Original Article Can Presence of a Dog Reduce Pain and Distress in Children during Venipuncture? Laura Vagnoli, MSc, Simona Caprilli, PhD, Chiara Vernucci, BSc, Silvia Zagni, BSc, Francesca Mugnai, BSc, and Andrea Messeri, MD ---
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From the Pain Service & Palliative Care, Meyer Children’s Hospital, Florence, Italy. Address correspondence to Laura Vagnoli, MSc, Pain Service & Palliative Care, Meyer Children’s Hospital, Florence, Italy. E-mail: l.vagnoli@ meyer.it
ABSTRACT:
The aim of this study was to investigate the effectiveness of animalassisted intervention as distraction for reducing children’s pain and distress before, during, and after standard blood collection procedure. Fifty children (ages 4-11 years) undergoing venipuncture were randomly assigned to the experimental group (EG; n ¼ 25) or to the control group (CG; n ¼ 25). The blood collection procedure was carried on the children in the EG arm in the presence of a dog, whereas no dog was present when venipuncture was conducted on children in CG. In both cases, parents accompanied the child in the procedure room. Distress experienced by the child was measured with the Amended Observation Scale of Behavioral Distress, while perceived pain was measured with a visual analog scale or the Wong Baker Scale (Faces Scale); levels of cortisol in blood also were analyzed. Parental anxiety during the procedure was measured with State Trait Anxiety Inventory. Children assigned to the EG group reacted with less distress than children in the CG arm. Furthermore, cortisol levels were lower in the EG group compared with the CG group. There were no significant differences in pain ratings and in the level of parental anxiety. It appears that the presence of dogs during blood draw procedures reduces distress in children. Ó 2015 by the American Society for Pain Management Nursing
Received December 2, 2012; Revised January 15, 2014; Accepted April 15, 2014. All authors were involved in the drafting and revising of the manuscript and have read and approved the final version. The authors have no conflicts of interest to disclose. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.04.004
BACKGROUND Needle-related procedures are a common source of pain and distress for children, and one of the most often performed invasive procedures during the day. Many psychological interventions are available to manage procedural pain and distress. Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing pain and distress associated with routine pediatric venipuncture (Chambers, Taddio, Uman, McMurtry, & HELPinKIDS Team, 2009; Uman, Chambers, McGrath, & Kisely, 2006). Animal-assisted intervention (AAI) Pain Management Nursing, Vol 16, No 2 (April), 2015: pp 89-95
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is considered a distraction technique and could play a key role in the control of pain and distress for children, as well as for their parents by lowering anxiety and producing a more relaxed environment (Braun, Stangler, Narveson, & Pettingell, 2009; Sobo, Eng, & KassityKrich, 2006). Furthermore, a recent study showed that AAIs have a beneficial effect in reducing the cortisol response and the number of disruptive behavioral incidents in children with autism spectrum disorders (Viau et al., 2010). Therefore, in line with these results, the aim of this study was to evaluate the beneficial effects of AAI in children undergoing blood testing in the hospital setting. We assessed these effects through distress, pain, and serum cortisol plasma levels. As a secondary end point, we aimed to identify the level of parental anxiety.
METHODS This study was conducted with 50 randomly selected patients aged between 4 and 11 who had to undergo pediatrician-requested blood tests for routine exams. The children were generally healthy. A sample size of 50 participants was calculated to be sufficient to detect a significant difference in the level of distress when considering the number of patients who undergo blood testing in our hospital as part of their routine exams. The children were residents of Florence or lived in the nearby surrounding area. We included children undergoing venipuncture for routine exams and at their first experience with the procedure. Only native-born and Italian-speaking children were enrolled in the study to avoid any misinterpretation of the evaluation instruments used. None of the children received a topical anesthetic (e.g., EMLA® cream) before the procedure. To avoid a familiarity effect, only children who had no dogs at home were included. Also, we only assessed children who were not afraid of dogs. We observed the patients at three different periods: Phase 1 began when the child entered in the procedure room and ended when the site was disinfected; phase 2 began with the blood sampling and ended when the needle was extracted; and phase 3 began when the cotton was placed on the child’s arm to stop the bleeding and ended when the child left the procedure room. Eligible patients were randomly assigned following simple randomization procedures (computerized random numbers) to one of the two study groups. Children in the experimental group (EG) were accompanied in the procedure room during the venipuncture by a parent and an AAI expert and the dog. They interacted with dog in each of three phases: before, during, and after the blood test.
Control group (CG) children were accompanied in the same room during the venipuncture by one parent, without any dogs. Parental presence was considered control group because it is the standard procedure in our hospital. The study protocol was approved by the hospital ethics committee and consent was obtained from parents before inclusion of their child in the study. Four dogs were used: one female Labrador, one male mixed-breed, and two small mongrels. All dogs were trained regarding their behavior and carefully examined by a vet. In each group, parents were contacted outside the procedure room and after consent was given, their children were randomly assigned to one of the two groups. In the EG, the AAI expert met the child and the parent in the waiting room and started an interaction with them. The AAI expert invited everybody to join the activity: The aim was to create a relationship with the child and the parents. Then, with the child’s consent to have a dog in the procedure room, the AAI continued as the procedure was conducted. After the blood test was performed, the AAI expert went back to the waiting room with the child and the parent, always interacting with them. During the entire procedure, the child interacted with the dog by petting or stroking or brushing it, thus focusing on the dog continuously, even when the needle became visible. The doctor and nurse who performed the procedure were the same for both groups, and were instructed to maintain their standard behavior. The blood test procedure generally took 10 minutes without a dog (CG) and 15 minutes in presence of a dog (EG). Children in both groups were informed that they were enrolled in a study: Children in the CG arm were aware they were participating in a study about behavior and pain in the hospital and children in the EG arm were informed that the researchers were observing the presence of dogs in hospital. We informed both groups of children about their participation in the study because it is standard procedure in our hospital to give information to children. We considered this a controlled variable because both groups were informed. The AAIs, during data collection, were repeated twice a week for 2 hours (usually from 8 to 10 a.m.) with a dog each hour and with the participation of multidisciplinary staff composed of the AAI representative, members of the Meyer Children’s Hospital pain service (anesthetists, psychologists, nurses), and volunteers from the Livia Benini Foundation, which helped in the realization of the investigation. The staff involved in the project had received training during several preliminary meetings. During the 2-month
