Effectiveness of distraction-based interventions for relieving anxiety, fear, and pain in hospitalized children during venous blood sampling: a systematic review protocol

OBJECTIVE

The aim of this review is to evaluate the effectiveness of active compared with passive distraction-based interventions for relieving anxiety, fear, and pain in hospitalized preschool and school-age children during venous blood sampling.

INTRODUCTION

Venous blood sampling remains the most common procedure that causes anxiety, fear, and pain among the pediatric population. It is important that health care professionals relieve a child's pain and the related emotions because untreated pain may have long-term effects on children's growth and development. It is necessary to determine which interventions are effective in relieving these outcomes in preschool and school-age children during blood sampling.

INCLUSION CRITERIA

This review will include randomized controlled trials and quasi-experimental studies that include active and passive distraction-based interventions for relieving hospitalized preschool and school-age children's anxiety, fear, and pain during venous blood sampling.

METHODS

CINAHL, PubMed, Scopus, and the Cochrane Library databases will be searched for published studies. MedNar, Google Scholar, and PsycEXTRA databases will be searched for in-progress and unpublished studies. Two independent researchers will perform critical appraisal and data extraction using the JBI methodology. Data describing randomized controlled trials and quasi-experimental studies will be pooled in a statistical meta-analysis. If statistical analysis is not possible, the findings will be reported narratively. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach will be used to assess certainty in the quality of evidence.

REVIEW REGISTRATION

PROSPERO CRD42023455617.

Benefits to Clinicians of Nonpharmacological Distraction During Pediatric Medical Procedure

CONTEXT

Nonpharmacologic distraction (NPD) during medical procedures in children is known to be beneficial to patients; however, no reviews have assessed their benefits to medical providers.

OBJECTIVES

We aimed to assess the benefits of NPD to medical providers.

DATA SOURCES

We searched 5 databases for relevant articles.

STUDY SELECTION

Peer-reviewed published randomized controlled trials comparing NPD with standard care that included children who had undergone medical procedures were included.

DATA EXTRACTION

Primary outcomes were procedure time, number of medical staff involved, and initial success rate of venipuncture. Two reviewers assessed the risk of bias by using the Cochrane Collaboration (Oxford, United Kingdom)'s Randomized Controlled Trials Risk of Bias Tool, and we performed a meta-analysis to assess efficacy.

RESULTS

We included 22 trials with 1968 participants. The main NPD was audiovisual distraction, such as tablets. No significant difference was found in venipuncture procedure time (mean difference: -9.79; 95% confidence interval: -22.38 to 2.81; low certainty). We found no studies on the number of medical staff.

CONCLUSIONS

Our review did not find any clear NPD-associated benefit for the medical provider. The review included a small amount of literature, analyzed a small number of cases, and had a low certainty of evidence regarding procedure duration; therefore, further studies are needed to conclude the benefits to clinicians of NPD.

External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol

INTRODUCTION

Needle-related procedures are considered as the most important source of pain and distress in children in hospital settings. Considering the physiological and psychological consequences that could result from these procedures, management of pain and distress through pharmacological and non-pharmacological methods is essential. Therefore, it is important to have interventions that are rapid, easy-to-use and likely to be translated into clinical practice for routine use. The aim of this study will be to determine whether a device combining cold and vibration (Buzzy) is non-inferior to a topical anaesthetic (liposomal lidocaine 4% cream) for pain management of children undergoing needle-related procedures in the emergency department.

METHODS AND ANALYSIS

This study will be a randomised controlled non-inferiority trial comparing the Buzzy device to liposomal lidocaine 4% cream for needle-related pain management. A total of 346 participants will be randomly assigned in a 1:1 ratio to one of the two study groups. The primary outcome will be the mean difference in pain intensity between groups during needle-related procedures. A non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. A Non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. The secondary outcomes will be the level of distress during the procedure, the success of the procedure at first attempt, the occurrence of adverse events, the satisfaction of both interventions and the memory of pain 24 hours after the procedure. The primary outcome will be assessed for non-inferiority and the secondary outcomes for superiority.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the institutional review board of the study setting. Findings of this trial will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02616419.

