READING JOURNAL

“EFEKTIVITAS DISTRAKSI BERBASIS SENI DALAM

MENGURANGI NYERI DAN KECEMASAN PADA
ANAK YANG DIRAWAT DI RUMAH SAKIT
SELAMA PROSEDUR KANULASI”

Diajukan Untuk Memenuhi Salah Satu Tugas Praktik Klinik Profesi Ners
Departemen Keperawatan Anak

Dosen Pembimbing:
Ns. Nanang Saprudin, S.Kep.,M.Kep
Ns. Neneng Aria Nengsih, S.Kep.,M.Kep

Disusun Oleh:
Kelompok ?

Cintia Rindyantika JNR0230013

Dinda Anggraeni JNR0230020
Firda Asri Nurdianti JNR0230036
Indy Mutia Teguh P JNR0230048
Ineu Jumiati JNR0230049
Riska Fatwamati JNR0230087
Lusy Marliana Azahra JNR0230058
Nida Silvia JNR0230069
Khamaludin JNR0230055
M. Fajar Triana JNR0230064

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN KUNINGAN
2023/2024
 EFEKTIVITAS DISTRAKSI BERBASIS SENI DALAM
MENGURANGI NYERI DAN KECEMASAN PADA
ANAK YANG DIRAWAT DI RUMAH SAKIT
SELAMA PROSEDUR KANULASI

1. PENDAHULUAN
Penanaman intravena vena perifer (PIVC) adalah suatu prosedur
invasif di mana kateter dimasukkan melalui kulit pasien ke dalam lumen
vena darah perifer. Ini menyebabkan nyeri yang parah pada anak-anak dan
meningkatkan kecemasan pada anak-anak dan pengasuh. Ini merupakan
prosedur stres umum bagi anak-anak, dan hampir semua pasien pediatrik
memiliki pengalaman dengan PIVC. Teknik ini umumnya
direkomendasikan untuk memberikan larutan, obat-obatan, darah, atau
produk darah kepada pasien pediatrik (Doyle & McCutcheon, 2015).
Jika tidak dikelola dengan cepat dan tegas, nyeri yang dialami oleh
anak-anak dapat memiliki implikasi fisik dan psikologis jangka panjang,
seperti fobia jarum, menghindari perawatan medis, dan kurangnya
kerjasama selama prosedur medis di masa depan. Oleh karena itu,
disarankan untuk mengelola nyeri secara proaktif selama pemasangan
kanula atau akses vena. Laporan menunjukkan bahwa pengurangan nyeri
selama prosedur yang menyakitkan adalah tanggung jawab penting bagi
dokter anak, staf keperawatan, dan personel kesehatan lainnya. WHO
menegaskan bahwa penghilangan nyeri adalah hak asasi manusia yang
mendasar. Oleh karena itu, penting untuk mengeksplorasi bentuk-bentuk
manajemen nyeri yang paling efektif (Uman 2013).
Strategi farmakologis umum adalah penggunaan krim topikal untuk
mengurangi nyeri yang disebabkan oleh prosedur medis (Trottier et al.,
2019). Namun, anak-anak mungkin mengalami nyeri dan kesulitan karena
krim-krim ini mengakibatkan efek samping yang mungkin terjadi. Krim-
krim ini memiliki efek fisiologis tanpa dampak pada sudut pandang
psikologis, seperti sikap pasien, sedangkan metode non-farmakologis
membantu memutuskan siklus berbahaya antara nyeri dan kecemasan
dengan mengontrol nyeri dan kecemasan anak-anak (Tick et al., 2018).
Metode non-farmakologis digunakan karena sederhana, mudah digunakan,
menghemat waktu, tidak memiliki efek samping, meningkatkan interaksi
individu terhadap kecemasan dan nyeri (Short et al., 2017).
Sebagai teknik non-farmakologis, distraksi adalah salah satu cara
paling efektif untuk mengurangi kecemasan dan nyeri. Ada dua jenis
distraksi: distraksi aktif dan distraksi pasif (Inan & Inal, 2019). Distraksi
aktif mendorong anak-anak untuk berpartisipasi dalam tugas-tugas tertentu
selama prosedur dengan merangsang satu atau lebih indra mereka dan
melibatkan keterampilan mereka selama prosedur yang menyakitkan.
Sebaliknya, dengan distraksi pasif, anak-anak tidak terlibat dalam kegiatan
selama prosedur terapeutik. Distraksi pasif hanya mengaktifkan indra
visual dan/atau auditori mereka (Inan & Inal, 2019).
Intervensi berbasis seni telah dilaporkan dapat meredakan nyeri
dan kecemasan pada anak-anak dengan berbagai penyakit dan situasi,
seperti anak-anak dengan kanker dan anak-anak yang dirawat di rumah
sakit (Shella, 2018). Buku gambar dan pewarnaan untuk Anak (TICK-B)
lebih efektif daripada intervensi distraksi lainnya karena banyak teknik
distraksi memerlukan pelatihan, mahal, tidak menarik bagi anak-anak,
rumit untuk diterapkan, dan tidak praktis, seperti permainan komputer,
realitas virtual, dan distraksi elektronik lainnya. Faktor-faktor ini
menghambat penerapan luas metode distraksi di rumah sakit. Di banyak
pengaturan klinis di negara-negara berkembang, anak-anak tidak
menerima intervensi farmakologis atau non-farmakologis untuk
mengurangi tingkat nyeri dan kecemasan.
Sampai saat ini, menurut pengetahuan peneliti, tidak ada studi
tentang penggunaan TICK-B sebagai distraksi berbasis seni untuk
mengurangi intensitas nyeri dan tingkat kecemasan anak-anak selama
PIVC dalam penelitian yang telah dipublikasikan. Teknik TICK-B adalah
intervensi berbasis seni yang mudah diterapkan oleh perawat. Ini tidak
 memerlukan pelatihan atau memiliki efek samping selama prosedur medis,
dan merupakan teknik yang hemat biaya dan menarik. Untuk alasan ini,
dalam penelitian ini, kami meneliti efektivitas TICK-B dalam mengurangi
nyeri dan kecemasan pada anak-anak yang dirawat di rumah sakit selama
PIVC. Kami berasumsi bahwa anak-anak yang menerima TICK-B akan
memiliki tingkat nyeri dan kecemasan yang signifikan lebih rendah
(Abdulah et al., 2019).

