ipad distraction and immunization in the primary care...
TRANSCRIPT
Running head: IPAD DISTRACTION
iPad Distraction and Immunization in the Primary Care Setting: A Quality Improvement Project
Bernadette Sobczak
Maryville University
Capstone Chair: Kathy Wright, DNP, APRN, CPNP
Capstone Committee Member: Therese Polo, MD
Date of Submission: December 1, 2017
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Running head: IPAD DISTRACTION
Table of Contents
Abstract………………………………………………………………………..4
Introduction…………………..……………………………………………….5
Background……………………………………………………………………6
Problem ……………………………………………………………………….7
Purpose and Aims……………………………………………………………..8
Literature Review……………………………………………………………..8
Pediatric distraction techniques in the acute care setting……………………8
Tablet and handheld device distraction in the acute setting………………...9
Pediatric distraction in the primary care setting for immunization……..…11
Tablet distraction for children receiving immunization …………………...11
Theoretical Framework…………………………………………………........12
Methodology…………………………………………………………………..13
Setting……………………………………………………………………....13
Project Design……………………………………………………………...14
Data Collection Instruments……………………………………………......15
Protection of Human Subjects…………………………………...…………16
Data Analysis…………………………………………...…………………..17
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Running head: IPAD DISTRACTION
Interpretation of Findings………………………………………………...17
Sample…………………………………………………………………...17
FACES and Parental Satisfaction Scores………………………………..18
Results…………………………………………………………………...20
Implications……………………………………………………………...22
Limitations and Strengths…………………………………………….…23
Recommendations………………………………………………….……23
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Abstract
Introduction. The purpose of the project was to determine in children age 4-12 years old
receiving immunizations, if iPad distraction during immunization administration, effected levels
of satisfaction during the immunization experience as reported by parents/caregivers of children
receiving the immunizations and pain as reported by children receiving the immunizations.
Methods. A total of 60 parents/child dyads participated by completing a parental satisfaction
survey and child reported FACES scale post immunization. Thirty patients were allowed to play
iPad games before and during immunization and thirty patients received no distraction. Results.
Mann Whitney U test showed no significant mean difference between the iPad distraction and no
distraction group. Discussion: The results of this project indicate that for this practice, iPad
distraction did not have an effect on parent satisfaction levels and pain scores.
Keywords: iPad, distraction, immunization, satisfaction, pain
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Chapter I: The Issue of Pediatric Childhood Immunization Pain
Before one year of age, infants receive approximately twelve vaccine injections as part of
the Centers for Disease Control (2016) recommended childhood vaccine schedule. The average
five-year old child, who is up to date on vaccinations, in the United States, can expect to receive
an average of three to five immunizations at their well child exam for Kindergarten entrance.
This chapter will review the significance of immunization pain to patients and the healthcare
system. In addition, the project background, problem and aims of the project will be presented.
Significance to Patients and Healthcare
Immunizations are key to the prevention of childhood illnesses that previously caused
significant morbidity and mortality. One example of a disease that has been nearly eliminated
due to routine childhood immunization is rubella. Prior to the release of rubella vaccine in 1969,
a large rubella epidemic in 1964-1965 occurred in which twelve million Americans became
infected, 2,000 infants died, and 11,000 miscarriages occurred (CDC, 2016). In 2012, only nine
cases of rubella were reported in the United States.
The importance of vaccines in the prevention of death and disability is obvious.
However, due to developmental stage, most children cannot rationalize the need for vaccines.
They frequently only remember the painful experience of needle sticks. Children develop fear.
Often times, they dread coming to the pediatrician’s office, if the fearful feelings are intense and
substantial. Fear and anxiety are emotional components that can augment the perception of pain,
especially in children (McMurtry et al., 2011).