Study protocol for a randomised controlled trial of humanoid robot-based distraction for venipuncture pain in children

INTRODUCTION

Intravenous insertion (IVI) is a very common procedure in the emergency department (ED). IVI is often painful and stressful for both children and their families. Currently, distraction therapy is not used as a standard of care for IVI in North America. We propose that interaction with a humanoid robot may effectively distract children during IVI thereby reducing their pain and distress.

METHODS AND ANALYSIS

This randomised controlled superiority trial will be conducted in a Canadian paediatric ED. We plan to recruit 80 patients. Children will be eligible if they (1) are 6 to 11 years of age, (2) need an IVI, (3) are fully conscious and alert, (4) have sufficient knowledge of the English language to understand and complete the study assessments and (5) are accompanied by a legal guardian. Our primary objective is to compare patient-reported pain and distress with the use of distraction (via a humanoid robot) versus standard care in children. The primary outcomes will be (1) self-reported pain, as measured by the Faces Pain Scale-Revised and (2) observed distress, as measured by the Observational Scale of Behavioural Distress-Revised. Secondary outcomes will include (1) measuring parental anxiety, (2) examining the association between parental anxiety and child outcomes and (3) children's degree of engagement with the humanoid robot via the Intrinsic Motivation Inventory tool. First enrolment occurred in April 2017 and is ongoing.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Ethics Board (University of Alberta). Informed consent to participate will be obtained from all participants' parents/guardian, in conjunction with assent from the participant themselves. This study data will be submitted for publication regardless of results. Purchase of the robot was facilitated through a Stollery Children's Hospital Foundation donation. Recruitment costs are supported by the Women and Children's Health Research Institute.

TRIAL REGISTRATION NUMBER

NCT02997631; Pre-results.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Effectiveness of non-pharmacological measures for reducing pain and fear in children during venipuncture in the emergency department: a vibrating cold devices versus distraction

OBJECTIVES

To assess the effectiveness of a physical method of managing pain and fear in children and anxiety in the accompanying adult during venous puncture in the emergency department.

MATERIAL AND METHODS

Quasi-experimental study of 3 groups: one group used a combination of directed distraction by means of a vibration device with ice pack, a second group received only distraction, and no strategy was used in the third.

RESULTS

Pain and adult anxiety were similar in the 2 groups in which a pain management strategy was applied. Pain and adult anxiety were greater when no strategy was adopted. We detected no differences in the level of the children's fear.

CONCLUSION

Directed distraction can be useful for managing pain in children and it reduces the anxiety experienced by accompanying adults. The use of a vibration device with ice does not add benefits. Fear is not reduced by any of these measures.

Mitochondrial disease patient motivations and barriers to participate in clinical trials

Background

Clinical treatment trials are increasingly being designed in primary mitochondrial disease (PMD), a phenotypically and genetically heterogeneous collection of inherited multi- system energy deficiency disorders that lack effective therapy. We sought to identify motivating factors and barriers to clinical trial participation in PMD.

Methods

A survey study was conducted in two independent mitochondrial disease subject cohorts. A discovery cohort invited subjects with well-defined biochemical or molecularly- confirmed PMD followed at a single medical center (CHOP, n = 30/67 (45%) respondents). A replication cohort included self-identified PMD subjects in the Rare Disease Clinical Research Network (RDCRN) national contact registry (n = 290/1119 (26%) respondents). Five-point Likert scale responses were analyzed using descriptive and quantitative statistics. Experienced and prioritized symptoms for trial participation, and patient attitudes toward detailed aspects of clinical trial drug features and study design.

Results

PMD subjects experienced an average of 16 symptoms. Muscle weakness, chronic fatigue, and exercise intolerance were the lead symptoms encouraging trial participation.

Motivating trial design factors included a self-administered study drug; vitamin, antioxidant, natural or plant-derivative; pills; daily treatment; guaranteed treatment access during and after study; short travel distances; and late-stage (phase 3) participation. Relative trial participation barriers included a new study drug; discontinuation of current medications; disease progression; daily phlebotomy; and requiring participant payment. Treatment trial type or design preferences were not influenced by population age (pediatric versus adult), prior research trial experience, or disease severity.

