Physical health

Distraction strategies are use such as exercise, play, massage, music and complementary therapies with physical health outcomes.

Exercise in physical health: with respect to exercise there was a reduction in general fatigue (p=0.01), with a program of progressive aerobic exercises 2 to 3 times a week with a duration of 20 to 40 minutes over the course of 6 to 16 weeks in children and adolescents aged 14 to 18 years with a diagnosis of solid and liquid tumors ^10),_. Another study showed decreased fatigue (p=0.05), with aerobic exercise and progressive muscle relaxation for 15 minutes for 5 days, in children aged 8 to 18 years with a diagnosis of solid or liquid tumors ^23),_. Another study implemented the use of exercise alone or combined with leisure activities in sessions of 45 to 60 minutes for 7 days, in children and adolescents aged 3 to 18 years with solid and fluid tumors ^15). Other activities in this exercise strategy that were used were playing, brisk walking at intervals of 3 times a week combined with educational intervention ^21). Walking, running, jumping, and playing over the course of 12 weeks resulted in significant long-term decrease in nausea using exercise combined with psychosocial training in addition to decreased pain using exercise alone or combined ^(16).

Games in physical health: pain was reduced with the use of a mobile application in children and adolescents aged 12 to 18 years with a diagnosis of solid and liquid tumors ^17). Another study with the intervention of a robot that sings and dances while a nurse performed needle insertion in children and adolescents aged 4 to 9 years with acute lymphoblastic leukemia, lymphoma and brain tumor ^18)."

Massage in physical health : decreased heart rate (p=0.02) in children and adolescents under 14 years (¹²⁾. Another study that was used was massage therapy of 4 weekly sessions ¹⁵. The respiratory rate was also decreased with four sessions of effleurage massage, petrissage, compressions and frictions for 30 minutes ^14). Fatigue was decreased with the use of acupressure at the ST3 point traditionally associated with "energy" for 3 minutes ^15). Pain was minimized (p<0.05) with massage session for 10 to 15 minutes ^20)..

Music in physical health: studies showed decreased pain, during (p<0.001) and after (p=0.003) lumbar puncture , traditional Vietnamese songs were used using a portable music player with headphones 10 minutes before the procedure ^11-13. As well as decreased fatigue and increased functional status (p<0.05) with instrumental music played on an MP3 player with headphones, 15 minutes before bedtime combined with the sleep hygiene educational intervention ^22).

Complementary therapies in physical health: pain reduction (p<0.002) was found with the use of direct hypnosis or self-hypnosis training and the use of topical anesthesia in venipuncture ¹¹⁾ . It was identified that it minimized fatigue and pain with the use of healing touch by laying on hands with a duration of 40 minutes, a theory that states that, if an energy field is present, balanced and flowing properly it produces well-being ⁽¹². Other results showed that with the use of yoga, there was greater physical well-being, increased energy, decreased analgesics, decreased nausea, with moderate and high intensity regimens 4 to 5 times per week ^15). Physical functioning has also been increased with supervised yoga sessions 2 times a week lasting 12 weeks ¹⁶.

Psychological health

In this dimension, the use of exercise, play, massage, music and complementary therapies have shown results in the benefit of psychological health.

Exercise in psychological health: better emotional well-being has been shown with the use of running, longitudinal jumping and lateral jumping, also when combining exercise and educational intervention with sessions of three times a week, anguish (p<0.001), sadness (p<0.001), irritability (p<0.001), nervousness (p= 0.002) acceptance of body image (p = 0.008), improves the ability to concentrate (p<0.001) and improves sleep (p=0.020) ²¹.

Games in psychological health: there was a decrease in venous puncture distress with the use of the technology robot games ¹⁸. Other studies used (robot, video games, virtual reality) found decreased anxiety, anger, stress, fear and depression . In another study, depression was decreased with computerized interactive virtual space in children (p = 0.02) on day 7¹⁹_.

Massage in psychological health: Anxiety reduction identification (P <0.05) ^12),(15_. With the use of Swedish massage and acupressure in sessions of 20 to 40 minutes between 4 and 6 weeks, a decrease in depression was shown ¹⁴. Other research showed the use of massage, decreased anxiety (p<0.05) and greater emotional well-being after intrathecal therapy or bone marrow aspiration ²⁰.

Music in psychological health: the use of the music strategy produced decreased levels of stress, anxiety, fear, anguish, and depression; it allows self-care, greater relaxation, greater creativity and lucid hope; and anxiety was lower both before and after the procedures ⁽¹². In addition, with the use of music there was an improvement in treatment anxiety, worries and cognitive problems ¹⁶. Another study showed differences in sleep quality before and after the intervention (p <0.05) ²².