In pediatrics, providers must also address parental perceptions. While many parents
understand the importance of childhood vaccines, there is an increased trend toward vaccine
refusal in the U.S. According to the CDC (2013), vaccine exemptions rose from 5.5% to 6.1% in
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the state of Illinois between the 2011-2012 and 2012-2013 school year, due largely in part to
non-medical exemptions. Vaccine refusal not only leaves the pediatric patient at risk for disease,
but it also poses a risk to immune compromised patients in the community (Centers for Disease
Control and Prevention, 2014). There are many reasons for vaccine refusal. Common reasons
for refusal of vaccines include fears that vaccines harm children, distrust of medical providers
and lack of belief in the efficacy of vaccines (Smith et al., 2011). Another reason for
immunization or refusal immunization is needle phobia; Taddio et al. (2012) found that 8% of
parents refused vaccination for their children due to fear of needles.
Negative immunization experiences can have significant consequences. The immediate
consequences are pain and fear. In addition, children who struggle and require vigorous restraint
during immunization may often experience increased injection site soreness and both staff and
the child are at an increased risk of injury (Taddio et al., 2009). Long-term consequences occur
as a result of negative immunization experiences. Children can develop anxiety about coming to
the primary care office ranging from mild to severe. Many times these fears persist into
adulthood. Taddio et al. (2009) report that approximately twenty five percent of adults report
needle phobia attributed to negative experiences medical experiences in childhood. Needle
phobia can cause children and adults to avoid medical and dental visits.
Background
Over the years, many studies have examined methods to reduce the pediatric pain during
various medical procedures including venipuncture and immunization. In recent times, a few
organizations have developed recommendations and practice guidelines to address the problem
of pain and distress during immunization. The CDC (2015) recommends the following evidence
based strategies for procedural pain management during immunization for children beyond
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infancy: giving the most painful injection last, no needle aspiration, tactile stimulation, and
distraction. In addition, the CDC (2015), states that topical lidocaine may be used per
manufacturer guidelines. Taddio et al. (2010) developed guidelines for the Canadian Institute of
Health Research for reducing childhood immunization pain. The Canadian guidelines are
congruent with the CDC guidelines but give the strong recommendation that distractions “should
be provided” during immunization and these distractions are best when clinician or child led
(Taddio et al., 2010). Formal primary care office policies addressing pediatric pain management
strategies and distraction techniques during immunization are lacking.
Problem
In 2015, the need for an intervention to help children cope with the fear and anxiety of
immunization was identified at a small Midwest pediatric primary care office. No formal
procedure or intervention existed at this clinic prior to implementation of this DNP project.
Many techniques and devices had been discussed but no formal research into practicality, cost,
and success rate had been conducted until the author conducted a review of literature. Modern
day handheld computers and tablets are easy to use and are fairly child intuitive. One advantage
of iPad distraction is that it does not require additional staff, which made it appealing to this
primary care office due to limited staff and resources. No research into the cost/benefit ratio of
iPad distraction had been conducted.
This project took place in a small rural pediatric office. The clinic is a single pediatrician
owned, pediatric primary care office. The author of this project is the sole pediatric nurse
practitioner in this practice. Other employees include a registered nurse and office manager. The
practice supported the project by establishing a written policy for providing child led iPad
distraction for the clinic. The practice agreed to provide an iPad to children receiving
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immunizations as a distraction for the purpose of piloting this quality measure at the clinic. In
addition, the clinic collected data from parents and children about parent satisfaction and pain.
Purpose/Aims
The purpose of this project was to determine in children age 4-12 years old receiving
immunizations, if iPad distraction during immunization administration, effected levels of
satisfaction during the immunization experience as reported by parents/caregivers of children
receiving the immunizations and pain as reported by children receiving the immunizations. This
scholarly project sought to establish standard office procedure for providing iPads as distraction
devices during immunization. An additional aim of the project was to establish a method of
assessing parental satisfaction with the immunization experience. The project also, sought to
establish a method of assessing pain in children receiving immunization.
Chapter II: Literature Review
The purpose of this project is to determine if distraction provided with an iPad during
immunization of children ages 4-12 years has an effect on parental satisfaction during
immunization visits. Research participants will be parents of children age 4-12 years old
receiving immunizations in a rural pediatric primary health clinic. As mentioned in Chapter I,
distraction is recommended during childhood immunization by organizations such as the Centers
for Disease Control and Prevention and the Canadian Institute of Health Research. Information
about different methods of distraction and the effect of these methods on children’s responses
during painful procedures is presented. Current research about use of tablets and handheld
devices as distraction tools for children during painful procedures is presented. Distraction as it
relates to the gate control theory (Melzack & Wall, 1965) is explored.