Conclusions

These data are the first to convey clear PMD subject preferences and priorities to enable improved clinical treatment trial design that cuts across the complex diversity of disease. Partnering with rare disease patient communities is essential to effectively design robust clinical trials that engage patients and enable meaningful evaluation of emerging treatment interventions.

Perceptions of blood donation among people in Africa: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The aim of this review is to synthesize the best available evidence on the perceptions of blood donation among people living in Africa.

Blood pressure and heart rate during stress in children born small for gestational age

BACKGROUND

Increased sympathetic nervous system activity has been proposed as a potential mechanism for the blood pressure (BP) elevation seen in individuals born small for gestational age (SGA). This study was carried out to detect the changes in BP and heart rate (HR) in children born SGA during exposure to stress and to assess for changes in urinary catecholamine excretion.

METHODS

Nineteen children aged 6-14 years born SGA and 17 age- and gender-matched healthy controls were included in the study. The stress test included a mathematical test and venipuncture. BP and HR were monitored during the test. Spot urine samples were collected at baseline and after the stress test to determine dopamine, epinephrine and norepinephrine levels.

RESULTS

At baseline, there was no difference in BP and HR between the SGA and control groups, but mean urinary norepinephrine levels were slightly higher in the SGA group (55.7 ± 16.1 vs. 43.4 ± 3.8 mcg/gCr; P = 0.10). Compared to the control group, mean maximal HR increase was higher in the SGA group (31.3 ± 3.1 vs. 19.2 ± 3.8%; P = 0.008), and mean duration of maximal HR to baseline HR was longer (186 ± 23 vs. 97 ± 13 s, respectively; P = 0.003). There was a significant negative correlation between birth weight and maximal HR increase (r = -0.497, P = 0.003).

CONCLUSION

Children born SGA showed significantly greater increases in HR and significantly longer periods of tachycardia during exposure to stress than did healthy controls. The rise in HR was inversely correlated with birth weight. These findings suggest that children born SGA have a greater increase in sympathetic response when exposed to stress than do healthy individuals.

The effect of phlebotomy training on blood sample rejection and phlebotomy knowledge of primary health care providers in Cape Town: A quasi-experimental study

BACKGROUND

There is an increasing amount of blood sample rejection at primary health care facilities (PHCFs), impacting negatively the staff, facility, patient and laboratory costs.

AIM

The primary objective was to determine the rejection rate and reasons for blood sample rejection at four PHCFs before and after a phlebotomy training programme. The secondary objective was to determine whether phlebotomy training improved knowledge among primary health care providers (HCPs) and to develop a tool for blood sample acceptability.

STUDY SETTING

Two community health centres (CHCs) and two community day centres (CDCs) in Cape Town.

METHODS

A quasi-experimental study design (before and after a phlebotomy training programme).

RESULTS

The sample rejection rate was 0.79% (n = 60) at CHC A, 1.13% (n = 45) at CHC B, 1.64% (n = 38) at CDC C and 1.36% (n = 8) at CDC D pre-training. The rejection rate remained approximately the same post-training (p > 0.05). The same phlebotomy questionnaire was administered pre- and post-training to HCPs. The average score increased from 63% (95% CI 6.97‒17.03) to 96% (95% CI 16.91‒20.09) at CHC A (p = 0.039), 58% (95% CI 9.09‒14.91) to 93% (95% CI 17.64‒18.76) at CHC B (p = 0.006), 60% (95% CI 8.84‒13.13) to 97% (95% CI 16.14‒19.29) at CDC C (p = 0.001) and 63% (95% CI 9.81‒13.33) to 97% (95% CI 18.08‒19.07) at CDC D (p = 0.001).

CONCLUSION

There is no statistically significant improvement in the rejection rate of blood samples (p > 0.05) post-training despite knowledge improving in all HCPs (p < 0.05).

Effects of a new device to guide venous puncture in elderly critically ill patients: results of a pilot randomized study

BACKGROUND

Novel devices based on the emission of near-infrared electromagnetic radiation (NIR) have been developed to minimize venous puncture failures. These instruments produce an "augmented reality" image, in which subcutaneous veins are depicted on a LCD display. We compared the new technique with standard venipuncture in a population of elderly patients.

METHODS

Patients admitted in Intensive Care Unit were randomized to standard or to NIR assisted procedure.

