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Psychological interventions helping pediatric oncology patients cope

with medical procedures: A nurse-centered approach


Aurlie G. Weinstein
*
, Christopher C. Henrich
Georgia State University, Department of Psychology, P.O. Box 5010, Atlanta, GA 30302-5010, USA
Keywords:
Children
Cancer
Interventions
Psychological support
Pediatric oncology nurses
Training
a b s t r a c t
Purpose of the research: This study explored whether psychological interventions are currently used by
pediatric oncology nurses to help children cope with their treatment and, if so, which interventions were
considered by oncology nurses to be the most effective.
Methods and sample: A web-based survey was developed to assess pediatric oncology nurses impres-
sions of psychological care for pediatric patients during their medical treatment. A sample of 88 pediatric
oncologic nurses from twelve leading pediatric oncology departments in the US participated in the
survey. The closed questions were analyzed through quantitative methods with statistics. The open
questions were examined through qualitative methods with report narratives and discourse analysis.
Key results: Pediatric oncology nurses identied three psychological interventions to reduce suffering:
educating children by explaining the procedure; providing emotional support to children by listening,
answering childrens worries, or holding their hands; and distracting children through passive and active
forms. The survey further showed that nurses spent on average 3 h per day providing emotional support,
would be willing to be trained in additional interventions (93%), and could devote at least 10 min per
treatment to provide support (77%).
Conclusions: This work demonstrates the central role nurses play as emotional support caregivers. Since
nurses would be willing to provide emotional support during treatments, training may be an approach to
incorporate the use of psychological interventions.
2013 Elsevier Ltd. All rights reserved.
Introduction
Today, thanks to improvements in the treatment for cancer,
most children survive. From 1975 to 2003, the ve-year survival
rate increased by over 20 percentage points and is over 80% today
(Ries et al., 2007). While the survival rate has increased substan-
tially, treatment is still quite intense and difcult to endure. In fact,
some studies show that children with cancer struggle more with
the procedures of treatment than with the illness itself (Manne
et al., 1999; Zernikow et al., 2005). For example, a child can un-
dergo numerous hospitalizations and medical procedures including
an initial catheter implant, regular implant cleanings, multiple
lumbar punctures, bone marrow aspirations and biopsies, and
continuous IV therapies and venipunctures.
Many researchers have developed specic psychological in-
terventions to help children deal with cancer treatment. These
psychological interventions have been effective in reducing pain
and anxiety, along with enhancing acceptance of medical treat-
ments. Controlled experiments have been conducted to support
evidence of the efcacy of psychological interventions. Cognitive-
Behavioral Therapies (CBT) have been considered as a well-
established intervention (Powers, 1999), effective in reducing
distress of childhood cancer during painful medical procedures
(Ellis and Spanos, 1994; Jay et al., 1985; Dahlquist et al., 1985; Kazak
et al., 2007; Mulhern and Butler, 2006). CBT produces better results
in reducing behavioral distress than pharmacological interventions
alone (Jay et al., 1987; Ries et al., 2007). Hypnosis has shown ef-
cacy in reducing pain and anxiety during medical procedures such
as lumbar punctures or bone marrow aspirations for leukemia
patients (Accardi and Milling, 2009; Liossi, 1999; Liossi et al., 2009).
Distraction techniques can help children perceive less pain and
display less behavioral distress during venipunctures, lumbar
punctures and catheter implants (Gershon et al., 2004; Nilsson
et al., 2009; Sander et al., 2002). In this study, we will explore
whether these psychological interventions are currently used to
help children cope with their treatment, and which interventions
are considered by oncology nurses to be the most effective.
* Corresponding author. Tel.: 1 404 219 7320; fax: 1 404 872 5820.
E-mail addresses: aweinstein4@student.gsu.edu (A.G. Weinstein), chenrich@
gsu.edu (C.C. Henrich).
