YJPDN-02403; No of Pages 6

Journal of Pediatric Nursing xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

journal homepage: www.pediatricnursing.org

A comparison of the effect of visual and auditory distractions on

physiological indicators and pain of burn dressing change among
6–12-year-oldchildren: A clinical trial study
Fatemeh Cheraghi a, Arash Kalili b, Alireza Soltanian c, Mahdi Eskandarlou d, Pegah Sharifian e,⁎
a
Associate Professor, Research Center for (Home Care)Chronic Diseases, Department of Pediatric Nursing,School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan,
Iran
b
Mother and Child Care Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
c
Professor, Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
d
Department of General Surgery, Hamadan University of Medical Sciences, Hamadan, Iran
e
Pediatric Nursing student, Hamadan University of Medical Sciences, Hamadan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Pourpose: This study aimed to compare the effect of audiovisual distraction on physiological indicators and pain
Received 18 May 2020 of burn dressing change among 6–12 year-old children.
Revised 16 January 2021 Design and methods: The study was a single-blind clinical trial with a three-group that sample size was 120 chil-
Accepted 16 January 2021 dren aged 6–12 years admitted to the burn ward of Hamadan Besat Hospital. Data collection tools were the
Available online xxxx
Oucher pain scale, a Cheklist form of the physiological Indicators, and apulse oximetry device. The cartoons
were shown for visual group and the melodic poems were played for the auditory group 2 min before the dress-
Keywords:
Pain
ing until the end of the procedure (at 2-min intervals). Data were analyzed by SPSS-16 software one-way, vari-
Burn ance analysis and post-hoc Bonferroni test.
Children Results: Therewere statistically significant differences between visual, auditory and control groups in the mean
Distraction pain intensity scores at all measurement times, the mean arterial blood oxygen saturation percentage at all mea-
surement times except for the10 min before the dressing and the start of the procedure and the mean heart rate
at all measurement times except for 10 min before dressing (p < 0.001). Post-hoc tests showed that the differ-
ence in the mean heart rate was related to the difference between the visual and auditory distraction groups dur-
ing and at the end of the dressing (p < 0.05), the visual and control groups at all measurement times (P < 0.001)
and the auditory and control groups at all measurement times (p < 0.05).
Conclusion: Audiovisual distraction is effective in reducing the fluctuations of physiological indicators and the
burn dressing pain intensity in children at all times of measurement, especially during changedressing.
Practice implications: The findings of this study are relevant to clinical practice because they suggest preparing
children before and during a burning procedure situation.
© 2021 Elsevier Inc. All rights reserved.

Introduction physical, psychological, social, and economic consequences to the pa-

tient, his/her family, and community (Ladwig et al., 2020). Burn injuries
Burn accidents and their consequences are the leading cause of are often painful and debilitating, and burn pain is one of the most se-
death and disability in children (Gandhi et al., 2010). Burn accidents ac- vere types of acute pain (Vagnoli et al., 2019). In addition to the burn in-
count for 6.48% of accidents in Iran (Sadeghi-Bazargani et al., 2017). Ac- juries, healthcare, and treatments such as dressing changes and wound
cording to the Burns Research Center at Iran University, the number of debridement are other causes of severe and prolonged pain in burn pa-
these patients in the country is eight times the global average (Aghaei tients (Doenges et al., 2014).
et al., 2018). According to the Ministry of Health, 150,000 to 180,000 Pain relief is one of the most important nursing diagnoses in burn
people have burned annually in Iran, of which 30,000 are hospitalized wards (Ladwig et al., 2020). Besides, it is a basic need of patients
and 3000 die each year (Saberi et al., 2016). Burn accidents have adverse (Peate, 2019). According to nursing standards, the comfort and relief
of burn pain, especially in children with burns, should be the priority
⁎ Corresponding author.
in planning and performing nursing care (Devlin et al., 2018). Unre-
E-mail addresses: soltanian@umsha.ac.ir (A. Soltanian), rsharifian7@gmail.com lieved pain in children will have significant negative physical, physio-
(P. Sharifian). logical, and psycho-social consequences. Also, unresolved acute pain

https://doi.org/10.1016/j.pedn.2021.01.011
0882-5963/© 2021 Elsevier Inc. All rights reserved.