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study period, the AAI had been repeated 16 times in the hospital, but dogs were only present in the procedure room on 8 days. The doctors, nurses, parents, and other observers were kept blinded to the purpose of the study and the groups involved, but it was impossible to be blind entirely to assignment for the children in the EG arm. Evaluation Instruments The following assessment tools were used: The amended Observation Scale of Behavioral Distress (OSBD-A) is a validated scale (Cromwell, 1997) used to measure the behavioral distress seen by an external observer in children from ages 2 to 16 years. The instrument is a 4-point Likert scale scoring the frequency of behaviors from 0 (not at all) to 3 (all the time) and presenting 11 operationally defined items. The OSBD-A evaluated the procedure in three distinct phases: before, during, and after the blood test. The 11 behaviors recorded in the OSBD-A were crying, screaming, physical restraint, verbal resistance, requesting of emotional support, muscular rigidity, verbal fear, verbal pain, thrashing, nervous behavior, and information seeking. The result is obtained by summing the values of the Likert scale assigned to each item. The score of distress was between 0 (no distress) and 33 (maximum distress). The OSBD-A presents a good reliability measured with Chronbach’s a coefficient (a ¼ 0.923) and a good validity in correlation with other instruments that measured anxiety (r ¼ 0.78; p < .001) and pain (r ¼ 0.76; p < .0001). For our study, the coding method was translated from English to Italian, with translation being followed by a reverse translation to check appropriateness. The Wong-Baker Scale (Faces Scale) was used to measure each child’s self-reported pain only once, immediately after the procedure. Children were asked to indicate which of the faces best shows how much pain he or she felt during the procedure. They were instructed to indicate one of six faces on the scale, which shows faces with increasing distress from neutral to crying. Face 0 is very happy because it does not hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you do not have to be crying to feel that bad. This scale can be used only for children over the age of 3 (Wong & Baker, 1998). The visual analog scale (VAS) is a self-report tool used to assess pain in children who are able to express their pain. The VAS is a picture of a thermometer that is numbered from 0 (no pain at all) to 10 (the worst pain possible); it is a self-rating procedure used for children over the age of 6 years (Wong & Baker, 1998). The State Trait Anxiety Inventory (STAI) is a self-report anxiety behavioral instrument that consists of two separate 20-item subscales to measure trait (baseline) and state (situational) anxiety in adults. The STAI trait
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subscale measures relatively stable individual differences in anxiety proneness (i.e., differences in the tendency to experience anxiety), and the STAI state subscale measures transitory anxiety states (i.e., subjective feelings of apprehension, tension, and worry that vary in intensity and fluctuate depending on the situation). Parents responded on a 4-point scale. Total scores for state and trait sections separately ranged from 20 to 80, with higher scores denoting higher levels of anxiety. Test-retest correlations for the STAI are high (range: 0.73-0.86), and the studies have demonstrated good validity. In this study we used only the form Y-1, developed by Spielberger (1983), as well as a table to calculate the score according to the Italian standard version (Pedrabissi & Santinello, 1989).
Data Analysis Two psychologists with significant background in behavioral research administered the instruments. The two independent observers evaluated the child’s distress (OSBD-A) in all three phases. The record was continuous with 15-sec intervals during the three phases. A psychologist assessed parental anxiety in the waiting room using STAI (Y-1) in phase 1. We measured state anxiety in that moment to avoid organizational problems in keeping contact with the families. Children’s pain was assessed at the end of the procedure when a researcher asked them how much pain they experienced during the procedure. This was done using the Faces Scale or VAS, depending on each child’s age. Serum cortisol plasma levels were determined in the blood samples collected during the experimental procedure, to study the hypothalamic–pituitary–adrenal changes induced by these procedures, and were analyzed in the hospital’s laboratory using standard procedures. After centrifugation, plasma samples were stored at 4 C and total plasma cortisol levels were determined with a commercially available chemiluminescent immunoassay kit within 2 hours of sampling. Descriptive statistics provided an overview of the relationship between children and parental variables, as well as anxiety levels in children and parents. The agreement between the two observers codifying the data of OSBD-A was verified through Cohen’s k calculation. Differences between groups were analyzed with Student’s t test and Pearson’s correlation coefficient (r) was used to evaluate the demographic characteristics and the relationship among cortisol plasma levels, OSBD-A, and VAS/Faces Scale. Data were analyzed with the use of SPSS version 12.0 for Windows (SPSS Inc, Chicago, IL) and are presented as mean SD; p < .05 was considered significant.
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RESULTS The demographic characteristics of the two groups are presented in Table 1 and they are similar across groups, with no significant differences in age or in sex distribution. The two observers who codified the data showed a high level of agreement. The results of Cohen’s k for every item of OSBD-A all three phases are broadly significant, with values between 0.80 and 0.91. The scores obtained by the two groups are shown in Table 2. The level of total distress was significantly lower in the EG arm than in the CG arm. The comparison of the score measured in the three phases were significant in phases 1 and 2, however, there were no significant differences in phase 3. There were no significant differences between the two groups of children in pain ratings, obtained with VAS/Faces Scale, and in the scores for level of parental anxiety assessed with STAI (Y1). Furthermore, in the EG arm, serum cortisol plasma levels were significantly lower than in the CG arm. Pearson’s correlations were statistically significant between VAS/Faces Scale and OSBD-A during the procedure (r ¼ 0.59), although there were no significant results for the two other variables (cortisol and OSBD-A, r ¼ 0.33; cortisol and VAS, r ¼ 0.17).
DISCUSSION Venipuncture is one of the most frightening medical procedures experienced by children (Kolk, Van Hoof, & Fiedeldij Dop, 2000; Taddio et al., 2010). To reduce emotional and physical effects during this intervention various approaches have been used including pharmacologic and nonpharmacologic methods €ko (T€ ufekci, C ¸ elebio glu, & K€ uc¸u glu, 2009; Wang, Sun, & Chen, 2008). Distraction is one of the most effective techniques for controlling and reducing pain and distress. Many studies have investigated the use of
TABLE 1. Demographics of Study Participants and Their Parents Variable
CG
EG
n Age of child, y (mean SD) Sex of child (male/female) (n) Parent (mother/father) (n) Age of parent, y (mean SD)
25 7.38 2.5 12/13 2/23 36 4.6
25 7.1 1.8 12/13 4/21 38.92 6.99
CG ¼ control group; EG ¼ experimental group.