RESULTS

In the 103 enrolled patients (age 74 ± 12 years; standard venipuncture-N = 56; NIR-N = 47), no differences were found in procedure length, number of attempts, and referred pain. With NIR there was a lower incidence of hematomas and fewer anxiety and depressive symptoms.

CONCLUSIONS

The use of the novel NIR-based device is safer and more psychologically tolerable, and it is not associated to an increase of procedure length or number of attempts.

Parents’ Positioning and Distracting Children During Venipuncture

The purpose of this study was to determine the effectiveness of parental positioning and distraction on the pain, fear, and distress of pediatric patients undergoing venipuncture. An experimental-comparison group design was used to evaluate 43 patients (20 experimental and 23 comparison) who were 4 to 11 years old. Experimental participants used parental positioning and distraction. All participants rated their pain and fear; parents and child life specialists (CLS) rated the child’s fear, and CLS rated the child’s distress. Self-reported pain and fear were highly correlated (p < .001) but not significantly different between the two groups. Fear rated by CLS (p < .001) and parents (p = .003) was significantly lower in experimental participants. Although no difference was found in distress between the two groups, a significant time trend was discovered (p < .001). The parental positioning-distraction intervention has the potential to enhance positive clinical outcomes with a primary benefit of decreased fear. Further research is warranted.

OC39 - The efficacy of a participatory approach in reducing pain related to venepuncture in children

Theme:

ETHICAL ISSUES

dignity and humanity.

INTRODUCTION

Venepuncture represents traumatic experience in childhood due to pain and discomfort.

AIMS

To compare the efficacy of a participatory approach with preliminary ice application to the skin.

METHODS

Two age-groups (respectively 3-7 and *8 years) were considered during day-hospital, hospitalization, and ER accesses. Venepuncture was described to patients with fables or illustration according to the age-group. Ice or cool-water-pack was randomly applied to skin for one minute before venepuncture. Pain measurement scales were Wong-Baker and VAS.

RESULTS

Preliminary data (55 patients) showed that the 3-7 years age group had better pain tolerance with a participatory approach, whilst ice was better in the older group. Generally previous venepunctures seem to worsen pain feeling.

DISCUSSION

Imagination seems to influence pain feeling in the 3-7 age group, while ice is more important in the older group. Previous experiences mark negatively successive venepunctures.

CONCLUSIONS

Participatory approaches can be cost-effective and influences positively venepuncture in the future.

The Effect of Distraction on Pain Level Felt by School-age Children During Venipuncture Procedure--Randomized Controlled Trial

The experimental study that follows was planned to determine the effectiveness of distraction on the pain level in school-age children as they underwent venipuncture. The study sample consisted of children between the ages of 7 and 12 years who underwent venipuncture at the Training and Research Hospital in Istanbul, Turkey between February and May 2012. A total of 144 children were conveniently sampled and evenly randomized into two groups of 72 children each. The primary instrument used to test children's pain level was the Faces Pain Scale-Revised (FPS-R). During the blood draw, the experimental group was given a kaleidoscope and told to look through it and describe what they saw, then rate their pain level on the FPS-R. Results showed that during venipuncture, the pain level of the control group was significantly higher (FPS-R = 3.27 ± 2.87) than the experimental group (FPS-R = 1.80 ± 1.84; p = .001) suggesting that distraction with a kaleidoscope is effective in reducing the pain children experience during venipuncture.