Please cite this article as: F. Cheraghi, A. Kalili, A. Soltanian, et al., A comparison of the effect of visual and auditory distractions on physiological
indicators and pain ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2021.01.011
F. Cheraghi, A. Kalili, A. Soltanian et al. Journal of Pediatric Nursing xxx (xxxx) xxx

leads to prolonged stress response after burn injury, sleep problems, However, in similar available studies, less attention has been paid to
excretory disorders, learning and attention disorders, patient restless- the physiological effects of pain on children, its prevention, and elimina-
ness, delayed recovery, and prolonged hospital stay (Jiang et al., 2019; tion. Therefore, the present study seeks to answer the question of
Saleh & Hassan, 2019). Pain is not only an unpleasant and annoying feel- whether the two methods of visual (watching cartoons) and auditory
ing for the child but also confuses the child when he or she is unable to distractions (listening to music) affectingthe physiological indicators
understand the reasons for the pain (Beltramini et al., 2019). Besides, as and reducing the pain of dressing change in children with burns, and
the pain impulses are transmitted from the spinal cord, the autonomic is this effect different?
nervous system is also stimulated and causes changes in physiological
indicators (Saleh & Hassan, 2019). These changes include bronchial Materials and methods
dilatation, respiratory rate fluctuations, heart rate, peripheral vasocon-
striction, hyperglycemia, sweating, pallor, increased muscle tone, di- Study design and population
lated pupils, and decreased gastrointestinal motility (Khonsary, 2017).
Therefore, it is necessary to seek an effective solution to help reduce The present study was a single-blind clinical trial with two interven-
the experience of pain in children with burns (Brand & Al-Rais, 2016). tion and one control groups. Using the convenient sampling method,
The most common way to deal with pain is to use prescription 120 children aged 6–12 years admitted to the burn ward of Besat Edu-
painkillers, the long-term use of which may have side effects such as cational and Medical Hospital with the criteria to enter the study.
respiratory and hemodynamic disorders. Therefore, nurses can help They were equally assigned to the visual distraction, auditory distrac-
reduce pain when performing painful procedures, such as changing tion, and control groups, by random block design. The following formula
dressings, by taking precautions (Ballantyne et al., 2009; Pickering was used to determine the sample size based on the study conducted by
et al., 2018). Combining nursing non-pharmacological measures with Abd Allah et al. (2018). According to their findings, the highest standard
painkillers can help relieve pain caused by treatment procedures with deviation of pain intensity scores in the intervention and control group
fewer risks and side effects (Edmond et al., 2018; Khalil, 2018). One of were 1.85 and 1.95, respectively. Considering the confidence level of
the most important non-pharmacological interventions for pain relief 95% and the type II error of 10% and the maximum significant difference
is cognitive-behavioral therapy, including the method of distraction of about 1.5, at least 34 patients in each group (control, auditory dis-
(Shih & Rosen, 2018). traction, and visual distraction groups) were required. Considering the
There are a variety of distractions, including visual distractions (such exclusion probability of 15%, the sample size in each group was esti-
as watching TV, guided mental imagery), auditory distractions (such as mated to be 40 patients.
listening to music, funny stories, and jokes), tactile distractions (such as
 2

