Turkish children loved distraction: using kaleidoscope to reduce perceived pain during venipuncture
Fatma Güdücü Tüfekci, Nursing School, Ataturk University, Turkey. Telephone: +90442 2313554.
Aim. To assess the effect of distraction (looking through kaleidoscopes) to reduce perceived pain, during venipuncture in healthy school-age children.
Background. Distraction has been noted to be an effective method to help children cope with painful procedures. In the studies carried out, although it was found out that distraction made with different distracters reduced the pain of venipuncture, there is only one study confirming analgesic effect of distracters.
Design. The study was carried out as an intervention–control group design.
Method. Children (n = 206), in whom venipuncture was applied in a laboratory for examination between the dates January–September 2006, were included in the study. The data were obtained by a form determining introductory features of the children and Wong–Baker FACES Pain Rating Scale and Visual Analogue Scale evaluating the pain. Descriptive statistics was used in the assessment of the data and t-test was used in comparisons of dependent-independent groups.
Results. Pain levels of the children according to both scales in intervention group were lower than those of control group. But, it was detected that the distinction between score averages of intervention and control group of Wong–Baker FACES Pain Rating Scale, not Visual Analogue Scale, was statistically significant (p < 0·001).
Conclusion. It was detected that the distraction made with kaleidoscope effectively reduced the pain related to venipuncture in healthy school children and that some features of the children influenced the perception of pain.
Relevance to clinical practice. Distraction with kaleidoscope is a method, which the nurse will be able to use for venipuncture to obtain optimal pain control. In addition, it is important for a nurse to know some features about the children for a pain free and positive experience.
Introduction and background
Pain is defined as one of the major health problems in children as in adults (Hasanpour et al. 2006). The procedures made by a needle in children are the most common sources of pain (Uman et al. 2006) and venipuncture has been evaluated as the most painful intervention commonly applied to children (Wong & Baker 1988, Young et al. 1996, Jacobson 1999, Smalley 1999). Thus, to reduce emotional and physical effects of painful interventions and to prevent long-term results of pain in children (Rogers & Ostrow 2004), the nurse should be able to manage painful procedures (Hasanpour et al. 2006). To this end, various approaches including pharmacological and non-pharmacological methods (Bellieni et al. 2006) have been described. Among these, independent or complementary non-pharmacological methods, in addition to medication, have been considered favourable strategies (Vessey & Carlson 1996) and research focusing on nurses’ use of non-pharmacological methods for relief of children’s pain has increased in recent years (Lambert 1999, He et al. 2005). Many non-pharmacological methods have been successful in reducing pain perception among school-age children who are able to cooperate and who have sufficient cognitive development (Vessey & Carlson 1996). One of the effective non-pharmacological methods is distraction. Distraction is a nursing attempt focusing a patient’s attention to any other stimulants to control and reduce pain better (McCaffery 1990, Hasanpour et al. 2006).
Simple distraction techniques, such as party blowers (Manne et al. 1990, Blount et al. 1992), distracting toys (Smith et al. 1996), blowing out air (French et al. 1994, Manne et al. 1994), music via earphones (Fowler-Kerry & Lander 1987), cartoon watching (Cohen et al. 1997) or non-procedural talk (Gonzalez et al. 1993) have been found effective and thus advocated by many studies to decrease self-reported pain in younger children during procedures such as venipuncture or immunisation.
In children of different age groups, different procedures and distractors have been used in various studies. In these studies, distraction reduced the pain perception; however, the difference between the groups was not statistically significant. Windich-Biermeier et al. (2007) determined that the distraction carried out by means of distracters preferred by 5–18 years of age children with cancer did not reduce the pain felt in venipuncture significantly in the intervention group compared with the control group. In a study by Press et al. (2003), listening to a song was used as a distraction method to reduce venipuncture pain in children (aged 6–16 years), who were admitted to paediatric emergency department. However, no significant differences were found between the experimental and control groups for levels of pain reported. Arts et al. (1994) compared music distraction and placebo cream and lidocaine–prilocaine emulsion (EMLA cream), which was administered routinely in painful procedures in reducing the pain associated with venous cannulation in children of 4–16 years of age scheduled for surgery. EMLA was more effective than placebo or music; however, no significant differences were determined on any of the rating scales for the 7–11 year olds. In the study by Sander Wint et al. (2002), the effects of virtual reality (VR) glasses on adolescents with cancer undergoing lumbar punctures (LPs) were evaluated. No significant differences were found between the Visual Analogue Scale (VAS) pain scores of the two groups. Nevertheless, VAS scores tended to be lower in the VR group than in the control group. In the studies by Vessey et al. (1994) on preschool and school age children and by Carlson et al. (2000) on children and adolescents, the distraction by means of an illusion kaleidoscope reduced the pain associated with venipuncture in the experimental group.
