103 Development and evalutation of the Hospital Hero app 4 in reducing (pre)procedural distress in children. Parental involvement has even been considered an important moderator of pain perception and stress response (13). Research has shown that children experience more distress and more intense pain during medical procedures if their caregivers show certain distress-related behaviours, such as (unconscious) projection of own psychological distress, provision of reassurance, empathic comments and excessive explanations and apologies to their children, whereas use of humour and talking about topics other than the medical procedure are associated with increases in a child’s adaptive coping (33, 34). The Hospital Hero can support caregivers by acting as a conversation tool and introduce stress-reducing terminology (i.e. comfort talk) that they can use. Future developments should explore how to enhance parental guidance within the Hospital Hero app and take the moderating effects of parental involvement into consideration. Finally, three design opportunities can be identified: 1) tailored journey, 2) differentiation and 3) timing of engagement. Whereas the current Hospital Hero app is built of fixed steps and focused on blood drawing only, future developments should be focused on the possibility to tailor a child’s journey to the specific procedures involved. Second, the app’s content should be differentiated according to age and medical experience of children. Children between four and seven generally liked the app, found it engaging and fitted their problem-solving skill levels. To appeal to older children it is important to differentiate in age and include more challenging activities (35). Use of, for example artificial intelligence, could be useful in tailoring and deriving the content to the knowledge level of each individual child, as applied to the ‘Xploro’ platform (14). Third, the timing of when and how long to engage with the app should fit with the particular hospital visit. For example, there should be no additional distraction during the consultation and children should be distracted long enough during the waiting to reach optimal effects on anxiety levels. Implications for practice and research Our study demonstrated multiple critical moments outside of the consultation room where stress and anxiety are present (e.g. anticipation of pain, new environment), some which have been described before (36). Future comfort care strategies should look beyond the hospital walls and explore how to diminish the build-up of stress. This asks for nurses and doctors to be more mindful of the entire experience journey of their patients (e.g. the child’s preparations, expectations, and previous experiences). While this study took the patient journey of children visiting the Willem-Alexander children’s hospital as starting point, the Hospital Hero application was built in a modular way. This allows the app to be tailored to other hospitals and to be extended with additional preparation modules (e.g. preparation game for weighing and measuring or spirometry). A modular build is important to create a product that transcends the medical silos and prevents the introduction of an app for every specialism or medical procedure. In addition, the modular build supports scale-up potentials and the adaptation to other healthcare settings where children undergo
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