53
Pain, 40 (1990) 53-60
Elsevier PAIN 01515
A prospective survey of reactions to blood tests by children and adolescents C. Fradet a, P.J. McCrath USchoolof F~yc~~~u~,
a,b*c*‘,J. Kay d, S. Adams
d and B, Luke ’
University of Ottcrwa, Ottawa, Ont. KIN SN5 ~C~nadu~, ’ P~v~~o~o~ De~urtme~t, ’ De~~rt~gnt and d Nursing Semites, Children’s Hospital of Eastem Olttario, Orrawa, Ont. (Canada)
of Pediatrics,
(Re&ised 3 July 1989, accepted 24 July 1989)
A sample of 171 children and adolescents aged 3-17 years requiring venepuncture for blood sampling were asked to report on their pain and anxiety and were observed imm~ately before and during blood drawing. Depending on the measures used, 36-64% of children from 3 to 6 years old experienced moderate to severe distress from blood drawing. Multiple regression analysis revealed that age and the parents’ prediction of how upset the child woutd feei before the blood test was a s~g~fi~nt predictor of the observed distress and the self-report of pain. Experience with previous needle procedures did not add significantly to the prediction of distress. Identification of children at high risk to respond poorly to painful medical procedures is discussed.
Summary
Key words: Venepuncture; Medical procedures; Pain; Distress; (Child)
Introduction Most children find having a needle stressful. In fact, blood tests for diagnostic and mo~ito~ng purposes are often perceived by children as the most difficult part of their hospital experience [26]. A number of investigations have reported behavioural distress and lack of cooperation in children during blood tests [~~,~4,29~30]and other studies [e.g., 22,311 have assessed self-report of pain in children undergoing needle procedures. The correlates of pain and distress with needle procedures have received some attention. Age
Now at Psychology Department, Dalbousie Halifax, Nova Scotia B3H 451, Canada.
University,
Cwwspondmee to: Christians Fradet, School of Psychofogy, University of Ottawa, 145 Jean-Jacques Lussier, Qttawa, Ont. KIN 6N5, Canada.
~304-3959/~/$~3.50
[5,23,27,29,30] has often been found to negatively correlate with pain or distress. Gender has not been clearly associated with varying levels of pain f22,31]. Sensitization [Ig], desensitization 1161 and no effect [31] because of prior experience with needle procedures have each been reported. Parents are able to accurately predict their child’s distress [5,16,17,32]. Finally, parental anxiety may be positively correlated to child distress 116,323;. However, no studies have comprehensively examined behavioural distress and self-reports of pain and anxiety with a large unselected sample of children undergoing venepuncture. normative data and predictors that identify children at risk to respond poorly to needle procedures are needed in order to plan possible interventions. A survey was undertaken to assess the reactions of children from blood test and to try to determine a subpopulation of children more at risk to experience pain and distress so that an
a 7990 Elsevier Science Publishers B.V. (3iomedical Division)
intervention can focus more specifically on those children. The influence of age, parents’ prediction of distress and previous medical experience in the past 2 years were studied in relation to the levels of distress. The principal hypotheses were: (1) distress will decrease with age; (2) parents will be able to predict their child’s level of distress; (3) children who have had many needle procedures will experience less distress than children who have had few needle procedures.
Methods Subjects Two hundred and twenty-eight children, aged 3- 17 years, who spoke English or French and were attending the blood drawing room of a paediatric hospital for venepuncture or finger prick to obtain a blood sample were invited to participate in the study. Children could participate only once in the study. Children undergoing venepuncture or finger prick with a medical, laboratory or nursing student were excluded. Sixteen boys and 16 girls were excluded because the parents or attending adult declined to participate in the study. The reasons for refusal were: was in a hurry (12); did not understand English or French (6); person accompanying the child was not the parent (3); child was sick or mentally deficient (5); others (6). A total of 196 children (mean age = 7.3 years; S.D. = 3.6) were included in the study. Characteristics of the population appear in Table I. The dist~bution of the procedure was the following: arm venepuncture (165); hand venepuncture (6) and finger prick (9). Procedure
Prior to the blood test, in the waiting room, the purpose and the procedure of the study were explained to the parent and the child and they were asked to sign a consent form. The parent was then asked to complete a brief questionnaire inquiring about the reason for blood work, the number of blood tests in the past 2 years, and the experience with other needle procedures. In the questionnaire, the parent was asked to indicate
‘TABLE I CHARACTERISTICS .l__l Characteristic
OF THE POPULATION _._.._. . .__ Percentages of children (N = 196) 3-6 (52.6%) male (55.1%)
_-.___7-17 (47.4) female (44.9%)
Reason for blood test Before operation Monitoring of drug level Regular check-up for chronic illness Investigation for unknown illness Other Number of blood tests (past 2 years) (I l-5 6 and more Other needle procedure (past 2 years) * Immunization Other injection Intravenous Lumbar puncture or bone marrow aspiration Days in the hospital (past 2 years)
I I- 10 12-126 * Parents remembered not the number.
