Parental holding to manage children’s anxiety with venipuncture: experiences from Qatar

ABSTRACT

Objective

The purpose of this randomized control trial with a pretest-posttest design was to compare the outcomes in one group of children (n = 56) being held upright in a comfortable position by a parent or family member during venipuncture procedures, with the second group of children (n = 51) lying flat (supine) on an exam table or bed.

Material and Methods

The three outcomes in both groups were: (a) The children’s behavior before, during, and after the venipuncture procedure using the distress scores measured with the Procedure Behavior Rating Scale (PBRS-R); (b) parent-reported satisfaction; (c) Nurses rated their satisfaction with the child’s position and reported the attempted number of needle-pricking attempts.

Results

The comfort position was more successful than the supine position in reducing the distress of venipuncture procedures. The satisfaction levels of the nurses and parents measured with quantitative and qualitative methods were contradictory. The number of needle-pricking attempts was not higher when using the comfort position.

Conclusion

Observational measurement found children less distressed in comfort than in the supine position. Responses to open-ended questions also suggested that the nurses and parents preferred the comfort position.

Introduction

It is vital to ensure that children undergoing painful procedures during acute or chronic medical treatment are provided with appropriate measures to minimize their suffering and promote their well-being (Pancekauskaitė & Jankauskaitė, 2018). Using needle or venipuncture procedures for blood work and intravenous (IV) cannulations could be perceived as potentially painful, emotionally challenging, and psychologically impactful experiences for children (Bisongi et al., 2014; Cavender et al., 2004; Ellis et al., 2004; McCarthy et al., 2010, 2014). The clinical implications of unmanaged needle insertion pain and distress in children include anticipatory fear or anxiety manifested by difficulties coping with future procedures (Kennedy et al., 2008).

Quality improvement projects in clinical settings are essential to determine the most effective management strategies to reduce the suffering of children experiencing traumatic clinical procedures (Fredrichsdorf & Weidner, 2016). Several documented projects reveal that numerous non-pharmacological strategies have been developed to reduce the pain and trauma associated with pediatric venipuncture. Pharmacological interventions (e.g., topical anesthetics) help minimize the pain of needle procedures but do not necessarily eliminate distress (Dastgheyb et al., 2018). Psychological interventions, including hypnosis and the distraction of a child’s attention (e.g., using video games and social interactions with parents or other children), may sometimes be effective tools to minimize distress (McCarthy et al., 2014; Piskorz & Czub, 2017; Uman et al., 2013).

Parental presence during venipuncture procedures is reputed to be an effective strategy to help manage the fears of some children during venipuncture procedures (Al-Eissa et al., 2015; Cavender et al., 2004). However, research findings are not conclusive regarding the role of parents because not all parents have the desire, or the ability, to provide adequate support to their children during medical procedures (McCarthy et al., 2014). Perhaps, for this reason, a less well-known strategy that may help to reduce pediatric stress during venipuncture is parental holding, also known as comfort positioning. This strategy has been developed in Western hospitals. It is rooted in research-based evidence, suggesting that parents who hold their children during the procedure may be more satisfied than parents who do not (Leahy et al., 2008; Sparks et al., 2007), due to an increase in child cooperation and decrease in symptoms of distress.

Pediatric venipuncture is associated with pain and emotional distress, and numerous non-pharmacological strategies have been developed to reduce the pain and trauma related to pediatric venipuncture. Parental holding or comfort positioning during venipuncture is a less well-known strategy that may help mitigate pediatric stress. The emphasis is placed on the specific positioning techniques employed, rather than solely on parents holding the children. Thus, quality improvement projects in clinical settings are essential to determine the most effective management strategies to reduce the suffering of children experiencing traumatic clinical procedures (Fredrichsdorf & Weidner, 2016).

The primary objectives of this study were to address the research questions below. These research questions are based on a previous study conducted by Sparks et al. (2007). In their study, a routine procedure in pediatric hospitals is described. Children are confined in this manner during painful medical procedures like venipuncture, despite the detrimental effects on the child’s distress and control.