Contents lists available at SciVerse ScienceDirect
European Journal of Oncology Nursing
j ournal homepage: www. el sevi er. com/ l ocat e/ ej on
1462-3889/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejon.2013.04.003
European Journal of Oncology Nursing 17 (2013) 726e731
Some previous work focused on the nurses role in being a
supportive caregiver to children with cancer (Bryant, 2003; Grealish
et al., 2000; McCarthy et al., 1996; Rheingans, 2008). Some psy-
chological interventions, such as providing information before
procedures and positive reinforcement after procedures, are already
offered by nurses in pediatric oncology centers (McCarthy et al.,
1996). McCarthys study emphasized that nurses are the main pro-
viders of daily interventions, whereas most of psychologists and
psychiatrists therapies with children are available on an as
needed basis (McCarthy et al., 1996). Furthermore, pediatric nurses
can be cost-effective targets to provide interventions. Some studies
showed the efcacy of nurses using distraction to reduce childrens
distress during immunization. This approach can be more
economical than training parents or children, or using local anes-
thetics (Cohen et al., 1997; Cohen et al., 1999). Based on these con-
clusions, one way to implement psychological interventions for
children during cancer treatment is to use the medical staff, spe-
cically nurses, who are already in contact with children and can
give them spontaneously support. Additionally, because of the fa-
miliarity that nurses have with their patients, they may be in the
best position to assess the child and customize a strategy to decrease
their pain and psychological distress.
Moreover, training can be an effective way to improve nurses
knowledge of psychological interventions and their ability to
implement them. For example, MacLaren et al. (2008) highlighted
the lack of cognitiveebehavioral pain management curricula dur-
ing nurses training. They found that on average, only 2.9 h of
coursework were devoted to non-pharmacological techniques
(MacLaren et al., 2008). Nursing students who were trained on
distraction and guided imagery techniques were able to use them
in a better way than a control group (MacLaren et al., 2008). Based
on these ndings, this study will explore if nurses will be willing to
be trained and implement new strategies in a hospital setting.
These research questions will be explored though this study:
Which psychological interventions do nurses report using and
which interventions do they consider to be the most effective
to reduce symptoms?
Are nurses willing to be trained in and implement effective psy-
chological interventions during childrens medical treatment?
Methods
Overview
A survey questionnaire was developed to obtain information in
a non-experimental research design. The data were collected by a
self-developed questionnaire, and administered to pediatric
oncology nurses who work in hospitals in the United States. The
University of West Georgia Institute Review Board (IRB) approved
this study. The type of design in this research in terms of the time
dimension is cross-sectional.
Sample
The participants of this study were pediatric oncology nurses
who are practicing in hospital settings as registered nurses or nurse
assistants. Nurses were selected by using snowball and purposive
sampling methods. Twelve of the leading pediatric oncology de-
partments in the country (ranked from the U.S. News and World
Reports for 2010e2011) were chosen to understand the best prac-
tices for psychological support. Five nurses per team in the pedi-
atric oncology department were randomly selected by the principal
investigator to be invited to participate in the online survey. In total,
sixty nurses were invited from the 12 leading hospitals. Once they
were selected, they received an email explaining the purpose of the
research and asking them to participate in this project. A link to the
online survey was attached to the email. In order to increase the
number of responses, those nurses were asked to forward this
online survey to any pediatric oncology nurses that they knew. As
5% of the participants did not entirely complete the survey, 88
participants in the US were actually taken into consideration. The
participants came from Los Angeles, Dallas, Chicago, Baltimore,
New York, Boston, Memphis, Atlanta, Philadelphia, Seattle, and
Houston.
The population that answered the survey was registered nurses
and certied nursing assistants. Registered nurses have successfully
completed an accredited nursing school program, which is usually a
Bachelor of Science degree in nursing and passed the NCLEX-RN
exam. Registered nurses have higher responsibilities than assis-
tant nurses, including a broad scope of patient care activities such
as treating patients, operating sophisticated equipment, adminis-
tering medication, and performing diagnostics. A certied nursing
assistant helps with patient healthcare needs under the direct su-
pervision of a registered nurse. Nursing assistants are generally
responsible for observing and reporting on the condition of pa-
tients, measuring and recording vital signs and other data, chang-
ing dressings, and preparing patients for procedures. To become a
nursing assistant, a high school diploma or GED and the completion
of a 6e12 week CNA certicate program is necessary. The average
number of years of experience as a nurse was 5 years and the
average number of years of experience in a pediatric oncology
department was 4 years. There were an average of 11 in-patients
per pediatric oncology department.