29.7 21.0 33.x 12.3 11.3 26.0 42.9 il.1 x3.9 55.6 26.0 29.6 1 f.2
53.6 24.3 13.0 if the child had a needle procedure
but
how he/she felt regarding the blood test of the child using a IO cm visual analogue scale (VAS). One end of the line was defined as ‘very calm, very relaxed’ and the other end as ‘very upset, very distressed.’ The parent was instructed to mark the line at a point corresponding to how he felt about his child’s blood test. The parent also rated how he thought the child would feel immediately before having the needle, using a VAS defined with the same anchors. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) was used to measure the behavioural distress during the venepuncture. The CHEOPS is a time-sampling behavioural pain scale developed for the measurement of postoperative pain in young children. It has been shown to have excellent inter-rater reliability and good validity f23]. The behaviours are separated in 6 categories: cry, facial expression, verbal complaints, torso
55
movements, touching, and legs movements Behaviours are assigned a score value ranging from 0 (the antithesis of pain) to 3. The totals from each category are summed to a global score ranging from 5 to 13. A 5 set observation period started when the child was sitting for blood drawing, followed by a 25 set period to score the observations. This cycle was repeated until the needle was inserted and then the timer was reset for a 5 set observation period, followed by 25 set to score the observations. The 5 set period immediately before and the 5 set period immediately after the insertion of the needle were the measures of distress. After the blood test, the nurse and the parent were asked to indicate how much pain the child had on a visual analogue scale defined with ‘no pain’ and ‘pain as severe as possible’ and also how they thought the child felt just before having the needle for the blood drawing on a visual analogue scale with anchors of ‘ very calm, very relaxed’ and ‘very upset, very distressed.’ Children over 7 years were asked to rate how they felt immediately before the procedure, on a similar scale. Children were also asked to report the pain experienced using the Oucher [Z], a poster-like device consisting of a vertical numerical scale (o-100) on the left and a vertical 6-picture photographic scale on the right. Several studies have reported good psychometric properties for this scale [ 1,3,4].
Results T tests using separate variance estimate revealed that finger pricks were observed to be significantly less painful and distressing than arm venepuncture on the observation before the blood test (CHEOPS) (t = 4.37, P < O.OOl), the nurse’s rating of pain (t = 2.33, P -c 0.05) and the nurse’s (t = 3.44, P < 0.01) and parent’s rating of distress (t = 4.80, P = 0.001). Hand venepuncture and arm venepuncture were not significantly different and were pooled for the analysis. For 16 subjects, the type of blood test was not noted. A total of 171 children having arm or hand venepuncture remained in the analysis.
TABLE
11
MEAN
RATINGS
Measure (range) Person reporting
OF PAIN AND
DISTRESS Finger prick
Venepuncture Arm N=165
Hand N=6
N=9
Mean (S.D.)
Mean (S.D.)
Mean (S.D.)