massage, gentle breathing, caressing petsor toys), and mental distrac- z1−2a þ z1−β σ 21 þ σ 22
tions (such as crossword puzzles, playing cards, using a bubble maker, N¼ 2
≅ 34
and writing stories) (Atzori et al., 2018). In the method of distraction, d
interventions affecting the five senses are used. In this method, by
2
encouraging the patient to pay attention to other thoughts, the focus N ¼ γ2 =d ¼ ð2:8Þ2 =ð0:5Þ2 ¼ 31
on the pain, and subsequently, the patient's level of stress is decreased
(Liu et al., 2019). Using music and watching movies and cartoons to con- where delta (ɣ) is the decentralization parameter and is proportional to
trol pain in hospital wards is a safe, easy, and inexpensive way to easily the confidence level of 95%and the test power of 80%, and is equal to 2.8.
fit into a daycare program for sick children. Listening to music and Criteria for entering this study included age 6 to 12 years (beginning
watching movies and cartoons relaxes the muscles, diverts the patient's of the sixth year to the end of the twelfth year), lacking speech, vision,
thought from the pain, reduces the severity of the pain, and sends nerve hearing, cognitive disability, and no neurological defects such as (limb
impulses to the central nervous system (Indhu Rekka et al., 2019). Vi- neuropathy, limb paralysis) affecting pain perception based on the
sual and auditory distractions are inexpensive, non-pharmacological, child's history and clinical examination. Other criteria included satisfac-
and non-invasive nursing interventions that have no side effects tion and willingness of the child and parents to cooperate with the re-
and can be used in conjunction with pain relief medications search team, burn rate of 9–35% in the body based on the doctor's
(Kim et al., 2019). diagnosis, second-degree burns based on the doctor's diagnosis, paren-
The results of similar available studies showed that different tal presence with the child during the dressing change, being in the sec-
methods of distraction such as video play and playing with musical ond day of hospitalization, and having no pain before the dressing
toys reduced pain when changing burn dressings in children with dif- change. The exclusion criteria included lack of cooperation between
ferent age groups (Abd Allah et al., 2018; Kaheni et al., 2016). In another the child, his/her parents, and team members, emergency conditions
study, watching cartoons or listening to music reduced the severity of such as cardiopulmonary resuscitation or seizures, the need for pain-
pain and anxiety in children with burn-inducedtissue damage (Sinha relievingmedications during the dressing procedure, and burns in the
et al., 2006). Yoo et al. found that distraction through animation reduced eyes and ears.
behavioral responses to pain caused by intravenous catheterization, and
consequently, cortisol levels, and blood glucose in the test group (Yoo Study tools
et al., 2011). SamadiFard et al. showed that the pain intensity caused
by chemotherapy in children with cancer decreased by watching car- Data collection tools in this study included a demographic informa-
toons and making bubbles (Mikaeili et al., 2019). tion questionnaire, Oucher pain scale, a researcher-made form for re-
Despite countless advances in health care, relieving children's pain cording physiological indicators, and a pulse oximetry device for
remains a clinical challenge in various hospital units and the commu- recording physiological indicators. Tablets and headphones were used
nity. Besides, unrelieved pain leads to physiological changes and physi- to perform interventions in the visual and auditory distraction groups.
cal and psychological harm to the child. Besides, stress, incompatibility, Ocher Pain Scale is a self-reporting tool for the assessment of pain in-
and fear are very high in the family members, which also affect society. tensity in 3–12 years old children, developed by Beyer in 1984. This
In addition to the above issues, the existence of little available research scale is a poster-shaped tool that consists of two parts: a numerical
and the need for further study in the field of pain in children with burns scale from 0 to 100 for older children on the left side, and a visual
emphasizes the importance of the present study. Meanwhile, most of scale for younger children on the rightside. The number or the image
the available studies have examined the effect of a distraction method that the child expresses or shows will be equivalent to the severity of
on children's pain, individually. his pain. The visual scale contains six faces with different states of