POTENTIAL USE OF MELATONIN IN PROCEDURAL ANXIETY AND PAIN IN CHILDREN UNDERGOING BLOOD WITHDRAWAL

The recognition of the value of pain, especially in the pediatric population, has increased over the last decade. It is known that pain-related anxiety can increase perceived pain intensity. There are several different approaches to the treatment of pre-procedural anxiety and procedural pain in children. Melatonin, a neurohormone with the profile of a novel hypnotic-anaesthetic agent, plays an important role in anxiolysis and analgesia. This study investigated the effects of oral melatonin premedication to reduce anxiety and pain in children having blood samples taken. The investigations were carried out on 60 children, aged 1-14 years, divided into 2 equal groups. Using a computer-generated randomization schedule, patients were given either melatonin orally (0.5 mg/kg BW, max 5 mg) or placebo 30 min before blood draw. Pre-procedural anxiety was assessed using the scale from the Children’s Anxiety and Pain Scales, while procedural pain used the Face, Legs, Activity, Cry and Consolability assessment tool for children under the age of 3 years, Faces Pain Scale-Revised for children aged 3-8 years and Numeric Rating Scale for children over the age of 8 years. Oral administration of melatonin before the blood withdrawal procedure significantly reduced both anxiety (p<0.0005) and pain levels than placebo (p<0.0002 for children under 3 years and p<0.0039 for children over 3 years). These data support the use of melatonin for taking blood samples due to its anxiolytic and analgesic properties. Further studies are needed to support the routine use of melatonin to alleviate anxiety and pain in pediatric patients having blood samples taken.

Physiological and pathological impact of blood sampling by retro-bulbar sinus puncture and facial vein phlebotomy in laboratory mice

Retro-bulbar sinus puncture and facial vein phlebotomy are two widely used methods for blood sampling in laboratory mice. However, the animal welfare implications associated with these techniques are currently debated, and the possible physiological and pathological implications of blood sampling using these methods have been sparsely investigated. Therefore, this study was conducted to assess and compare the impacts of blood sampling by retro-bulbar sinus puncture and facial vein phlebotomy. Blood was obtained from either the retro-bulbar sinus or the facial vein from male C57BL/6J mice at two time points, and the samples were analyzed for plasma corticosterone. Body weights were measured at the day of blood sampling and the day after blood sampling, and the food consumption was recorded automatically during the 24 hours post-procedure. At the end of study, cheeks and orbital regions were collected for histopathological analysis to assess the degree of tissue trauma. Mice subjected to facial vein phlebotomy had significantly elevated plasma corticosterone levels at both time points in contrast to mice subjected to retro-bulbar sinus puncture, which did not. Both groups of sampled mice lost weight following blood sampling, but the body weight loss was higher in mice subjected to facial vein phlebotomy. The food consumption was not significantly different between the two groups. At gross necropsy, subcutaneous hematomas were found in both groups and the histopathological analyses revealed extensive tissue trauma after both facial vein phlebotomy and retro-bulbar sinus puncture. This study demonstrates that both blood sampling methods have a considerable impact on the animals' physiological condition, which should be considered whenever blood samples are obtained.

Doctors and vampires in sub-Saharan Africa: ethical challenges in clinical trial research

Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding "blood stealing" or "blood selling." Such fears can potentially have dire effects on the success of research projects--for example, high dropout rates that would invalidate the trial's results--and have ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population's ignorance, these rumors represent a social diagnosis and a logical attempt to make sense of sickness and health. Born from historical antecedents, they reflect implicit contemporary structural inequalities and the social distance between communities and public health institutions. We aim at illustrating the underlying logic governing patients' fear and argue that the management of these beliefs should become an intrinsic component of clinical research.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This review is an updated version of the original Cochrane review published in Issue 4, 2006. Needle-related procedures are a common source of pain and distress for children. Our previous review on this topic indicated that a number of psychological interventions were efficacious in managing pediatric needle pain, including distraction, hypnosis, and combined cognitive behavioural interventions. Considerable additional research in the area has been published since that time.

OBJECTIVES

To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

Searches of the following databases were conducted for relevant randomized controlled trials (RCTs): Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Web of Science. Requests for relevant studies were also posted on various electronic list servers. We ran an updated search in March 2012, and again in March 2013.

SELECTION CRITERIA

Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only RCTs with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed trial quality and a third author helped with data extraction and coding for one non-English study. Included studies were coded for quality using the Cochrane Risk of bias tool. Standardized mean differences with 95% confidence intervals were computed for all analyses using Review Manager 5.2 software.