RQ1:

What are the within-subjects effects of the two positions (comfort and supine) on the distress scores of the children, measured over time using the PBRS-R before, during, and after the venipuncture procedure?

RQ2:

What are the between-subjects effects of the two positions (comfort and supine) on the distress scores of the children, measured using the PBRS-R before, during, and after the venipuncture procedure?

RQ3:

What are the effects of the two positions (comfort and supine) on the levels of parent satisfaction, measured using a quantitative Likert scale after the venipuncture procedure?

RQ4:

What are the effects of the two positions (comfort and supine) on the levels of nurse satisfaction measured using a quantitative Likert scale after the venipuncture procedure?

RQ5:

What are the effects of the two positions (comfort and supine) on the number of needle-pricking attempts needed for the venipuncture procedure?

Methods and materials

Setting

The healthcare setting was the Pediatric Emergency Center (PEC) Al-Sadd (Hamad Medical Corporation) in Doha, Qatar. This center is one of the busiest PECs in Qatar, with 230,000 patients, ten triage beds, two urgent beds, and 42 observation beds. The healthcare staff includes about 200 nurses and 85 doctors. We utilized the context of routine pediatric care to understand better the effects of the outcomes of the two positions (comfort and supine) in a clinical setting.

Participants

The participants comprised 107 children who experienced venipuncture in the stated healthcare setting. The inclusion criteria were young males or females of age nine months to 6 years, categorized by observation as requiring non-urgent observational unit care, needing a blood draw or IV catheter placement in the presence of a parent or guardian who could give informed consent. The age group of 9 months to 6 years was selected because younger children may be more anxious and fearful of hospital procedures than older children (Koller, 2008). The families who agreed to participate were randomly assigned to Group C or S and signed research assent and consent forms. Group C was exposed to the comfort position, an evidenced-based intervention technique commonly used by child life specialists. Parents are taught to hold their children in their laps during venipuncture, nebulization, N.G. tube placement, and catheterization. Group S was exposed to the supine position, where the nurses restrained the children on the procedure table. The supine position was the most commonly used procedure at the PEC prior to the start of this trial. At a minimum, two nurses per venipuncture procedure were present per the clinical standard.

The study was elucidated to parents/guardians of qualified study participants (children) by research assistants who were trained in data collection, and their consent was obtained. The research assistants in question consisted of child life specialists, a nurse, and a physician. The parents were administered a concise pre-questionnaire following the provision of consent and preceding the procedure. This questionnaire was designed to elicit demographic information and general details pertaining to the child’s prior encounters with healthcare. The study participants, namely nurses and parents, provided their consent for their involvement in the research. The study’s participation details were communicated to the nurses via a consent form. Consent in both Arabic and English languages was provided to the parents. The Institutional Review Board (IRB) of the Hamad Medical Corporation approved the research. Each of the two nurses could voluntarily participate in the study by answering the questionnaire questions. According to IRB guidelines, nurses were informed of the study details and their voluntary participation through a research information sheet posted in the nurse’s station.

Sampling procedure

An open-level simple randomization procedure was used to randomly assign the 107 participants into Group C and Group S. The randomization procedure was conducted using the “Select cases…Random sample of cases… Approximately 50% of cases” procedure in IBM SPSS v.24.0, as described by Field (2013).

Instruments and data collection

The following instruments were used to collect the outcome measures:

Procedure Behavior Rating Scale (PBRS-R). The PBRS-R is a widely recognized instrument for assessing pain, anxiety, and fear in pediatric patients undergoing medical interventions. The scale’s psychometric properties have been demonstrated to be sound, as evidenced by its strong reliability and validity (Katz et al., 1982). Specifically, the scale exhibits high inter-rater reliability and a robust association with other indices of psychological distress. The PBRS-R has been employed in diverse clinical contexts and research investigations to evaluate the efficacy of interventions to mitigate procedural distress among pediatric patients.

