Journal of Pediatric Nursing (2013) 28, 158–166

Active and Passive Distraction in Children Undergoing

Wound Dressings1
Stefan Nilsson RN, PhD a,b,⁎, Karin Enskär RN, PhD c ,
Carina Hallqvist BSc, PhLic, PhD d , Eva Kokinsky MD, PhD b
a
School of Health Sciences, Borås University, Borås, Sweden
b
Department of Paediatric Anaesthesia and Intensive Care Unit, the Queen Silvia Children's Hospital,
Sahlgrenska University Hospital, Gothenburg, Sweden
c
Department of Nursing Science, School of Health Sciences, Jönköping University, Jönköping, Sweden
d
Department of Information Technology and Media, Mid Sweden University, Sundsvall, Sweden

Key words: The aim of this study was to test how distraction influences pain, distress and anxiety in children during
Coping behaviour;
wound care. Sixty participants aged 5–12 years were randomized to three groups: serious gaming, the
Injuries and wounds;
use of lollipops and a control group. Self-reported pain, distress, anxiety and observed pain behaviour
Pain
were recorded in conjunction with wound care. Serious gaming, an active distraction, reduced the
observed pain behaviour and self-reported distress compared with the other groups. A sense of control
and engagement in the distraction, together, may be the explanation for the different pain behaviours
when children use serious gaming.
© 2013 Elsevier Inc. All rights reserved.

Background
THERE IS GREAT value in offering atraumatic care when
children undergo wound dressings, and an overview of this
topic will be discussed in this section. A common reason for
hospital visits by children is wounds from trauma, which in
themselves can cause pain. Procedural pain in conjunction
with wound care is a multidimensional experience that
induces anxiety and distress in children (Byers, Bridges, Kijek,
& LaBorde, 2001). As opposed to the trauma, procedural pain
is a painful experience that health professionals cause a child in
conjunction with examinations and treatments. During wound
dressings, pain is related to the actions of the nurse, and
children may put their blame for the pain experience on him or
her. The minimization of pain, distress and anxiety in these
situations may influence future fear of health care and reduce
harmful and long-standing negative effects of procedural pain
1
Potential conflicts of interest: None of the authors have any conflicts.
⁎ Corresponding author: Stefan Nilsson, RN, PhD.
E-mail address: stefan_r.nilsson@hb.se (S. Nilsson).
(Rocha, Marche, & von Baeyer, 2009). Satisfactory pain relief
is necessary but not always feasible. It is not possible to
provide anaesthesia for every minor procedure. Distraction
may alleviate pain, distress and anxiety during procedures
and has proven beneficial according to a review by Cochrane
library, which contains high-quality and independent
evidence that facilitate decision-making in clinical practice
(Uman, Chambers, McGrath, & Kisely, 2006). There is a
need for effective combinations of pharmacological and non-
pharmacological interventions in conjunction with painful
procedures such as wound dressings (Summer, Puntillo,
Miaskowski, Green, & Levine, 2007).
Serious gaming is one method of distraction (Uman et al.,
2006). The method is designed for other primary purposes
than pure entertainment (Adams, 2010), such as training,
advertising, simulation and education, and it runs on personal
computers or video game consoles (Susi, Johannesson, &
Backlund, 2007). Serious games may also be defined as
cognitive and behavioural distractions. Cognitive and
behavioural distractions are both techniques that deviate
attention away from procedure-related pain to more enjoyable