Distraction reduced venipuncture pain in many earlier studies. However, to date, no studies have statistically confirmed the analgesic effects of distracters (Vessey et al. 1994) and in Turkey, parental presence is the only well-addressed non-pharmacological method for procedural pain relief (Güdücü-Tüfekci & Erci 2007). In addition, to reduce pain in children, it is known that no non-pharmacological methods or distractions are used routinely (Carlson et al. 2000). This study aimed to assess the effect of distraction (looking through kaleidoscopes) to reduce perceived pain during venipuncture in healthy school-age children.
Design and methods
This descriptive study involved intervention and control groups and was performed at the Biochemical Laboratory of Ataturk University, Yakutiye Research Hospital Erzurum, Turkey between January–September 2006. In Turkey and in Erzurum, the nurses conduct the procedure of blood sampling in laboratories. No routine non-pharmacological methods have been described or used to reduce the pain associated with the process of venipuncture in any of the hospitals.
The study involved 206 children who underwent venipuncture process. One hundred and five of these children who came only on one day of the week formed the intervention group. These children watched the shapes in a kaleidoscope during venipuncture procedure. The control group consisted of 101 children coming on another day of the week. These children underwent venipuncture through standard procedure. The sampling criteria of the study were:
- •Age between 7–11 years;
- •Need for venipuncture;
- •Identifying and reporting numbers;
- •Having no developmental problem or other disabilities that would make communication difficult and no chronic diseases.
The children who were subjected to venipuncture on a randomly selected day of the week comprised the control group and those who received venipuncture on another day of the same week comprised the intervention group. The groups were formed in two consecutive weeks and children of the same age and gender were chosen to constitute each group to achieve homogeneity. After the children, accompanied by their parents (mother and/or father) in the intervention group, were admitted to waiting room for venipuncture, they were introduced to a kaleidoscope and then instructed as to how they could use the kaleidoscope.
A kaleidoscope is a toy through which various shapes and colours observed when looked in with one eye while rotating one of the cylinders. It contains various coloured beads between broken mirrors adjacent to each other. As it is turned over the level of the eye, beads move and combine the appearances in the mirrors. Thus, various appealing designs are formed and observed. When a kaleidoscope is turned, designs vary according to the movement of beads and the same design rarely occurs. Hence, in each turn, different designs strike children’s interest (Figures 1, 2 and 3).
Hypothesis of the research
Hypothesis I: Looking through kaleidoscopes reduces the pain felt during venipuncture in children.
Hypothesis II: Some characteristics of children affect their pain perception.
Data were obtained by interviewing the children, using VAS (Abu-Saad & Holzemer 1981) and Wong–Baker FACES Pain Rating Scale (WB-FPRS) (Wong & Baker 1988, Whaley & Wong 1991, Kocaman 1994, West et al. 1994, Mayer et al. 2001) to assess the pain and a form to determine general characteristics of the children (gender, age, previous experience of venipuncture and level of fear).
Pain in WB-FPRS is evaluated according to numeric values given to six faces arranged side by side from the worst pain to the mildest one (0–5). The lowest point is ‘1’ and the highest one is ‘5’. WB-FPRS is defined as the most accurate pain scale in 3–18 age group (Wong & Baker 1988, Whaley & Wong 1991, Kocaman 1994, West et al. 1994, Mayer et al. 2001).
Pain was also evaluated with VAS according to numerical values (0–10) starting with ‘no pain’ and ending with ‘unbearable pain’ on a 10 cm horizontal or vertical line. VAS is considered easily understandable and practicable for children of five years and older (Güzeldemir 1995, Duff 2003). VAS has been used successfully in school-age children (Abu-Saad & Holzemer 1981).
The characteristics of children were expressed in percentages and mean values. A sample t test was used to compare intragroup pain scores and independent samples t test was used to compare intergroup pain scores.