The researcher measured the distress scores of children before, during, and after blood draw or IV placement using the PBRS-R scale (Katz et al., 1982). This scale measures 11 symptoms of distress, including crying, clinging, screaming, pain, refusing, and muscular rigidity. The purpose of a scale is to measure a complex, multifaceted human behavior, feeling, attitude, or action using a single score (Boeteng et al., 2018). During the procedure, behaviors are evaluated and categorized as present or absent across three distinct periods. According to Sparks et al. (2007), the total score for the PBRS-R can range from 0 to 33, with higher scores indicating a greater degree of distress. The PBRS-R assessment tool has been employed in evaluating individuals across a wide age range, from 7 months to 20 years. The interrater reliability of this study is 0.93. According to Sparks et al. (2007), research has demonstrated a significant correlation between the scale range of 0.81–0.93 and other indicators of behavioral distress, such as self-report.

Parent questionnaire (quantitative)

Parents self-reported their satisfaction level immediately following the venipuncture procedure using a 5-point Likert scale. The questions were: 1. “How satisfied are you with how your child was held/your child’s position during the procedure? 2. “How satisfied are you with the staff’s intervention to help you calm your child during the procedure?” 3. “How satisfied are you with your child’s level of anxiety during the procedure?” These items were also acquired from the Parent Perceptions of Specialty Care assessment tool created by Naar-King et al. (2000).

Parent questionnaire (qualitative)

The parents provided narrative answers to the open-ended questions 1. “Do you have any comments you would like to share about how your child was held/the position of your child during the procedure?;” and 2. “Do you have any comments about the questionnaire or the study?”

Nurse questionnaire (quantitative)

Nurses self-reported their satisfaction level immediately following the venipuncture procedure using a 5-point Likert scale. The nurses also reported the number of needle-pricking attempts during the venipuncture procedure on each child and a “Yes” or “No” response to the question “, Did your technique need to be altered due to the position used for the child.” These items were also acquired from the Parent Perceptions of Specialty Care assessment tool created by Naar-King et al. (2000).

Nurse questionnaire (qualitative)

The nurses provided narrative answers to the open-ended question, “Do you have any comments about the position used for the child?”

Language considerations

Of note, all parent and nursing questionnaires and assent and consent forms were provided in Arabic and English as per the official languages used within the clinical setting. The research team consisted of Arabic and English-speaking members.

Safety considerations

Doctors ordered the venipuncture procedure while the children were admitted to the observation unit, thus allowing time to conduct this trial under non-urgent care. The families were given at least 30 minutes to read and complete the consent form. Following standard clinical practice, all the children received a topical anesthetic (EMLA®; AstraZeneca Pharmaceuticals L.P., Wilmington, Delaware), applied 30 minutes before the venipuncture procedure for pharmacological pain management.

Data analysis

The quantitative data were analyzed using SPSS v. 24.0. The associations between the definite characteristics of the children (position, age, gender, and race) were estimated using Chi-Square tests. A repeated-measures ANOVA model was used to estimate the within-subjects effects of time and the between-subjects-effects of Group C vs. Group S on the three continuous level PBRS-R ratings to measure the levels of distress of the children. The Greenhouse-Geisser correction was applied because the data violated the sphericity assumption. The self-reported satisfaction levels of the parents and nurses of the children in Group C vs. Group S immediately following the venipuncture procedures (measured with 5-point Likert scales) and the frequencies of the number of IV/blood draw attempts needed for Group C vs. Group S (measured using a 10-point scale) were compared using Z tests for the comparison of two median scores. The extent to which the nurses needed to alter their technique due to the child’s position, based on a “Yes” or “No” answer, was examined using Z tests to compare two proportions. The strengths of the associations between the definite characteristics of the children were estimated by Cramer’s V. The interrater reliability of this study was 0.93. The effects of the child position on the continuous level PBRS-R ratings were estimated using η2. The effects of the child’s position on the ordinal scores were estimated by the Z statistic divided by the sample size (N = 107). The interpretation of the effect sizes was ≤ 0.04 is negligible, whilst ≥ 0.041 is the recommended minimum effect size representing a practically significant effect (Ferguson, 2009). A content analysis of the emergent themes extracted from the narrative answers to the open-ended questions was conducted. The frequencies of each theme were computed. The results of the content analysis of the qualitative data were compared and contrasted with the results of the statistical analysis of the quantitative data.

