This is a Clinical trial with control and intervention group, non-randomized (quasi-experimental), non-blind study. The study was carried out at Shahid Rajaee Hospital in Qazvin, Iran. The participants of the study consisted of all traumatized children and one of their parents (the father or mother who had more contact and provided much care for the child).
Sample size was determined at 95% confidence level with 80% test power and 102 participants (51 in each group). Finally, a total of 110 individuals were included in the study using available sampling method from 06 march 2018 to 21 April 2018. In order to prevent mixing of samples and data contamination, a 15- day interval between selection of control and intervention group was considered, as a result, 15 days after discharge of last sample of control group, the intervention group was sampled.
The participants’ inclusion criteria were as follows: age range of 10–18, hospitalization of a child due to a traumatic accident including crashes, car and motor vehicle accidents, limb fractures, multiple injuries, limb injuries, vein injuries, visceral injuries, burns and mild head injuries (GCS: Glasgow Coma Scale > 14), child hospitalization 3 days to one-month post-traumatic injury, score above 17 on the CRIES-8 questionnaire, and no evidence of parental abuse due to child injury. Parents’ inclusion criteria were: the ability to read and write in Persian, holding a high school diploma, the ability to use the internet, surf the web and handle electronic devices and the possession of no known mental or physical impairment. Exclusion criteria included: child death during the study, GCS decline, and change in child's level of consciousness after entering the study and unwillingness to the continuation of the study.
The instrument used in this study was a two-part questionnaire. The first part was a researcher-made demographic questionnaire that developed based on the literature review and under the supervision of pediatric nursing and psychiatric experts and included 12 questions about child and parent demographic information, parental access to the Internet, and their ability to use the internet; and the second part was the CRIES-8, which has 8 questions and two subscales; designed for use on children aged 8 years and older who are able to read independently and include 4 questions to measure Intrusion subscale and 4 questions to avoidance subscale are hence called it CRIES-8. Each question is scored using a 4-point Likert scale of zero (never) to 5 (most of the time) and the total score is obtained by summing the scores of each question. A score above 17 indicates a child with PTSD (20, 21).
To determine the validity, the questionnaires were distributed to 10 nursing faculty members and experts in psychiatric and pediatric nursing. In order to determine the reliability using Cronbach's alpha method, the total correlation coefficient was 0.91 and 0.8 and 0.65 for each of the avoidance and intrusion subscales, respectively.
The researcher referred to the research environment. The researcher first prepared a list of eligible patients using patient records and information obtained from nurses in the ward, and after explaining their study goals and their willingness to accept or reject participation with informed consent and written consent questionnaires, the participants were asked to complete a demographic questionnaire by a parent and the CRIES-8 questionnaire by a child. After determining the samples based on inclusion criteria, these questionnaires were considered as pre-test. The questionnaires were coded after completion. The participants were assured that their personal information and responses would remain confidential. The control group received no intervention other than the routine care provided by the research setting, but the intervention group received a four-week child and parent stress training course and psychotherapy online via the researcher website (www. PTSD- pediatric-nursing-care.ir). The educational content of the website was compiled and completed by the researcher and finally designed by a computer engineer under the supervision of the researcher. The website content included topics related to the definition of PTSD, its symptoms in the child, and how to treat the child and help him/her to improve mental health. After completing the design of website, in order to determine the content validity and final approval, it was reviewed by IT experts, pediatric and psychiatric nursing team members, as well as by an emergency medicine physician and a child psychologist; after that supplementary comments were applied to the structure and content of the site. The intervention group were trained for 4 weeks and then for two weeks the study samples were given time to influence the intervention. After the sixth week, the level of child stress was again measured by CRIES-8 in two groups and the results were compared. Post-test data were collected by the researcher through telephone, e-mail and, in some cases, in person.
Data were analyzed using descriptive (frequency, mean) and inferential statistics (chi-square, independent t-test, paired t-test) in SPSS V.22 software. Significance level was considered p < 0.05.