0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pedn.2012.06.003
Distraction in Children Undergoing Wound Dressings
activities (Uman et al., 2006). Cognitive interventions include
those that target mainly central mechanisms, such as thoughts
and feelings. Behavioural tools are defined mainly as
interventions based on principles of behavioural science for
the purpose of changing the children's behaviour in a fearful
situation (Uman et al., 2006).
Distraction techniques differ in several dimensions, for
example, the amount of interaction that is required by the
child. The theoretical description of distraction suggests that
its efficacy depends on its ability to exploit cognitive
capacity. It has been suggested that distraction is more
effective if it requires action and engagement from the child
(MacLaren & Cohen, 2005). Based on this definition,
distraction can be divided into two parts: active and passive.
A study of 40 children aged 5–13 years who underwent a
cold pressor trial (CPT) showed that active distraction (i.e.,
playing a video game), was more effective than passive
distraction (i.e., watching pre-recorded footage generated by
someone else playing the same video game). When children
underwent active distraction, they showed significantly
higher pain thresholds than during passive distraction.
They also demonstrated the greatest pain tolerance during
active distraction (Dahlquist et al., 2007). The opposite effect
was found in a study of 88 children aged 1–7 years who
underwent venipunctures. That study indicated that a film
was more distracting than an interactive toy. The children
who watched a film were also less distressed. An explanation
for this finding may be that the toy was not as engaging as the
film in this instance. This argument suggests that not only
does a distraction need to be interactive, but an effective
distraction also needs to be fun for children (MacLaren &
Cohen, 2005). A similar result was found in another study in
which the 13 children who were satisfied with the game they
played reported significantly less pain intensity than the eight
children who were dissatified with the game (Nilsson,
Finnstrom, Kokinsky, & Enskar, 2009).
In serious gaming, children need to solve problems, which
means that they are stimulated to be active and engage their
minds. Serious gaming is one mode of active distraction
(Dahlquist et al., 2007). A systematic review revealed that
serious gaming is an effective intervention in pain manage-
ment. This review included 11 studies that evaluated serious
gaming in all age groups (3.5–84 years). Four studies
evaluated serious gaming during experimental pain, while
six studies evaluated this intervention during procedural pain,
for the treatment of such as burn injuries and venipunctures.
An effect size (d), defined as the difference between the two
means expressed in standard deviation units (Streiner &
Norman, 2008), was calculated in 7 of the 11 studies included.
The mean effect sizes for serious gaming differed between
these studies and ranged from 0.12 to 1.98. This review also
weighted the effect sizes by the size of the samples from which
they were obtained, and the researchers found that the mean
weighted effect size was 0.94 (Malloy & Milling, 2010).
The lollipop is a distraction technique that is used to create
well-being and reduce pain, distress and anxiety in children
159
undergoing painful procedures. Sweets, such as glucose, are
well known to alleviate pain in young children (Morelius,
Theodorsson, & Nelson, 2009; Stevens, Yamada, & Ohlsson,
2004). There have also been published two different reports on
sweets for this purpose in older children (Lewkowski et al.,
2003; Miller, Barr, & Young, 1994). In a report on two
different studies, 214 children (aged 7–12) undergoing needle-
related procedures were randomized to four different study
groups. In both studies, these four study groups were control,
sweet taste, rhythmic oral movements and sweet taste plus
rhythmic oral movements. Rhythmic oral movements were
produced by chewing gum that was sweetened or unswee-
tened. Pain intensity was rated with the Coloured Analogue
Scale (CAS) and unpleasantness was scored with the Faces
Pain Scale (FPS). The results of these studies did not support an
analgesic effect of sweets (Lewkowski et al., 2003). In contrast,
another report published that the analgesic effect of sweets has
been found to be more evident in school age children. Forty-
two children aged 8–11 underwent a CPT at 10 °C. The
children held either 24% sucrose or water in their mouths, and
the threshold time was prolonged in children with the use of
sucrose (Miller et al., 1994). It is possible that an experimental
study design using a CPT differs from the context of clinical
practice, which was used in the two studies conducted by
Lewkowski et al. (2003). The difference between a CPT and a
clinical practice indicates that it is important to conduct more
clinical trials in this area (Lewkowski et al., 2003).
There is a lack of studies comparing serious gaming with
other distraction methods (Dahlquist et al., 2009), and more
research is needed to evaluate the effects of active and
passive distraction techniques in conjunction with procedural
pain. Our study tested the hypothesis that 5 to 12 year old
children who are involved in active gaming will experience a
significant decrease in pain, distress and anxiety compared
with children who receive standard care or lollipops when
undergoing wound care. The specific aim of this study was to
test if serious gaming and lollipops influence pain, distress
and anxiety in conjunction with a wound care session. The
primary outcome variables observed were pain behaviour
and self-reported pain intensity, and the secondary outcomes
were distress and anxiety.
Methods
Study Design
This study was a non-blinded randomized clinical trial that
was conducted at a large urban centre. It is difficult to make a
study design blinded with a non-pharmacological method
because it is often impossible to create a trustworthy placebo.
Participants
Children aged 5 to 12 were recruited from the paediatric day
care unit at the Queen Silvia Children's Hospital, Gothenburg,
160 S. Nilsson et al.