Results

Participants

After excluding three participants who provided missing values, the sample consisted of N = 107, randomly assigned to Group A: Comfort Position (n = 56) and Group B: Supine Position (n = 51). Table 1 summarizes the frequencies of the definite characteristics of the children, who ranged in age from 9 months to 6 years. The positions of the children during venipuncture were closely associated with their age (χ² (6) = 13.02, p = .043; Cramer’s V = .349). The frequencies of the youngest children (less than two years old) were more significant in Group C (comfort position) than in Group S (supine position). The within-subjects and the between-subjects effects, including the age of the children on the PBRS-R scores, were examined using ANOVA. The gender and age of the children were included in the model as covariates (per the results in Table 2). The reported conclusion was “ … we found no systematic relationship between the children’s ages and their levels of distress using the PBRS-R scale.”

Table 1. Characteristics of children.

Characteristic	Category	Group C: Comfort Position (N = 56)		Group S: Supine Position (N = 51)		Total (Group C and Group S) (N = 107)
		N	% Within-group	n	% Within-group	n	% Within group
Gender	Female	30	53.6	19	37.3	49	45.8
	Male	26	46.4	32	62.7	58	54.2
Age (years)	0.75 to 1	11	19.6	5	9.8	16	15.0
	1 to 1.9	16	28.8	8	15.7	24	22.4
	2	12	21.4	11	21.6	23	21.5
	3	9	8.9	5	9.8	14	13.1
	4	5	7.9	10	19.6	15	14.0
	5	2	3.6	9	17.6	11	10.3
	6	1	1.8	3	5.9	4	3.7
Nationality	Algerian	1	1.8	1	2.0	2	1.9
	Bangladeshi	1	1.8	0	0.0	1	0.9
	Beninese	0	0.0	1	2.0	1	0.9
	Egyptian	7	12.5	4	7.8	11	10.3
	Emirati	1	1.8	0	0.0	1	0.9
	Filipino	12	21.4	3	5.9	15	14.0
	French	1	1.8	0	0.0	1	0.9
	Indian	10	17.9	17	33.3	27	25.2
	Indonesian	1	1.8	0	0.0	1	0.9
	Jordanian	0	0.0	1	2.0	1	0.9
	Lebanese	1	1.8	0	0.0	1	0.9
	Nepalese	0	0.0	1	2.0	1	0.9
	Pakistani	8	14.3	4	7.8	12	11.2
	Qatari	8	14.3	7	13.7	15	14.0
	Sudanese	2	3.6	2	3.9	4	3.7
	Saudi	1	1.8	0	0.0	1	0.9
	Sri Lankan	0	0.0	5	9.8	5	4.7
	Syrian	2	3.6	1	2.0	3	2.8
	Turkish	0	0.0	1	2.0	1	0.9
	Tunisian	0	0.0	2	3.9	2	1.9
	Yemeni	0	0.0	1	2.0	1	0.9
Race	African	8	14.3	8	15.7	16	15.0
	Asian	47	83.9	42	82.4	89	83.2
	European	1	1.8	1	2.0	2	1.9

Table 2. Within-subjects and between-subjects effects on the PBRS-R ratings.

Effects	Variables	df	F	p	Effect Size
Within-Subjects	Time	2	19.28	<.001	.159
	Time x Child Position	2	22.19	<.001	.179
	Time x Gender	2	.005	.995	.000
	Time x Age	2	0.34	.714	.003
Between-Subjects	Child Position	1	21.09	<.001	.191
	Gender	1	3.26	.074	.031
	Age	1	1.31	.255	.011

The proportions of male and female children were approximately equivalent in each group. The positions of the children were not dependent on their gender (χ² (1) = 2.86, p = 0.091; Cramer’s V = 0.164). A total of 21 nationalities representing African, Asian, and European races were included. Most participants’ dominant culture/religion was Islam (n = 59, 54.8%). The positions of the children were not dependent on their race (χ² (2) = 0.047, p = .977; Cramer’s V = 0.021).

