Convergent validity of pain measuring tools among Nigerian children

This prospective study was carried out at the Children Outpatient Clinic of the University College Hospital (UCH), Ibadan, Nigeria. The study aims to determine the convergent validity of the Oucher, Observer Pain Scale, Visual Analogue Scale (VAS) and the Numeric Rating Scale (NRS) among Nigerian children. Children aged between 6 months and 12 years who required venepuncture or phlebotomy for various investigative procedures were recruited. Demographic data and pain assessment scores were documented on a data collection form. Pain was assessed by a trained research assistant at baseline, during the procedure and immediately after the procedure using the 4 pain scales. The mean age (+/- SD) of the children was 5.5 +/- 4.3 years, boys accounted for 93 (52%) and girls 86 (48%). Pain score ranged from 0 (no pain) to 10 (worst pain) during the procedure; 72% (125) of the children had a pain score of at least 4. The median pain score during the procedure were 4 (Observer Pain Scale), 5 (Oucher) and 4 (VAS and NRS).The average measure intra-class correlation coefficient (ICC) showed that the Oucher, the VAS and the NRS pain scales are reliable pain measuring tools with an ICC of 0.63-0.69 at baseline and 0.72 - 0.73 during the procedure. The VAS, NRS and Oucher pain scales are valid pain tools that can be used to assess pain in Nigerian children.

Maximizing clinical research participation in vulnerable older persons: identification of barriers and motivators

OBJECTIVES

To identify barriers and motivators to participation in long-term clinical research by high-risk elderly people and to develop procedures to maximize recruitment and retention.

DESIGN

Quantitative and qualitative survey.

SETTING

Academic primary care medicine and pre-anesthesia testing clinics.

PARTICIPANTS

Fifty patients aged 70 and older, including 25 medical patients at high risk of hospitalization and 25 patients with planned major surgery.

MEASUREMENTS

Fifteen- to 20-minute interviews involved open- and closed-ended questions guided by an in-depth script. Two planned study protocols were presented to each participant. Both involved serial neuropsychological assessments, blood testing, and magnetic resonance brain imaging (MRI); one added lumbar puncture (LP). Participants were asked whether they would be willing to participate in these protocols, rated barriers and incentives to participation, and were probed with open-ended questions.

RESULTS

Of 50 participants (average age 78, 44% male, 40% nonwhite), 32 (64%) expressed willingness to participate in the LP-containing protocol, with LP cited as the strongest disincentive. Thirty-eight (76%) expressed willingness to participate in the protocol without LP, with phlebotomy and long interviews cited as the strongest disincentives. Altruism was a strong motivator for participation, whereas transportation was a major barrier. Study visits at home, flexible appointment times, assessments shorter than 75 minutes, and providing transportation and free parking were strategies developed to maximize study participation.

CONCLUSION

Vulnerable elderly people expressed a high rate of willingness to participate in an 18-month prospective study. Participants identified incentives and barriers that enabled investigators to develop procedures to maximize recruitment and retention.

Familiarity breeds content? Soothing effect of a familiar odor on full-term newborns

OBJECTIVE

This study tested the effects of familiar and unfamiliar odors during a heel stick in full-term newborns.

METHOD

Forty-four newborns were exposed to vanillin (via their mother or via their crib) or no odor prior to a heel stick. On the day of the heel stick, infants were either exposed to a familiar odor, an unfamiliar odor, or no odor before, during, and after the procedure. Crying, grimacing, and oral movements were scored.

RESULTS

Infants exposed to a familiar odor displayed little distress and more oral movements during the procedure compared to the unfamiliar group. No advantage was found when infants were exposed to an odor learned via their mother compared to when the odor was learned via the crib. Exposure to an unfamiliar odor did not lessen distress compared to exposure to no odor.

CONCLUSION

A familiar odor is effective in significantly reducing crying and grimacing during a minor painful procedure. Olfactory support is a useful intervention that may potentially help minimize deleterious effects of neonatal pain.

Effects of programmed information on coping behavior and emotions of mothers of young children undergoing IV procedures

PURPOSE

To determine the effects of provision of information on mother's problem focused coping ability during their child's intravenous procedure.

METHODS

Data were collected from 56 mothers whose children have admitted to pediatric ward in the hospital. The participants included 27 intervention group mothers and 29 control group mothers. For the information intervention, "Programmed Information for Parental Coping before Intravenous Procedure (PIPC-IP)", video program was made based on self-regulation theory for the experimental group mothers. Mother's coping ability was measured by parental supportive behavior, parental beliefs and Profile of Mood State (POMS).

