Essay

1Worldviews on Evidence-Based Nursing, 2019; 1–6. © 2019 Sigma Theta Tau International

Original Article

The Effect of Distraction Cards on Reducing Pain and Anxiety During Intramuscular Injection in Children Nejla Canbulat Şahiner, PhD ● Ayşe Sonay Türkmen, PhD

ABSTRACT Aim: The aim of the present study was to evaluate the effectiveness of distraction cards in re- ducing pain and anxiety during intramuscular (IM) injection in children aged between 6 and 11 years.

Methods: Sixty children were randomized into two groups, the distraction group and controls. The children in the distraction group viewed distraction cards during the procedure. The chil- dren in the control group were allowed to have their family nearby when the routine injection procedure was performed, but no distraction techniques were employed. Children’s Fear Scale was used to assess children’s anxiety levels. Pain levels were assessed using the Wong- Baker FACES pain rating scale via self- reports, which were completed by the children and also by the parents and observer.

Results: There were significant differences in the self-, parent-, and observer-reported pain and parent- and observer-reported anxiety levels between the distraction and control groups.

Linking Evidence to Action: Distraction methods, such as distraction cards, should be used as a nursing intervention to reduce pain and anxiety during IM injection in children. This study contributes to the literature on nonpharmacologic pain relief methods during IM injection in children.

INTRODUCTION One of the most extraordinary phenomena first ex- perienced in childhood is pain (Cohen et al., 2008; O’Rourke, 2004; Young, 2005). As such, pain is a qual- ity improvement measure in many hospitals and even considered as the fifth vital sign (American Academy of Pediatrics, Committee on Psychosocial Aspects of Child, Family Health, Task Force on Pain in Infants, Children, and Adolescents, 2001). Needle- requiring medical pro- cedures such as venipuncture and intramuscular (IM) injections are common and significant sources of pain for children that cause anxiety, distress and fear (Blount et al., 2009; Leahy et al., 2008; Uman, Chambers, McGrath, & Kisely, 2006). Pain experiences in infancy and childhood may result in long- term changes in phys- iologic and behavioral responses to pain (Anand, 2001). The American Academy of Pediatrics and the American Pain Society recommend that, wherever possible, stress and pain should be minimized or lessened, even in minor practices such as IM injection (American Academy of Pediatrics, Committee on Psychosocial Aspects of Child, Family Health, Task Force on Pain in Infants, Children, and Adolescents, 2001). Pain in children can result in

profound long- term physical and psychologic sequelae if it is not managed quickly and decisively. Therefore, knowledge of the importance of effective pain control in children is vitally important for physicians, nurses and other healthcare providers (Wong, Lau, Palozzi, & Campbell, 2012).

Pain management includes pharmacologic and non- pharmacologic approaches (Taddio et al., 2010). Different nonpharmacologic methods can be used in children to significantly decrease acute procedural pain (Pillai Riddell et al., 2011; Wente, 2013). Distraction techniques divert children’s focus from grievous stimuli and are very simple and effective methods of reducing stress and pain, and there are many methods and products associated with distraction (Koller & Goldman, 2012). Distraction cards (Flippits; see Figure 1) have recently been shown to be effective at reducing pain during phlebotomy (Canbulat, Inal, & Sonmezer, 2014; Canbulat Sahiner & Demirgöz Bal, 2015; Inal & Kelleci, 2012). The aim of the present study was to evaluate the effec- tiveness of distraction cards in reducing pain and anxi- ety during IM injection in children aged between 6 and 11 years.

Key words

pediatric nursing, pain management,

nursing practice, distraction

 

 

Worldviews on Evidence-Based Nursing, 2019; 1–6. © 2019 Sigma Theta Tau International

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The Effects of Distraction on Pain

METHODS Study Design This prospective randomized clinical study was undertaken in the injection unit of Karaman National Hospital, Turkey. The study aimed to evaluate the effects of distraction cards on pain and anxiety levels of children during IM injection.