Procedure Behavior Rating Scale (PBRS-R)

Table 2 presents the within-subjects effects, reflecting that the mean PBRS-R scale changed over time (before, during, and after the procedures) with a practically significant effect size; however, the age and gender of the children were found to have negligible effects on the changes in the ratings over time. An interaction between time x child position was found, with a larger effect size, reflecting its practical importance. The changes in the PBRS-R scale over time depended on whether the children were in the comfort or supine position. Figure 1 displays the structure of this interaction. Before and after the venipuncture procedures, the PBRS-R scores for the comfort and supine positions were equivalent. During the procedures, the PBRS-R scores for the supine position exceeded the PBRS-R scores for the comfort position, implying that the children in the supine position experienced the most distress.

Figure 1. Interaction between time x child position on the PBRS-R ratings.

Table 2 also presents the between-subjects effects, reflecting that the positions of the children had a practically significant effect on the PBRS-R scale. Figure 2 shows that the mean distress ratings were over 1.6 times higher among the children in the supine position than the children’s ratings in the comfort position. Figure 3 shows that differences in the gender and ages of the children across the range of 9 months to 6 years appeared to have negligible effects on the variance in the PBRS-R scale. The PBRS-R measures a unidimensional factor of multiple interrelated symptoms (including crying, clinging, screaming, pain, refusing, and muscular rigidity). The scores for the 11 items in the PBRS-R are aggregated to operationalize a single complex symptom (i.e., distress). The 11 individual item scores in the PBRS-R cannot be separated into mutually exclusive symptoms because they are all inter-correlated. Because the contribution of each item to the PBRS-R is assumed to be equivalent, it was impossible to split the scale-up into 11 separate items or comment on which items of the PBRS-R were affected.

Figure 2. Differences in PBRS-R ratings by comfort vs. supine positions.

Figure 3. Differences in PBRS-R ratings by age (years) and gender.

Parent questionnaire (quantitative)

Table 3 compares the scores for the three questions used to measure the parents’ self-reported satisfaction levels immediately following the venipuncture procedures in Group C and Group S. The results of the Z tests indicated that the child position had negligible effects on the satisfaction levels of the parents.

Table 3. Effects of child position on the median scores for the parents’ perceived satisfaction levels.

Question	Grouped Median		Z	p	Effect Size
	Group C: Comfort Position (N = 56)	Group S: Supine Position (N = 51)
1. How satisfied are you with how your child was held/the position of your child during the procedure?	3.81	3.76	−0.62	.535	.005
2. How satisfied are you with the staff’s intervention to help your child during the procedure?	3.76	3.74	−0.28	.777	.007
3. How satisfied are you with your child’s level of anxiety during the procedure?	3.57	3.33	−1.63	.102	.000

Nurse questionnaire (quantitative)

Tables 4 and 5 compare the scores for the three questions used to measure the self-reported perceptions of two nurses of Group C and Group S regarding their satisfaction levels, whether their technique needs to be altered due to the position used for the child, and the number of IV/blood draw attempts needed. The results of the Z tests indicated that the child’s position had negligible effects on the perceptions of both nurses.

Table 4. Effects of child position on the perceptions of the first nurse.

Question	Grouped Median or Proportion		Z	p	Effect Size
	Group C: Comfort Position (N = 56)	Group S: Supine Position (N = 51)
1. Please rate your satisfaction level with the child’s position for the IV insertion and/or blood draw	4.33	4.78	−1.28	.200	.011
2. Did your technique need to be altered due to the position used for the child?	n = 9, 8.4%	n = 4, 3.7%	1.36	.241	.012
3. Please state the number of IV/blood draw attempts needed	1.28	1.28	−.037	−.970	.000

Table 5. Effects of child position on the perceptions of the second nurse.