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F. Cheraghi, A. Kalili, A. Soltanian et al. Journal of Pediatric Nursing xxx (xxxx) xxx

pain. Scoring is as follows: From the bottom of the screen, the first to (ANOVA), and Bonferroni tests were used. The confidence level
sixth images are equivalent to the numerical values of 0, 20, 40, 60, was 95%.
80, and 100, respectively. On a numerical and visual scale, 0 indicates
a painless condition, 20 mild pain, 40 and 60 moderate pain, 80 severe Results
pain, and 100 very severe pain. In this study, the reliability of the Oucher
pain scale obtained by calculating the Kendall coefficientof concor- The mean standard deviation of children's age in the visual, auditory,
dance. It was equal to 0.89, which indicated the good reliability of and control groups were 2.26 ± 8.26, 2.46 ± 8.56, and 2.27 ± 8.22, re-
this tool. spectively. The majority of the research units in the visual (62.5%), audi-
tory (52.5%), and control (72.5%) groups were male. The mean standard
Procedure deviation of the burn level in the visual, auditory, and control groups
were 3.97 ± 12.13, 3.86 ± 12.28, and 4.08 ± 12.42. The most burned
Data collection in all three groups of control, visual distraction, and limbs in the visual (50%) and auditory (50%) groups were the upper
auditory distraction was performed in the morning shift between 8 limbs and in the control group (35%) were the lower limbs. There
and 11 o'clock by two nurses. The objectives and research methods were no statistically significant differences in demographic characteris-
were explained to them. According to the doctor's instructions, 15 min tics between the three groups and were homogeneous (Table 1).
before dressing, all children in all three groups received morphine intra- The results showed that there were statistical differences between
venously at a dose of 0.05 mg per kg body weight. The average time to the three groups in the mean heart rate at all measurement times except
change dressings in all three groups was 10 min. In the visual group, for 10 min before dressing change, the mean arterial blood oxygen sat-
after transferring the children to the dressing room, they watched uration percentage at all measurement times except for 10 min before
Tom & Jerry cartoons on the tablet from 2 min before the start of the dressing and the start of the procedure, and the mean pain intensity
dressing change until the end of the procedure. The reason for choosing score at all measurement times (P < 0.001) (Table 2).
these cartoons was that their episodes were short, so it was possible to Post-hoc Bonferroni test showed that the difference in the mean
show one or more episodes that fit the different lengths of the dressings heart rate of the research units was related to the observed difference
until the end of the procedure. between the visual and control groups and the auditory and control
In the auditory group, the children's songs released by the Institute groups (P < 0.05); the difference in the mean arterial blood oxygen sat-
for the Intellectual Development of Children and Young Adults with uration percentage of the research units was related to the observed dif-
the approval of the Ministry of Culture and Islamic Guidance were ference between the visual and control groups, and the auditory and
used. 10 short songs were selected and recorded on a tablet. The reason control groups (P < 0.001); and the difference in the mean pain inten-
for choosing short songs was the possibility of playing one or more sity was related to the difference between the visual and control groups,
songs until the end of the dressing because the duration of the dressings the auditory and control groups (P < 0.001), and the visual and auditory
was not the same for all of the patients. The auditory group, also like the groups (P < 0.05) (Table 3).
visual group after transferring to the dressing room were listening to
the songs with headphones from 2 min before the start of the dressing Discussion
change until the end of the procedure. In the control group, the dressing
was changed according to the usual routine of the ward. In all three The present study was conducted to compare the effect of visual and
groups, pain intensity, heart rate, and arterial blood oxygen saturation auditory distractions on physiological indicators and pain of dressing
percentage of the research units were measured and recorded 10 min change in children aged 6–12 years hospitalized in the burn ward of
before and 5 min after dressing in the child's room, at the beginning of Besat Educational and Medical Center. When pain impulses are trans-
the procedure (after the burn bath), at intervals of once every two mitted from the spinal cord, the autonomic nervous system is also stim-
min during the dressing (average was recorded), and at the end of the ulated and changes in physiological parameters. These changes include
procedure. It was not possible to measure the two physiological indica- bronchodilation, respiratory rate fluctuations, heart rate, peripheral va-
tors of blood pressure and body temperature because during dressing, soconstriction, hyperglycemia, sweating, paleness, increased muscle
due to the humidity in the environment and interfering with the dress- tone, dilated pupils, and decreased gastrointestinal motility. The distrac-
ing, it was not possible to use a pressure gauge cuff and body tempera- tion method can reduce the transmission of nerve impulses to the brain,
ture probe. The child's mother was present throughout the study. The which can be justified according to Gate theory.
choice of measurement times was the same for all groups, based on
the study method (Kaheni et al., 2016; Sinha et al., 2006). Heart rate and saturation