2. METODE

Penelitian Ini adalah sebuah uji klinis paralel, acak, ganda-butak

yang dilakukan pada pasien pediatrik. Pasien yang memerlukan prosedur
PIVC secara acak dibagi menjadi dua kelompok, kelompok intervensi dan
kelompok kontrol.
Pasien-pasien dari ward medis Rumah Sakit Pendidikan Pediatrik
Heevi di kota Duhok, Kurdistan Irak, direkrut antara November 2019 dan
Februari 2020. Rumah Sakit Pendidikan Pediatrik Heevi adalah satu-
satunya rumah sakit pediatrik yang menangani kondisi medis,
kegawatdaruratan, dan bedah di Duhok. Rumah sakit ini memiliki ruang
perawatan intensif anak (CCU), ruang perawatan intensif neonatal
(NICU), unit operasi, unit penerimaan, serta ward medis, gawat darurat,
dan bedah.
Informasi dasar pasien dievaluasi sesuai dengan kriteria kelayakan
oleh penulis utama. Selain itu, catatan medis pasien diperiksa untuk
kriteria kelayakan. Pasien yang memenuhi syarat secara acak dialokasikan
ke kelompok intervensi atau kontrol. Sampel studi mencakup pasien yang
dirawat di ward medis pediatrik berusia 6–12 tahun dari kedua jenis
kelamin yang memerlukan PIVC. Kami mendapatkan persetujuan dari
orang tua anak-anak. Pasien-pasien yang memiliki penyakit kronis, tidak
sadar, memiliki keterlambatan perkembangan neuro (didiagnosis melalui
laporan orang tua), tidak dapat berkomunikasi secara verbal, memiliki
gangguan pendengaran atau penglihatan, atau telah mengonsumsi
 analgesik dalam 6 jam terakhir, dikecualikan dari penelitian ini.
Karakteristik umum kedua kelompok pasien dan orang tua mereka adalah
serupa.
Peneliti menentukan ukuran sampel berdasarkan program G-power
(Faul et al., 2007). Tingkat nyeri dari lima kasus pertama dalam kelompok
kontrol dinilai oleh pengamat, dan nilai rata-rata serta deviasi standarnya
dari lima kasus ini diukur sesuai. Skor yang diperoleh adalah 6,53 (SD =
1,5). Peneliti percaya intervensi akan memiliki efek besar pada nyeri
dalam penelitian ini. Oleh karena itu, peneliti berasumsi nilai ini dapat
turun menjadi 5,53 (SD = 0,85) setelah intervensi. Besar pengaruh sebesar
0,820, dua sisi, α 0,05, dan power (1-β), 0,95 dianggap menggunakan dua
kelompok independen. Jumlah pasien yang diperlukan di setiap kelompok
adalah 40, tetapi kami meningkatkan ukuran sampel kami sekitar 50%
untuk menghindari kehilangan informasi akibat masalah teknis yang
mungkin terjadi. Selain itu, kasus-kasus tersedia luas di rumah sakit, dan
intervensi dapat dilakukan dengan mudah dengan waktu tindak lanjut yang
singkat. Dengan demikian, kedua faktor ini memungkinkan peneliti untuk
meningkatkan ukuran sampel.