Procedure
The questionnaire was implemented as a web-based survey
(surveygizmo.com). Emails with a link to the questionnaire were
sent to nurses to explain the purpose of the research and to ask
them to participate in the research project. Nurses were advised
that all information provided would serve only the purpose of this
research and personal information would remain strictly con-
dential. Nurses answered the questions directly online within the
SurveyGizmo website, which made the data collected anonymous.
All questionnaires were collected within a 6-week span.
Survey design
The survey questions were developed specically for this study
to assess nurses impressions of psychological care for pediatric
oncology patients. Several research professors in the Psychology
and Nursing Departments at the University of West Georgia
reviewed the questionnaire for face validity. Topics emphasized
patientenurse relationships, nurses training, and current and best
interventions used by nurses. The questions were of the following
forms: multiple choice, open questions, Likert scale, and yes/no
responses.
Data analysis
The closed questions were analyzed through quantitative
methods with statistics, and the open questions were analyzed
through qualitative methods with report narratives. Statistical an-
alyses were conducted using the statistical software SPSS, version
19. Descriptive statistics were generated to answer certain research
questions, such as the main psychological interventions that nurses
were currently using and if nurses were willing to be trained and to
implement new coping strategies during childrens medical
treatment.
A.G. Weinstein, C.C. Henrich / European Journal of Oncology Nursing 17 (2013) 726e731 727
Non-parametric tests were utilized to determine statistical in-
dependence among Likert scale and other ordinal data. Friedmans
test was conducted to compare the different types of interventions
used by nurses. A ManneWhitney test examined the type of in-
terventions used by nurses with the number of years of experience
they have been working in pediatric oncology centers.
Qualitative methods have also been used to report nurses
opinions. We performed a discourse analysis on the qualitative
data. This method was used to obtain nurses perspectives on the
most benecial strategies to help children cope with painful and
anxiety-inducing medical procedures. The goal was to identify
those particular and meaningful themes, categories, and ideas that
emerged from the nurses answers. Quotes and expressions were
kept to keep the initial perspective of the writer and to not change
the tone of the message nurses provided through their writing. The
open question on future treatment therapies enabled nurses to
express in their own words what they think is most effective at
helping children during painful and anxiety-inducing procedures.
Results
Preliminary analyses
In general, 80% of nurses reported spending an average of three
hours daily answering questions, explaining treatments, and
calming patients. Results also indicated that nearly all the nurses
felt that their patients trusted them (97%, N 88)) and shared their
fears and concerns with them (90%, N 88). In addition, 93%
(N 88) of the nurses reported that they provided psychological
support before, during, and after a medical procedure.
Nurses psychological interventions
Current psychological interventions in use
Three themes appeared to be crucial to help children before they
undergo a painful or anxiety-inducing procedure: educating chil-
dren by explaining the procedure (96% of the responses, N 82);
providing emotional support to children by listening and
answering childrens fears and worries (85%, N 82), or holding
their hands (75%, N 82); distracting children through passive
forms such as music, television, books, or through active forms such
as playing, telling stories, singing, and using bubbles (68%, N 82).
The least commonly reported strategies that nurses used were
breathing exercises to relax the child (45%, N 82), using books,
tapes, and videos to educate children on their treatment (34%,
N 82), and hypnosis (2%, N 82). The Fig. 1 showed all the in-
terventions reported by nurses to use when pediatric oncology
patients go through a painful or anxiety-inducing procedure. A
Friedman test was conducted to conrm the types of interventions
that were chosen the most by nurses (see Table 1). The result
showed that explaining the treatment had the rst rank
(mean 3.88, p .001) followed by providing emotional support
expressed as either listening to their fears (mean 3.68, p .001)
or spending more time with them (mean 3.64, p .001).
Distraction was chosen third with either the passive forms
(mean 3.49, p .001) or the active forms (mean 3.28, p .001).
The test was signicant (5, N 80) 28.86, p .001.
Other techniques were suggested by nurses such as involving
child-life therapists for distraction techniques, involving parents for
soothing the child during a procedure, providing massages to
reduce pain, using guided imagery to relax the child, spending
more time with the child, and showing empathy. Furthermore,
nurses insisted on the role of play for children as an effective
strategy to distract them and to educate them on their treatment.