Complementary therapies in psychological health: hypnosis produced a decrease in anxiety and anguish during venipuncture; and when using hypnosis combined with a topical analgesic, anxiety was lower (p <0.001) in venipuncture ¹¹. With the use of yoga 4 to 5 times a week, anxiety, agitation, cognitive fatigue were minimized, there was greater quality of sleep and relaxation ¹⁵. Emotional function improves with yoga ¹⁶. In addition, the healing touch helped to reduce stress (p = 0.0001) ^12,15.

Social health

In this dimension, the use of exercise, play, music and complementary therapies have shown results for the benefit of social health.

Exercise in social health: The use of various physical exercise programs showed increased quality of life, when using physical activity of walking. Also with aerobic exercise (walking, running and playing) for 12 weeks increases quality of life and school functioning ¹⁶. This exercise distraction strategy increased quality of life levels by combining physical exercises based on adventure activities in conjunction with educational activities ⁽¹⁶.

Games in social health: the use of games with technology showed increased adaptive behaviors during the nurse's approach to the child (P = 0.012), palpation of the subcutaneous port by the nurse (P = 0.006) and the steps of "needle insertion" (P = 0.02) ¹⁸_. Similarly, greater adherence to treatment and quality of life were found when using the technology game ⁽¹⁷_.

Music in social health: Music during hospitalization or outpatient treatment promotes supportive relationships and helped bring the family closer together in their children's coping process ⁽¹³ . Another study using music therapy during and after hematopoietic stem cell transplantation showed increased generic quality of life score and communication ¹⁶_.

Complementary therapies in social health: yoga promoted adaptation to the hospital environment ¹⁵ and significant increase in total quality of life score, psychosocial, school functioning and social function ¹⁶_.

Immune health

Immune health is one of the fundamental aspects in the child and adolescent with oncological diagnosis. Using the strategy of therapeutic massage throughout the body with the techniques of effleurage, petrissage and circular movements in supine and prone position, there was an increase in white blood cells and neutrophils remaining for 30 days ¹⁴.

Exercise and its results in physical, psychological and social health

In physical activity, any movement produced by skeletal muscles that requires energy expenditure is associated with physiological and psychological health benefits. The Canadian Society of Exercise Physiology (CSEP), the American College of Sports Medicine (ACSM) and the World Health Organization (WHO) have published guidelines for physical activity and its link to health benefits. Physical exercise is a nursing NIC (0200) to maintain or improve physical condition and level of health ³_. exercise. It is a distraction strategy because it directs the attention of children and adolescents with an oncological diagnosis towards something more pleasant, fun and that encourages them to perform physical activities such as running, walking, cycling, swimming, gymnastics, among others; moving it away from undesirable situations typical of its diagnosis, procedures and oncological treatments ²⁴.

The exercise linked to Roy's Adaptation model acts as a contextual stimulus that favors the coping processes reflected in the results for the benefit of physical, psychological and social health, that is, when using the exercise, adaptation is generated to the oncological diagnosis as a focal stimulus. For the same reason, this distraction strategy must be promoted and used in daily practice by nursing to achieve the fullness of the pediatric oncological patient.

Games and its results in physical, psychological and social health

Games are a very rewarding and important activity for the child's development that allows him to experiment with his social and behavioral repertoire by practicing his physical and communication skills. Games facilitates the development of social competence, emotional abilities, resilience, creativity, and problem-solving skills ²⁵_. Games are NIC (4430), and are the intentional use of toys or other equipment to help the patient communicate their perception of the world and help their interaction with the environment ³_. It is a distraction strategy because it diverts the focus of attention from children and adolescents with an oncological diagnosis, allowing the reduction of the perception of pain, anxiety and improve their comfort in the oncological environment ²⁴.

Seus, A and their collaborators in their study mentioned that pediatric nurses can use games as a strategy because of their numerous advantages in hospitalization. The relief of anxiety, facilitates the care of the child in the hospital and becomes familiar with the unit and with the health professionals who assist him ⁽²⁶_.

Massage and its results in physical, psychological, social and immune health

Massage is a non-invasive therapeutic modality to control the side effects associated with cancer treatment in children and adolescents ²⁷ and is considered as a distraction strategy because it helps connect the body, mind and spirit as a natural healing process, because it produces therapeutic effects on multiple organ systems ⁽²⁸_. causes an increase in skin temperature, promotes relaxation, metabolic activity, the release of tissue adhesions and increased threshold of uptake of the nociceptive message ²⁹_. Massage is a NIC (1480), defined as stimulation of the skin and underlying tissues with varying degrees of manual pressure to decrease pain, induce relaxation and/or improve circulation ³_.