Sweden. The researchers asked the children to participate in
this study when they visited a specialized wound care nurse for
the first time. This occurred approximately 2 to 7 days after
their visit on the emergency room, where dressings and/or
sutures had been applied. All the wounds were acute due to a
minor trauma (Table 1). The children who were included had
wounds that differed in size and location but that were too
extensive to be handled in a primary care setting.
Children with long-standing wounds, care-related pres-
sure wounds and wounds in body areas with decreased
sensitivity were excluded from this study, as well as children
with cognitive impairments and children and parents who did
not have a good command of Swedish.
The Regional Medical Ethics Review Board of Gothen-
burg approved the study. Participants were given identical
oral information about the study. Verbal consent was
obtained from all the participants and written consent was
collected from all the parents.
standardized as the nurse, who had more than 30 years of
experience, and had developed a standardized procedure for
her treatment. The children were given local anaesthesia with
equal amounts of lidocaine, 40 mg/ml, instilled in their
wounds. Standardized information about analgesics was
given to all the children and parents. The parents received
written information about analgesics when they visited the
emergency department and when their child was due to see
the specialized wound care nurse. The handout provided
parents with information about the administration of
acetaminophen and non-steroidal anti-inflammatory drugs
(NSAID) according to predetermined doses about an hour
before the wound dressing. All the parents were asked by the
researcher before the wound dressing started whether they
had given the recommended doses of analgesics to their
child. No child was given sedative drugs or other analgesics
during the wound dressings.