Setting and Samples The study population comprised of children aged 6–11 years undergoing IM injection. The study sample size was deter- mined using a literature- based power analysis (Canbulat et al., 2014; Inal & Kelleci, 2012), with a 1.5- point standard deviation for the experimental group and 2.0 for the con- trol group. With a power of 0.8 and an acceptable Type I α error size of 0.05, each group required 60 participants. The children were randomized into two groups, the distraction and control. All data were obtained through face- to- face interviews held after the injection with the children, their parents and the observer.

The current practice in our hospital in which this study was conducted involves nurses performing IM injections on an injection unit. Hospitals in Turkey do not routinely use pharmacologic or nonpharmacologic methods to reduce pain and anxiety during IM injections. Parents are permit- ted to be with their children during IM injections, but this is not a requirement. In the present study, parents from both groups stayed with the children during IM injections.

Ethical Considerations Selcuk University Medical Faculty’s Ethics Committee gave approval for the study (2015). The aim and method of the study were outlined for the children and their parents. They were also told that they were under no obligation and that they could leave the study anytime without having to give any reasons.

Measurement and Instruments The distraction cards (MMJ Labs, Atlanta, GA, USA) were 5- ×- 8- cm visual cards with a variety of pictures and shapes. The children were first allowed to explore the cards. The researcher then asked the children questions about objects that appeared in the cards. The distraction procedure com- menced immediately prior to the IM injection and con- tinued until completion. An expert who is fluent in both languages conducted a translation and back translation of the instrument because the children were not native English speakers.

The children in the control group were allowed to have their family nearby when the routine injection proce- dure was performed, but no distraction techniques were employed.

Pain levels were assessed using the Wong- Baker FACES® (WB- FACES) pain rating scale via self- reports, which were completed by the children, parents and observer. The WB- FACES scale is a 0–10 scale with six illustrated faces ranging from a happy face (0 = very happy/no pain) to a sad, crying face (10 = very painful). Children’s Fear Scale (CFS) was used to assess children’s anxiety levels. CFS is a 0–4 scale, again with illustrated faces (five) ranging from a neutral expres- sion (0 = no anxiety) to a frightened face (4 = extreme anxiety). Preprocedural and procedural pain and anxiety were eval- uated for each child by the parents and researchers using CFS.

Data Collection and Procedure Two volunteer nurses with a minimum of 5 years’ expe- rience in pediatric patient care and IM injections were trained for and assisted in conduct of the study. The nurses had no conflict of interest. A pediatrician made the clinical decision for IM injection. Patient demographics were col- lected using the self- report forms; these included medical history, recent analgesic use and body mass index (BMI). Prior to the randomization, the researcher read a stand- ardized description of the pain and anxiety tools to the parents and children, both of whom acknowledged that they understood how to complete the measurement tasks.

The first nurse, who functioned as an observer, evalu- ated the preprocedural and procedural anxiety and pain for each child using the 0–4 CFS scale for anxiety and the 0–10 WB- FACES scale for pain. The second nurse performed all IM injections. Children’s anxiety levels were subsequently reviewed by the parents and observers. A total of 120 chil- dren were randomized using a computer- generated table of random numbers into two groups of 60 each. After the group assignment, the children and their parents went to the injection unit to undergo IM injection. IM injection ses- sions were held between 8 a.m.–12 p.m. and 12 p.m.–16 p.m. and performed using a 5- ml injector and a 22- gauge needle. The researcher conducted the distraction cards for all children. All parents stayed with their children in the in- jection unit. The distraction cards were used continuously

Figure 1. Distraction cards (Flippits; MMJ Labs, Atlanta, GA, USA).

 

 

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Original Article

prior to and during the IM injection. Children’s pain levels were assessed postprocedure using the same method used with anxiety levels.

Data Analysis All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 21.0 for Windows. Baseline characteristics among the groups and all parametric data were analyzed using the Chi- square test and Student’s t test. Statistical significance was set at p < .05.