Nurses encouraged children to play with their toys to rehearse the
medical procedure before or after a treatment to better understand
what they went through.
Some nurses differentiated giving support to young children vs.
older children. These nurses suggested that techniques should be
adapted to the childs individual personality, as techniques could
have varied effectiveness across patients. For example, techniques
such as play therapy, distraction techniques, or holding them were
most common and effective for younger children. Older children
would prefer sharing their thoughts with the nurses.
The types of interventions used by nurses were compared with
the number of years of experience nurses had in pediatric oncology
departments (see Table 2). A ManneWhitney U test was conducted
to validate the hypothesis that less experienced nurses would use
more distraction techniques (watching cartoons or playing) than
more experienced nurses. The test result was in the expected di-
rection and was signicant. Nurses newer to the profession were
more willing to watch cartoons with children (z 2.76, p <.01) or
to use play therapy as a coping strategy than experienced nurses
(z 2.46, p < .05).
Nurses opinion on the best strategies
Fig. 2 showed all the best strategies suggested by nurses. Edu-
cation refers to all the information nurses give to the child about
the treatment. Distraction concerns both behavioral and cognitive
types of distraction. Relaxation is used to help children regulate
their emotion and behavior. Emotional support is provided when
Fig. 1. Interventions used by pediatric oncology nurses to help children cope with
medical procedures (in %).
Table 1
Types of interventions used the most by pediatric oncology patients.
Types of intervention Mean
Explaining treatment 3.88
Emotional support by listening to their fears or worries 3.68
Emotional support by spending time with children 3.64
Passive forms of distraction 3.49
Active forms of distraction 3.28
Note. p .001, c
2
28.86.
Table 2
Nurses experiences with distraction techniques.
N Mean rank ManneWhitney U Z
Passive distraction techniques
(ex. watching cartoons)
Yes 44 34.25 517** 2.76**
No 36 48.14
Active distraction techniques
(ex. play)
Yes 56 36.46 446* 2.46*
No 24 49.92
Note. *p < .05, **p < .01.
A.G. Weinstein, C.C. Henrich / European Journal of Oncology Nursing 17 (2013) 726e731 728
nurses are listening to childrens worries, are comforting children,
are showing empathy and compassion, or are holding childrens
hands. Social support is provided by peers and family to help
children cope with their medical procedures.
Patient education. The rst strategy chosen by nurses was to
educate patients about their treatment. Twenty-two nurses (28%)
mentioned educating children, which involved explaining to chil-
dren their treatment, describing each step that they were going
through, and telling them what would happen next. The goal
behind education was to inform the patient so they were able to
understand their disease and to be more prepared and ready to
accept their treatment. Nurses suggested different methods to
educate children. For example, nurses could answer childrens
questions about the treatment and the disease through speaking
honestly and adapting their speech to the language level of the
child. In another example, the nurse might encourage the child to
read a book that explains the different steps of his or her upcoming
medical procedure. Others mentioned that the child could play
with a doll to rehearse the procedure that he or she would undergo
as a way to master it and feel more in control of their response to
their treatment.
Distraction techniques. Twenty nurses (25%) highlighted the
important role of distracting children as a way to decrease their
struggles. Nurses usually received the help of a child life therapist to
distract children before, during, or after a medical procedure. The
methods were varied depending on what the child liked to do and
on the age of the child. Children may choose to watch cartoons, to
listen to music, to read a book, to sing a song, or to play with toys
and games. Nurses have emphasized the power of sense of humor
in comforting children. They would tell jokes to children and make
them laugh as a way to help them cope with their difculties.
Emotional support. Seventeen nurses (21%) considered that giving
emotional support, developing a trusting relationship with chil-
dren, and implementing a strong nurseechild interaction were
essential for helping children. Nurses tried to be present and
available if the child would like to open up and to speak about his or
her thoughts and fears. Nurses valued open communication and
discussions with children. Several nurses emphasized the impor-
tance of being there for children. Others believed that they should
encourage children to express what was bothering them so that
nurses could assist them.