Wound Dressing Interventions

The wound dressing procedures were standardized and In an earlier study, children reported that it was important
the pain experiences were expected to be similar for all the to use a game that was fun and easy to use. The children did
included children. The same specialized wound care nurse not think that 3D effects or a calming environment in the
treated all the wounds, and the procedure was carried out in game was necessary to relieve pain or distress (Nilsson et al.,
one dressing room with the same equipment. The specialized 2009). The choice of game and equipment was based on
wound care nurse was told to standardize her interaction as these results. The equipment was easy to use, well known,
much as possible with all the children who participated in the and inexpensive to buy, i.e., a Wiimote (a remote control)
study. The interaction with the child was supposed to be and a laptop. The game of choice was the open sourced game
Tux Racer. The game idea is to control a penguin sliding
down a slalom path, collecting as many fish as possible. The
Table 1 Descriptions of the Participants in the Intervention
player earned points for the fish that were collected and
and Control Groups
credits for the flying time and speed. All the text in the game
Lollipop Serious Game Control had been translated into Swedish, and the children chose
(n = 20) (n = 20) (n = 20) between several paths of play. Each path lasted for
Gender (no of patients) approximately 1 to 5 minutes and differed in difficulty. The
Boys 15 15 12 children steered the game using a Wiimote that sometimes
Girls 5 5 8 vibrated when the children gave a command. All children
Age (median), year 7 8 7 adapted, due to the wireless nature of device, their steering to
Preprocedural medication (no of patients) their body position required of the wound care session.
NSAID 1 5 2 The data reported in this paper were also amplified and
Acetaminophen 10 10 9
clarified in a qualitative report on 39 children. The children
Duration of procedure 25 25 20
(mean), minutes
reported that the steering was easy and that their body
Type of minor trauma (no. of patients) position did not affect their ability to play and engage in Tux
Bicycle accident 3 1 8⁎ Racer. They were also able to use one hand for all the
(body/head/limbs) necessary game action when they underwent the wound
Been pinched in 6 3 4 dressing (Nilsson, Hallqvist, Sidenvall, & Enskar, 2011).
fingers/thumbs The children began to play approximately 3 to 5 minutes
Burns 5† 7‡ 0 before the wound care session started and continued to play
Fall over 3 5 6 different game paths throughout the session.
Postoperative stitches 1 1 1 The lollipops varied in colour, and each colour had a
Dog bite 0 2 0 different flavour. The children chose from blue, green, red,
Other minor traumas 2 1 1
orange and yellow lollipops. The children started to lick the
⁎ p b .05 between control and serious game.
†
lollipops approximately 3 to 5 minutes before the wound
p b .05 between lollipop and control.
‡ care and continued to do so throughout the session. No child
p b .05 between serious game and control.
reported that he or she was diabetic.
Distraction in Children Undergoing Wound Dressings
The participants in the control group were offered
standard care without any specific distraction techniques
added to the care. The nurse informed each child in each
group about what he or she would undergo during the wound
care. Based on the child's reaction, the nurse also used
consolation and encouragement. This behaviour was not
driven by any guideline that directed the nurse in her actions
and communication with the child. Instead, the nurse was
prompted to treat all the children, regardless of the added
intervention, as equally as possible with her usual style
of care.
Data Collection
Data were collected consecutively depending on the
schedule of the specialized wound care nurse on duty.
Sixty protocols were blindly randomized and distributed
in a predetermined order. The randomization process was
performed using a deck of cards. Sixty cards consisted of
the following types: 20 spades (serious games), 20
diamonds (lollipops) and 20 hearts (control), were well
shuffled. The cards in the deck determined the distribu-
tion of the interventions. They eventually became 60
protocols in a given order. Each one was placed in a
white, unmarked envelope and when a child accepted
participation in the study, the envelope on top was picked
up. Twenty participants were randomized to a serious
game, 20 participants to a lollipop and 20 participants to
a control group (Figure 1). Two researchers who were
trained to use the observation scale Face, Legs, Activity,
Cry and Consolability (FLACC) were employed to collect
the data during the wound care procedure. The re-
searchers, the nurse and the children did not know until
the wound care started to which intervention the child
was randomized.
Self-Reports
Pain Intensity
The children used the CAS to score their pain intensity
from 0 to 10. A study has shown that the psychometric
properties of the CAS are equivalent to those of a
horizontal visual analogue scale (VAS) (McGrath et al.,
1996). The CAS has been validated to measure the
intensity of pain in children aged 5 and above. The scale
is designed to provide gradations in colour and width
along its length, reflecting different values of pain
intensity. The CAS scores have shown clinical validity
for acute pain (Bulloch & Tenenbein, 2002) and construct
validity was demonstrated when the CAS was used to
measure pain intensity following administration of anal-
gesics (Finnström, Söderhamn, & Kokinsky, 2008). In
procedural pain, when comparing FLACC with CAS,
lower CAS scores were also shown before and after
needle-related procedures (Finnström et al., 2008). The
161
pain intensity was recorded on three occasions. The first
occasion was in conjunction with the children's arrival on
the ward, when they had accepted participation in the
study. When all the data had been collected, the children
went to the dressing room. The second occasion of self-
reported pain intensity reflected the children's pain
intensity during the procedure. This score was collected
after the wound care and the child retrospectively
estimated its pain intensity. The recording during the
procedure reflected the most painful parts of the wound
dressing, which were the removal of the dressings (or
sutures) or cleaning of the wound. The third occasion of
self-reports was the children's self-reported pain intensity
after the wound dressing.
Distress
The Facial Affective Scale (FAS) was used to rate the
level of distress by marking one of nine faces presented
in an ordered sequence from least (0.04) to most
distressed (0.97). The reliability and validity of the
FAS have been evaluated in an earlier study (McGrath et
al., 1996). The FAS has been correlated more highly with
the VAS for unpleasantness (r = 0.64) than for pain
intensity on an FPS (r = 0.51) (Goodenough, van
Dongen, Brouwer, Abu-Saad, & Champion, 1999).
Perrott, Goodenough, and Champion (2004) also found
that the FAS correlated more closely with the CAS for
unpleasantness than with the CAS for pain intensity. In
this study, the distress was recorded at the same time
points as the pain intensity.
Anxiety
The children filled out the short form of the State-Trait
Anxiety Inventory (STAI) in conjunction with their first
and last self-reports on the CAS and the FAS. The short
form of the STAI is an instrument with six statements
about negative and positive emotions. The range of the
short STAI is 6 to 24 points: 6 points signifies no anxiety
and 24 points signifies the highest level of anxiety
(Marteau & Bekker, 1992). The short STAI has previously
been used to evaluate anxiety when children aged 7–
16 years underwent lumbar punctures (Nguyen, Nilsson,
Hellstrom, & Bengtson, 2010). The validity and reliability
of short STAI have been tested in a pilot study where
children aged 5–16 years underwent procedures that
induced pain. The construct validity was confirmed, as
the scores on short STAI decreased significantly from
before to after a medical procedure that was associated
with anxiety. The concurrent validity was established by
comparing the short STAI with the validated scale State-
Trait Anxiety Inventory for Children (STAIC). The
correlation between the scales was high; the Spearman's
correlation coefficient was 0.88 before and 0.75 after a
medical procedure. Cronbach's alpha of short STAI was
0.82, indicating good internal consistency (Apell, Paradi,
Kokinsky, & Nilsson, 2011).
162 S. Nilsson et al.