MAIN RESULTS

Thirty-nine trials with 3394 participants were included. The most commonly studied needle procedures were venipuncture, intravenous (IV) line insertion, and immunization. Studies included children aged two to 19 years, with the most evidence available for children under 12 years of age. Consistent with the original review, the most commonly studied psychological interventions for needle procedures were distraction, hypnosis, and cognitive behavioural therapy (CBT). The majority of included studies (19 of 39) examined distraction only. The additional studies from this review update continued to provide strong evidence for the efficacy of distraction and hypnosis. No evidence was available to support the efficacy of preparation and information, combined CBT (at least two or more cognitive or behavioural strategies combined), parent coaching plus distraction, suggestion, or virtual reality for reducing children's pain and distress. No conclusions could be drawn about interventions of memory alteration, parent positioning plus distraction, blowing out air, or distraction plus suggestion, as evidence was available from single studies only. In addition, the Risk of bias scores indicated several domains with high or unclear bias scores (for example, selection, detection, and performance bias) suggesting that the methodological rigour and reporting of RCTs of psychological interventions continue to have considerable room for improvement.

AUTHORS' CONCLUSIONS

Overall, there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality. Additional research is needed to further assess interventions that have only been investigated in one RCT to date (that is, memory alteration, parent positioning plus distraction, blowing out air, and distraction plus suggestion). There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress.

Providing information to children before and during venepuncture

AIM

To explore the nature, process and consequences of giving information to children aged three to 11 years before and during venepuncture.

METHOD

This was a non-participant, observational, qualitative study of 11 children and four healthcare professionals before and during venepuncture. The healthcare professionals were: a sister, a healthcare assistant, a junior doctor and a staff nurse.

FINDINGS

There was little assessment of children's levels of knowledge of venepuncture and they received no information before the procedure. During the procedure, the children under six years of age only received information about the local anaesthetic cream during the application of the cream, not the venepuncture; the older children received information about the application of the cream and the venepuncture during both procedures. Practitioners used different language with the younger children when applying the local anaesthetic cream. Although the younger children did not appear distressed by the application of the cream, they appeared to be distressed by the venepuncture--more so than the older children--protesting and crying during the procedure.

CONCLUSION

Some of the distress associated with venepuncture can be avoided if children are given information about the procedure in a way they can understand.

Distraction techniques in children during venipuncture: an Italian experience

INTRODUCTION

Venepuncture in chronically-ill patients is one of the invasive procedures most frequently repeated during the day. Most children are frightened and anxious before this procedure, and during venepuncture they cry, suffer pain and refuse to cooperate, whereas parents are often worried and do not know how to help. Studies suggest that the first experiences of pain in neonatal age can be associated with altered reactions to pain during childhood and in adulthood.

METHODS

Our sample included 203 patients aged between 2 and 15 years. During venepuncture a video was shown to the patient. Pain and parent collaboration were measured using validated scales.

RESULTS

Significant differences were observed between the mean score of pain in patients undergoing venepuncture with audiovisual distracting technique (2.53 +/- 1.76) and the mean score obtained in those undergoing venepuncture without this technique (5.22 +/- 2.53). In the group with audio-video distractors, the mean level of cooperation was 0.38 (SD = 0.63) compared to 0.20 (SD = 0.54) in the control group. In relation to the presence of parents, no significant differences were found in the mean pain scores (P = 0,5 > 0,05), whereas the mean scores of cooperation were significantly different (P = 0.0076 < 0.05)

DISCUSSION

Audio-visual distraction effectively improved pain management and favoured children's cooperation during venepuncture. This technique is cost-effective, so it can be widely used for pain management and to promote cooperation with the child, two aspects that are of key importance in building a relationship of trustworthiness

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.

Peripheral venepuncture in infants and children

Venepuncture can be a painful and frightening experience for children. Nurses play an active role in helping them to cope with this experience and in reducing the adverse effects of venepuncture. This article explains how infants, children and their families can be supported and cared for before, during and after venepuncture.

Changing practice in invasive procedures: the experience of the Krishnan Chandran children's centre

The UK government's clinical governance strategy places emphasis on the provision of evidence-based, effective and client-focused care. This provided the framework for developing nurse-led venepuncture and immunization clinics. Evidence from research and examples of good practice were used to guide the structure and ethos of the new service. The professional development required to train one staff member in venepuncture and immunization techniques was adapted from already existing training. A specific training package was then developed to facilitate professional development of further staff. Audit was used, both to identify the need for the service and to assess its quality and cost-effectiveness. Consumer views were obtained through informal discussion and interviews with parents. This article explores how the concepts of clinical governance, together with the commitment of the multi-professional team, have resulted in a transformation of care for children undergoing invasive procedures in the outpatient department.