bubbles, books, music, handheld video games, virtual reality glasses, TV watching, and balloon inflation (Caprilli & Messeri, 2006; Hasanpour, Tootoonchi, Aein, & Yadegafar, 2006; Landier & Tse, 2010). AAI is also considered a distraction technique for hospitalized children (Braun et al., 2009; Sobo et al., 2006). In our hospital, we began using AAI in June 2002. The project Pets in Hospital was created in association with Livia Benini Foundation and ONLUS Antropozoa and now is supported by the Meyer Foundation (Caprilli & Messeri, 2006). The aim of this activity is to help hospitalized children feel better through their contact with animals. AAI representatives who work in our hospital are professionals. They are in hospital three times a week for 3 hours each time. This activity is part of the hospital routine for children’s care and health. The sanitary protocol followed was drafted by the Guidelines for Environmental Infection Control in Health-Care Facilities (recommendations of the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee; Sehulster et al., 2004). This study investigated the effectiveness of AAI as a distraction for reducing children’s pain and distress before, during, and after routine blood test. We used OSBD-A, the Faces Scale, and VAS to measure distress and pain as they are considered good instruments for assessment in pediatric hospitals (Caprilli et al., 2007; Garra et al., 2010; Urbanski & Lazenby, 2012; Wolyniez et al., 2013). Distress is a complex condition. It is a combination of fear, anxiety, and pain and has motivated researchers to combine analysis of physiological stress responses (cortisol) and psychological behaviors (observer distress and self-reported pain) (Duff, 2003). The results show a lower level of total distress when a dog is present during the procedure. In other words, it is suggested that exposure to a dog, in this stressful situation, induces a feeling of well-being. We found that there was a significant difference in distress levels in phases 1 and 2 between the two groups of children. Indeed, children who interacted with a dog manifested less behavioral distress, according to a recent study that found a lower level of behavioral distress statistically significant in children undergoing a physical examination when a dog was present (Hansen, Messinger, Baun, & Megel, 1999). In phase 3, although distress levels in the EG arm remained lower than in the CG group, distress decreased in both groups. These results underline that AAI could act on anxiety and fear before and during a venipuncture, as well as in other hospital environments, according to recent studies (Hoffmann et al., 2009; Matuszek, 2010).
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TABLE 2. Mean ± SD of Intervention Outcome Variables 95% Confidence Interval of the Difference Variable
CG
EG
p
Mean Difference
Lower
Upper
Distress (OSBD-A total) Distress (OSBD-A before) Distress (OSBD-A during) Distress (OSBD-A after) Pain (VAS or Faces Scale) STAI-Y1 Cortisol (mg/dL)
33.15 22.97 7.08 7.37 18.08 9.46 8 9.14 5.08 2.93 48.23 9.43 13.37 4.92
14.15 22.24 1.38 3.28 8.85 12.65 3.92 8.25 4.69 3.82 50.46 11.69 9.63 3.40
.042 .018 .046 .244 .776 .597 .034
8.87 5.69 9.23 4.08 .38 2.23 3.74
37.29 10.31 18.27 11.12 3.14 6.37 7.16
0.70 1.08 0.19 2.97 2.37 10.83 0.31
CG ¼ control group; EG ¼ experimental group; OSBD-A ¼ Amended Observation Scale of Behavioral Distress; VAS ¼ visual analog scale; STAI-Y1 ¼ State Trait Anxiety Inventory. Student’s t test; p < .05.
We found no significant differences in pain ratings between the two groups. This is contrary to the results of a recent study that found a significant reduction in the pain levels of children in an acute care pediatric setting when a dog was present (Braun et al., 2009). This could be due to the small size of our sample. In the past 30 years, several different studies have focused on the link between children and animals (Anderson, 2008; Arluke, 2010; Kaminski, Pellino, & Wish, 2002). These studies clearly demonstrated that children, especially those with health-related problems, show positive behavioral responses when a dog is present as it increases the child’s skill to socialize with others because it enhances their self-esteem and they feel more confident. It has been verified that having contact with animals reduces the consequences caused by separation and loneliness, and can bring comfort and gratification. Indeed, the aim of the AAI program is to improve the quality of life of patients by creating benefits and well-being (Coakley & Mahoney, 2009; Havener et al., 2001; Lang, Jansen, Wertenauer, Gallinat, & Rapp, 2010). A previous study showed that the presence of dogs in pediatric wards was considered a positive event with a high participation rate of hospitalized patients and a high level of satisfaction expressed by both parents and medical staff (Caprilli & Messeri, 2006). An intense and correct relationship between man and animal is in fact a psychological stimulus that can encompass various aspects of an individual’s life (social, intellectual, emotional). Additionally, we found that the hospital infection rate did not change and there were no new infections developed after the introduction of dogs into the setting (Arluke, 2010). Furthermore, this study, to the best of our knowledge, for the first time assesses serum cortisol plasma
levels in the blood to gauge responses to stressful stimuli and to determine the effectiveness of interventions intended to reduce distress and pain during venipuncture. We found that cortisol levels were significantly lower in children in the EG arm than those in the CG group. Cortisol is secreted in response to increased stress in an individual’s environment and can be used to assess responses to stressful stimuli or to determine the effectiveness of stress-reducing interventions (Hanrahan, McCarthy, Kleiber, Lutgendorf, & Tsalikian, 2006). Moreover we wanted to consider our study a starting point for future research that will aim to better evaluate serum cortisol plasma levels in the blood. We acknowledge that our results are subject to variations related to individual patterns, time of day, activity, sleeping, eating, certain medications, and certain illnesses. Therefore, they are not definitive and must be examined further. The correlations between the three different instruments used to analyze children’s responses to venipuncture were statistically significant between VAS/Faces Scale and OSBD-A only during the procedure: These data suggest that a high level of distress increases pain and vice versa. Moreover, in our study, the secondary end point was the level of parental anxiety present during the procedure. No significant differences were seen between the two groups of parents. Study limitations include small sample size and lack of data for each group to address any difference in adverse behavioral responses in a short period of time after the venipuncture for each group. Moreover, further investigation is needed to understand the role of cortisol. This hormone is highly variable and is responsive to a wide range of factors that should be considered when incorporating this measure into
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pediatric research (Hanrahan et al., 2006). Therefore, future studies about cortisol could improve knowledge of children’s responses to stressful events, and could lead to the hormone becoming an appropriate biological indicator of stress.
additional studies in different contexts and cultures will be beneficial to assess the presence of dogs during venipuncture and also to evaluate other physiologic indicators. Moreover it would be desirable to compare AAI with other methods of distraction and their feasibility/cost.
CONCLUSION In our study, it appears that the presence of dogs during venipuncture reduces distress in children and improves physical, social, emotional, and cognitive functioning. We suggest that this effect is due to interactions with a dog, which helps reduce fear and anxiety. However,
Acknowledgment The authors acknowledge Livia Benini Foundation and the Meyer Foundation for making possible the project Pets in Hospital and Antopozoa ONLUS, Francesca Mugnai and Alexis G. Gerakis for their work into the hospital.