The Consort E-Flowchart

Assessed for eligibility

(n = 62)

Excluded (n = 0)

Not meeting inclusion criteria (n = 0)

Refused to participate (n = 1)

Randomized (n = 61) Other reasons (n = 0)

Allocated to game (n = 21) Allocated to lollipop (n = 20) Allocated to control (n = 20)

Received allocated game (n = 21) Received allocated lollipop (n = 20) Received allocated control (n = 20)

Lost to follow-up (n = 0) Lost to follow-up (n = 0) Lost to follow-up (n = 0)

Give reasons Give reasons Give reasons

Discontinued intervention (n = 1) Discontinued intervention (n = 0) Discontinued intervention (n = 0)

Give reasons: In need of general

anesthesia

Analyzed (n = 20) Analyzed (n = 20) Analyzed (n = 20)

Excluded from analysis (n = 0) Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Figure 1 Randomisation diagram of included children.

Observations
The FLACC contains five categories, each of which is
scored from 0 to 2, providing a total score ranging from 0 to
10. A high score indicates a high level of pain intensity. The
FLACC has the established validity and reliability to
measure pain intensity in acute and procedural pain (Merkel,
Voepel-Lewis, Shayevitz, & Malviya, 1997; Nilsson,
Finnstrom, & Kokinsky, 2008).
In the actual study, one of two experienced researchers
familiar with the FLACC scale observed the children and
recorded the FLACC scores before, during and after the
procedure. It was not possible to measure the interrater-
reliability, because it was unsuitable that there were
simultaneously more than one observer in the room where
the wound dressings were conducted. In an earlier study, the
interrater-reliability between these researchers was 0.85 with
a weighted kappa coefficient for the total scores on the
FLACC (Nilsson et al., 2008). The scoring during the
procedure reflected the most painful part of the wound
dressing, which was the removal of the dressings (or stitches)
or cleaning of the wound.
Distraction in Children Undergoing Wound Dressings 163