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Pediatric distraction techniques in the acute care setting
Pediatric patients are subject to a variety of painful procedures in the acute care setting.
Common painful procedures in pediatric hospitals include dressing changes, IV insertions,
casting, bone marrow aspirations, urinary catheterization, and lumbar punctures. Pain is a
complex phenomenon and has both physiologic effects and emotional components such as
anxiety, which can increase the intensity of the experience (McMurtry, Noel, Chambers, &
McGrath, 2011). Many attempts both pharmaceutical and non-pharmaceutical are made to
decrease the intensity of these experiences for children. The use of distraction techniques such
as toys, television, puppets, games and music are commonplace. In fact, many pediatric centers
of excellence promote their child life specialist and distraction techniques as an indication of
quality pediatric care. For example, St. Louis Children’s Hospital is a nationally recognized
pediatric hospital in St. Louis, Missouri that widely promotes the idea of “ouchless ER visits” in
which topical lidocaine and distraction techniques are used for every pediatric needle stick (St.
Louis Children’s, 2016). Many non-pharmaceutical distraction techniques have been studied in
the past several decades to determine which techniques are most effective at reducing various
aspects of painful procedures for children.
Children who receive distraction during painful hospital procedures have lower reported
behavioral distress, fear, anxiety and pain (Koller & Goldman, 2012). Whitehead-Pleaux et al.
(2007) found that children had significantly less behavioral distress while undergoing burn care
when music therapy was utilized with premedication as compared to premedication alone.
Sharar et al. (2007) found that patients who received virtual reality helmet distraction during post
burn physical therapy had significant reductions in self-reported pain and self-reported time
spend worrying about pain, compared to standard treatment. Research has shown that parents can
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be trained to successfully provide their children with distraction in the acute care setting.
McCarthy et al. (2010) report lower pediatric lower observational behavioral distress scores
(OBDS), parent reports of distress scores, lower salivary cortisol levels, and lower child reported
pain scores with IV insertion among children age 4-10 years old whose parents performed
distraction compared to a group that received no distraction.
Many studies have examined the impact of various distraction techniques on pediatric
pain in the acute setting. Some distraction techniques have been shown to be superior over
others. An extensive literature review by Koller & Goldman (2012) found that across several
studies, the following distraction techniques are shown to reduce the intensity of pain among
children exposed to painful stimuli in research studies: interactive toys, video games, guided
imagery, virtual reality, and controlled breathing. Music and television have shown to be
effective when used in conjunction with pharmaceutical therapy.
Tablet and handheld device distraction in the acute setting
The use of tablets in the United States and worldwide has skyrocketed. In 2010,
approximately 18 million tablets were sold worldwide but in 2015, yearly worldwide tablet sales
soared to 233 million (Gartner, 2015). There are some negative connotations to the distraction
that tablets provide to children such as decreased interpersonal skills, overreliance on
technology, and creating a new generation of “couch potatoes”. However, tablets can also
improve lives by improving communication, information seeking, allowing cameras to capture
moments and providing entertainment and distraction. The distraction provided by these devices
has been utilized as a new technique for distraction from painful procedures in the pediatric acute
care settings.
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Studies of tablets as a distraction technique are emerging. Ko et al. (2016) found that
children age 1 through 18 years of age who were given an iPad with videos playing had
significant decreases in heart rate from the waiting room to cast room. Casting fractures can be
very anxiety producing. It is assumed that the significant decrease in heart rate between the iPad
group and the group without iPad was due to decreased anxiety. Crevatin et al. (2016) compared
child reported pain scores (FACES or numeric scale) between standard pediatric distraction
techniques to hand held computer distraction among children age 4 to 13 years and found that
these distraction techniques produced equal results. The standard distraction performed involved
the use of a second nurse either do a puppet show, sing or blow bubbles. Modern day handheld
computers and tablets are fairly easy to use and are fairly child intuitive. One advantage of the
iPad as a distraction tool is that it does not require additional staff.
