Children regularly experience fear, anxiety, distress, and pain as a part of routine and episodic healthcare (Author & Wyatt, 2017). In fact, evidence suggests that poor management of discomfort does not discriminate based on age, gender, race, or socioeconomic status and it can lead to future negative physical and psychosocial outcomes including depression, anger, insomnia, poor concentration, and future distrust of health care providers (Czarnecki et al., 2011). Nurses caring for infants, children, and adolescents have a unique but complex responsibility to provide what Kolcaba (2013) calls holistic comfort- an immediate experience of being strengthened through feeling relief, ease, and transcendence. For nurses to provide optimal holistic comfort, a focus on developmentally appropriate interventions must be implemented.
Background
One unique aspect of pediatric holistic comfort is the necessary consideration of child development. Given the wide range of cognitive, emotional, physical, and neurological growth as well as the effects of various diseases leading to delays in this growth, children require holistic comfort needs to be met in a way that is developmentally appropriate to them as an individual. According to Piaget (1964; 1972), humans belong to one of four stages of development as they grow from infancy to adulthood: (a) sensorimotor- birth to 24 months, (b) preoperational- age 2-7 years, (c) concrete operational- age 7-11 years, and (d) formal operational- from adolescence to adulthood. Piaget’s stages provide chronological guidance on human cognition- the ability to engage in object permanence, symbolic thought, operational thought, and abstract thought, respectively. Holistic comfort interventions in the pediatric population must be tailored to these developmental stages for optimal patient outcomes. There are four main contexts where holistic comfort exists: the physical, psychospiritual, sociocultural, and environmental domains (Kolcaba, 1994; Kolcaba, 2013; Kolcaba & DiMarco, 2005). Providing developmentally appropriate comfort in these contexts is important to caring for the whole child- mind, body, and spirit.
Purpose
The purpose of this session is to critically present an evidence-based collection of nursing pearls focused on the provision of developmentally appropriate holistic comfort for infants, children, and adolescents in Kolcaba's four comfort contexts.
Methods and Evaluation Strategies
For this symposium session, a critical appraisal of evidence related to developmentally appropriate pediatric holistic comfort interventions was conducted using the Johns Hopkins Nursing Evidence Based Practice Model of evaluation. The appraisal was guided by Kolcaba’s (1992; 1994; 2013) theory of holistic comfort with the aim of integrating theory into the clinical practice evidence appraised and presented. Evidence in this appraisal was found in CINAHL, PubMed, Google Scholar, and PsycINFO and includes seminal studies, seminal theory, and/or research conducted within the last 5 years. Both qualitative and quantitative research as well as international evidence was included.
Comfort Context Evidence Appraisal
Physical.
Evidence shows that infants, children, and adolescents benefit from a variety of interventions to enhance comfort of their physical bodies. Breastfeeding and swaddling for infants has demonstrated a reduction in pain during heel lancing procedures (Erkut & Yildiz, 2017; Zhu et al., 2015). Additionally, in a recent meta-analysis, authors showed topical anesthetics in combination with breastfeeding decreases painful responses to vaccine injections (Shah et al., 2015). Researchers have also investigated animal-assisted therapy on the bodies of children- showing that 20 minutes of play time with a dog yields lower pain scores, increased vigilance and activity, and induced emotional prefrontal responses on electroencephalogram after anesthesia (Calcaterra et al., 2015). Enhanced sleep comfort has also been shown in children with autism spectrum disorder after exposure to a brief education sleep intervention (Loring et al., 2016).
Psychospiritual.
Many interventions have outcomes on the psychospiritual domain of children. For instance, caregivers and children describe “clinician secrets” and having a “good nurse” as an important part of procedural holistic comfort (Author, Hall, & Devereaux, 2018. p. 114). Additionally, spirituality and spiritual education has been shown to increase resilience in children of divorced parents (Pandya, 2017) while pet therapy with a live dog has been shown to decrease: (a) distress in children during needle procedures (Vagnoli, 2014), and (b) stress in children undergoing a forensic interview for suspected child abuse (Krause-Parello et al., 2018).
Sociocultural.
One of the most essential sociocultural comfort practices in pediatrics involves consideration of the complete family unit. This is often referred to as family-centered care. The American Academy of Pediatrics (2015, p. 1451) defines a family-centered approach as one where care is coordinated in a compassionate way- forming links among the patient, family, healthcare provider, nurses, educators, hospitals, and other important collaborators. Children and caregivers have described social presence of loved people in a child’s life to be an important part of procedural holistic comfort (Author et al., 2018). Additionally, evidence shows that adolescents who have high family conflict and less social support at home, engage in more risky behaviors that negatively affect both themselves and their parents (Guassi, Moreira & Telzer, 2017).
Environmental.
Essential needs of infants, children, and adolescents exist in the environment. For example, infants in the neonatal intensive care unit are sensitive to harsh noise and have been shown to experience lower activity level, decreased heart rate, and decreased respiratory rate with recorded maternal voice and soft lullaby (Wirth et al., 2016). Additionally, children and caregivers have described the comforting effects of a decorated room, soft pillows, chairs around them, and being comfortably warm during times of venipuncture procedures (Author et al., 2018). Temperature reduction in a classroom of a tropical climate has also shown increased thermal comfort and performance enhancement of school-aged children (Porras-Salazar et al., 2018).
Implications and Conclusion
Providing developmentally appropriate holistic care in the pediatric population has the potential to be globally impactful. Comfort is an optimistic result that theoretically permits children and their families to take part in health seeking behaviors, which are good for nursing productivity, cost effectiveness, and overall patient outcomes (Kolcaba, 2013). Moreover, cognitive, emotional, and physical responses to discomfort are learned in childhood and can later affect responses to discomfort as an adult (Institute of Medicine, 2011). Hence, appropriate enhancement of holistic comfort in childhood is vital- having important implications for nursing practice, health policy, and future patient health outcomes. The strength of our future depends on the wellbeing our children (First Focus, 2018)- the same children who will be making up the future of world health in years to come.