Data Analysis
The primary outcome and calculation of the sample size
were based on self-reported pain scores in a previously
published study of distraction techniques during procedural
pain (Bellieni et al., 2006). With a difference in pain scores
of 2.5 in the control group and 1 in the intervention group
and a standard deviation of 1.5, a power of 0.80 for a group
size of 16 participants in each group was calculated. It was
therefore decided that each group should contain 20
participants to avoid a type II error (Willan & Pinto, 2005).
The statistical significance was set at p b .05. Nonparametric
statistics were used, as the data were ordinal and considered
not to be normally distributed. The Kruskal–Wallis test was
used to compare the CAS, the FAS, the FLACC and the short
STAI between the three groups. In addition, the Mann–
Whitney U test was used to compare the CAS, the FAS, the
FLACC and the short STAI between each pair of groups.
Wilcoxon signed rank test was used for comparing changes
in the CAS, the FAS, the FLACC and the short STAI scores
before, during and after the procedures. The ages of the
children and the durations of the procedures were tested with
an ANOVA test. The gender, type of procedures and
analgesics were compared with the Fishers exact test.
Results
This study was conducted between May 2008 and June
2010. Sixty-two children were consecutively asked to
participate in this study. One child declined to participate
and another participant who was randomized to serious
games withdrew from the intervention. The child who
withdrew reported anxiety and needed general anaesthesia
for the wound dressing change. Data were analyzed for 60
children aged 5–12 years. Demographic data, the analgesics
administered at home before the procedure and the type of
procedures are presented in Table 1. The three groups were
comparable with respect to duration of the procedures,
gender, age and administration of analgesics. There were
more children with burns in the study group who were given
serious games and lollipops than in the control group, and
more bicycle accidents in the control group compared with
the study group that was involved in serious gaming. No
child had the previous experience of using the Tux Racer;
however, it was easy to learn this game and this inexperience
probably did not influence the results.
One of the primary outcomes, i.e., self-reported pain
intensity (CAS), did not differ between the study groups
(Table 2). The effect size (d) for serious gaming was 0.26
(95% confidence interval [CI], − 0.37 to 0.87) compared with
lollipops and 0.07 (95% CI, − 0.55 to 0.69) compared with
the control group. The observational pain scores (FLACC)
were lower in the participants who were involved in serious
gaming than in both of the other study groups, and the effect
size (d) for serious gaming was 0.72 (95% CI, 0.07–1.35)
compared with lollipops and 0.80 (95% CI, 0.14–1.42)
compared with the control group. The level of distress (FAS)
was lower in the children who were involved in serious
gaming than in the children who licked a lollipop but not
compared with the control group. The effect size (d) for
serious gaming was 0.72 (95% CI, 0.06–1.34) compared
with lollipops and 0.29 (95% CI, − 0.34 to 0.91) compared
with the control group. No other significant differences were
found between the three study groups with regard to pain
intensity, distress and anxiety during the procedure.
The Wilcoxon signed rank test showed that the individual
pain intensity (CAS, FLACC) increased significantly from
before to during the procedure (Table 3). These pain scores