RESULTS Comparison of the Groups One hundred twenty children (58 [48.3%] girls & 62 [51.7%] boys) comprised the study groups. The mean age of the children was 8.6 ± 1.4 years (range, 6–11 years). Children’s characteristics are shown in Table 1. Age, sex, BMI, injection area, administered drugs, time (sec) of total procedure and pre- injection anxiety levels of chil- dren were similar between the two groups. There were no significant differences in pre- injection self- , parent- and

observer- reported anxiety levels (p = .172, p = .381 & p = .255, respectively).

Comparison of Pain Levels Between the Groups The results of the IM injection pain level are shown in Table 2. There were significant differences in the self- reported pain levels between the distraction and control groups (p = .001); the distraction group (5.67 ± 3.50) had significantly lower pain levels compared with the controls (7.63 ± 2.77). Pain levels recorded by the par- ents of the distraction group were also significantly lower than those of the controls (p = .001). Similarly, the pain levels reported by the observer of the distraction group were also significantly lower compared with the controls (p = .007).

Comparison of Anxiety Levels The IM injection anxiety levels are recorded in Table 3. The anxiety levels noted by the observer were found sig- nificantly different between the groups (p = .003). The anxiety levels scored by the parents in the distraction group were significantly lower than those of the controls (p = .003).

Table 1. Baseline Characteristics and Preprocedural Anxiety Scores of the Study Groups

Distraction card group (n = 60)

Control group (n = 60) χ2 p

Gender

Female 28 (46.7) 30 (50) 0.133 .428

Male 32 (53.3) 30 (50)

Injection area

Right vastus lateralis 26 (43.3) 23 (38.3) .405

Left vastus lateralis 16 (26.7) 20 (33.3) 2.057

Right gluteal area 13 (21.7) 15 (25)

Left gluteal area 5 (8.3) 2 (3.3)

Administered drugs

Analgesic 27 (45) 21 (35) .530

Antibiotic 22 (36.7) 29 (48.3) 1.758

Antihistaminic 11 (18.3) 10 (16.7)

Age 8.90 ± 1.4 8.43 ± 1.3 1.822 .071

BMI 16.35 ± 3.0 17.30 ± 3.3 0.044 .834

Seconds of total procedure 8.07 ± 2.69 7.15 ± 3.14 1.713 .89

Preprocedural anxiety levels

Self- reported 1.87 ± 1.41 2.23 ± 1.51 −1.375 .172

Parent- reported 1.67 ± 1.47 1.90 ± 1.43 −.880 .381

Observer- reported 1.70 ± 1.41 1.98 ± 1.31 −1.143 .255

Notes. Data are represented as number (percentage) or mean ± standard deviation, where appropriate. BMI = Body mass index.

 

 

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DISCUSSION Pharmacologic and nonpharmacologic approaches should be used to control incidental pain and the resulting fu- ture sequelae that may result, as recommended by the American Society for Pain Management Nursing, which states that optimal pain control before and during pain- ful procedures must be provided. Distraction is one of the many interventions used for the reduction of pain and anxiety during medical interventions, and the cards have been found extremely effective (Canbulat Sahiner & Demirgöz Bal, 2015; Canbulat et al., 2014; Inal & Kelleci, 2012; Karakaya & Gözen, 2015; Mutlu & Balcւ, 2015; Schechter et al., 2007; Singh, 2012; Tüfekci, Celebioǧlu, & Küçükoǧlu, 2009). The methods used during medical procedures to divert the focus of attention, which are per- formed in various ways, include kaleidoscope (Karakaya & Gözen, 2015; Tüfekci et al., 2009), audiovisual distrac- tion (Cassidy et al., 2002), short story (Mason, Johnson, & Woolley, 1999), coughing and inflating balloons (Mutlu & Balcւ, 2015), music (Arts et al., 1994), and cartoons (Cerne, Sannino, & Petean, 2015). Recently, Inal and Kelleci (2012), Canbulat et al. (2014), and Canbulat Sahiner and Demirgöz Bal (2015) demonstrated that distraction cards (MMJ Labs) were very effective in children for reducing pain and anxi- ety in phlebotomy.

