson, W. (2015), “A survey of parental barriers to using pain-reduction strategies during childhood immunizations”, University of British Columbia Medical School Journal, Vol. 6 No. 2, pp. 11-14, available at: http://ubcmj.med.ubc.ca/a-survey-of-parental- barriers-to-using-pain-reduction-strategies-during-childhood-immunizations/
Corresponding author
Terri MacDougall can be contacted at: t..l@gmail.com; t..l@nbnplc.com
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Vol. 54 No. 4 October 2017 Journal of Pain and Symptom Management 589
Review Article
The Effectiveness of Distraction as Procedural Pain
Management Technique in Pediatric Oncology Patients: A
Meta-analysis and Systematic Review
Ibitoye M. Bukola, MSc, BSc, RN, and Dawson Paula, MSc, BSc, RN
Department of Nursing Science (I.M.B.), College of Health Sciences, University of Ilorin, Ilorin, Kwara State, Nigeria; School of Health Sciences (D.P.), University of Nottingham, Nottingham, UK
Abstract
Context. Diagnostic tests and treatment regimens for pediatric cancers involve invasive and painful procedures. Effective management of such pain has been shown to be suboptimal in many parts of the world, often because of the cost and limited availability of appropriate medications. Current evidence suggests that distraction (a relatively low-cost technique) is a promising intervention for procedural pain management. There is, however, limited evidence demonstrating its effectiveness in pediatric oncology patients.
Objectives. A systematic review was conducted to ascertain the effectiveness of distraction as a procedural pain management technique in pediatric oncology patients.
Methods. Using a comprehensive search strategy, MEDLINE, PsycINFO, Cochrane Library, AMED, CINAHL, Web of Science, and EMBASE electronic databases were searched for studies comparing distraction techniques to standard care/any intervention. Using the selected studies, a systematic review and meta-analysis of randomized controlled trials was conducted.
Results. Two hundred ninety-nine studies were identified, with seven randomized control trials identified as eligible for inclusion. Pain was assessed using self-report, observer-report, and physiological measures. A meta-analysis of four studies showed distraction as effective in reducing procedural pain, based on self-reported pain. A meta-analysis of three studies, based on pulse rates, demonstrated similar results. For observer-reported pain, limited evidence supported the effectiveness of distraction.
Conclusion. This systematic review demonstrates that distraction is a promising intervention for procedural pain. Future research should assess effectiveness of distraction in varied populations, to explore evidence of cultural influences on pain expression, measurement, and management approaches. J Pain Symptom Manage 2017;54:589e600. ! 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Key Words
Distraction, procedural pain, children, cancer, pediatric oncology
Introduction
Pain is a prevalent symptom among pediatric oncology patients (POPs).1,2 Pain may be disease- related and/or due to invasive medical procedures such as lumbar punctures, venepuncture, intramus- cular injections, port access, finger pricks, bone marrow aspiration, and biopsy. Although cancer-
Address correspondence to: Ibitoye M. Bukola, MSc, BSc, RN, Department of Nursing Science, College of Health Sciences, University of Ilorin, P.M.B. 1515, Ilorin, Kwara State, Nigeria.
! 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
related pain is distressing, POPs report that invasive procedures are the most feared and most prevalent source of pain.3e6 Unfortunately, numerous invasive procedures will be required for the diagnosis and treatment of the disease. Additional pain and distress may result from the side effects from chemotherapy and other treatments.2,7,8 Studies have shown that
Accepted for publication: July 7, 2017.
0885-3924/$ – see front matter
http://dx.doi.org/10.1016/j.jpainsymman.2017.07.006
590 Bukola and Paula
Vol. 54 No. 4 October 2017
persistent and unrelieved procedural pain can be detrimental to the physical, psychological, and social well-being of POPs.9e12 Moreover, pain relief is closely associated with patient satisfaction and is considered a fundamental human right.13 Hence, it is imperative that procedural pain is effectively managed to reduce anxiety and promote the well-being of POPs.
Procedural pain is often managed with pharmacologic and nonpharmacologic interventions or both (as integra- tive medicine); in some settings, no therapy is administered.14e16 Depending on the procedure, phar- macological interventions such as opioids, non-steroidal anti-inflammatory drugs (NSAIDs), sedatives, local and general anesthesia can be used.17 Research studies have demonstrated the effectiveness of these drugs.14,18-20 However, in many developing countries, these drugs are not readily unavailable, mainly due to cost.15 Therefore, nurses and parents have to restrain a child during a pain- ful procedure.21 This can cause physical harm to the child. Even in areas where medications are available, it has been shown that pharmacologic interventions do not improve the overall pain experience of children as they still complain of pain and remain distressed.22,23,17 Thus, research studies and clinical guidelines have rec- ommended the use of nonpharmacologic interventions, which can be cheaper and more accessible.24e27
There are different types of nonpharmacologic inter- ventions.28 A Cochrane review classified them into psy- chological (e.g., distraction and guided imagery) and nonpsychological (e.g., acupuncture).29 It claimed that psychological interventions are the most commonly used interventions for procedural pain re- lief. Nevertheless, in pediatrics, the efficacies of some interventions (e.g., suggestion) remain elusive, whereas others (e.g., distraction and hypnosis) are be- ing established as efficacious interventions.17,28,29 In pediatric oncology, two systematic reviews concluded that hypnosis might be an effective intervention for procedural pain relief; nevertheless, the quality of the included papers limited the validity of their results.30,31 Whereas, for distraction, no systematic reviews evalu- ating its effectiveness for procedural pain relief in POPs was found. Although primary studies have been conducted, their results are inconsistent.32e34 More- over, the small sample sizes of these studies limits the generalization of their results. Hence, there is no strong evidence demonstrating the effect of distraction on procedural pain in POPs. Despite the lack of strong evidence, distraction is commonly used in some hospi- tals around the world.35,36 In an era of evidenced-based practice, health interventions ought to be grounded on empirical evidence. Therefore, this systematic review aimed to conduct a meta-analysis of these primary studies to generate the pooled treatment effect of distraction on procedural-related pain in children and adolescents with cancer.
Methods
Design
A systematic review was conducted using the guide- lines from Cochrane37 and Joana Briggs Institute.38 When possible, a meta-analysis was carried out.
Search Strategy
Published articles, dissertations, and grey literature were sought via strategies developed using the appro- priate MeSH terms of various databases. Keywords such as ”pediatric oncology,” ”cancer,” and ”distrac- tion” were used. The search strategies were screened by the two reviewers. A sample of the search strategies is in Appendix. No date, language, or country limita- tions were applied to searches. Eight databases were searched: Cochrane library (1992e2016), Cumulative Index to Nursing and Allied Health Literature (CI- NAHL) (1982e2016), Embase (1974e2016), Medline (1946e2016), Allied and complementary Medicine (1985e2016), Web of Science (1900e2016), PsycIN- FO (1806e2016), and ProQuest Dissertation and The- ses (2001e2016). ClinicalTrials.gov and International Clinical Trials Registry Platform Web sites were searched for the possible identification of on
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