These effects are related to the findings of a randomized controlled trial design study, conducted in 2013 in Portugal by Da Cunha and Mota where massage was used as a strategy by nurses who used almond oil, in sessions of 20 to 30 minutes for 1 week, resulting in the decrease of pain interference with gait (p<0.05) and decrease in pain intensity ( p<0.001) in children and adolescents aged 10 to 18 years with a diagnosis of leukemias, lymphomas and sarcomas ⁽²⁹. Another important aspect before an oncological diagnosis is immune health. According to the evidence found in a study, it showed an increase in white blood cells and neutrophils remaining for 30 days; it was observed from the first day of the intervention, with the use of the therapeutic massage strategy throughout the body ¹⁴_.

Music and its results in physical, psychological and social health

Oncology is usually accompanied by other non-pharmacological therapeutic options such as music therapy that offers a multimodal and holistic approach, which allows to provide results in favor of health ³⁰. The first therapeutic use of music as a way to humanize health care was carried out in 1859 by nurse Florence Nightingale ⁽³¹_. In 1978, Munro and Mount described the application and efficacy of music therapy in oncology; those and other studies have described music therapy in this context ³⁰_. In nursing it is a NIC (4400), which helps to change behaviors, feelings or physiological condition, at the same time it has been described as an important distraction strategy³. In the present study we found 5 articles made by nursing that show results with the use of music for the benefit of physical, psychological and social health in oncological children and adolescents with a diagnosis of solid or liquid tumor in different stages; this is because music when occupying the channels of attention in the brain using significant auditory stimuli causes distraction. In addition, the use of music provides a comforting family stimulus to the patient, which can evoke pleasurable sensations while redirecting the focus of the individual's attention from stressful thoughts or other environmental stimuli, to music ²⁸_.

Similar results show this distraction strategy in a study published in 2019 in China by Haizhi Liu and collaborators who used music therapy for 30 minutes in children aged 10 to 21 years with a diagnosis of osteosarcoma evidencing decrease of pain, anxiety and higher sleep quality ³²_.

Complementary therapies and their results in physical, psychological and social health

Complementary therapies as a distraction strategy help to manage the side effects derived from diagnosis, treatments and oncological procedures constituting an important part of nursing care, invite the stimulation of the senses and sensory integration, which allows to correctly process sensory stimuli and generate adaptive responses ^33). In this research we found results of strategies that are also NIC such as hypnosis (5920) , healing touch (5465) and yoga (6040) ⁽³. According to E. Loeffen and collaborators, the use of hypnosis generates a state of consciousness similar to trance, which allows it to be very focused on images or ideas suggested or created; presenting results in the reduction of pain, anguish and fear ³⁴_.

The use of distraction and its results articulated with nursing knowledge from Callista Roy's Adaptation model, allow us to understand the phenomenon of distraction from its three abstract concepts, which contributes to the human adaptive system, reaching the goal or perspective of nursing in the process of promoting adaptation to different situations that arise with the oncological diagnosis.

According to the above, Callista Roy's conceptual model of nursing allows linking the concept of distraction with some of its concepts: stimuli, coping processes and adaptive modes, which are permanently interrelated. In the distraction we start from the fact that the nurse oncologist before an oncological diagnosis as a focal stimulus, seeks to promote adaptation through a contextual stimulus through the use of distraction strategies in children and adolescents with an oncological diagnosis, because Roy mentions that they have the ability to adjust effectively to changes in the environment. Therefore, with distraction as a stimulus, coping processes are promoted in the two cognitive and regulatory subsystems, which is evidenced in the health outcomes in the physical, psychological, social and immune dimensions, and thus, the adaptation of the child and adolescent to the disease process ^4)." Therefore, distraction strategies should be promoted and used in daily practice by nursing to achieve the well-being of pediatric cancer patients in undesirable situations.

Implications for practice, teaching and research

For practice, the nursing professional must take into account the results in the dimensions of health, to visualize them in the care identifying preferences and clinical condition of the pediatric patient, the duration, intensity, interval and follow-up of the diverse strategies of distraction. For teaching, the articulation of Roy's conceptual model with distraction strategies and their results in physical, psychological, social and immune health, evidences innovation and use of nursing knowledge in postgraduate training in the pediatric oncology area. For research, it provides useful results in practice. Future research should be oriented to the study of the effects of distraction strategies on immune health, due to the immunosuppression produced by the oncological diagnosis and its treatments bringing with it complications in health, long hospital stays and greater costs for the family and for the health system.