REFERENCES Anderson, P. E. (2008). The powerful bond between people and pets: Our boundless connections to companion animals. Westport, CT: Author. Arluke, A. (2010). Animal-assisted activity as a social experience. In A. Fine (Ed.), Handbook of animal assisted therapy: Theoretical foundations and guidelines for practice (pp. 401–419). New York: Academic Press. Braun, C., Stangler, T., Narveson, J., & Pettingell, S. (2009). Animal-assisted therapy as a pain relief intervention for children. Complementary Therapies in Clinical Practice, 15, 105–109. Caprilli, S., & Messeri, A. (2006). Animal assisted activity at A. Meyer children’s hospital: A pilot study. Evidence-Based Complementary and Alternative Medicine, 3(3), 379–383. Caprilli, S., Anastasi, F., Grotto, R. P., Scollo Abeti, M., & Messeri, A. (2007). Interactive music as a treatment for pain and stress in children during venipuncture: A randomized prospective study. Journal of Developmental and Behavioural Pediatrics, 28(5), 399–403. Chambers, C. T., Taddio, A., Uman, L. S., McMurtry, C. M., & HELPinKIDS Team (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review. Clinical Therapeutics, 31(2), S77–S103. Coakley, A., & Mahoney, E. (2009). Creating a therapeutic and healing environment with a pet therapy program. Complementary Therapies in Clinical Practice, 15, 141–146. Cromwell, J. A. (1997). An amended form of the Observation Scale of Behavioral Distress. Academic, Research and Clinical Summary. PsychD, Clinical Psychology [website]. Available from: http://www.jimcromwell.com/thesis/ 14_aims.txt. Accessed January 2014. Duff, A. J. (2003). Incorporating psychological approaches into routine paediatric venepuncture. Archive of Disease in Childhood, 88, 931–937. Garra, G., Singer, A. J., Taira, B. R., Chohan, J., Cardoz, H., Chisena, E., & Thode H. C. Jr. (2010). Validation of the WongBaker FACES Pain Rating Scale in pediatric emergency department patients. Academic Emergency Medicine, 17(1), 50–54. Hanrahan, K., McCarthy, A. M., Kleiber, C., Lutgendorf, S., & Tsalikian, E. (2006). Strategies for salivary cortisol collection and analysis in research with children. Applied Nursing Research, 19, 95–101.
Hansen, K. M., Messinger, C. J., Baun, M. M., & Megel, M. (1999). Companion animals alleviating distress in children. Anthrozo€ os, 12(3), 142–148. Hasanpour, M., Tootoonchi, M., Aein, F., & Yadegafar, G. (2006). The effects of two nonpharmacologic pain management methods for intramuscular injection pain in children. Acute Pain, 8(1), 7–12. Havener, L., Gentes, L., Thaler, B., Megel, M. E., Baun, M. M., Driscoll, F. A., Beirahi, S., & Agrawal, S. (2001). The effects of a companion animal on distress in children undergoing dental procedures. Issues in Comprehensive Pediatric Nursing, 24(2), 137–152. Hoffmann, A. O. M., Lee, A. H., Wertenauer, F., Ricken, R., Jansen, J. J., Gallinat, J., & Lang, U. E. (2009). Dog-assisted intervention significantly reduce anxiety in hospitalized patients with major depression. European Journal of Integrative Medicine, 1, 145–148. Kaminski, M., Pellino, T., & Wish, J. (2002). Play and pets: The physical and emotional impact of child-life and pet-therapy on hospitalized children. Children’s Health Care, 31(4), 321–335. Kolk, A. M., Van Hoof, R., & Fiedeldij Dop, M. J. (2000). Preparing children for venipuncture. The effect of an integrated intervention on distress before and during venipuncture. Child: Care, Health and Development, 26, 251–260. Landier, W., & Tse, A. M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25(6), 566–579. Lang, U. E., Jansen, J. B., Wertenauer, F., Gallinat, J., & Rapp, M. A. (2010). Reduced anxiety during dog assisted interviews in acute schizophrenic patients. European Journal of Integrative Medicine, 2(3), 123–127. Matuszek, S. (2010). Animal-facilitated therapy in various patient populations: Systematic literature review. Holistic Nursing Practice, 24(4), 187–203. Pedrabissi, L., & Santinello, M. (1989). Inventario per l’ansia di ‘‘stato’’ e di ‘‘tratto’’. Nuova versione italiana dello S.T.A.I. – Forma Y. Manuale [State-Trait Anxiety Inventory. New italian version of S.T.A.I. – Form Y. Manual]. Firenze: Organizzazioni Speciali. Sehulster, L. M., Chinn, R. Y. W., Carpenter, J., Donlan, R., Ashford, D., Besser, R., Fields, B., McNeil, M. M., Whitney, C., Wong, S., Juranek, D., & Cleveland, J. (2004). Guidelines for environmental infection control in health-care facilities:
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Recommendation of CDC and the Healthcare infection control practices advisory committee (HICPAC). Chicago, IL: American Society for Healthcare Engineering/American Hospital Association. Sobo, E. J., Eng, B., & Kassity-Krich, N. (2006). Canine visitation (pet) therapy: Pilot data on decreases in child pain perception. Journal of Holistic Nursing, 24(1), 51–57. Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI: Form y). Palo Alto, CA: Consulting Psychologist. Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., Hanrahan, A., Ipp, M., Lockett, D., MacDonald, N., Midmer, D., Mousmanis, P., Palda, V., Pielak, K., Riddell, R. P., Rieder, M., Scott, J., & Shah, V. (2010). Reducing the pain of childhood vaccination: An evidence-based clinical practice guideline. Canadian Medical Association Journal, 182(18), 1989–1995. €kolu, S. (2009). TurkT€ ufekci, F. G., C ¸ elebiolu, A., & K€ uc¸u ish children loved distraction: Using kaleidoscope to reduce perceived pain during venipuncture. Journal of Clinical Nursing, 18, 2180–2186. Uman, L. S., Chambers, C. T., McGrath, P. J., & Kisely, S. (2006). Psychological interventions for needle-related
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procedural pain and distress in children and adolescents. Cochrane Database System Review, 18(4), CD005179. Urbanski, B. L., & Lazenby, M. (2012). Distress among hospitalized pediatric cancer patients modified by pettherapy intervention to improve quality of life. Journal of the Association of Pediatric Oncology Nurses, 29(5), 272–282. Viau, R., Arsenault-Lapierre, G., Fecteau, S., Champagne, N., Walker, C. D., & Lupien, S. (2010). Effect of service dogs on salivary cortisol secretion in autistic children. Psychoneuroendocrinology, 35(8), 1187–1193. Wang, Z., Sun, L., & Chen, A. (2008). The efficacy of nonpharmacological methods of pain management in school age children receiving venepuncture in a paediatric department: A randomized controlled trial of audiovisual distraction and routine psychological intervention. Swiss Medical Weekly, 138(39–40), 579–584. Wolyniez, I., Rimon, A., Scolnik, D., Gruber, A., Tavor, O., Haviv, E., & Glatstein, M. (2013). The effect of a medical clown on pain during intravenous access in the pediatric emergency department: A randomized prospective pilot study. Clinical Pediatrics, 52(12), 1168–1172. Wong, D., & Baker, C. (1998). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14, 9–17.