The findings of the study showed that there were statistically signif-
Ethical considerations icant differences between the visual, auditory, and control groups in the
mean heart rates of the research units at all measurement times, except
The present study was approved bytheresearch ethics committee for the 10 min before dressing (P < 0.001). The mean arterial blood ox-
with the code of ethics of IR.UMSHA.REC.1397.565 and was registered ygen saturation percentage was also significantly different between the
with the proposal number of 9712077450 in the Research Council of Ha- three visual, auditory, and control groups at all measurement times ex-
madan University of Medical Sciences and with the code number of cept for the 10 min before the dressing and the start of dressing
IRCT2017011703202025N4 at the Iranian Registry of Clinical Trials. (P < 0.001). Although in all three groups during dressing, the mean
After making the necessary arrangements, the research units with the heart rate was ascending and the mean percentage of arterial blood ox-
criteria for entering the study were selected based on the files of hospi- ygen saturation was descending, the range of changes in the heart rate
talized patients in the burn ward. Then, written consent was obtained and the arterial oxygen saturation percentage of the research units in
from the parents of the children. the visual group was less than the auditory and in the auditory group
was less than the control group, especially during the burn dressing.
Data analysis In other words, the visual distraction group compared to the auditory
distraction and the auditory distraction compared to the control group
Data were analyzed using SPSS v.16 (SPSS Inc., Chicago, IL). The had a greater effect on preventing the increase in the heart rate and
Kolmogorov–Smirnov test showed a normal distribution of research the decrease in the percentage of oxygen saturation of arterial blood
data. Therefore, Chi-square or Fisher, one-way analysis of variance in children, especially during dressings.

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F. Cheraghi, A. Kalili, A. Soltanian et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Table 1
Demographic characteristics of research units in all three study groups.

Group Demographic characteristics Visual Auditory Control Test statistic P-value

Number Percent Number Percent Number Percent

Age (year) 6–8 25 62.5 22 55 25 62.5 0.79 0.939

8–10 5 12.5 5 12.5 5 12.5
10–12 10 25 13 32.5 10 25
Gender Female 15 37.5 19 47.5 11 27.5 3.41 0.181
Male 25 62.5 21 52.5 29 72.5
Burnt limbs Upper limbs 20 50 20 50 13 32.5 0.952 0.09
Lower limbs 9 22.5 10 25 14 35
Body 11 27.5 10 25 13 32.5
Burn agent Fire 9 22.5 4 10 9 22.5 4.57 0.334
Boiling water 25 62.5 33 82.5 27 67.5
Incendiary materials 6 15 3 7.5 4 10

Pain They found that there was a statistically significant difference in the
mean pain intensity between the intervention and control groups.
At all measurement times, the mean pain intensity score of the re- Therefore, the method of visual distraction using video games reduced
search units in the visual group was less than auditory and in the audi- the pain of burn dressing change in children aged 3–6 years (Kaheni
tory group less than the control group, and this difference was et al., 2016). Mikaeili et al. (2019) studied the effect of watching car-
significant (P < 0.001). In other words, the visual distraction reduced toons and making bubbles in reducing pain caused by chemotherapy
the pain intensity more than the auditory distraction and the auditory in all children with cancer. They found that there was a statistically sig-
distraction more than the control group, especially during dressing. nificant difference in the mean pain intensity between the bubble- mak-
The findings of Vosoghi et al. (2011) were in line with the results of ing and cartoon-watching groups and between both test groups and the
this study. They aimed to study the effect of distraction on physiological control group. These results suggest that watching cartoons and making
indicators and pain caused by venipuncture in children 3 to 6 years. The bubbles helps relieve pain in children during chemotherapy. The results
results showed that the percentage of arterial blood oxygen saturation also show that the method of making bubbles more than watching
in the test group was higher than the control group (Vosoghi et al., cartoons helps reduce children's pain during chemotherapy. The re-
2011). searchers concluded that the distraction method is one of the non-
Also, Kaheni et al. (2016) studied the effect of visual distraction pharmacological interventions effectifve in re; eving pain (Mikaeili
method on the pain during dressing change in 3–6 years old children. et al., 2019).