Pediatric distraction in the primary care setting for immunization
The primary care setting is a distinct setting from the hospital. In general, distraction
techniques are not utilized in the primary care setting to the extent as they are in pediatric
hospitals. Many pediatric hospitals employ child life specialists whose sole job is to make the
environment child friendly and to provide distraction. The most common painful experience in
the primary pediatric care office is immunization intramuscular and subcutaneous injection
(Reis, Roth, & Syphan, 2003).
Most distraction techniques studied in the primary care setting for immunizations differ
from those studied in acute care settings. In general, the techniques utilized in primary care are
different. There were more studies in primary care that explored the use of different topic
numbing medications, cold therapy, vibrating devices and simple techniques or patient led
activities. This may be due in part to cost and availability of staff in the primary setting.
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Berberich and Landman (2009) found that the combined use of topical ethyl chloride, a multi-
pronged arm gripper and the use of a vibrating tool on contralateral arm for immunization
resulted in significantly lower parent and patient Face, Leg, Activity, Cry and Consolability
(FLACC) scores and Faces pain scales scores in 4 to 6-year olds. (Burgess, Nativio, & Penrose,
(2015) found significant decreases in child and parent distress during immunization of 4 to 6-
year olds with the use of topical spray anesthetic and encouraging children to use a party blower
toy.
Tablet distraction for children receiving immunization
Tablet and handheld device distraction is an appealing distraction technique in the
primary care setting because it is inexpensive and does not involve additional staff resources or
coaching. The effectiveness of this strategy as a method of distraction during immunization is
unclear. Burns-Nadler, Atencio & Chavez (2016) found no significant differences in observatory
rated scales of pain and behavioral distress (OBDS) among children age 4 through 11 years old
who received distraction while receiving immunization. Another study found iPad distraction
techniques effective. Shahid, Benedic, Mishra, S., Muyle, & Guo (2015) found that “the use of
iPad distraction significantly reduced the parent’s perception of their child’s level of anxiety,
need to be held, and amount of crying during immunization compared to no distraction”(p. 145).
This study also found significantly higher parent satisfaction scores among parents whose child
used the iPad for distraction.
The use of distractions techniques such as guided imagery, video games, interactive
games and virtual reality have demonstrated reduced pediatric distress and pain scores in the
acute care setting. The use of iPad distraction has also shown benefits in the acute care setting.
The benefit of iPad distraction in the primary care setting for immunizations is still somewhat
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unclear. Shahid et al. (2015) found the benefits of increased parental satisfaction and reduced
anxiety and pediatric distress with the use of iPads. This project will pilot the use of iPad games
as a form of distraction during immunization to determine if it improves the quality of care at
this clinic in terms of child pain scores and parental satisfaction.
Theoretical Framework
The most popular pain control theory of modern times is the gate control theory. The
gate control theory holds that, “neural impulses that potentially signal pain from the peripheral
nervous system are subject to a number of modulations in the spinal cord by a gate-like
mechanism in the dorsal horn before the experience of pain is transmitted to the central nervous
system” (Melzack & Wall, 1965). The gate control theory holds that painful sensations are
reduced when other signals to the brain are sent down the same pathway.
The painful stimuli presented in this project were single or multiple needle injections of
vaccine. Gate control theory holds that painful stimuli can be modulated in the spinal cord by
another equal or more powerful stimuli. The distracting stimulus for this DNP project is child
interest in an iPad game. The hypothesis was that the children who are in the experimental group
who receive iPad distraction will experience less pain and anxiety than those without distraction.
One assumption is that if a child’s pain is reduced, a parent’s level of satisfaction with the child’s
immunization visit will increase.
For the purpose of this project, pain was defined in accordance with the gate control
theory as endorsed by Melzack who is responsible for the gate control theory of pain. Loesser &
Melzack (1999) endorse the International Asssociation for the Study of Pain’s (ISPA) definition
of pain. According to the ISPA, pain is “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in terms of such damage”
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(Merskey &Bogduk, 1994, p. 210). The unpleasant stimuli was intramuscular or subcutaneous
injections as a route of vaccine administration. Parent satisfaction is the degree to which parents
are pleased with certain aspects of their child’s care (Gerkensmeyer, Austin, & Miller, 2006).