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From the Pain Service & Palliative Care, Meyer Children’s Hospital, Florence, Italy. Address correspondence to Laura Vagnoli, MSc, Pain Service & Palliative Care, Meyer Children’s Hospital, Florence, Italy. E-mail: l.vagnoli@ meyer.it
ABSTRACT:
The aim of this study was to investigate the effectiveness of animalassisted intervention as distraction for reducing children’s pain and distress before, during, and after standard blood collection procedure. Fifty children (ages 4-11 years) undergoing venipuncture were randomly assigned to the experimental group (EG; n ¼ 25) or to the control group (CG; n ¼ 25). The blood collection procedure was carried on the children in the EG arm in the presence of a dog, whereas no dog was present when venipuncture was conducted on children in CG. In both cases, parents accompanied the child in the procedure room. Distress experienced by the child was measured with the Amended Observation Scale of Behavioral Distress, while perceived pain was measured with a visual analog scale or the Wong Baker Scale (Faces Scale); levels of cortisol in blood also were analyzed. Parental anxiety during the procedure was measured with State Trait Anxiety Inventory. Children assigned to the EG group reacted with less distress than children in the CG arm. Furthermore, cortisol levels were lower in the EG group compared with the CG group. There were no significant differences in pain ratings and in the level of parental anxiety. It appears that the presence of dogs during blood draw procedures reduces distress in children. Ó 2015 by the American Society for Pain Management Nursing
Received December 2, 2012; Revised January 15, 2014; Accepted April 15, 2014. All authors were involved in the drafting and revising of the manuscript and have read and approved the final version. The authors have no conflicts of interest to disclose. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.04.004
BACKGROUND Needle-related procedures are a common source of pain and distress for children, and one of the most often performed invasive procedures during the day. Many psychological interventions are available to manage procedural pain and distress. Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing pain and distress associated with routine pediatric venipuncture (Chambers, Taddio, Uman, McMurtry, & HELPinKIDS Team, 2009; Uman, Chambers, McGrath, & Kisely, 2006). Animal-assisted intervention (AAI) Pain Management Nursing, Vol 16, No 2 (April), 2015: pp 89-95
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is considered a distraction technique and could play a key role in the control of pain and distress for children, as well as for their parents by lowering anxiety and producing a more relaxed environment (Braun, Stangler, Narveson, & Pettingell, 2009; Sobo, Eng, & KassityKrich, 2006). Furthermore, a recent study showed that AAIs have a beneficial effect in reducing the cortisol response and the number of disruptive behavioral incidents in children with autism spectrum disorders (Viau et al., 2010). Therefore, in line with these results, the aim of this study was to evaluate the beneficial effects of AAI in children undergoing blood testing in the hospital setting. We assessed these effects through distress, pain, and serum cortisol plasma levels. As a secondary end point, we aimed to identify the level of parental anxiety.
METHODS This study was conducted with 50 randomly selected patients aged between 4 and 11 who had to undergo pediatrician-requested blood tests for routine exams. The children were generally healthy. A sample size of 50 participants was calculated to be sufficient to detect a significant difference in the level of distress when considering the number of patients who undergo blood testing in our hospital as part of their routine exams. The children were residents of Florence or lived in the nearby surrounding area. We included children undergoing venipuncture for routine exams and at their first experience with the procedure. Only native-born and Italian-speaking children were enrolled in the study to avoid any misinterpretation of the evaluation instruments used. None of the children received a topical anesthetic (e.g., EMLA® cream) before the procedure. To avoid a familiarity effect, only children who had no dogs at home were included. Also, we only assessed children who were not afraid of dogs. We observed the patients at three different periods: Phase 1 began when the child entered in the procedure room and ended when the site was disinfected; phase 2 began with the blood sampling and ended when the needle was extracted; and phase 3 began when the cotton was placed on the child’s arm to stop the bleeding and ended when the child left the procedure room. Eligible patients were randomly assigned following simple randomization procedures (computerized random numbers) to one of the two study groups. Children in the experimental group (EG) were accompanied in the procedure room during the venipuncture by a parent and an AAI expert and the dog. They interacted with dog in each of three phases: before, during, and after the blood test.
Control group (CG) children were accompanied in the same room during the venipuncture by one parent, without any dogs. Parental presence was considered control group because it is the standard procedure in our hospital. The study protocol was approved by the hospital ethics committee and consent was obtained from parents before inclusion of their child in the study. Four dogs were used: one female Labrador, one male mixed-breed, and two small mongrels. All dogs were trained regarding their behavior and carefully examined by a vet. In each group, parents were contacted outside the procedure room and after consent was given, their children were randomly assigned to one of the two groups. In the EG, the AAI expert met the child and the parent in the waiting room and started an interaction with them. The AAI expert invited everybody to join the activity: The aim was to create a relationship with the child and the parents. Then, with the child’s consent to have a dog in the procedure room, the AAI continued as the procedure was conducted. After the blood test was performed, the AAI expert went back to the waiting room with the child and the parent, always interacting with them. During the entire procedure, the child interacted with the dog by petting or stroking or brushing it, thus focusing on the dog continuously, even when the needle became visible. The doctor and nurse who performed the procedure were the same for both groups, and were instructed to maintain their standard behavior. The blood test procedure generally took 10 minutes without a dog (CG) and 15 minutes in presence of a dog (EG). Children in both groups were informed that they were enrolled in a study: Children in the CG arm were aware they were participating in a study about behavior and pain in the hospital and children in the EG arm were informed that the researchers were observing the presence of dogs in hospital. We informed both groups of children about their participation in the study because it is standard procedure in our hospital to give information to children. We considered this a controlled variable because both groups were informed. The AAIs, during data collection, were repeated twice a week for 2 hours (usually from 8 to 10 a.m.) with a dog each hour and with the participation of multidisciplinary staff composed of the AAI representative, members of the Meyer Children’s Hospital pain service (anesthetists, psychologists, nurses), and volunteers from the Livia Benini Foundation, which helped in the realization of the investigation. The staff involved in the project had received training during several preliminary meetings. During the 2-month