RESULTS

Mothers who received PIPC-IP showed significantly higher levels of supportive behavior (t = 3.55, p = .005) and Parental Beliefs (t = 2.95, p = .005), but no significant difference in negative mood on POMS (t = .15, p = .87) compared to mothers in the control group.

CONCLUSIONS

These results demonstrate that PIPC-IP is an effective intervention to increase the supportive behaviors and beliefs of mothers' problem focused coping ability but not the negative mood.

[Physiological and behavioral responses of newborns at risk to nurse's care]

Daily tasks carried out by nurses working at the Neonatal Unit (NU) require expanding practice and observation skills, from the perspective of professional activities. The aim of this study was to investigate physiological and behavioral responses of newborns (NB) at risk being cared by NU nurses. This exploratory-descriptive study was carried out with 33 NB at risk admitted to the NU of a public maternity ward, in Fortaleza, Ceara, Brazil, from December/2004 to March/2005. Direct observation of care provided by, nurses to the NB, and medical records on birth conditions were used. The most frequent physiological response was change in the heart rate, followed by changes in oxygen saturation and skin color. It was also observed that, by means of face expression, body movement, and crying, that infants tried to communicate their feelings.

[Effective and efficient method of painless venepuncture in children]

Venepuncture for routine blood sampling is not only a very distressing experience for a considerable number of children but also leading to unreliable data because of hemolytic sample by patients' fighting during procedure. The children express both high levels of distress during venepuncture and anticipation of the procedure. Therefore, prevention or reduction of distress should focus on both phases of the procedure. To this end, several elements should be considered: preparation of procedural information, distraction during painful procedures, and local anesthesia. Current concepts to understand these elements are presented in this review.

Fear of blood/injection in healthy and unhealthy adults admitted to a teaching hospital

Blood/injury phobia is one of the specific phobias. The aim of this study was to determine the fear of injection and blood in patients and healthy people. This study was carried out at Tepecik Hospital, Clinical Biochemistry Laboratory and Blood Center. Data were collected from 1500 adults who agreed to participate in the study (237 patients with chronic diseases and 1263 healthy people) during the period from January 2003 to February 2005. All participants completed two self-administered questionnaires (17-item Symptom Questionnaire and 20-item Blood/Injection Fear Scale) after giving blood samples by blood donation. 30.1% of the patients and 19.5% of the healthy adults reported that they had fear of blood/injection. Symptoms related to having blood drawn or injection were more frequently reported among women than men. Patients' educational level was also associated with the Symptom Questionnaire and fear of blood/injection scores. Fear of blood/injection was significantly higher in patients with chronic diseases. Fear of blood/injection should be considered by healthcare professionals as it is important for assessing the treatment-seeking individuals.

Fear of needles and vasovagal reactions among phlebotomy patients

Anxiety associated with blood and injections is a common problem in medical settings and, in severe cases, affects sufferers' ability to receive medically essential treatment. The present study was conducted to examine incidence of adverse reactions to venipunctures among phlebotomy patients, as well as to understand the demographic and psychological characteristics associated with such reactions. A large sample of participants undergoing venipuncture (N=3315) was recruited from hospital-based phlebotomy laboratories. Participants completed a brief questionnaire assessing psychological and physiological reactions to having their blood drawn. Results indicated that a small minority of patients experienced significant anxiety symptoms during venipuncture. Vasovagal reactions and vasovagal syncope were extremely infrequent. A tendency to experience pain, disgust, and fear of fainting during injections was associated with anxious responding to the venipuncture and a probable diagnosis of needle phobia. Theoretical and practical implications are discussed.

Fear of venepuncture as a barrier to testing for blood-borne infection and use of an oral fluid test as an alternative to venepuncture in a genitourinary medicine clinic

OBJECTIVE

A survey of 505 consecutive patients attending a UK genitourinary medicine clinic (GUM) included a psychometric tool to compute a fear of venepuncture (FOV) score, responses to the offer of venepuncture and to alternative testing.

METHOD

An oral fluid test (OFT) was available to test for blood-borne infection (BBI). Completed fear scores were provided by 299 (59%) patients routinely offered venepuncture, of whom 72 (24%) who did not have venepuncture had higher fear scores compared with 227 (76%) who had venepuncture (p<0.001).

RESULTS

Both FOV and female sex were independent predictors of not having venepuncture.

CONCLUSIONS

FOV is an important barrier to uptake of venepuncture. FOV may not always be recognised by health carers. OFT is an acceptable alternative test for some patients with needle aversion who decline venepuncture.

Evaluation of psychosomatic stress in children by measuring salivary chromogranin A

AIM

To investigate the usefulness of salivary chromogranin A (CgA) and cortisol as stress markers, and the effects of distraction on the suppression of stress in children.