Distress (O-10 cm) 4.3 Parent 3.7 Nurse
(3.2) (3.4)
5.5 4.6
(4.0) (4.2)
1.3 * 1.5 *
(1.6) (1.8)
Pain (O-10 cm) Child Parent Nurse
(2.9) (2.4) (2.5)
2.5 2.2 2.4
(2.8) (2.6) (1.8)
1.9 1.1 1.3 *
(3.4) (2.0) (1.5)
Observation CHEOPS (5-13) Before 6.7 (1.7) blood test During 7.8 (2.1) blood test
7.5
(2.3)
5.8 *
(0.4)
9.5
(1.8)
7.4
(1.5)
2.0 2.7 2.5
* These ratings were lower than the ratings puncture (Z-tailed t test, P < 0.05).
from arm vene-
The mean ratings of pain and distress for the entire sample are presented in Table 71. Two-tailed paired t tests revealed that the only significant differences between means were between the nurses and children’s ratings of pain during venepuncture t (1, 145) = 2.01, P > 0.05. These results must be taken with caution because the children used the Oucher to rate their pain, while the parents and nurses used a visual analogue scale. Table III contains data from children aged 3-6 years while Table IV presents the ratings for
TABLE
III
LEVELS OF YEARS OLD Measure
PAIN
Person reporting
AND
N
UPSET
IN
CHILDREN
Mild (O-3)
Moderate (3-7)
Severe (7-10)
(%)
(S)
(45)
3-6
Mean (cm)
Distress before
Parent Nurse
86 88
44 36
24 31
31 33
4.7 4.7
Pain
Child Parent Nurse
75 86 88
64 62 51
19 30 36
17 8 13
3.0 2.9 3.2
T-ABLE IV
fABLE
LEVELS OF YEARS OLD Measure
PAIN
AND
Person reporting
--Distress hcfore
Pain
N
Child Parent Nurse
*
Chtld Parent Nurse
*
* Twenty-six
lJPSET
IN
Mild
Moderate
(O-3)
(337)
CHILDREN
7-17
tgi ~.___ x0 65 57 46 x3 65
(%) 20 3Y 112
I5 16 13
76 57 x3
I0
3
1.2
16 I6
7 6
2.3 1.x
parents
were not present
PERCENTAGES OF TRESS BEHAVIOURS
_II__Severe Mean (7 -10) (R)
x7 77 7x
V
during
(cm)
2.x 3.9 2.x
the blood
C’ry Grimace Verbal complaints I orso movements Arm movements
test.
CHILDREN DISPLAY IN
Pain, 40 (1990) 53-60
Elsevier PAIN 01515
A prospective survey of reactions to blood tests by children and adolescents C. Fradet a, P.J. McCrath USchoolof F~yc~~~u~,
a,b*c*‘,J. Kay d, S. Adams
d and B, Luke ’
University of Ottcrwa, Ottawa, Ont. KIN SN5 ~C~nadu~, ’ P~v~~o~o~ De~urtme~t, ’ De~~rt~gnt and d Nursing Semites, Children’s Hospital of Eastem Olttario, Orrawa, Ont. (Canada)
of Pediatrics,
(Re&ised 3 July 1989, accepted 24 July 1989)
A sample of 171 children and adolescents aged 3-17 years requiring venepuncture for blood sampling were asked to report on their pain and anxiety and were observed imm~ately before and during blood drawing. Depending on the measures used, 36-64% of children from 3 to 6 years old experienced moderate to severe distress from blood drawing. Multiple regression analysis revealed that age and the parents’ prediction of how upset the child woutd feei before the blood test was a s~g~fi~nt predictor of the observed distress and the self-report of pain. Experience with previous needle procedures did not add significantly to the prediction of distress. Identification of children at high risk to respond poorly to painful medical procedures is discussed.
Summary
Key words: Venepuncture; Medical procedures; Pain; Distress; (Child)
Introduction Most children find having a needle stressful. In fact, blood tests for diagnostic and mo~ito~ng purposes are often perceived by children as the most difficult part of their hospital experience [26]. A number of investigations have reported behavioural distress and lack of cooperation in children during blood tests [~~,~4,29~30]and other studies [e.g., 22,311 have assessed self-report of pain in children undergoing needle procedures. The correlates of pain and distress with needle procedures have received some attention. Age
Now at Psychology Department, Dalbousie Halifax, Nova Scotia B3H 451, Canada.
University,
Cwwspondmee to: Christians Fradet, School of Psychofogy, University of Ottawa, 145 Jean-Jacques Lussier, Qttawa, Ont. KIN 6N5, Canada.