Question	Grouped Median or Proportion		Z	p	Effect Size
	Group C: Comfort Position (N = 56)	Group S: Supine Position (N = 51)
1. Please rate your satisfaction level with the child’s position for the IV insertion and/or blood draw	3.77	4.23	−1.28	.200	.011
2. Did your technique need to be altered due to the position used for the child?	n = 8, 7.5%	n = 4, 3.7%	1.07	.284	.002
3. Please state the number of IV/blood draw attempts needed	1.26	1.27	−.009	.993	.000

Parent questionnaire (qualitative)

Sixteen of the parents provided useable narrative responses to the open-ended questions: “Do you have any comments you would like to share about how your child was held/the position of your child during the procedure;” Table 6 presents a content analysis of the themes that emerged from the responses. Most parents preferred the comfort position because it was more comfortable for the child, improved the child’s safety, and reduced the child’s anxiety.

Table 6. Content analysis of parents’ responses to open-ended question (N = 16).

Question	Theme	Frequency
		n	%
Do you have any comments you would like to share about how your child was held during the procedure”?	Comfort position is preferred	9	8.4
	Supine position is preferred	3	2.8
	Comfort position is more comfortable for child	2	1.9
	Comfort position improves safety of child	1	0.9
	Comfort position reduces anxiety of child	1	0.9

Nurse questionnaire (qualitative)

Fifty-six nurses provided useable narrative answers to the open-ended question: “Do you have any comments about the position used for the child.“Table 7 presents a content analysis of the themes that emerged from the responses. Most nurses prefer the comfort position because it reduces the child’s anxiety, mainly if the child and parent are cooperative and particularly suitable for small babies.

Table 7. Content analysis of nurses’ responses to open-ended questions (N = 56).

Question	Theme	n	%
Do you have any comments about the position used for the child”?	Comfort position is preferred	34	31.7
	Supine position is preferred	14	13.1
	Supine position is preferred if child is not cooperative	2	1.9
	Comfort position is preferred if parent/child are cooperative	2	1.9
	Comfort position reduces anxiety of parent/child	2	1.9
	Comfort position is preferred for small babies	2	1.9

Discussion

The comfort position involving the parental holding of a child in an upright posture appeared to be more successful than the supine position in reducing the distress of venipuncture procedures among the sample N = 107 children in the PEC in Qatar. Based on an inferential statistical analysis of the PBRS-R scale, the within-subjects effect was that the children were most distressed during the procedure but less distressed before and after the procedure. The between-subjects effect was that children were less distressed in comfort than in the supine position. The content analysis results of the responses to open-ended questions also suggested that the nurses and parents preferred the comfort position mainly because it helped reduce the children’s anxiety. These findings were consistent with previous research in Western hospitals, concluding that children tend to be less fearful about receiving a needle procedure if they are sitting up than when lying down (Lacey et al., 2008; Sparks et al., 2007). However, we found no systematic relationship between the children’s ages and their levels of distress using the PBRS-R scale. This finding was not consistent with other researchers who reported that pediatric distress levels vary with age (Koller, 2008) and that due to the unique needs of each age group, the age of the child must be factored into the choice of comfort method (Dastgheyb et al., 2018).

The difference between the two positions (comfort vs. supine) appeared to have a negligible effect on the levels of parental satisfaction measured using a quantitative Likert scale after the venipuncture procedure. However, among the parents who answered the question, “Do you have any comments you would like to share about how your child was held during the procedure”? The most frequent response was that comfort positioning was preferred. The qualitative data (but not the quantitative data) were consistent with previous research in Western hospitals, concluding that parents who hold their children during the venipuncture procedure may be more satisfied than those who do not (Leahy et al., 2008; Sparks et al., 2007).

