Abstract
This study was conducted to find out the effects of different means of games used during pediatric blood draw on the levels of procedure-induced fear and anxiety. Patient descriptive information form and selected scales were completed for both the experimental and control group before the blood drawing procedure. During the blood draw procedure, the children in the experimental group listened to music and watched video games. Following the blood draw procedure, the children were given the Fear of Medical Procedure Scale and State Anxiety Inventory for a second time. The results of the study showed that differences between pre- and postprocedure average total scores of Fear of Medical Procedure Scale were statistically significant for all groups (p < .05). As a conclusion, it was found that making children listen to music or watch a video during blood draw was effective in decreasing their medical procedure fear levels and state anxiety.
Effective management of pain in painful interventions of children is also effective in decreasing pain and anxiety. Although venous interventions such as blood draw look like minor interventions, they can be perceived as painful and scary interventions by children (Uman et al., 2013; Wang, Sun, & Chen, 2008). Painful experiences for children during blood draws and other invasive procedures can cause negative consequences such as extreme anxiety during future procedures and extreme physiological reactions during the current procedure. In addition, previous painful experiences, fear of needles, and anxiety continue into adulthood, and this situation can cause increased pain reaction and may result in avoiding medical procedures. For all these reasons, venous interventions, for example, which are an important source of fear and anxiety in children, should be managed effectively (Canbulat, Inal, & Sönmezer, 2014; Singh, 2012).
Nurses should know about and apply nonpharmacological methods as much as pharmacological methods in stopping the pain. Distraction technique, which is among nonpharmacological methods, is used to decrease sensitivity for pain, fear, and anxiety by distracting the attention away from the pain to another interesting stimulant (Canbulat et al., 2014; Şahiner & Bal, 2015; Yoo, Hur, & Kim, 2011). Distraction provides a feeling of control by making the patient pay attention to other things through the distraction methods. With this method, the person’s pain does not go away completely; however, the tolerance increases, which means the threshold of pain increases. Active methods that are used to distract are blowing up balloons, singing, squeezing plastic balls, breathing exercises, and playing with electronic devices, while passive methods are watching videos, listening to songs, reading, and telling stories (Karakaya & Gözen, 2016; Şahiner & Bal, 2015; Singh, 2012; Uman et al., 2013; Yoo et al., 2011). There are a great number of studies that show that music and videos, which are passive methods, are effective in decreasing procedure-induced pain, fear, and anxiety (Caprilli, Anastasi, Grotto, Abeti, & Messeri, 2007; Kaheni, Bagheri-Nesami, Goudarzian, & Sadegh Rezai, 2016; Wang et al., 2008; Yoo et al., 2011).
Music therapy is a tool for relaxation, healing, and comfort. Music therapy distracts the attention to another stimulant other than pain, increases endorphin release, and provides comfort (Augustine & Umarani, 2013; Balan, Bavdekar, & Jadhav, 2009; Hartling et al., 2013). Watching videos and television, which are other passive methods, are effective in decreasing procedure-induced pain, fear, and anxiety (Bellieni et al., 2006; Kaheni et al., 2016; Yoo et al., 2011).
Methods
Aim
This particular quasi-experimental study was conducted to find the effects of music and watching videos (distracting methods) on decreasing fear and anxiety in children during blood draws (the invasive intervention).
Design
A randomized controlled study was conducted.
Sample
The universe of the study consists of children who were referred to the Ondokuz Mayıs University Hospital Pediatric Blood Draw unit between July 2015 and September 2015. The sample of the study was calculated according to the number of registered patients between the ages of 8 and 12 within the period of 3 months and also according to the results of previously conducted studies. According to power analysis results, sample size was found to be 182, with an α of 0.05 and a confidence interval of 95% and error margin of 5%. Thus, the study was conducted with 200 children. The children were randomized into three groups: music groups (n = 50), video groups (n = 50), and the control group (n = 100). Numbers from 1 to 200 were randomly distributed to the three groups with no number repetition using a computer program in order to determine which child would be in which group. The inclusion criteria were as follows: between 8 and 12 years of age, literate, no mental problems, able to communicate easily, and willing to participate in the study.