Parent expectations of their child’s health care contrasted with their actual experience determine
their satisfaction. “Satisfaction is defined as the emotional response to the judgment of the
difference between perceived services and consumers' desired and expected services”
(Gerkensmeyer, Austin & Miller, 2006).
Chapter III: Methodology
Chapter III will discuss the methods used in this doctoral project. The setting for this
project is discussed. In addition, a description of project design is given. The project utilized the
Wong-Baker FACES pain scale to measure child pain. Parental satisfaction was measured using
a new survey developed by the author. A discussion of data collection instrument validity and
reliability is presented. Information about how human subjects were protected is given. Finally
data analysis, interpretation and results are discussed.
Setting
The setting for this quality improvement project was a small physician owned pediatric
primary care clinic in the Midwest. The clinic is well established having served the community
for 14 years. The pediatric nurse practitioner and author of this project has been at the practice
for 8 years. The office manager and nurse have been with the practice 4 years. The practice sees
an equal number of patients with Medicaid and private insurance. The clinic does not participate
in the Vaccines for Children Program, therefore, the parent child dyads participants all had
private insurance and Medicaid patients were not included in the project.
Project design
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The project utilized a quasi-experimental design. Patients were between the age of 4-12
years old and received at least one vaccination per the CDC recommended childhood vaccination
schedule at their visit. At least one parent or legal guardian was present to consent to project
participation. If two parents or legal guardians were present, the older parent or guardian was
asked to complete the parent satisfaction survey. The pediatrician and pediatric nurse
practitioner identified patients who were project eligible and then notified the office manager.
The office manager read a recruitment script for study participation. Of those approached for
project participation, only one parent declined due to time constrains. Informed consent was
obtained from parents for participation. Assent was obtained from children age 7 and older.
Every other patient/parent dyad was assigned to the experimental group.
Patients in the control group received standard immunization care. Patients in the
experimental group were given an iPad with pre-loaded child friendly games to play after
informed consent was obtained. These children were encouraged to play iPad games as they
received immunizations administered by the office nurse. Immediately after immunization, the
nurse presented all child participants with the Wong-Baker FACES scale and instructed them to
point to how they felt on the FACES scale. The nurse marked the patient’s response and gave the
parent the patient’s completed FACES scale. The nurse gave then gave parents a satisfaction
survey to complete and instructed the parent to place both their child’s FACES scale and the
parent satisfaction scale in an envelope. The nurse instructed the parent to place completed
surveys in a locked box at the reception desk as they exited the office.
Data Collection Instruments
Immediately after immunization administration, the nurse presented child participants
with the Wong-Baker FACES scale. Children were asked to point to a face on the FACES scale
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to indicate how they felt post- immunization. The FACES Scale has been used in many studies
and has shown reliability and validity Keck et al. (1996) report a statistically significant test-
retest reliability of r= 0.83 and a statistically significant concurrent validity when compared to
both a word graphic scale (r = .63) and a numerical scale (r = .75) for children age 3-7 years old.
Luffy & Grove (2003), reported statistically significant test retest reliability of r=.78 and a
validity of r=.81 among children age 8-12 years old. Permission to use the FACES scale was
granted from Connie Baker via email to the author on February 18, 2017.
The author of this paper created the parent satisfaction survey in 2015. A standard
established tool to measure parental satisfaction with immunization does not exist. Therefore,
validity and reliability measurements are not available for the parent satisfaction tool that was
utilized. Efforts were made to address content validity. The author researched and found three
urban clinics that have online parent immunization satisfaction surveys. The author reviewed
these parent immunization satisfaction surveys and drew common themes from the surveys to
develop the survey for this project. The parent satisfaction survey was reviewed and critiqued by
an expert epidemiologist/statistician. Three experienced pediatric nurse practitioners who are
experts in pediatric immunization, reviewed the questionnaire and provided critique. In addition,
the tool was presented to three parents of patients at the clinic who provided suggestions.