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study period, the AAI had been repeated 16 times in the hospital, but dogs were only present in the procedure room on 8 days. The doctors, nurses, parents, and other observers were kept blinded to the purpose of the study and the groups involved, but it was impossible to be blind entirely to assignment for the children in the EG arm. Evaluation Instruments The following assessment tools were used: The amended Observation Scale of Behavioral Distress (OSBD-A) is a validated scale (Cromwell, 1997) used to measure the behavioral distress seen by an external observer in children from ages 2 to 16 years. The instrument is a 4-point Likert scale scoring the frequency of behaviors from 0 (not at all) to 3 (all the time) and presenting 11 operationally defined items. The OSBD-A evaluated the procedure in three distinct phases: before, during, and after the blood test. The 11 behaviors recorded in the OSBD-A were crying, screaming, physical restraint, verbal resistance, requesting of emotional support, muscular rigidity, verbal fear, verbal pain, thrashing, nervous behavior, and information seeking. The result is obtained by summing the values of the Likert scale assigned to each item. The score of distress was between 0 (no distress) and 33 (maximum distress). The OSBD-A presents a good reliability measured with Chronbach’s a coefficient (a ¼ 0.923) and a good validity in correlation with other instruments that measured anxiety (r ¼ 0.78; p < .001) and pain (r ¼ 0.76; p < .0001). For our study, the coding method was translated from English to Italian, with translation being followed by a reverse translation to check appropriateness. The Wong-Baker Scale (Faces Scale) was used to measure each child’s self-reported pain only once, immediately after the procedure. Children were asked to indicate which of the faces best shows how much pain he or she felt during the procedure. They were instructed to indicate one of six faces on the scale, which shows faces with increasing distress from neutral to crying. Face 0 is very happy because it does not hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you do not have to be crying to feel that bad. This scale can be used only for children over the age of 3 (Wong & Baker, 1998). The visual analog scale (VAS) is a self-report tool used to assess pain in children who are able to express their pain. The VAS is a picture of a thermometer that is numbered from 0 (no pain at all) to 10 (the worst pain possible); it is a self-rating procedure used for children over the age of 6 years (Wong & Baker, 1998). The State Trait Anxiety Inventory (STAI) is a self-report anxiety behavioral instrument that consists of two separate 20-item subscales to measure trait (baseline) and state (situational) anxiety in adults. The STAI trait
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subscale measures relatively stable individual differences in anxiety proneness (i.e., differences in the tendency to experience anxiety), and the STAI state subscale measures transitory anxiety states (i.e., subjective feelings of apprehension, tension, and worry that vary in intensity and fluctuate depending on the situation). Parents responded on a 4-point scale. Total scores for state and trait sections separately ranged from 20 to 80, with higher scores denoting higher levels of anxiety. Test-retest correlations for the STAI are high (range: 0.73-0.86), and the studies have demonstrated good validity. In this study we used only the form Y-1, developed by Spielberger (1983), as well as a table to calculate the score according to the Italian standard version (Pedrabissi & Santinello, 1989).
Data Analysis Two psychologists with significant background in behavioral research administered the instruments. The two independent observers evaluated the child’s distress (OSBD-A) in all three phases. The record was continuous with 15-sec intervals during the three phases. A psychologist assessed parental anxiety in the waiting room using STAI (Y-1) in phase 1. We measured state anxiety in that moment to avoid organizational problems in keeping contact with the families. Children’s pain was assessed at the end of the procedure when a researcher asked them how much pain they experienced during the procedure. This was done using the Faces Scale or VAS, depending on each child’s age. Serum cortisol plasma levels were determined in the blood samples collected during the experimental procedure, to study the hypothalamic–pituitary–adrenal changes induced by these procedures, and were analyzed in the hospital’s laboratory using standard procedures. After centrifugation, plasma samples were stored at 4 C and total plasma cortisol levels were determined with a commercially available chemiluminescent immunoassay kit within 2 hours of sampling. Descriptive statistics provided an overview of the relationship between children and parental variables, as well as anxiety levels in children and parents. The agreement between the two observers codifying the data of OSBD-A was verified through Cohen’s k calculation. Differences between groups were analyzed with Student’s t test and Pearson’s correlation coefficient (r) was used to evaluate the demographic characteristics and the relationship among cortisol plasma levels, OSBD-A, and VAS/Faces Scale. Data were analyzed with the use of SPSS version 12.0 for Windows (SPSS Inc, Chicago, IL) and are presented as mean SD; p < .05 was considered significant.
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RESULTS The demographic characteristics of the two groups are presented in Table 1 and they are similar across groups, with no significant differences in age or in sex distribution. The two observers who codified the data showed a high level of agreement. The results of Cohen’s k for every item of OSBD-A all three phases are broadly significant, with values between 0.80 and 0.91. The scores obtained by the two groups are shown in Table 2. The level of total distress was significantly lower in the EG arm than in the CG arm. The comparison of the score measured in the three phases were significant in phases 1 and 2, however, there were no significant differences in phase 3. There were no significant differences between the two groups of children in pain ratings, obtained with VAS/Faces Scale, and in the scores for level of parental anxiety assessed with STAI (Y1). Furthermore, in the EG arm, serum cortisol plasma levels were significantly lower than in the CG arm. Pearson’s correlations were statistically significant between VAS/Faces Scale and OSBD-A during the procedure (r ¼ 0.59), although there were no significant results for the two other variables (cortisol and OSBD-A, r ¼ 0.33; cortisol and VAS, r ¼ 0.17).
DISCUSSION Venipuncture is one of the most frightening medical procedures experienced by children (Kolk, Van Hoof, & Fiedeldij Dop, 2000; Taddio et al., 2010). To reduce emotional and physical effects during this intervention various approaches have been used including pharmacologic and nonpharmacologic methods €ko (T€ ufekci, C ¸ elebio glu, & K€ uc¸u glu, 2009; Wang, Sun, & Chen, 2008). Distraction is one of the most effective techniques for controlling and reducing pain and distress. Many studies have investigated the use of
TABLE 1. Demographics of Study Participants and Their Parents Variable
CG
EG
n Age of child, y (mean SD) Sex of child (male/female) (n) Parent (mother/father) (n) Age of parent, y (mean SD)
25 7.38 2.5 12/13 2/23 36 4.6
25 7.1 1.8 12/13 4/21 38.92 6.99
CG ¼ control group; EG ¼ experimental group.