The study was approved by ethics committee of the hospital. The aim and the method of the research were explained to the parents and children and informed written consent of the parents was obtained. They were informed that if they did not want to continue, they could withdraw from the study without stating a reason.
Of 206 children, 53% were female and 47% were male. The mean age of the children was 9·07 (SD 1·51) years. Sixty per cent of the children had four or more previous experiences of venipuncture and 69% feared the procedure. Of 206 children, 51% comprised the intervention group and 49% comprised the control group. The mean age of the intervention group was 9·12 (SD 1·53) years and of the control group, 9·01 (SD 1·50) years (Table 1).
Table 1. Demographic characteristics of the sample
|Age, years (Mean ± SD)||9·12 ± 1·53 ||9·01 ± 1·50 ||9·07 ± 1·51 |
|Gender||n (%) ||n (%) ||n (%)|
| Female||55 (52)||55 (55)||110 (53)|
| Male||50 (48)||46 (45)||96 (47)|
| 1–3||44 (42)||39 (39)||83 (40)|
| 4≤||61 (58)||62 (61)||123 (60)|
|Fear related to procedure|
| No fear||32 (30)||17 (17)||49 (31)|
| Fear||73 (70)||84 (83)||157 (69)|
In the comparisons of the groups for perceived pain levels, the perceived pain levels of the intervention group were lower (3·14, SD 1·41) according to WB-FPRS and 4·64 (SD 2·40) according to VAS) than those of the control group (3·80, SD 1·42) according to WB-FPRS and 5·14 (SD 2·25) according to VAS). However, according to the results of WB-FPRS, the difference between the mean scores of the intervention group (3·14, SD 1·41) and the control group (3·80, SD 1·42) was statistically significant (t = 3·144, p < 0·01).
In intragroup evaluations, the difference between the mean scores (3·14, SD 1·41 in WB-FPRS and 4·64, SD 2·40 in VAS) of the intervention group (t = 7·745, p < 0·001) and the mean scores (3·80, SD 1·42 in WB-FPRS and 5·14, SD 2·25 in VAS) of the control group was statically significant (t = 7·602, p < 0·001) (Table 2). In the intervention group, the male children with 1–3 previous experiences of venipuncture who feared the procedure experienced more pain (p < 0·05).
Table 2. Intra and inter-group comparisons of the mean WB-FPRS and VAS scores of the groups
|Intervention group||3·14 ± 1·41 ||4·64 ± 2·40 ||t = 7·745, p < 0·001|
|Control group||3·80 ± 1·42 ||5·14 ± 2·25 ||t = 7·602, p < 0·001|
|Test||t = 3·144, p < 0·01||t = 1·455, p > 0·05|| |
The results of the control group were similar to those of the intervention group. Nevertheless, in the control group, the differences for all the parameters were statistically significant [gender: VAS (t = 2·661, p < 0·05), venipuncture experience: WB-FPRS (t = 2·942, p < 0·05) and fear related to orienting to the procedure: VAS, WB-FPRS (t = 4·443, p < 0·001; t = 7·627, p < 0·001 respectively)] (Table 3).