Data Collection Tools
Information Form
The question form was in line with the literature and included questions about the children’s and parents’ descriptive characteristics (age, gender, social security, place of residence, parents’ age, level of education, and work status).
Fear of Medical Procedures Scale (FMPS)
FMPS is a scale to measure children’s fears about medical procedure and practices and was developed by Broome and Hellier (1987). Medical fears were addressed within 29 questions. The scale consists of four subdimensions. The items of the scale consist of groups that include procedural, environmental, personal, and interpersonal questions. Validity and reliability of the scale was conducted by Alak (1993) in Turkey. The scale has a total of 29 questions, and the lowest score one can get from the scale is 29, while the highest score is 87. Participants who get 0-29 are assessed as those who have little fear, those who score 29-58 are assessed as those who have some fear, and those who score 58-87 are assessed as those who have too much fear. The scale’s reliability was found by using Split-Half Reliability criteria and Spearman Brown Technique. In Alak’s study conducted with 100 healthy children between the ages of 7 and 14, Spearman Brown reliability coefficient was found as 0.93 in reliability analyses (Alak, 1993). In this study, Cronbach alpha values for FMPS were found as 0.92.
The State-Trait Anxiety Inventory for Children State Form
The State-Trait Anxiety Inventory for Children State Form was developed by Spielberger in 1973 in order to measure state anxiety that occurs as a result of special situations being interpreted as threatening in children. Studies were conducted by Şeniz Özusta (1995) to obtain the Turkey norms and to find out the validity and reliability of The State-Trait Anxiety Inventory for Children State Form. The inventory, which includes 20 items, aims to assess feelings related with state inventory such as tension, nervousness, hurry, and uneasiness. The highest score one can get from the inventory is 60, while the lowest score is 20. In the Turkish version, the reliability coefficient calculated by alpha correlations is .82 and test-retest reliability coefficient is .65 (Özusta, 1995). In the present study, the Cronbach alpha value of the State Anxiety Inventory was found as 0.66.
Data Collection
Before the venipuncture procedure
Twenty minutes before the procedure, the researcher introduced herself, stated the purpose of the study, and took the necessary permissions. The demographic questionnaire was completed by the parents of children in each of the three groups. The parents were asked about experiences with the blood draw procedure previously in the past year. Experimental and control groups were given a patient descriptive data form titled the Pediatric Fear of Medical Procedure Scale and State Anxiety Inventory.
Venipuncture procedure
All of the participating children were approached by a nurse experienced in taking children’s blood samples; the vein was accessed on the left arm with a 21 gauge × 1.5-inch vacuum blood collection needle. Blood was collected from all of the children on the first try, with no need for a second try in any child. In all of the groups, parents accompanied their children during the procedure.
Control group
The children in the control group (those who received only the blood draw procedure) and their parents were informed and the procedure was conducted. Meanwhile, necessary explanations were made for the questions asked by children and their parents. Parents were allowed to accompany their children, but no pain-reducing intervention of any kind was applied in the blood testing room of the pediatric department. This was the usual procedure in the blood testing room. The control group, for which no intervention was performed, was recruited in order to be able to compare the pain levels of the study groups with those of the children in the control group, where no pain-reducing method had been used.
Intervention groups
The children in the experimental group were asked which of the two methods—music or video—they preferred. The children who chose to listen to music were made to listen to one of the three songs intended to attract the children’s attention through earphones, and the blood draw procedure was conducted when the children were busy listening. The children who chose to watch the video were made to watch to a video they preferred among three different cartoons through 3D glasses, and the blood draw procedure was conducted when the children were busy watching. The video game tool and the tool for listening to music used in the experimental group and other materials were presented by the researcher. The children were made to listen to music or watch a video at least for 5 minutes before and during the procedure until the end of procedure. The children were recorded whether crying or not during the process. It was ensured that the parents were near their children during the procedure. The blood draw process took an average of 3 minutes (range, 1 to 5 minutes). Also before the procedure, no pharmacological methods to reduce pain, fear, and anxiety were used. After the blood draw procedure, the scales were completed by the children.