~304-3959/~/$~3.50
[5,23,27,29,30] has often been found to negatively correlate with pain or distress. Gender has not been clearly associated with varying levels of pain f22,31]. Sensitization [Ig], desensitization 1161 and no effect [31] because of prior experience with needle procedures have each been reported. Parents are able to accurately predict their child’s distress [5,16,17,32]. Finally, parental anxiety may be positively correlated to child distress 116,323;. However, no studies have comprehensively examined behavioural distress and self-reports of pain and anxiety with a large unselected sample of children undergoing venepuncture. normative data and predictors that identify children at risk to respond poorly to needle procedures are needed in order to plan possible interventions. A survey was undertaken to assess the reactions of children from blood test and to try to determine a subpopulation of children more at risk to experience pain and distress so that an
a 7990 Elsevier Science Publishers B.V. (3iomedical Division)
intervention can focus more specifically on those children. The influence of age, parents’ prediction of distress and previous medical experience in the past 2 years were studied in relation to the levels of distress. The principal hypotheses were: (1) distress will decrease with age; (2) parents will be able to predict their child’s level of distress; (3) children who have had many needle procedures will experience less distress than children who have had few needle procedures.
Methods Subjects Two hundred and twenty-eight children, aged 3- 17 years, who spoke English or French and were attending the blood drawing room of a paediatric hospital for venepuncture or finger prick to obtain a blood sample were invited to participate in the study. Children could participate only once in the study. Children undergoing venepuncture or finger prick with a medical, laboratory or nursing student were excluded. Sixteen boys and 16 girls were excluded because the parents or attending adult declined to participate in the study. The reasons for refusal were: was in a hurry (12); did not understand English or French (6); person accompanying the child was not the parent (3); child was sick or mentally deficient (5); others (6). A total of 196 children (mean age = 7.3 years; S.D. = 3.6) were included in the study. Characteristics of the population appear in Table I. The dist~bution of the procedure was the following: arm venepuncture (165); hand venepuncture (6) and finger prick (9). Procedure
Prior to the blood test, in the waiting room, the purpose and the procedure of the study were explained to the parent and the child and they were asked to sign a consent form. The parent was then asked to complete a brief questionnaire inquiring about the reason for blood work, the number of blood tests in the past 2 years, and the experience with other needle procedures. In the questionnaire, the parent was asked to indicate
‘TABLE I CHARACTERISTICS .l__l Characteristic
OF THE POPULATION _._.._. . .__ Percentages of children (N = 196) 3-6 (52.6%) male (55.1%)
_-.___7-17 (47.4) female (44.9%)
Reason for blood test Before operation Monitoring of drug level Regular check-up for chronic illness Investigation for unknown illness Other Number of blood tests (past 2 years) (I l-5 6 and more Other needle procedure (past 2 years) * Immunization Other injection Intravenous Lumbar puncture or bone marrow aspiration Days in the hospital (past 2 years)
I I- 10 12-126 * Parents remembered not the number.
29.7 21.0 33.x 12.3 11.3 26.0 42.9 il.1 x3.9 55.6 26.0 29.6 1 f.2
53.6 24.3 13.0 if the child had a needle procedure
but
how he/she felt regarding the blood test of the child using a IO cm visual analogue scale (VAS). One end of the line was defined as ‘very calm, very relaxed’ and the other end as ‘very upset, very distressed.’ The parent was instructed to mark the line at a point corresponding to how he felt about his child’s blood test. The parent also rated how he thought the child would feel immediately before having the needle, using a VAS defined with the same anchors. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) was used to measure the behavioural distress during the venepuncture. The CHEOPS is a time-sampling behavioural pain scale developed for the measurement of postoperative pain in young children. It has been shown to have excellent inter-rater reliability and good validity f23]. The behaviours are separated in 6 categories: cry, facial expression, verbal complaints, torso
55
movements, touching, and legs movements Behaviours are assigned a score value ranging from 0 (the antithesis of pain) to 3. The totals from each category are summed to a global score ranging from 5 to 13. A 5 set observation period started when the child was sitting for blood drawing, followed by a 25 set period to score the observations. This cycle was repeated until the needle was inserted and then the timer was reset for a 5 set observation period, followed by 25 set to score the observations. The 5 set period immediately before and the 5 set period immediately after the insertion of the needle were the measures of distress. After the blood test, the nurse and the parent were asked to indicate how much pain the child had on a visual analogue scale defined with ‘no pain’ and ‘pain as severe as possible’ and also how they thought the child felt just before having the needle for the blood drawing on a visual analogue scale with anchors of ‘ very calm, very relaxed’ and ‘very upset, very distressed.’ Children over 7 years were asked to rate how they felt immediately before the procedure, on a similar scale. Children were also asked to report the pain experienced using the Oucher [Z], a poster-like device consisting of a vertical numerical scale (o-100) on the left and a vertical 6-picture photographic scale on the right. Several studies have reported good psychometric properties for this scale [ 1,3,4].