Common themes emerged from review of existing surveys and evaluation of the parental
satisfaction survey tool that will be used for the project. A common agreement was that many
factors can impact overall parental satisfaction with their child’s visit including wait time,
cleanliness of the office, professionalism or staff and having their question about vaccines
answered. Therefore, these items were included on the survey along with a general satisfaction
questions.
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Protection of Human Subjects
Due to the project involving children, a vulnerable population, the project went through
full IRB review at Maryville University. IRB approved was received on May 24, 2017. Several
safeguards were in place to protect both the parents and child participants. To minimize any
pressure from providers to participate, the office manager approached parent child dyads for
project recruitment, using a standard recruitment script. The author of this paper and the
pediatrician were not involved in project recruitment, data collection or informed consent. The
office manager and clinic nurse completed citi training on March 10, 2017. The office manager
obtained informed consent from a parent or legal guardian for project participation. Assent was
obtained from participants 7 years of age or older.
No identifying information or HIPPA protected information were collected from
children. A HIPPA exempt form was submitted and approved by the IRB. The FACES scale and
parent satisfaction survey were administered via pen and paper. Surveys were coded to identify
membership in the control or experimental group and to link parent and child responses. The
FACES scale and parent satisfaction were place in sealed envelopes by parents and deposited in
a locked box at the reception area. This box was only accessible to the project author and was
opened weekly during the data collection phase. The data collected was de-identified data that
was entered into SPSS by the author for data analysis.
Informed consent forms were stored in a separate location from medical records and
survey responses. All consents and survey responses were kept separate from patient medical
records. Paper copies of consents and assents, completed FACES scales and parent satisfaction
surveys are stored in locked boxes and will be destroyed along with SPSS files on August 1,
2020 (three years after project completion).
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Data Analysis
Each FACES scale and parent satisfaction survey were labeled with a code. Child/parent
dyads had the same code written in the corner to link parent child responses. Every other
child/parent dyad was in the experimental group. Members of the experimental group
child/parent dyad had their FACES scale and parent satisfaction survey printed on blue paper.
Members of the control group had their FACES and parent satisfaction survey printed on white
paper. Data was entered into SPSS by code. No names were entered into SPSS. Descriptive
statistics were obtained from the data. The Mann-Whitney U non-parametric test was used to
evaluate the relationship between the independent and dependent variables.
Interpretations of Findings
Sample
Descriptive statistics for project participants are presented in Table 1. The sample
consisted of 60 parent/child dyads. A total of 30 children were in the experimental group that
received iPad distraction during immunization and 30 children were in the control group that did
not receive iPad distraction. The control and experimental groups were fairly similar in gender
composition with the control group having slightly more males (60%)than females (40%). The
experimental group had an even number of males and females.
Children ages 4-12 years of age were included in the project. Children 10-12 years old
composed 63.3% of the sample, followed by children 4-6 years of age at 30% . Only 6.7% of
children in the sample were age 7-9 years old. The experimental and control groups did not differ
much in age with a mean age of 8.9 years and 8.97 respectively.
Children in the sample received one to three immunizations at their visit depending on
what immunizations they were due for according to the CDC recommended vaccination
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schedule. The number of vaccinations received by the control and experimental group at their
visit was similar with a mean of 1.8 for the experimental group and 1.6 for the control group.
