Measuring children’s distress during burns dressing changes: literature search for measures appropriate for indigenous children in South Africa

Journal of Pain Research Dovepress open access to scientific and medical research O r i g i n al R e s e ar c h Journal of Pain Research downloaded from https://www.dovepress.com/ by 54.38.22.118 on 12-Jul-2018 For personal use only. Open Access Full Text Article Measuring children’s distress during burns dressing changes: literature search for measures appropriate for indigenous children in South Africa This article was published in the following Dove Press journal: Journal of Pain Research 5 September 2011 Number of times this article has been viewed Quinette Louw 1,2 Karen Grimmer-Somers 2 Angie Schrikk 3 1 Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa; 2International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia, Australia; 3Red Cross Children’s Hospital, Cape Town, South Africa Correspondence: Karen Grimmer-Somers International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide, SA 5000, Australia Tel +61 8 8302 2769 Fax +61 8 8302 2766 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/JPR.S21821 Powered by TCPDF (www.tcpdf.org) Background: Virtual reality is consistently reported as effective in reducing pain and anxiety in children during burns dressing changes in recent Western studies. Pain scales are a commonly reported outcome measure. Virtual reality is persuasive for all children in distress during medical procedures, because it is a nonaddictive, novel, and inexpensive form of distraction which can be applied repeatedly with good effect. We intend to use virtual reality in South Africa for the many children hospitalized with severe burns from mechanisms rarely seen in the Western world (paraffin/kerosene stoves exploding, electrical fires, shack/township fires, boiling liquid spills). Many severely burnt children are indigenous South Africans who did not speak English, and whose illiteracy levels, cultures, family dynamics, and experiences of pain potentially invalidate the use of conventional pain scales as outcome measures. The purpose of this study was to identify objective measures with sound psychometric properties and strong clinical utility, to assess distress during burns dressing changes in hospitalized indigenous South African children. Choice of measures was constrained by the burns dressing change environment, the ethics of doing no harm whilst measuring distress in vulnerable children, and of capturing valid measures of distress over the entire burns dressing change procedure. Methods: We conducted two targeted systematic reviews of the literature. All major library databases were searched, and measures with strong psychometric properties and sound clinical utility were sought. Results: Seven potentially useful measures were identified, ie, child’s and caregivers’ heart rate, which was measured continuously throughout the procedure, observed physical manifestations of distress using different scales (FLACCs [Face, Legs, Activity, Cry, Consolability Scale] and/ or Pain Behavior Checklist), time taken, and number of staff required to complete the procedure, and staff perspectives on the ease of use of the procedure. Conclusion: These psychometrically sound, clinically useful measures are alternatives to conventional pain scales, and should support valid research into the effectiveness of virtual reality for illiterate children with non-Western cultures and languages. Keywords: children, burns, distress, anxiety, pain, validity, measurement Introduction This paper outlines the rationale for choosing outcome measures to assess the effectiveness of virtual reality for children with burns undergoing dressing changes at the Red Cross Children’s Hospital (RCCH) in Cape Town, South Africa. We have previously reported a profile of burns inpatients at the RCCH.1 Over 600 children up Journal of Pain Research 2011:4 263–277 © 2011 Louw et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 263 Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 54.38.22.118 on 12-Jul-2018 For personal use only. Louw et al to 15 years of age are admitted to the RCCH annually with burns from hot water, explosions, or fires. The criterion for admission to the RCCH is a burn greater than 10% of total body surface area, although all burns involving inhalation, electrical injuries, or face, hands, perineum, or body circumference are admitted. Approximately 1000 other children are treated each year as outpatients. Many burns require extensive skin grafting from nonburnt body parts. Most inpatients are indigenous Xhosa-speaking South African children who, along with their parents, are often poorly educated and illiterate, with minimal exposure to computers. Their home lives are often violent, and they suffer significant impact from human immunodeficiency virus/acquired immune deficiency syndrome, poverty, and community disintegration.2,3 The burns treated at the RCCH are rarely seen in the Western world where building standards, occupational health and safety legislation, child protection legislation, and product design have all but eliminated pediatric burns hazards.1–3 However, in the informal South African townships, many thousands of children live in poorly built shacks with no electricity, running water, or sanitation, with unprotected open-flame cooking, heating, and lighting.4 Similar situations are reported in other developing countries, including Africa, India, and Southeast Asia.5–7 Most burns patients at the RCCH endure serial painful, and prolonged wound dressing changes to prevent infection and promote healing. These procedures can last up to 40 minutes.1 Despite the standard use of opioid and anxiolytic pharmacological interventions, many children still suffer high levels of distress8–11 which commence prior to and throughout the burn dressing change. Parents sometimes accompany children to the treatment room and then wait outside, thus becoming partly involved in the procedure. The RCCH has a small contingent of dedicated nurses who undertake daily burns dressings. The children’s distress is frequently manifested by extreme behaviors, such as fighting, biting, kicking, and resisting these nurses, as well as screaming and crying. This can hinder efficiency by making the procedure longer and more distressing for everyone involved, and requiring more nursing staff. A bath bed with a mobile shower head is used for most dressing changes (Figure 1). The dressing change consists of three parts (Figure 2). Firstly, removal of the soiled burn wound dressing (Part 1), secondly, showering and debridement (Part 2), and, lastly, redressing (Part 3). When the child has multiple burnt areas and/or skin grafts, dressing (...truncated)