bubbles, books, music, handheld video games, virtual reality glasses, TV watching, and balloon inflation (Caprilli & Messeri, 2006; Hasanpour, Tootoonchi, Aein, & Yadegafar, 2006; Landier & Tse, 2010). AAI is also considered a distraction technique for hospitalized children (Braun et al., 2009; Sobo et al., 2006). In our hospital, we began using AAI in June 2002. The project Pets in Hospital was created in association with Livia Benini Foundation and ONLUS Antropozoa and now is supported by the Meyer Foundation (Caprilli & Messeri, 2006). The aim of this activity is to help hospitalized children feel better through their contact with animals. AAI representatives who work in our hospital are professionals. They are in hospital three times a week for 3 hours each time. This activity is part of the hospital routine for children’s care and health. The sanitary protocol followed was drafted by the Guidelines for Environmental Infection Control in Health-Care Facilities (recommendations of the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee; Sehulster et al., 2004). This study investigated the effectiveness of AAI as a distraction for reducing children’s pain and distress before, during, and after routine blood test. We used OSBD-A, the Faces Scale, and VAS to measure distress and pain as they are considered good instruments for assessment in pediatric hospitals (Caprilli et al., 2007; Garra et al., 2010; Urbanski & Lazenby, 2012; Wolyniez et al., 2013). Distress is a complex condition. It is a combination of fear, anxiety, and pain and has motivated researchers to combine analysis of physiological stress responses (cortisol) and psychological behaviors (observer distress and self-reported pain) (Duff, 2003). The results show a lower level of total distress when a dog is present during the procedure. In other words, it is suggested that exposure to a dog, in this stressful situation, induces a feeling of well-being. We found that there was a significant difference in distress levels in phases 1 and 2 between the two groups of children. Indeed, children who interacted with a dog manifested less behavioral distress, according to a recent study that found a lower level of behavioral distress statistically significant in children undergoing a physical examination when a dog was present (Hansen, Messinger, Baun, & Megel, 1999). In phase 3, although distress levels in the EG arm remained lower than in the CG group, distress decreased in both groups. These results underline that AAI could act on anxiety and fear before and during a venipuncture, as well as in other hospital environments, according to recent studies (Hoffmann et al., 2009; Matuszek, 2010).
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Dog’s Presence and Children’s Pain and Distress
TABLE 2. Mean ± SD of Intervention Outcome Variables 95% Confidence Interval of the Difference Variable
CG
EG
p
Mean Difference
Lower
Upper
Distress (OSBD-A total) Distress (OSBD-A before) Distress (OSBD-A during) Distress (OSBD-A after) Pain (VAS or Faces Scale) STAI-Y1 Cortisol (mg/dL)
33.15 22.97 7.08 7.37 18.08 9.46 8 9.14 5.08 2.93 48.23 9.43 13.37 4.92
14.15 22.24 1.38 3.28 8.85 12.65 3.92 8.25 4.69 3.82 50.46 11.69 9.63 3.40
.042 .018 .046 .244 .776 .597 .034
8.87 5.69 9.23 4.08 .38 2.23 3.74
37.29 10.31 18.27 11.12 3.14 6.37 7.16
0.70 1.08 0.19 2.97 2.37 10.83 0.31
CG ¼ control group; EG ¼ experimental group; OSBD-A ¼ Amended Observation Scale of Behavioral Distress; VAS ¼ visual analog scale; STAI-Y1 ¼ State Trait Anxiety Inventory. Student’s t test; p < .05.
We found no significant differences in pain ratings between the two groups. This is contrary to the results of a recent study that found a significant reduction in the pain levels of children in an acute care pediatric setting when a dog was present (Braun et al., 2009). This could be due to the small size of our sample. In the past 30 years, several different studies have focused on the link between children and animals (Anderson, 2008; Arluke, 2010; Kaminski, Pellino, & Wish, 2002). These studies clearly demonstrated that children, especially those with health-related problems, show positive behavioral responses when a dog is present as it increases the child’s skill to socialize with others because it enhances their self-esteem and they feel more confident. It has been verified that having contact with animals reduces the consequences caused by separation and loneliness, and can bring comfort and gratification. Indeed, the aim of the AAI program is to improve the quality of life of patients by creating benefits and well-being (Coakley & Mahoney, 2009; Havener et al., 2001; Lang, Jansen, Wertenauer, Gallinat, & Rapp, 2010). A previous study showed that the presence of dogs in pediatric wards was considered a positive event with a high participation rate of hospitalized patients and a high level of satisfaction expressed by both parents and medical staff (Caprilli & Messeri, 2006). An intense and correct relationship between man and animal is in fact a psychological stimulus that can encompass various aspects of an individual’s life (social, intellectual, emotional). Additionally, we found that the hospital infection rate did not change and there were no new infections developed after the introduction of dogs into the setting (Arluke, 2010). Furthermore, this study, to the best of our knowledge, for the first time assesses serum cortisol plasma
levels in the blood to gauge responses to stressful stimuli and to determine the effectiveness of interventions intended to reduce distress and pain during venipuncture. We found that cortisol levels were significantly lower in children in the EG arm than those in the CG group. Cortisol is secreted in response to increased stress in an individual’s environment and can be used to assess responses to stressful stimuli or to determine the effectiveness of stress-reducing interventions (Hanrahan, McCarthy, Kleiber, Lutgendorf, & Tsalikian, 2006). Moreover we wanted to consider our study a starting point for future research that will aim to better evaluate serum cortisol plasma levels in the blood. We acknowledge that our results are subject to variations related to individual patterns, time of day, activity, sleeping, eating, certain medications, and certain illnesses. Therefore, they are not definitive and must be examined further. The correlations between the three different instruments used to analyze children’s responses to venipuncture were statistically significant between VAS/Faces Scale and OSBD-A only during the procedure: These data suggest that a high level of distress increases pain and vice versa. Moreover, in our study, the secondary end point was the level of parental anxiety present during the procedure. No significant differences were seen between the two groups of parents. Study limitations include small sample size and lack of data for each group to address any difference in adverse behavioral responses in a short period of time after the venipuncture for each group. Moreover, further investigation is needed to understand the role of cortisol. This hormone is highly variable and is responsive to a wide range of factors that should be considered when incorporating this measure into
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pediatric research (Hanrahan et al., 2006). Therefore, future studies about cortisol could improve knowledge of children’s responses to stressful events, and could lead to the hormone becoming an appropriate biological indicator of stress.
additional studies in different contexts and cultures will be beneficial to assess the presence of dogs during venipuncture and also to evaluate other physiologic indicators. Moreover it would be desirable to compare AAI with other methods of distraction and their feasibility/cost.
CONCLUSION In our study, it appears that the presence of dogs during venipuncture reduces distress in children and improves physical, social, emotional, and cognitive functioning. We suggest that this effect is due to interactions with a dog, which helps reduce fear and anxiety. However,
Acknowledgment The authors acknowledge Livia Benini Foundation and the Meyer Foundation for making possible the project Pets in Hospital and Antopozoa ONLUS, Francesca Mugnai and Alexis G. Gerakis for their work into the hospital.