Table 1
Gender, Age and Number of Vaccines Given by iPad Group Classification
Characteristic iPad distraction(n=30)percent of total experimental group
No iPad distraction(n=30)percent of total control group
Sample Total(n=60)percent of total sample
GenderFemaleMale
15 (50%)15 (50%)
12 (40%)18 (60%)
27 (45%)33 (55%)
Age4 to 67 to 910 to 12MeanMedian
9 (30%)1 (3.3%)20 (66.7%)8.910
9 (30%)3 (10%)18 (60%)8.9710.5
18 (30%)4 (6.7%)38 (63.3%)8.9310
Number vaccines given123MeanMedian
11 (36.7%)14 (46.7%)5 (16.7%)1.82
13 (43.3%)16 (53.3%)1 (3.3%)1.62
24 (40%)30 (50%)6 (10%)1.72
Parental Satisfaction and Child FACES Scores
Parental satisfaction survey and FACES score response frequencies for the control and
experimental group are presented in Table 2. Parental satisfaction was high for extraneous
factors that can affect visit satisfaction such as wait time, cleanliness, vaccine education and
child treatment in both the experimental and control groups. No parent in the sample indicated
dissatisfaction in how their child was treated during their visit or dissatisfaction with vaccine
explanation and education provided at the visit. Regarding clinic wait time and cleanliness, one
parent in the control group disagreed that clinic wait time was acceptable and that the
vaccination room was clean. Otherwise, the sample showed high levels of satisfaction with wait
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time and cleanliness of rooms. Overall satisfaction and likelihood of recommending service
scores were very high for both experimental and control groups.
The experiment and control groups had similar FACES scale responses. The total sample
trended toward lower pain scale rankings on the FACES scale with 81.7% of children reporting
FACES score values between 0-4 on a 0-10 ordinal scale.
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Table 2
Survey Response Frequencies for Parental Satisfaction Surveys and Child FACES Score by iPad Classification and for the Total Sample
Characteristic iPad Distraction(n=30)
No iPad Distraction(n=30)
Total(n=60)
Wait TimeDisagreeNeitherAgreeStrongly Agree
01722
101217
1 (1.7%)1 (1.7%)19 (31.7%)39 (65%)
Cleanliness of RoomDisagreeAgreeStrongly Agree
0426
1821
1 (1.7%)12 (20%)47 (78.3%)
ExplanationAgreeStrongly Agree
030
327
3 (5%)57 (95%)
Treatment of ChildSomewhat satisfiedExtremely Satisfied
129
030
1 (1.7%)59 (98.3%)
Overall SatisfactionSomewhat SatisfiedExtremely Satisfied
129
129
2 (3.3%)58 (96.7%)
Would RecommendExtremely Likely 30 30 60 (100%)Child FACES scoreNo PainHurts a BitHurts MoreHurts Even MoreHurts a Whole LotHurts Worse
9124203
3165222
12 (20%)28 (46.7%)9 (15%)4 (6.7%)2 (3.3%)5 (8.3%)
Results
Median parental satisfaction and FACES scores for the control (no iPad distraction) and
experimental (iPad distraction) group and independent samples Mann Whitney U tests of
significant mean differences are presented in Table 3. Median scores were the same for the
experimental and control groups on all measures of parental satisfaction and child FACES
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scores. A median score of extremely satisfied (5) was obtained for every question on the
parental satisfaction survey for both experimental and control groups. The median FACES scale
score for both the experimental and control group was hurts a bit (2). Children ages 4-12 years
who received iPad distraction during immunization had no significant differences in parental
satisfaction and child reported FACES scores than children who received no iPad distraction.
There was no clinical or statistically significant differences between groups.