Social support. Fifteen nurses (19%) specied that children need
support fromtheir family and friends. Childrenwere often suffering
from loneliness; they were isolated in their hospital room for
months without contact from other peers. They suggested that
parents should be involved and be present during procedures. They
also suggested that patients from the same age group should be
encouraged to interact together to share the common experiences
that they were concurrently dealing with. Nurses should foster
friendships by facilitating introductions to other children who were
close in age and who were going through the same treatment.
Mental wellbeing. Twelve nurses (15%) have noticed that some
children have suffered fromtheir change of appearance through the
loss of hair or through a change in their body, which may cause
them to feel depressed or saddened by their new living condition.
Nurses suggested that children need activities to boost their self-
esteem and self-image to nd alternative ways to accept them-
selves. They encouraged children to practice activities that they
enjoy, such as playing, using arts and crafts, or writing in a journal e
anything that can be an outlet for children. One nurse explained
that children should be allowed to be a kid again and to do those
activities that are expected for a child of that age.
Relaxation. Eight nurses (10%) suggested using various relaxation
techniques to enhance emotional and behavioral regulation. In
particular, they mentioned using breathing exercises, massages,
self-imagery, and hypnosis.
Hospital staff restructuring. Five nurses (6%) considered that an
analysis should be done on their role, on other medical staffs role,
and on the overall organization of the hospital. They highlighted
the necessity to spend more time with children, to listen more to
children, and to be able to sometimes slow down. They also sug-
gested that there should be one primary nurse for a child so that the
child could build trusting relationship with that nurse.
These practitioners noticed that other medical staff, such as
child-life therapists and psychologists should be able to intervene
more with children, if there were more of them lling those roles.
They considered that psychological support personnel should be
present to accompany children during their everyday treatments
and to guide them through coping mechanisms and support. One
nurse said that life threatening diagnosis is stressful for everyone
e it should not take special consideration to bring on psychological
assistance.
Nurses training
The most common types of training reported by nurses were
based on distraction techniques such as playing with games or toys,
using bubbles, and asking questions about their life and hobbies.
These types of techniques were taught by child-life therapists, by
other nurses, or through online training. Massage techniques were
offered as a training option in hospitals. Nurses also learned art and
music therapy, and deep breathing exercises. Some nurses referred
to communication skills that they have learned, such as holding and
comforting the child during a procedure. A few nurses also
described guided imagery techniques that they have learned at the
hospital. Pain management techniques or complementary-
alternative therapies were also briey studied in school as re-
ported by a few nurses. However, two nurses confessed that they
did not use what they had learned in school and preferred
continuous training at work.
More than 93% of nurses were willing to be trained in new
techniques. This answer showed that nurses were open to learn
new techniques. In addition, an average of 77% of nurses would be
willing to devote more than 10 min to apply these techniques that
they have learned.
Fig. 2. Best strategies suggested by nurses to help children cope with their treatment.
A.G. Weinstein, C.C. Henrich / European Journal of Oncology Nursing 17 (2013) 726e731 729
Discussion
The survey demonstrates that nurses are focusing on simple
interventions and on the patientenurse relationship, which is
effectively the essence of their role. They are spontaneously
spending time with children, explaining their treatment, devel-
oping trusting relationships with patients, and listening to chil-
drens fears. The majority of nurses spend over three hours per day
providing emotional support. This acknowledges that nurses play a
crucial and central role as an everyday caregiver helping children
go through medical procedures while the patients learn more about
their disease and their treatment.
The nurse and child interaction is at the center of the cancer-care
provided at the hospital. Nurses are helped by other staff such as
child-life therapists, psychologists, and social workers to provide
psychological support. Inparticular, child-life therapists help nurses
with distraction techniques before or during a painful medical
procedure. Nurses will refer to psychologists or social workers for
more in-depth psychological interventions when children suffer
fromfear of needles, fear of death, depression, or anxiety. As nurses
reported, children need the emotional support of their parents to
reduce psychological distress during medical procedures. In addi-
tion, nurses suggest that children need social support from their
peers to help them deal with loneliness and isolation.
The three types of support that seemed to represent what
nurses provide to children before they undergo a painful or
anxiety-inducing treatment are: educating children, providing
emotional support, and distracting them. Skilled techniques such as
breathing exercises and hypnosis were listed least often. It appears
that nurses value using more relationship-oriented support than
technical skills to cater to their patients emotional needs. In other
words, nurses use those skills that are performed through a
genuine presence. It is more by being than by doing that nurses
feel that they can help children.