Table 3. Comparison of the mean WB-FPRS and VAS scores of the groups according to characteristics of the children
| Female||55||3·05 ± 1·52 ||4·52 ± 2·30 ||55||3·67 ± 1·40 ||4·61 ± 2·35 |
| Male||50||3·24 ± 1·28 ||4·78 ± 2·53 ||46||3·95 ± 1·44 ||5·78 ± 1·97 |
| || ||t = 0·671, p > 0·05 ||t = 0·535, p > 0·05 || ||t = 0·999, p > 0·05 ||t = 2·661, p < 0·05|
| 1–3 ||44||3·31 ± 1·49 ||5·04 ± 2·38 ||39||4·30 ± 1·28 ||5·69 ± 1·93 |
| 4≤||61||3·01 ± 1·34 ||4·36 ± 2·40 ||62||3·48 ± 1·42 ||4·80 ± 2·38 |
| || ||t = 1·083, p > 0·05 ||t = 1·444, p > 0·05 || ||t = 2·942, p < 0·05 ||t = 1·948, p > 0·05 |
|Fear related to the procedure|
| No fear||32||2·43 ± 1·10 ||3·59 ± 2·31 ||31||2·93 ± 1·38 ||3·09 ± 1·42 |
| Fear||73||3·45 ± 1·42 ||5·10 ± 2·31 ||70||4·18 ± 1·26 ||6·05 ± 1·94 |
| || ||t = 3·581, p < 0·05 ||t = 3·086, p < 0·05 || ||t = 4·443, p < 0·001 ||t = 7·627, p < 0·001|
This study investigated whether distraction made by kaleidoscope reduced the pain perception associated with venipuncture in healthy school-age children (7–11 years of age). A statistically significant difference was determined between the pain perception levels of the two groups, supporting the first hypothesis of the research. In addition, these results support the findings of the study by Vessey et al. (1994) who successfully demonstrated the effect of illusion kaleidoscope to decrease pain of venipuncture in preschool and school aged children. Distraction acts as a gate-control; thus, when child’s attention is distracted away from the pain stimuli, the method of distraction can be effective (Gedaly 1991). Looking through a kaleidoscope might be effective in distracting the children (Hasanpour et al. 2006). However, in children of different age groups and in some studies, which used different distracters, distraction was found to reduce the pain, but the difference between the groups was not statistically significant (Arts et al. 1994, Kleiber & Harper 1999, Sparks 2001, Sander Wint et al. 2002, Press et al. 2003, Windich-Biermeier et al. 2007).
In our study, some characteristics (gender, previous venipuncture experience, fear related to procedure) of the children affected their perception of the pain, which supports the second hypothesis of the study. In both groups, the female children felt less pain than the male children and the pain perception levels were statistically significantly higher in the control group. Literature presents only one study supporting this finding (Gauthier et al. 1998). In other studies, it was determined that the gender affected pain tolerance of the children and unlike in our study, the male children had higher pain tolerance (Fowler-Kerry & Lander 1991, Bournaki 1997, Carr et al. 1998, McCaffery 1999, Güdücü-Tüfekci & Erci 2007). Some cultures impose certain responsibilities on genders in dealing with pain and thus, high pain tolerance and calmness of males might be culture related (Eti-Aslan 1998). However, in several studies, gender was not found to be an effective factor in pain response (Unruh et al. 1983, Lander et al. 1989, 1990, Fradet et al. 1990, Wilkie et al. 1990, Harbeck & Peterson 1992, Humphrey et al. 1992, Conner-Warren 1996, Hogeweg et al. 1996, Taimela et al. 1997, Palermo et al. 1998, Goodenough et al. 1999, List et al. 1999). This finding shows that gender of children affects the pain perception and that male children have low tolerance to pain.
In the study, the children with four or more previous venipuncture experiences had lower pain perception than the others. The difference between the pain perception levels of the control group was statistically significant. Previous pain experiences have been reported to affect the later ones (Pennebaker 1982, Fordyce 1990, McCarthy & Kleiber 2006). Similarly, McGrath (1990) reported that children who had routinely experienced injections reported less pain than children who had experienced only a few injections. In some studies, however, there was no correlation between previous pain experiences and later ones (Van Aken et al. 1989, Harbeck & Peterson 1992, Hays et al. 1992, Kotzer 2000). In our study, the children who expressed no fear of the procedure experienced less pain during venipuncture. This finding is supported by the findings of previous studies (Sparks 2001, McCarthy & Kleiber 2006).
The distraction performed by using a kaleidoscope reduced the pain perception associated with venipuncture in school-age children. Thus, it can be said that this distraction method may be routinely used in children. However, in school-age children who need to undergo procedures other than venipuncture, further studies are needed to evaluate the pain reducing effect of a kaleidoscope used as a distracter and studies investigating the effective distracters for various interventional procedures will be contributory.
Another finding of the study indicated that male children with 1–3 previous experiences of venipuncture who feared the procedure experienced higher level of pain. In the light of this finding, nurses should take gender and other characteristics of children into consideration before beginning the procedure to provide a less painful and a positive experience.
To evaluate the pain levels perceived, two different scales were used. In response to both WB-FPRS and VAS, the children were able to evaluate their pain more easily with WB-FPRS. Thus, in school-age children, using more than one scale in pain evaluation may be useful.
Study design: FGT; data collection and analysis: FGT, SK and manuscript preparation: FGT, AÇ.