The difference between the two positions (comfort vs. supine) appeared to have a negligible effect on the levels of nurse satisfaction measured using a quantitative Likert scale after the venipuncture procedure. However, among the nurses who answered the question, “Do you have any comments about the position used for the child”? “The most frequent response was that the comfort position was preferred. The qualitative data (but not the quantitative data) were consistent with previous research in Western hospitals, concluding that nurses are more satisfied by the comfort position (Sparks et al., 2007).

The difference between the two positions (comfort and supine) appeared to have a negligible effect on the number of needle-pricking attempts needed for the venipuncture procedure. This finding was consistent with previous research in Western hospitals, concluding that the comfort position does not alter the number of venipuncture attempts needed (Sparks et al., 2007).

Limitations

Many validity issues limit the conclusions that can be drawn from trials examining interventions to reduce needle-related pain and distress in children. The methodological rigor of such trials needs to be improved before guidelines can be developed for clinical practice (Birnie et al., 2014; Oliveira et al., 2017).

The nurses’ self-reported data in our trial was questionable. Choi and Pak (2005) identified 48 sources of response bias in self-reported questionnaire data administered in clinical settings. Some nurses may exhibit a self-positivity bias when responding to self-report questions, potentially aiming to portray themselves and their healthcare organizations in a positive light (van de Mortel, 2008, p. 40). Physiological responses, including increased heart rate, blood pressure, and stress hormones (e.g., salivary cortisol), maybe more accurate measures of pediatric distress than perceptions of nurses (Oliveira et al., 2017).

The qualitative and quantitative data were not equivalent concerning the satisfaction levels of the parents and nurses. This discrepancy may have arisen because satisfaction is an extremely difficult dynamic to measure in clinical settings (Berkowtiz, 2016). Patient satisfaction surveys conducted in clinical settings are often unreliable due to biased responses, resulting in a distortion of the results and threatening the evaluation of the quality of healthcare (Burroughs et al., 2015; Dunsch et al., 2018).

Cultural issues may also have biased the results. The effects of authoritarianism may have biased the freedom of speech of some Muslim respondents, especially women (Al-Amer et al., 2018; Benstead, 2018). The data may have been contaminated by acquiescent response bias, a cultural communication style common among some Arab respondents who may, for a variety of complex psycho-social reasons, provide agreeable answers to questions, irrespective of whether or not they agree in reality (Baron-Epel et al., 2010; Harzing, 2006; Smith, 2004).

Our conclusions may have limited external validity because the data were collected from a relatively small number of children, their parents, and nurses in one clinical setting (the PEC at Al-Sadd in Doha, Qatar). The child participant age range of 9 months to 6 years also did not capture the full pediatric range receiving venipuncture in our emergency center (birth to 14 years.) Our conclusions may not be generalizable to all other clinical settings in Qatar or elsewhere.

Some caution is warranted when interpreting the p values in this study. The sample sizes are small overall, which could raise the possibility of false positives or negatives. There is also the possibility that the results might not apply to other medical procedures or other techniques, as the study solely examines two venipuncture positions. Moreover, whether these positions have long-term advantages or disadvantages is unknown, as the study design primarily examines short-term results. Lastly, readers should remember that the findings should be interpreted cautiously due to the possibility of bias in the study, including measurement or selection bias.

Due to these limitations, more objective evidence is suggested before we recommend that the comfort position be used at all times and in all clinical settings to reduce the distress of children experiencing venipuncture. We recommend more research before guidelines can be developed for clinical practice.

Recommendations for future research

Additional research is required before the use of parental holding to manage the distress of children undergoing venipuncture procedures can be universally recommended in all clinical settings. Because of its limitations (e.g., the inability to obtain reliable results for parental and nurse satisfaction and the likelihood of biased responses to the self-report questionnaire), we suggest enhancements to strengthen the study design and results should the study be repeated elsewhere. For future research, we recommend a phenomenological approach underpinned by a sound theoretical domains framework, specifically the COM-B model. This model explains how the enablers and barriers to Capability (C), Opportunity (O), and Motivation (M) interact to generate effective Behavior (B) in the context of healthcare. The COM-B model has been previously applied in healthcare settings to predict the need for facilitating interventions that reinforce the enablers and overcome the barriers to pediatric care (Alexander et al., 2014; Cassidy et al. (2019).