Evaluation of Data
The data were analyzed using the Statistical Package for Social Science (SPSS®) Version 16.0. Descriptive statistics were used to analyze group characteristics (mean, standard deviation). In general, parametric tests (dependent t test, ANOVA) were used in the comparison of two variables since the dataset was normally distributed. Significance was accepted at the p < .05 level.
Ethical Aspects of the Study
Required permissions were provided by Avrasya University School of Nursing Scientific Ethical Board (B.30.2.ODM.0.20.1738) and the ethical board of the hospital where the study was conducted. After the children and their families were instructed about the subject and the purpose of the study, they were informed that they were free to participate, their information would not be disclosed to other people, and their oral and written consents were taken. Before beginning the study, permissions were taken from the related authors to use the scales in the study.
The Research Question
Will listening to music or watching videos reduce fear and anxiety in children during a blood draw?
Does music reduce fear and anxiety during blood draw in children?
Does watching a video reduce fear and anxiety during blood draw in children?
Results
In this study, the average age of the children was 9.73 + 1.48 (minimum: 8; maximum: 12 years of age), the ages of the participants in the study were 11 with 24.0% in the control group and 8 with 36.0% in the music group and 44.0% in the video group. While it was found that the number of female and male children who participated in the study was close, it was found that 52.0% of the control and music group consisted of female students, while 44.0% of the video group consisted of female students. It was found that 98% of the children in the control and music group and all of the children in the video group had experienced a blood draw procedure previously. During the procedure, it was found that 25% of the children in the control group cried, while 16% of the children in the music group and 8% of the children in the video group cried during the procedure (Table 1).
Demographic Characteristics of the Sample.
Table 2 shows the pre-procedure and actual procedure of the FMPS and subdimensions and State Anxiety Inventory scores of children. Dependent samples t test was used to find out how the pre-procedure scale and subscale factor scores changed as a result of the procedures. One-way ANOVA analysis was used to compare the differences in pain score averages of these three groups in independent groups.
Comparison of Pre-Procedure and Post-Procedure Fear of Medical Procedure and State Anxiety Score Averages of Children in Terms of Groups.
Note: a = control group; b = music group; c = video group.
Dependent t test.
One-way analysis (ANOVA)
When the FMPS procedural items, environmental items, personal items, and interpersonal items subfactor score changes were examined, the changes in all groups were found to be statistically significant (p < .05). According to the Tukey tests conducted, average scores of music group and video group were found to be higher and to differ significantly when compared with the average scores of the control group. When FMPS total score changes were analyzed, the changes in all groups were found to be statistically significant (p < .05), and less of a decrease was found in the post-procedure fear score averages of the control group when compared with the other groups. No statistically significant difference was found between the FMPS total score averages of the music group and the control group (p > .05) (Table 2).
When the changes in State Anxiety Inventory Scale were analyzed, it was found that the change in music and video groups was statistically significant (p < .05). Pre-procedure State Anxiety Scale score average of the control group was not found to differ statistically significantly when compared with the post-procedure score average (t = -0. 621, p = 0.536). According to this result, the State Anxiety Scale scores in the experimental groups were found to differ significantly when compared with the control group. In our study, it was found that the practice of listening to music did not cause statistically significant differences in state anxiety levels when compared with the video watching practice (p > .05) (Table 2).
Discussion
In this study, methods of having children listen to music or watch video games decreased children’s fear of medical procedure and state anxiety levels. However, no statistically significant difference was detected among music and video groups. The methods of having children listen to music and watch video games were found in the literature to be effective in decreasing the level of anxiety and pain. When studies conducted on the method of music during different invasive procedures such as blood draw, establishing vascular access, and vaccination were analyzed, Augustine and Umarani (2013) (3-7 years of age, n = 80) found that music therapy was found to cause less pain during invasive procedures, and it was found to be more effective when compared with an IM (intramuscular) procedure. Caprilli et al. (2007) (n = 108, 4-13 years of age) found that the group that listened to music during the venous blood draw was found to have lower levels of pain and stress. Balan et al. (2009) (5-12 years of age, n = 150) found that music and local anesthetic (EMLA) applied together were more effective in decreasing pain. Kristjansdottir and Kristjansdottir (2011) (n = 118, 13-15 years of age) found lower pain scores in adolescent groups that listened to music during polio vaccination. Hartling et al. (2013) (n = 42, 3-11 years of age) found that music was effective in decreasing pain and anxiety. Singh (2012) (n = 90, 1-3 years of age) found that playing with toys and music therapy methods were effective in decreasing the pain during vaccination when compared with the control group. Caprilli et al. (2007) found that while establishing vascular access, pain and stress levels were significantly lower in the music group when compared with the control group, while Press et al. (2003) (n = 97, 6-16 years of age) found that the group that listened to music during a venous blood draw in the emergency room had lower levels of pain when compared with the control group.