Table 2
Comparison of the mean heart rate, arterial blood oxygen saturation percentage, and pain intensity of research units in study groups according to measurement times.

Group Measurement time Visual Auditory Control Test statistic P-value

Mean (standard deviation) Mean (standard deviation) Mean (standard deviation)

10 min before dressing Heart rate 128.45 132.75 149.77 1.32 0.271
(9.83) (12.11) (17.11)
Oxygen saturation percentage 96.00 95.80 96.07 1.195 0.307
(0.64) (0.99) (0.79)
At the beginning of the dressing Heart rate 141.60 145.27 153.55 12 <0.001
(10.92) (11.27) (11.32)
Oxygen saturation percentage 96.15 96.12 95.77 2.008 0.139
(0.80) (1.06) (0.92)
Pain intensity 6.95 7.85 8.98 42.78 <0.001
(0.85) (0.95) (0.92)
At the beginning of the dressing Heart rate 132.90 139.67 151.95 34.3 <0.001
(8.99) (10.90) (11.24)
Oxygen saturation percentage 97.62 97.07 93.50 152.3 <0.001
(0.74) (0.76) (1.67)
Pain intensity 6.62 7.4 8.77 42.69 <0.001
(0.92) (1.21) (0.99)
At the end of the dressing Heart rate 132.52 137.52 147.55 26.7 <0.001
(7.54) (9.27) (10.96)
Oxygen saturation percentage 97.02 96.90 94.50 100.216 <0.001
(0.65) (1.00) (0.98)
Pain intensity 2.1 3.25 4.62 39.26 <0.001
(1.12) (1.27) (1.4)
5 min after the dressing Heart rate 121.35 123.85 136.55 18.4 <0.001
(10.14) (12.30) (13.37)
Oxygen saturation percentage 97.27 97.07 95.82 28.748 <0.001
(1.01) (0.88) (0.87)
Pain intensity 0.57 1.35 2.57 36.42 <0.001
(0.59) (1.07) (1.35)

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F. Cheraghi, A. Kalili, A. Soltanian et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Table 3
Results of multiple comparisons of the mean heart rates, arterial blood oxygen saturation percentage, and pain intensity at the measurement times according to the studied groups.

Measurement time Variables Groups Mean difference Standard error 95% confidence interval P-value