METHODS

We examined salivary CgA and cortisol responses before and after venipuncture in hospitalized children with and without distraction using a kaleidoscope.

RESULTS

Salivary CgA levels immediately after venipuncture were significantly higher than those immediately before it, and at 60 min after venipuncture they were significantly lower than those immediately after it. However, salivary cortisol showed no significant differences at any of the three time points. In contrast, distracted by the kaleidoscope, there were no significant differences in salivary CgA and cortisol levels at all three time points.

CONCLUSION

In children, salivary CgA level is a useful marker of stress. As an index of the effect of distraction, the measurement of salivary CgA is useful.

Speaking of research advance directives: Planning for future research participation

OBJECTIVE

To examine one model of research advance directive as a possible way to reduce the mismatch between patient and proxy choices and also to learn more about how patients with mild to moderate dementia may want to keep decision making or cede it to their proxies in the future.

METHODS

Separate interviews were conducted with 149 dyads of dementia patients and family proxies about future enrollment in five types of research. Subsequent joint interviews were conducted with 69 of those dyads to discuss their separately articulated decisions and ask whether the patient prefers future enrollment decisions to be made as he or she directs today or as the proxy deems best in the future.

RESULTS

Patients chose to cede future decision making to their proxies in 82.9% of the trials. Patients ceded decisions to their proxies in 80.7% of those trials about which the dyad had given opposite answers (n = 74, 49.7%). Patients who had expressed discomfort about the prospect of the proxy making an enrollment decision in a trial (n = 49, 32.9%) ceded decision making to their proxies in 45.7% of those trials.

CONCLUSIONS

Both patients and proxies were willing to discuss future research enrollment in the context of an advance directive for research. Such a document may be helpful to proxies and researchers in the future to judge the types of research and associated risks patients are willing to enroll in. Although most patients willingly cede future decisions to their proxies, a sizeable minority do not wish to do so.

Pain- and distress-reducing interventions for venepuncture in children

OBJECTIVE

To compare the effect of eutectic mixture of local anaesthetics (EMLA) and a placebo cream on reported pain and observed distress associated with venepuncture, and to investigate effects of procedural information before and distraction during venepuncture.

METHODS

Children 3-12 years of age undergoing venepuncture under five experimental and a control condition reported their pain at venepuncture on visual scales. Distress was observed when the child entered the waiting room, just before, and during venepuncture.

RESULTS

Distress increased over the measurement occasions, but a distress-reducing effect of EMLA only was found at the actual venepuncture. The placebo diminished the reported pain, but the effect of EMLA was larger. Procedural information and distraction showed no effects.

CONCLUSIONS

EMLA reduces pain from venepuncture. The placebo effect probably results from desirable responding. Behavioural distress is a more direct measure than self-reported pain. More sophisticated designs should be used for the provision of procedural information and distraction.

Dental and medical injections: prevalence of self-reported problems among 18-yr-old subjects in Norway

The aim of the present study was to evaluate the prevalence of self-reported problems (fear, pain, unpleasantness, fainting) of dental and medical injections, and the extent to which such problems may lead to avoidance of necessary treatment. The study included a representative sample (n = 1385) of 18-yr-old students attending high schools in the county of Hordaland, Norway. Data were collected by use of questionnaires completed in the classrooms. More problems were reported during dental than medical injections. About 17% and 15% of participants reported high fear during their last dental and medical injection, respectively. Fainting had been experienced by 2% during a dental injection and by 7% during a medical injection. Avoidance of treatment when an injection is needed was 6.7% for dental treatment and 5.2% for medical treatment. In multiple regression analyses, fear was the only explanatory factor for the avoidance of dental treatment. It is concluded that self-reported problems of injections are prevalent in this age group, particularly among girls, and that it may lead to the avoidance of necessary treatment in 5-7% of the adolescent population.

Blood-injury phobia with and without a history of fainting: disgust sensitivity does not explain the fainting response

OBJECTIVE

Individuals diagnosed with blood-injury phobia respond to venipuncture with strong psychophysiological responses. We investigated whether disgust sensitivity contributes to the fainting response and is associated with parasympathetic activation, as suggested by previous research.

METHODS

Twenty individuals diagnosed with blood-injury phobia (9 with a history of fainting to the sight of blood, 11 without such a fainting history) and 20 healthy controls were compared. Psychophysiological responses and self-report measures of anxiety, disgust, and embarrassment were monitored during rest, a paced breathing task, and venipuncture. In addition, trait disgust sensitivity and blood-injury fears were assessed.