In the context of the recommended future research, the target behavior is parental holding associated with other modalities of parent-child interaction during pediatric venipuncture. Capability refers to the variable cognitive and physical abilities and skills of nurses, children, and their parents to engage in the necessary tasks to facilitate effective parental holding. Opportunity refers to the factors that prompt or make the target behavior possible. A nurse or a parent may be exposed to two types of opportunities: physical or social. Physical opportunities include training for nurses, parents, and their children to support parental holding. Concerning motivation, it may be possible to distinguish between (a) reflective processes (e.g., the enthusiasm of nurses, parents, and their children for the comfort position, based on previous experiences) and (b) automatic processes (e.g., the a priori perceptions, emotions, and impulses arising from innate dispositions).

We recommend that future research underpinned by the COM-B model involve collecting qualitative data from a representative sample of stakeholders (clinicians, nurses, parents, and children with or without experience in pediatric venipuncture) through in-depth interviews and focus groups. An integrated phenomenological analysis of the saturated qualitative data may (or may not) provide evidence-based conclusions leading to policy decisions that may (or may not) promote the superiority of the comfort position over the supine position during pediatric venipuncture in clinical settings.

It is relevant to add that automated digital technologies in the informatics arena are emerging to screen the levels of distress in patients in clinical settings through a single score recorded on a computer (e.g., Rana et al., 2019). Novel technologies may ultimately replace old-fashioned screening tools, such as the PBRS. So it will no longer be necessary for a person to complete a questionnaire with multiple items in order to operationalize a single distress score. An additional recommendation for future research is that digital technologies, rather than the tools such as the PBRS, could potentially be implemented to screen the levels of distress among children undergoing acupuncture and other distressing clinical procedures.

Implications for practice

The results of this study have many implications for practice, namely that parents or caregivers should be offered the option to hold their children during venipuncture. Despite a negligible effect on nurse and parent satisfaction and the number of times venipuncture needed to be attempted before success, both participants identified that the comfort position was preferred. For this reason, parents should be allowed to hold their children in a comfortable position at their discretion. More research will lead to best practices and opportunities for continuous improvement and provide longitudinal data that may support these implications. The effect of the number of needed attempts for successful venipuncture not being affected by using the comfort position is consistent with the literature (Leahy et al., 2008; Sparks et al., 2007). Seminal research suggests that some parents do not wish to be present, even though their presence can effectively comfort their child (Al-Eissa et al., 2015; Cavender et al., 2004). Exploring the efficacy of this intervention may help these parents decide the best course of action if they are allowed to hold their child simultaneously. However, it is important to consider that parents must be able to remain calm, despite having to bear witness to their child enduring pain. More research is needed to understand better how to make parents comfortable while being present while holding their children during venipuncture.

It is further possible that the option to hold a child during venipuncture may not always be present, and these parents should be provided alternative means for comforting their children. Exploring other options for comforting a child during venipuncture will help uncover an acceptable approach for parents who do not prefer to do so, parents, who do not have the skills to do so, and in conditions when doing so would not be appropriate. The holding positions were preferred by other parents, which was evident in the present study and further supported in the literature. The culmination of this research highlights that parental presence is an effective strategy for reducing distress in children during venipuncture (Al-Eissa et al., 2015; Cavender et al., 2004). Allowing parents to be present during venipuncture would allow researchers to explore the effect of parental presence. Future research can examine how offering a holding position to hesitant parents can influence their desire to be present and build upon the limited quantitative and qualitative data regarding parental presence. Additional research in this area will establish benchmarks for continuous improvement and inform best practices for doctors, nurses, and parents involved in venipuncture.

Acknowledgments

Open Access funding provided by the University of Luxembourg

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Funding

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