Some similarities and differences appear between the literature
and the responses provided by nurses in this study. Nurses
mentioned distraction techniques as predominant techniques,
which were each well developed in the literature (Garipy and
Howe, 2003; Gershon et al., 2004; Nilsson et al., 2009). Compared
to distraction techniques, little previous work highlighted the role
of emotional support: being present for children, listening to them,
explaining their disease, and creating a trustworthy relationship
(Hockenberry et al., 2011; Zeltzer et al., 1990). Among therapies,
cognitive-behavioral therapy was also not mentioned. Perhaps
cognitive-behavioral therapy is more often used among psycholo-
gists than nurses.
Limitations
The survey developed for this study had some limitations. In
light of the ndings, it would have been useful for some questions
to have gone further in depth to obtain specic answers on the
types of support nurses perceive should be provided based on a
number of conditions or factors, such as the types of procedures
that patients are going through, the symptoms experienced by
children, the age and sex of children, the type of oncology disease,
and the phase of the disease.
In addition, this study focused only on a specic population of
American nurses who are working in the leading oncology hospi-
tals. The interventions that they use or consider benecial in
helping children cope with medical procedures may be different
from nurses in other countries or from smaller departments in
America. The results obtained should be taken into perspective
with the specicity of the participants and may not be transposed
to other participants not tting the target prole.
Implications for practice
One of the primary benets of psychological interventions is
that children shift from a passive and helpless state of pain and
anxiety, to a state of control and empowerment with an active
adaptive attitude toward life. Through these therapies, children are
considered an active participant within their own care. Further-
more, these interventions may prevent the development of psy-
chopathologies in childhood or later in life. By preparing children
psychologically for medical procedures and teaching them coping
strategies, nurses may help reduce the risk of developing mal-
adaptive behaviors and psychopathologies.
Training nurses can have implications for practice. Almost every
nurse agreed to be trained on new techniques, and they would be
willing to devote 10e15 min on average to apply these newly
learned techniques. This result shows that training can be a way to
develop new skills for nurses. A systematic training for every new
nurse in the department can be suggested to ensure that nurses
have the knowledge and the skills to provide psychological support.
This training could include for example, lessons on patientenurse
interactions, how to educate children on their disease and treat-
ment, how to answer questions on their treatment, and how to
listen and discuss childrens fears and worries. Some simple in-
terventions, such as distraction techniques and play therapy, can
also be introduced. New training techniques would need to be
evaluated for their effectiveness in modifying nurses behavior,
acceptability by nurses and hospital administration, and sustain-
ability (this statement needs a citation).
Future research
In this study, nurses reported the current and best strategies to
help children cope with their treatment. However, the efcacy of
these strategies was not assessed. It would be interesting in future
research to assess the current strategies that they are using and see
if these strategies are reducing the level of psychological distress of
children or improving psychological outcomes for children. In
addition, the efcacy of these strategies should be compared when
the conditions in which they are provided are different. These
conditions include the types of medical procedures, the symptoms
experienced by children, the age and sex of children, the type of
oncology disease, and the phase that children are in the disease.
Furthermore, nurses highlighted the role of other population
around children who play also a crucial role in providing support to
children. To extend this research, it would be interesting to include
the perspective of other relevant populations such as the family,
psychologists, and child-life therapists, to have their opinion on
what would be the most helpful coping strategies for children
during a procedure and which strategies they are using to help
children cope with their treatment. Nonetheless, future research
should focus on the opinion of the main character, children, to
know what they consider to be more helpful for them to cope with
treatment, and which support they receive from each provider.
Finally, it would be helpful to discover which coping strategies
children are using before or during a procedure to relieve their
distress and measure if these strategies are actually effective.
Conict of interest statement
None declared.
Acknowledgements
The authors would like to thank Dr. Tobin Hart and Dr. Krystal
Perkins from the University of West Georgia and Dr. Randy
A.G. Weinstein, C.C. Henrich / European Journal of Oncology Nursing 17 (2013) 726e731 730
Weinstein for their helpful advice and guidance throughout this
research project.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ejon.2013.04.003.
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