Table 2 Median Scores and Statistical Difference (Mann–Withney U test) Between the Three Study Groups
Lollipop Serious Game Control Lollipop/Control Serious Serious
Games/Control Games/Lollipop
Median (range) p-Value
Before
FLACC 0 (0–2) 0 (0–4) 0 (0–2) .453 .643 .809
CAS 0 (0–2) 0 (0–6) 0 (0–4) .533 .337 .605
FAS 0.37 (0.04–0.75) 0.37 (0.04–0.75) 0.17 (0.04–0.85) .236 .347 .856
Short STAI 10 (6–17) 10.5 (6–18) 9 (6–13) .240 .165 .622
During
FLACC 4 (0–8) 2 (0–10) 4 (1–9) .783 .007 ⁎ .006 ⁎
CAS 4 (0–10) 3.5 (0–6) 2.375 (0–10) .606 .616 .714
FAS 0.75 (0.04–0.97) 0.59 (0.17–0.79) 0.59 (0.04–0.97) .521 .307 .022 ⁎
After
FLACC 0 (0–2) 0 (0–1) 0 (0–1) .287 .553 .604
CAS 0.375 (0–4.5) 0 (0–3.5) 0 (0–7.25) .07 .546 .258
FAS 0.17 (0.04–0.75) 0.27 (0.04–0.59) 0.27 (0.04–0.59) .546 .583 .933
Short STAI 8 (6–15) 7.5 (6–15) 6.5 (6–10) .024 ⁎ .224 .223
⁎ p b .05.
164
also decreased from during to after the procedure. The same
result was shown for the distress scores (FAS) in all three
of the study groups. The children who used serious gaming
or licked the lollipop reported significantly lower anxiety
(short STAI) scores after they underwent the wound
dressing than the children in the control group. The effect
size (d) for changes of the short STAI before and after
serious gaming was 0.44 (95% CI, − 0.2 to 1.06) compared
with lollipops and 0.26 (95% CI, − 0.37 to 0.88) compared
with the control group.
Discussion
The use of serious gaming resulted in lower observed
behavioural pain scores compared with those of the other two
study groups. A reduction in observed pain behaviour might
convince the nurse that the child is able to sustain the wound
care, and in this way facilitate for the nurse to carry out the
dressing change. This study was a part of a larger study
where also qualitative data were analysed using qualitative
content analysis. The results showed that the children
thought that nurses' clinical competence was important to
achieve pain relief (Nilsson et al., 2011). Another qualitative
study with a phenomenological approach showed that nurses
often felt helplessness when they not were able to offer
comfort for the child. A successful relief of children's pain
helped nurses in this study to alleviate their own anxiety and
gave them a sense of satisfaction and well-being (Hilliard &
O'Neill, 2010). This probably influences nurses' ability to
enhance their clinical competence during the wound care,
resulting in the experience of pain relief.
Changed pain behaviours in children involved in serious
gaming have also been shown in two other studies (Gershon,
Zimand, Pickering, Rothbaum, & Hodges, 2004; Nilsson
et al., 2009). These two studies involved venipunctures or
venous port punctures for which lower FLACC scores were
Table 3 The Median Scores of the Individual Differences Between Before, During and After the Procedure for FLACC, CAS and FAS,
Before and After for Short STAI and the Statistical Significance of Differences Between Groups
Lollipop Serious Game
Median (range)
Before–during
FLACC −4 (−8 to 1) ⁎ − 2 (− 7 to 0) ⁎
CAS −3.25 (−10 to 0) ⁎ −2.75 (− 5.5 to 2.5) ⁎ −2.25 (−10 to 2.25) ⁎
FAS −0.27 (−0.71 to 0.2) ⁎ −0.11 (− 0.75 to 0.22) ⁎ −0.31 (−0.93 to 0.10) ⁎
During–after
FLACC 4 (0 to 8) ⁎ 2 (0 to 10) ⁎
CAS 2 (−2 to 10) ⁎ 2.75 (0 to 5.5) ⁎ 1.875 (−2.25 to 10) ⁎
FAS 0.4 (−0.16 to 0.81) ⁎ 0.22 (0.0 to 0.75) ⁎
Before–after
Short STAI 0.5 (−6 to 9) 2.5 (− 4 to 10) ⁎
⁎ p b .05 (Wilcoxon signed rank test).
†
p b .05 (Mann–Whitney U test).
S. Nilsson et al.
recorded, in contrast to our study, which recorded FLACC
scores in children undergoing wound dressings. Wound
dressings generated more distress and lasted longer than
venipunctures or venous port punctures (Landolt, Marti,
Widmer, & Meuli, 2002).
There was a discrepancy between the observed pain and
the self-reported pain intensity when the children used
serious gaming. Serious gaming reduced the children's pain
behaviour but did not change their self-reported level of
pain intensity. In another study, the most important
outcomes demonstrated that children showed significantly
higher pain tolerance as well as higher pain thresholds
during active distraction, i.e., serious gaming. A higher pain
tolerance implied that the children endured the pain better
when they used serious gaming (Dahlquist et al., 2007). It is
a challenge to assess children's pain and their levels of
distress since the individual child's cognitive and commu-
nicative competence complicate the ability to obtain a valid
and reliable value (Schiavenato & Craig, 2010). Differences
in observed pain behaviour and self-reported pain intensity
may show different dimensions of children's pain experi-
ence (Craig, Versloot, Goubert, Vervoort, & Crombez,
2009). The behavioural pain scores presumably demon-
strated another dimension of pain, such as pain tolerance.
The results also clarified the importance of assessing pain in
different ways. It is not always possible to decide which
measurement is most valid and several difficulties remain to
be considered before the nurse can decide if self-reports or
behavioural assessments show trustworthy responses of
children's pain experience. Although self-reports are
considered to be “the golden standard” a behavioural