Lower range Upper range

At the beginning of the dressing Heart rate Visual and control −11.95 2.49 −18.01 −5.88 <0.001
Auditory and control −8.28 2.49 −14.34 2.2 0.004
Visual and auditory −3.67 2.49 −9.74 2.39 0.432
Pain intensity Visual and control −2.03 0.22 −2.59 −1.49 <0.001
Auditory and control −1.13 0.22 −1.6 −0.54 <0.001
Visual and auditory −0.9 0.22 −1.21 −0.31 <0.001
During the dressing Heart rate Visual and control −19.05 2.33 −24.71 −13.38 <0.001
Auditory and control −12.7 2.33 −17.93 −6.61 <0.001
Visual and auditory −6.78 2.33 −12.43 −1.11 0.013
Arterial blood oxygen saturation Visual and control 4.12 0.25 3.5 4.74 <0.001
Auditory and control 3.57 0.25 2.95 4.19 <0.001
Visual and auditory 0.55 0.25 −0.07 1.17 0.256
Pain intensity Visual and control −2.15 0.23 −2.72 −1.57 <0.001
Auditory and control −1.37 0.23 −1.94 −0.8 <0.001
Visual and auditory −0.77 0.23 −1.34 −0.2 0.004
At the end of the dressing Heart rate Visual and control −15.03 2.09 −20.11 −9.93 <0.001
Auditory and control −10.03 2.09 −15.11 −4.93 <0.001
Visual and auditory −5 2.09 −10.08 0.08 0.048
Arterial blood oxygen saturation Visual and control 2.52 0.2 2.03 3.01 <0.001
Auditory and control 2.4 0.2 1.91 2.88 <0.001
Visual and auditory 0.12 0.2 −0.36 0.61 1.00
Pain intensity Visual and control −2.02 0.28 −3.21 −1.83 <0.001
Auditory and control −1.37 0.28 −2.06 −0.68 <0.001
Visual and auditory −1.15 0.28 −1.84 −0.45 <0.001
5 min after the dressing Heart rate Visual and control −15.2 2.68 −21.72 −8.67 <0.001
Auditory and control −12.28 2.68 −19.22 −6.17 <0.001
Visual and auditory −2.5 2.68 −9.02 4.02 1.00
Arterial blood oxygen saturation Visual and control 1.45 0.2 0.94 1.95 <0.001
Auditory and control 1.25 0.2 0.74 1.75 <0.001
Visual and auditory 0.2 0.2 0.3 0.7 1.00
Pain intensity Visual and control −2.0 0.23 −2.57 −1.42 <0.001
Auditory and control −1.22 0.23 −1.79 −0.65 <0.001
Visual and auditory −0.77 0.23 −1.34 −0.2 0.004

Hua et al. (2015) examined the effect of distraction with the help of not play an effective role in reducing children's pain. The study con-
virtual reality on reducing pain during dressing in children with chronic straints and the small number of subjects were among the factors
lower limb ulcers. They concluded that there was a significant statistical influencing the results. Also, some of the observed cartoons did not at-
difference in the mean pain intensity between the test and control tract the subjects'attention in the intervention (Landolt et al., 2002).
groups. On the other hand, the mean heart rate in the distraction Therefore, great care should be taken in the child's acceptance of the in-
group showed fewer changes compared to the control group during tervention method. Finally, the study hypothesis was accepted.
the dressing change. However, there was no significant statistical differ- This study aimed to compare the effect of visual and auditory dis-
ence in mean arterial blood oxygen saturation between the test and tractions on physiological indicators and pain of dressing change in chil-
control groups. The authors concluded that the distraction method dren aged 6–12 years hospitalized in the burn ward of Besat Educational
used in this study could reduce the dressing pain of children (Hua and Medical Center. The results of the study showed that the two
et al., 2015). The difference between the findings of Hua et al. (2015) methods of visual and auditory distraction had a positive effect on re-
and the present study, could be due to several limitations in their ducing pain and physiological indicators of children while changing
work such as the lack of random allocation and its impact on study var- the burn dressing. However, the effect of the visual distraction method
iables as a limiting factor. Also, the researcher had not been able to elim- was more than the auditory method.
inate the effect of previous experiences of dressing pain on the current
experience of patients. Besides, virtual reality as a newer technology is Practice implications
less likely to be accepted and cause anxiety in. That it could be examined
in future studies more. Abd Allah et al. (2018) studied the effect of video The findings of the present study can be used in various clinical, ed-
games and playing with toys on pain during burn dressing change in ucational, managerial, and research fields. Nurses, as one of the most ef-
preschool children. They found that there was a significant difference fective members of the treatment team, have a significant role in
between these groups and the control group in the mean score of pain relieving children's pain and can use the benefits of these two methods
intensity, body temperature, heart rate, and breathing. Therefore, as a complementary treatment or alone to reduce children's pain during
methods of distraction in the form of video games and playing with the burn dressing changes. According to the results of the present study,
toys were effective in reducing physiological responses and the pain in- audiovisual distraction can be introduced as an effective treatment in
tensity during burn dressing change in preschool children (Abd Allah reducing pain and changes in physiological indicators of children to
et al., 2018). Brown et al. (2012) also found that interventions through nursing students, nurses, and all members of the treatment staff. Be-
distraction methods significantly reduced pain, fear, and anxiety of the sides, the findings of this study can be a guide for planners and officials
children during dressing change (Brown et al., 2012). to use these techniques as two inexpensive and affordable methods to
Landolt et al. (2002) examined the effect of the children's program avoid wasting time, money, and resources. Also implementing these
on the dressing pain of children. However, their findings were contrary methods and training them to the parents can be an effective step to-
to the results of the present study. They found that this intervention did wards improving the quality of life of children and improving society