Table 3
Median Parent Satisfaction Scale Values (Wait Time, Cleanliness, Explanation, Treatment of Child, Overall Satisfaction and Would Recommend) and Child FACES scores by iPad Group Classification and Independent Mann Whitney-U Test p values
Characteristic iPad Distraction(n=30)
No iPad Distraction(n=30)
Sigp value
Satisfactiona
Wait TimeMedian 5 5 .195Satisfactionb
Cleanliness of RoomMedian 5 5 .111Satisfactionc
ExplanationMedian 5 5 .078Satisfactiond
Treatment of ChildMedian 5 5 .317Satisfactione
OverallMedian 5 5 1.00Satisfactionf
Would RecommendMedian 5 5 1.00Child FACES scoreg
Median 2 2 .121Note. The significance level is .05. a Wait time satisfaction 1=Strongly disagree 2=Disagree 3=Neither Agree=4 Strongly Agree=5bCleanliness of Room 1=Strongly disagree 2=Disagree 3=Neither Agree=4 Strongly Agree=5c Explanation 1=Strongly disagree 2=Disagree 3=Neither Agree=4 Strongly Agree=5d Treatment of Child 1=Extremely Dissatisfied 2=Dissatisfied 3=Neither 4=Somewhat Satisfied 5=Extremely SatisfiedeOverall Satisfaction 1=Extremely Dissatisfied 2=Dissatisfied 3=Neither 4=Somewhat Satisfied
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5=Extremely Satisfiedf Would Recommend 1=Extremely Unlikely 2=Somewhat Unlikely 3=Neutral 4=Somewhat Likely 5= Extremely Likely
Chapter IV: Implications
The findings of this DNP project have implications for both this practice setting and other
settings that offer pediatric immunization. The practice successfully accomplished the goals of
establishing standard office procedure for distraction during immunization and establishing a
method of assessing parental immunization visit satisfaction. Baseline parental satisfaction levels
and child pain scores are now known. This practice has high levels of parental satisfaction with
immunization. This affirms that the clinic should continue with current immunization practices
in such areas as vaccine education. This data and establishment of procedures from this project
will assist this practice in exploration and evaluation of other modalities to reduce immunization
pain. The results of this project indicate that for this practice, iPad distraction did not have an
effect on parent satisfaction levels and pain scores. Therefore, purchasing iPads for patient use
as a distraction method during immunization is not indicated. The practice should explore other
methods of pain reduction during immunization.
The findings of this scholarly project have implications for other clinics that are
considering the purchase of electronic devices as a method of distraction during pediatric
immunization. Data is well established on the benefits of iPad distraction in the acute care
setting. Children in these settings are likely exposed to more unfamiliar, invasive and stronger
pain and anxiety producing procedures as compared to the primary care setting. The current
benefit of iPads as a form of distraction from pain during immunization is unclear. Clinics may
want to conduct their own pilot studies to determine if electronic tablet distraction has a benefit
for patients in their practice before investing in these devices.
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Chapter V: Discussion
Limitations and Strengths
There are many limitations to the generalizability of project findings. The project sample
was composed of primarily Caucasian, rural community children and parents with private health
insurance. Caution is advised in applying findings from this project to urban, culturally diverse,
and Medicaid insured populations. The practice setting in which the project was conducted was a
small practice with two providers and two staff members. Application to large healthcare
organizations may be limited. In addition, parental satisfaction with services appears to be very
high in at this practice, which may make this population different from the general population.
Limitations also exist in methodology. Larger sample sizes may reveal significant
differences in pain and parental satisfaction that this project failed to reveal. In addition, this was
a convenience sample with non-random assignment to control and experimental groups. In
addition, the age range of children was fairly board at 4-12 years of age with over 60% of the
sample consisting of children in the age range of 10-12 years of age. Studies of children in the 4-
6 year old age group may reveal significant differences.
Strengths of the project include demographic similarities in the control and experimental
groups in terms of gender, age, number of vaccines administered, and insurance type, thus
reducing the risk of these confounding variables contributing to a type II error. Data and
informed consent were obtained in a consistent manner. The same nurse administered all of the
vaccines given to children in the sample assuring similar administration technique.
Recommendations
The practice in which this DNP project was conducted should continue to explore other
methods of addressing pain for children receiving immunization, especially now that procedure
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is in place to collect data. Distraction techniques such as party blowers or the use of topical
benzocaine spray could be investigated in the future.
More research is needed to determine if iPad distraction during immunization is useful in
in other settings with a more diverse patient population. This project only examined the effect of
iPad distraction on parental satisfaction and FACES pain score but the effect on anxiety and
distress scores is unclear. This project had a small sample size. Studies in larger health care
organizations with larger sample sizes are needed. Studies utilizing other pain measurement
scales such as the FLACC (Faces, Legs, Activity, Consolability and Crying) may show different
results and the use of these measurements should be explored in further studies. The benefits of
iPad distraction for painful procedure in the acute care setting is well established and should
continue. The experience of the painful stimuli of immunization is short and is often not as
intense as painful stimuli in an acute care setting. Therefore, results of this DNP project should
not be applied to an acute care setting.
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