RESULTS

Blood-injury phobics reported enhanced anxiety, disgust, and embarrassment during venipuncture. They also experienced heightened arousal, as indicated by heart rate, respiration rate, and minute ventilation. Blood-injury phobics without a fainting history tended toward higher anxiety and disgust scores. There was no evidence for increased parasympathetic activation in either blood-injury phobic subgroup or of an association of disgust and parasympathetic activation.

CONCLUSION

The tendency to faint when exposed to blood-injury stimuli may suffice as a conditioning event leading into phobia, without specific involvement of disgust sensitivity and parasympathetic activation.

Needle phobia--changing venepuncture practice in ambulatory care

Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.

Parents' willingness to pay for diminishing children's pain during blood sampling

BACKGROUND

Blood sampling is a frequent medical procedure, very often considered as a stressful experience by children. Local anesthetics have been developed, but are expensive and not reimbursed by insurance companies in our country. We wanted to assess parents' willingness to pay (WTP) for this kind of drug.

PATIENTS AND METHODS

Over 6 months, all parents of children presenting for general (GV) or specialized visit (SV) with blood sampling. WTP was assessed through three scenarios [avoiding blood sampling (ABS), using the drug on prescription (PD), or over the counter (OTC)], with a payment card system randomized to ascending or descending order of prices (AO or DO).

RESULTS

Fifty-six responses were collected (34 GV, 22 SV, 27 AO and 29 DO), response rate 40%. Response distribution was wide, with median WTP of 40 for ABS, 25 for PD, 10 for OTC, which is close to the drug's real price. Responses were similar for GV and SV. Median WTP amounted to 0.71, 0.67, 0.20% of respondents' monthly income for the three scenarios, respectively, with a maximum at 10%.

CONCLUSIONS

Assessing parents' WTP in an outpatient setting is difficult, with wide result distribution, but median WTP is close to the real drug price. This finding could be used to promote insurance coverage for this drug.

A comparison of distraction strategies for venipuncture distress in children

OBJECTIVE

To compare the effects of two pediatric venipuncture distress-management distraction strategies that differed in the degree to which they required children's interaction.

METHODS

Eighty-eight 1- to 7-year-old children receiving venipuncture were randomly assigned to one of three treatment conditions: interactive toy distraction, passive movie distraction, or standard care. Distress was examined via parent, nurse, self-report (children over 4 years), and observational coding. Engagement in distraction was assessed via observational coding.

RESULTS

Children in the passive condition were more distracted and less distressed than children in the interactive condition. Although children in the interactive condition were more distracted than standard care children, there were no differences in distress between these groups.

CONCLUSIONS

Despite literature that suggests that interactive distraction should lower distress more than passive distraction, results indicate that a passive strategy might be most effective for children's venipuncture. It is possible that children's distress interfered with their ability to interact with the distractor.

The challenges of emotional labor and emotional dissonance for the hospital phlebotomy team

Competitive pressures are forcing hospital leaders to closely examine the role of direct caregivers in improving the level of satisfaction for the treatment and services received by patients. Often, the clinical laboratory's sole representative in bedside care is the phlebotomist. Despite the physical and behavioral challenges presented by difficult patients, laboratory managers expect phlebotomists to perform their duties in a consistently efficient and friendly manner. However, time constraints often prevent phlebotomists from engaging in lengthy conversations with their patients to build trust or convey compassion. Balancing task requirements with people skills prompts phlebotomists to develop coping strategies that emphasize professional demeanor, the display of skillful technical judgment, and the creation of an image of personal concern for the patient's illness and well-being. While these behaviors may or may not be authentic, the patient's perception of the behavior is genuine. Caregivers who perform procedures directly on patients, such as phlebotomists, must be able to find the right balance of scripted, authentic, and projected behaviors to satisfy patient expectations and maintain their own level of job satisfaction. The inability of the phlebotomist to handle high levels of emotional dissonance may lead to burnout, job dissatisfaction, and increased personnel turnover.

Recruitment rates and fear of phlebotomy in pediatric patients in a genetic study of epilepsy

This study examined participation rates and reasons for refusal in a genetic study of human epilepsy. The study enrolled children with epilepsy and their parents, and required signing informed consent, verbalizing assent, and giving a peripheral blood sample. One hundred sixty-eight children met inclusion criteria; 137 agreed to enroll (82%), and 31 refused (18%). Sixteen of thirty-one patients (52%) who refused cited fear of phlebotomy as the reason for refusal. All patients refusing due to fear of phlebotomy did not require blood tests for clinical purposes. As fear of phlebotomy is the primary reason for study refusal, obtaining DNA samples from a buccal swab or mouthwash protocol may be an alternative for some studies, although there are limitations to these methods. Further analysis of the factors influencing decisions to decline study enrollment is warranted. These data will help in the design of future genetic studies and may increase future participation rates.