assessment, such as the FLACC, probably adds context
and meaning to self-reports and can sometimes also be
perceived as more credible than self-reports in clinical trials
(Craig et al., 2009).
The children who used serious gaming reported that they
repeatedly changed their focus between the serious game and
Control Lollipop/ Serious Serious
Control Games/Control Games/Lollipop
p-Value (Mann–Whitney U test)
−4 (−8 to −1) ⁎ .710 .002 † .004 †
.568 .849 .322
.849 .211 .211
4 (1 to 8) ⁎ .499 .004 † .008 †
.675 .256 .162
0.38 (0.0 to 0.93) ⁎ .745 .569 .978
1 (−4 to 7) ⁎ .360 .334 .090
Distraction in Children Undergoing Wound Dressings
the wound dressing giving them a sense of control of the
wound dressing (Nilsson et al., 2011). The sense of control
was also important to children in another study. That study
categorized children into attenders or distracters. Attenders
were children who directed their focus of attention towards
the procedure. Distracters were children who directed their
focus away from the procedure (Fanurik, Zeltzer, Roberts,
& Blount, 1993). As mentioned earlier, children who use
serious gaming are able to shift their cognitive focus
between playing the game and watching the wound
dressing. In this way, both attenders and distracters may
benefit from serious gaming.
Lollipops did not appear to change the children's pain
behaviour or pain perception. There is little previous
knowledge of the effectiveness of lollipops in older children
(Lewkowski et al., 2003; Pepino & Mennella, 2005). It is
therefore unclear whether this group differs from the control
group. A lollipop can offer a taste sensation but does not
require the child to be active and engaged in the distraction.
A negative and harmful effect of stress that is caused by
the fear associated with pain is often defined in the literature
as distress (Berde & Wolfe, 2003). Serious gaming reduced
this perception of distress compared with using a lollipop,
which was not enough to reduce the distress. The distraction
needs to disengage the child from the procedural pain. The
findings of the study suggest that active distraction may be
superior to passive distraction, as previously reported
(Dahlquist et al., 2007). The control group did not show
higher FAS scores than the children who were involved in
serious gaming, which was expected since serious gaming
probably is more active than standard care. One reason for
this may be related to enhanced nurse communication with
the children who had no other distraction despite the
intention of standardized interaction.
No difference was shown in the self-reported form of the
short STAI scores between the study groups. This result
differs from that of a study in which children over the age of
10 actually showed a decreased level of anxiety when using
non-pharmacological methods in an emergency department
(Sinha, Christopher, Fenn, & Reeves, 2006). We found low
anxiety scores before and after the wound dressings. The
reason for this is unclear, but one reason could be that the
children in our study were carefully informed in advance
about the wound dressing. Preparation and information for
children have been effective to reduce anxiety in other
contexts, such as preoperatively before acute appendectomy
(Edwinson, Arnbjornsson, & Ekman, 1988). The reduction
in anxiety is important, as it influences the children's
memories of procedural pain (Rocha et al., 2009).
This study showed changed pain behaviour with a simple
and inexpensive intervention, serious game. To date, few
studies have found expensive serious games that use
advanced equipment to be more effective than cheaper
serious games that use an ordinary display (Mahrer & Gold,
2009). Non-pharmacological methods that require trained
165
personnel and have high costs are often not a clinical reality
(Landolt et al., 2002).
Limitations
The different actions and perceptions of children in
relation to their cognitive development may impact the
results and are a weakness of this study. This study meets the
criteria for an acceptable power calculation, although it has a
small study population. It would therefore be worthwhile to
repeat this study with a larger sample. A larger sample size
would also reduce the differences in size and location of the
wounds. The demographic data showed a difference in the
randomization of bicycle accidents and burns; the lack of
control for confounding variables is a limitation. It was not
possible to use a blinded design for this study, which might
have led to a sense of missing intervention in the control
group. In addition, it was not possible to measure the
interrater-reliability on the FLACC scores. Although the
participants were recommended to take analgesics at home,
only about half of them did. The results of this study can
assist paediatric nurses in their pain management of children
undergoing wound dressings. The results demonstrate that
serious gaming can be used to reduce pain behaviour and
distress, and this intervention should be available to children
undergoing painful procedures, such as wound dressings.
Conclusion
Serious gaming is an active distraction, which, compared
with passive distraction, can lead to a decrease in pain
behaviour and reduce distress.
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