REFERENCES Anderson, P. E. (2008). The powerful bond between people and pets: Our boundless connections to companion animals. Westport, CT: Author. Arluke, A. (2010). Animal-assisted activity as a social experience. In A. Fine (Ed.), Handbook of animal assisted therapy: Theoretical foundations and guidelines for practice (pp. 401–419). New York: Academic Press. Braun, C., Stangler, T., Narveson, J., & Pettingell, S. (2009). Animal-assisted therapy as a pain relief intervention for children. Complementary Therapies in Clinical Practice, 15, 105–109. Caprilli, S., & Messeri, A. (2006). Animal assisted activity at A. Meyer children’s hospital: A pilot study. Evidence-Based Complementary and Alternative Medicine, 3(3), 379–383. Caprilli, S., Anastasi, F., Grotto, R. P., Scollo Abeti, M., & Messeri, A. (2007). Interactive music as a treatment for pain and stress in children during venipuncture: A randomized prospective study. Journal of Developmental and Behavioural Pediatrics, 28(5), 399–403. Chambers, C. T., Taddio, A., Uman, L. S., McMurtry, C. M., & HELPinKIDS Team (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review. Clinical Therapeutics, 31(2), S77–S103. Coakley, A., & Mahoney, E. (2009). Creating a therapeutic and healing environment with a pet therapy program. Complementary Therapies in Clinical Practice, 15, 141–146. Cromwell, J. A. (1997). An amended form of the Observation Scale of Behavioral Distress. Academic, Research and Clinical Summary. PsychD, Clinical Psychology [website]. Available from: http://www.jimcromwell.com/thesis/ 14_aims.txt. Accessed January 2014. Duff, A. J. (2003). Incorporating psychological approaches into routine paediatric venepuncture. Archive of Disease in Childhood, 88, 931–937. Garra, G., Singer, A. J., Taira, B. R., Chohan, J., Cardoz, H., Chisena, E., & Thode H. C. Jr. (2010). Validation of the WongBaker FACES Pain Rating Scale in pediatric emergency department patients. Academic Emergency Medicine, 17(1), 50–54. Hanrahan, K., McCarthy, A. M., Kleiber, C., Lutgendorf, S., & Tsalikian, E. (2006). Strategies for salivary cortisol collection and analysis in research with children. Applied Nursing Research, 19, 95–101.
Hansen, K. M., Messinger, C. J., Baun, M. M., & Megel, M. (1999). Companion animals alleviating distress in children. Anthrozo€ os, 12(3), 142–148. Hasanpour, M., Tootoonchi, M., Aein, F., & Yadegafar, G. (2006). The effects of two nonpharmacologic pain management methods for intramuscular injection pain in children. Acute Pain, 8(1), 7–12. Havener, L., Gentes, L., Thaler, B., Megel, M. E., Baun, M. M., Driscoll, F. A., Beirahi, S., & Agrawal, S. (2001). The effects of a companion animal on distress in children undergoing dental procedures. Issues in Comprehensive Pediatric Nursing, 24(2), 137–152. Hoffmann, A. O. M., Lee, A. H., Wertenauer, F., Ricken, R., Jansen, J. J., Gallinat, J., & Lang, U. E. (2009). Dog-assisted intervention significantly reduce anxiety in hospitalized patients with major depression. European Journal of Integrative Medicine, 1, 145–148. Kaminski, M., Pellino, T., & Wish, J. (2002). Play and pets: The physical and emotional impact of child-life and pet-therapy on hospitalized children. Children’s Health Care, 31(4), 321–335. Kolk, A. M., Van Hoof, R., & Fiedeldij Dop, M. J. (2000). Preparing children for venipuncture. The effect of an integrated intervention on distress before and during venipuncture. Child: Care, Health and Development, 26, 251–260. Landier, W., & Tse, A. M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25(6), 566–579. Lang, U. E., Jansen, J. B., Wertenauer, F., Gallinat, J., & Rapp, M. A. (2010). Reduced anxiety during dog assisted interviews in acute schizophrenic patients. European Journal of Integrative Medicine, 2(3), 123–127. Matuszek, S. (2010). Animal-facilitated therapy in various patient populations: Systematic literature review. Holistic Nursing Practice, 24(4), 187–203. Pedrabissi, L., & Santinello, M. (1989). Inventario per l’ansia di ‘‘stato’’ e di ‘‘tratto’’. Nuova versione italiana dello S.T.A.I. – Forma Y. Manuale [State-Trait Anxiety Inventory. New italian version of S.T.A.I. – Form Y. Manual]. Firenze: Organizzazioni Speciali. Sehulster, L. M., Chinn, R. Y. W., Carpenter, J., Donlan, R., Ashford, D., Besser, R., Fields, B., McNeil, M. M., Whitney, C., Wong, S., Juranek, D., & Cleveland, J. (2004). Guidelines for environmental infection control in health-care facilities:
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Recommendation of CDC and the Healthcare infection control practices advisory committee (HICPAC). Chicago, IL: American Society for Healthcare Engineering/American Hospital Association. Sobo, E. J., Eng, B., & Kassity-Krich, N. (2006). Canine visitation (pet) therapy: Pilot data on decreases in child pain perception. Journal of Holistic Nursing, 24(1), 51–57. Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI: Form y). Palo Alto, CA: Consulting Psychologist. Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., Hanrahan, A., Ipp, M., Lockett, D., MacDonald, N., Midmer, D., Mousmanis, P., Palda, V., Pielak, K., Riddell, R. P., Rieder, M., Scott, J., & Shah, V. (2010). Reducing the pain of childhood vaccination: An evidence-based clinical practice guideline. Canadian Medical Association Journal, 182(18), 1989–1995. €kolu, S. (2009). TurkT€ ufekci, F. G., C ¸ elebiolu, A., & K€ uc¸u ish children loved distraction: Using kaleidoscope to reduce perceived pain during venipuncture. Journal of Clinical Nursing, 18, 2180–2186. Uman, L. S., Chambers, C. T., McGrath, P. J., & Kisely, S. (2006). Psychological interventions for needle-related
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procedural pain and distress in children and adolescents. Cochrane Database System Review, 18(4), CD005179. Urbanski, B. L., & Lazenby, M. (2012). Distress among hospitalized pediatric cancer patients modified by pettherapy intervention to improve quality of life. Journal of the Association of Pediatric Oncology Nurses, 29(5), 272–282. Viau, R., Arsenault-Lapierre, G., Fecteau, S., Champagne, N., Walker, C. D., & Lupien, S. (2010). Effect of service dogs on salivary cortisol secretion in autistic children. Psychoneuroendocrinology, 35(8), 1187–1193. Wang, Z., Sun, L., & Chen, A. (2008). The efficacy of nonpharmacological methods of pain management in school age children receiving venepuncture in a paediatric department: A randomized controlled trial of audiovisual distraction and routine psychological intervention. Swiss Medical Weekly, 138(39–40), 579–584. Wolyniez, I., Rimon, A., Scolnik, D., Gruber, A., Tavor, O., Haviv, E., & Glatstein, M. (2013). The effect of a medical clown on pain during intravenous access in the pediatric emergency department: A randomized prospective pilot study. Clinical Pediatrics, 52(12), 1168–1172. Wong, D., & Baker, C. (1998). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14, 9–17.