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F. Cheraghi, A. Kalili, A. Soltanian et al. Journal of Pediatric Nursing xxx (xxxx) xxx

as much as possible. Also, the results of this study can be a way to con- Brand, K., & Al-Rais, A. (2016). Pain assessment in children. Anaesthesia & Intensive Care
Medicine, 20(6), 314–317.
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areas are rubbed with a cloth. Therefore, it is recommended that this cartoon distractions in the management of anxiety in children undergoing restorative
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The present study was conducted to compare the effect of visual and Khalil, N. S. (2018). Critical care nurses’ use of non-pharmacological pain management
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Besat Educational and Medical Center. The results of this study showed
Kim, J., Chiesa, N., Raazi, M., & Wright, K. D. (2019). A systematic review of technology-
that visual and auditory distractions could reduce the range of heart rate based preoperative preparation interventions for child and parent anxiety.
fluctuations, the percentage of oxygen saturation of arterial blood, espe- Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 66(8), 966–986.
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Elsevier Health Sciences.
aged 6–12 years. The visual distraction method had a greater effect on Landolt, M. A., Marti, D., Widmer, J., & Meuli, M. (2002). Does cartoon movie distraction de-
the pain and physiological indicators of the burn dressing than the audi- crease burned children’s pain behavior? 23(1). (pp. 61–65), 61–65.
tory distraction method. Therefore, nurses can use visual and auditory Liu, Y., Gu, Z., Wang, Y., Wu, Q., Chen, V., Xu, X., & Zhou, X. (2019). Effect of audiovisual
distraction on the management of dental anxiety in children: A systematic review.
distraction as a complementary medicine to drugs by considering the International Journal of Paediatric Dentistry, 29(1), 14–21.
child's need for comfort and convenience to reduce pain and physiolog- Mikaeili, N., Fathi, A., Kanani, S., & Samadifard, H. R. (2019). A comparison of distraction
ical indicators caused by dressing changes. Besides, the audiovisual techniques (bubble and cartoon) on reducing chemotherapy induced pain in children
with cancer. Iranian Journal of Cancer Nursing (IJCN), 1(1), 15–23.
distractions as inexpensive, efficient, and harmless methods of comple- Peate, I. (2019). Learning to care e-book: The nurse associate. Elsevier Health Sciences.
mentary medicine are easy to use by nurses and do not interfere with Pickering, G., Zwakhalen, S., & Kaasalainen, S. (2018). Epidemiology of pain in older peo-
other medical care. ple. Pain management in older adults (pp. 1–6). Springer.
Saberi, M., Fatemi, M. J., Soroush, M. R., Masoumi, M., & Niazi, M. (2016). Burn epidemiol-
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Sadeghi-Bazargani, H., Mohammadi, R., Ayubi, E., Almasi-Hashiani, A., Pakzad, R., Sullman,
Declaration of Competing Interest M. J. M., & Safiri, S. (2017). Caregiver-related predictors of thermal burn injuries
among Iranian children: A case-control study. PLoS One, 12(2), Article e0170982.
Saleh, A. H., & Hassan, P. F. (2019). The prophylactic effect of rectal diclofenac versus in-
In this study, there is no conflict of interest between the authors. travenous pethidine on postoperative pain after tonsillectomy in children. Ain-Shams
Journal of Anesthesiology, 11(1), 1.
Shih, S., & Rosen, P. (2018). Pain management for nasogastric intubation in pediatrics.
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