When studies conducted on watching videos during invasive procedures were analyzed, Wang et al. (2008) (8-9 years of age, n = 300) found that children who watched cartoons during a venous blood draw procedure experienced less pain when compared with the group that received psychological help and the control group. Windich-Biermier, Sjoberg, Dale, Eshelman, and Guzzetta (2007) (5-18 years of age, n = 50) found that children whose procedures were conducted with different distractive materials, such as books, music, and videos, experienced less stress and fear when compared with the control group. Yoo et al. (2011) (n = 40, 3-7 years of age) found that computer games caused significant differences in decreasing procedure-induced pain and also in blood cortisol and glucose levels. Kaheni et al. (2016) (3-6 years of age, n = 80) found statistically significant differences in pain averages of the video games group when compared with the control group. Bellieni et al. (2006) found that the Visual Analogue Scale (VAS) pain score averages of children who watched television for distraction while establishing vascular access were significantly lower.
During the procedure of blood draw, there are also other distraction methods other than music and videos, which are effective in decreasing pain and anxiety. Numerous studies have reported the effectiveness of a variety of distraction methods used by healthcare professionals to relieve medical procedure-related pain, fear, and anxiety (Caprilli et al., 2007; Inal & Kelleci, 2012; Karakaya & Gozen, 2016; Mutlu & Balcı, 2015). When these studies were analyzed, Karakaya and Gözen (2016) (7-12 years of age, n = 72) found that the group in which a kaleidoscope was used during blood draw felt less pain when compared with the control group. Tüfekçi, Celebioğlu, and Küçükoğlu (2009) (n = 206, 7-11 years of age) found decreases in the pain levels of the group in which a kaleidoscope was used during venous blood draw when compared with the control group. İnal and Kelleci (2012) reported that using cards to distract while blood was drawn was effective in decreasing children’s pain. Caprilli et al. (2007) found that children who were made to blow balloon foams had statistically significant lower pain score averages when compared with the control group. Şahiner and Bal (2015) (6-12 years of age, n = 120) found that the method of blowing balloons was more effective in decreasing pain and anxiety levels when compared with other methods of music, distracting cards, and also with the group that listened to music when compared with the control group. Canbulat et al. (2014) (n = 188, 7-11 years of age) found that the methods of distracting cards and kaleidoscope during blood draw were effective in decreasing anxiety and pain. Mutlu and Balcı (2015) (n = 133, 7-12 years of age) found that the methods of blowing balloons and coughing during blood draw decreased pain score averages.
Conclusion
This study found that the methods of having children listen to music or watch videos, which are among distraction methods used during blood draw, had a positive effect in decreasing fear and anxiety levels during the invasive procedure of blood draw.
Linking Evidence to Action
The results of the study will be a guide for nurses in using these simple, easily applicable, and very effective methods to decrease fear and anxiety during blood draw in children. It is also predicted that using these methods in painful practices (such as blood draw) will be useful in decreasing the problems of children, families, health workers, and others. It is recommended that the efficiency of other distractive active and passive methods in decreasing procedure-induced pain, fear, and anxiety should be researched with a wider sample and different age groups.
Limitations
The child’s sociocultural context, which can influence the pain experience of children, was not controllable in the present study. The study was conducted in one geographic area, and surely one of the limitations is that the findings cannot be generalized to children living in other geographical regions of the country.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.