Results T tests using separate variance estimate revealed that finger pricks were observed to be significantly less painful and distressing than arm venepuncture on the observation before the blood test (CHEOPS) (t = 4.37, P < O.OOl), the nurse’s rating of pain (t = 2.33, P -c 0.05) and the nurse’s (t = 3.44, P < 0.01) and parent’s rating of distress (t = 4.80, P = 0.001). Hand venepuncture and arm venepuncture were not significantly different and were pooled for the analysis. For 16 subjects, the type of blood test was not noted. A total of 171 children having arm or hand venepuncture remained in the analysis.
TABLE
11
MEAN
RATINGS
Measure (range) Person reporting
OF PAIN AND
DISTRESS Finger prick
Venepuncture Arm N=165
Hand N=6
N=9
Mean (S.D.)
Mean (S.D.)
Mean (S.D.)
Distress (O-10 cm) 4.3 Parent 3.7 Nurse
(3.2) (3.4)
5.5 4.6
(4.0) (4.2)
1.3 * 1.5 *
(1.6) (1.8)
Pain (O-10 cm) Child Parent Nurse
(2.9) (2.4) (2.5)
2.5 2.2 2.4
(2.8) (2.6) (1.8)
1.9 1.1 1.3 *
(3.4) (2.0) (1.5)
Observation CHEOPS (5-13) Before 6.7 (1.7) blood test During 7.8 (2.1) blood test
7.5
(2.3)
5.8 *
(0.4)
9.5
(1.8)
7.4
(1.5)
2.0 2.7 2.5
* These ratings were lower than the ratings puncture (Z-tailed t test, P < 0.05).
from arm vene-
The mean ratings of pain and distress for the entire sample are presented in Table 71. Two-tailed paired t tests revealed that the only significant differences between means were between the nurses and children’s ratings of pain during venepuncture t (1, 145) = 2.01, P > 0.05. These results must be taken with caution because the children used the Oucher to rate their pain, while the parents and nurses used a visual analogue scale. Table III contains data from children aged 3-6 years while Table IV presents the ratings for
TABLE
III
LEVELS OF YEARS OLD Measure
PAIN
Person reporting
AND
N
UPSET
IN
CHILDREN
Mild (O-3)
Moderate (3-7)
Severe (7-10)
(%)
(S)
(45)
3-6
Mean (cm)
Distress before
Parent Nurse
86 88
44 36
24 31
31 33
4.7 4.7
Pain
Child Parent Nurse
75 86 88
64 62 51
19 30 36
17 8 13
3.0 2.9 3.2
T-ABLE IV
fABLE
LEVELS OF YEARS OLD Measure
PAIN
AND
Person reporting
--Distress hcfore
Pain
N
Child Parent Nurse
*
Chtld Parent Nurse
*
* Twenty-six
lJPSET
IN
Mild
Moderate
(O-3)
(337)
CHILDREN
7-17
tgi ~.___ x0 65 57 46 x3 65
(%) 20 3Y 112
I5 16 13
76 57 x3
I0
3
1.2
16 I6
7 6
2.3 1.x
parents
were not present
PERCENTAGES OF TRESS BEHAVIOURS
_II__Severe Mean (7 -10) (R)
x7 77 7x
V
during
(cm)
2.x 3.9 2.x
the blood
C’ry Grimace Verbal complaints I orso movements Arm movements
test.
CHILDREN DISPLAY IN