In this study, in parallel to the literature, distraction during IM injection in the card group was found to have sta- tistically significantly lower pain scores in the self- reported and parent scores compared with the control group. We also found that distraction cards were efficacious in reduc- ing pain and anxiety during IM injections in children aged between 6 and 11 years. This suggests that distraction cards might be effective in a variety of procedures that induce pain or anxiety, which should be tested in further studies using different age groups.

CONCLUSIONS Distraction cards significantly reduced the perception of pain and anxiety. Healthcare workers must keep in mind the im- portance of anxiety and pain generated during procedures— even simple procedures such as IM injection. Every step should be taken to decrease this anxiety and pain, especially in children for whom the use of distraction cards has been found very effective during IM injection. Further broader and repeat studies are needed to substantiate our results.

LINKING EVIDENCE TO ACTION

• Healthcare workers must keep in mind the importance of anxiety and pain generated during procedures, even simple procedures such as IM injections.

• Distraction methods, such as distraction cards, should be used as a nursing intervention to reduce the pain during IM injection in children.

• Distraction methods, such as distraction cards, should be used as a nursing intervention to reduce anxiety during IM injection in children.

• This study contributes to the literature on nonpharma- cologic pain relief methods during IM injections in children.

LIMITATIONS There are two significant limitations in the current in- vestigation. First, this does not constitute a double- blind research design because the researchers knew if a given child belonged to the experimental or control groups. To rectify any possible prejudice, the researchers may have

Table 2. Comparison of Procedural Pain Scores of the Study Groups

Procedural pain scores according to WB- FACES

Distraction card group (n = 60)

Control group (n = 60) t p

Self- reported 5.67 ± 3.50 7.63 ± 2.77 −3.416 .001

Parent- reported 4.37 ± 3.44 6.50 ± 2.89 −3.675 .000

Observer- reported 5.00 ± 3.58 6.63 ± 2.91 −2.742 .007

Note. Data are represented as mean ± standard deviation. WB- FACES = Wong- Baker Faces.

Table 3. Comparison of Procedural Anxiety Scores of the Study Groups

Procedural anxiety scores

Distraction card group (n = 60)

Control group (n = 60) t p

Parent- reported 1.73 ± 1.49 2.53 ± 1.35 −3.081 .003

Observer- reported 1.63 ± 1.61 2.47 ± .36 −3.070 .003

Note. Data are represented as mean ± standard deviation.

 

 

Worldviews on Evidence-Based Nursing, 2019; 1–6. © 2019 Sigma Theta Tau International

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Original Article

had both the nurses and parents evaluate the pain and anxiety levels, alongside children’s self- reports. Secondly, child’s experience of anxiety was assessed before the procedure but not while undergoing IM injection.

IMPLICATIONS FOR PRACTICE Pain experiences in infancy and childhood may result in long- term changes in physiologic and behavioral re- sponses to pain (Anand, 2001). Therefore, knowledge of the importance of effective pain control in children is vital for nurses and other healthcare providers (Wong et al., 2012). Hospitals in Turkey do not routinely use pharmacologic or nonpharmacologic methods to reduce pain and anxiety during IM injections. Previous studies used nonpharmacologic treatment methods such as au- diovisual distraction, short story, coughing and inflating balloons, and music to reduce the effect of painful proce- dures on children. WVN

Author information Nejla Canbulat Sa̧hiner, Associate Professor, Pediatric Nursing Department, Health Science Faculty, Karamanoglu Mehmetbey University, Karaman, Turkey; Ayse Sonay Türkmen, Associate Professor, Pediatric Nursing Department,  Health Science Faculty,  Karamanoglu Mehmetbey University, Karaman, Turkey

We are grateful to the subjects of this study for agreeing to participate in this study.

Address correspondence to Nejla Canbulat Sahiner, Pediatric Nursing Department, Health Science Faculty, Karamanoglu Mehmetbey University, Karaman, Turkey; ncanbulat@gmail.com

Accepted 15 April 2016 © 2019 Sigma Theta Tau International

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