3. HASIL

Penulis mempertimbangkan 120 anak untuk disertakan dalam

penelitian ini, di mana 110 di antaranya memenuhi syarat dan
berpartisipasi, sepuluh tidak disertakan karena terlalu muda. Dari 110 yang
disertakan dalam penelitian ini, orang tua sepuluh di antaranya menolak
prosedur tersebut, tujuh pasien dalam kelompok intervensi dan tiga dalam
kelompok kontrol. Pasien-pasien dalam kedua kelompok studi serupa
dalam hal usia, jenis kelamin, jumlah suntikan, usia ibu, dan pendidikan
(Tabel 1).
Tabel 1 Perbandingan antara Kelompok Kontrol dan Intervensi
karakteristik Study Groups Statistic
Kontrol Intervensi Value (Chi- P-value
(n=52) (n=48) square)
Umur 7,98 7,79 0,998 0,321
Lama Rawat Inap 3,38 3,33 0,245 0,807
Jumlah Percobaan 1,13 1,23 -0,954 0,342
Suntikan
Usia Ibu 40,98 40,46 0,631 0,530
Jenis Kelamin
Responden
Laki-laki 25 24 0,037 0,848
Perempuan 27 24
Pendidikan Ibu 1,175 0,907
Buta Huruf 4 4
Lulus SD 25 19
Lulus SMP 14 16
Lulus SMA 4 5
Lulus Perguruan 5 4
Tinggi

Pasien dalam kelompok intervensi melaporkan tingkat nyeri yang

signifikan lebih rendah selama prosedur (t = 11,37 p < 0,001) dengan efek
sedang (2,27) dan setelah prosedur (t = 12,08 p < 0,001) dengan efek
sedang (2,43) dibandingkan dengan pasien dalam kelompok kontrol. Pola
yang sama diamati untuk kecemasan selama prosedur (t = 16,76 p < 0,001)
dengan efek sedang (3,34) dan setelah prosedur (t = 17,00 p < 0,001)
dengan efek sedang (3,41). Pasien dalam kelompok intervensi dan kontrol
memiliki tingkat kecemasan dan nyeri yang serupa sebelum memulai
prosedur kanulasi (p > 0,05). Studi ini tidak menemukan perbedaan yang
signifikan secara statistik dalam nyeri dan kecemasan dari waktu ke waktu
di kelompok kontrol, sementara tingkat nyeri dan kecemasan mengalami
penurunan signifikan dari waktu ke waktu di kelompok intervensi (Tabel
2).
 Tabel 2 Perbandingan skor nyeri dan kecemasan antara kelompok
intervensi dan kontrol
Nyeri dan Study Groups Degree of p-value Effect
kecemasan Kontrol Intervensi Freedom size
(n=52) (n=48) t (df) (Cohen’s
d)
Nyeri sebelum 7.13 7.00 0.381 98 0.704 Na
tindakan
Nyeri selama 7.12 3.27 11.37 98 <0.001 2.27
tindakan
Nyeri setelah 7.06 3.08 12.08 98 <0.001 2.43
tindakan
Kecemasan 3.25 3.19 0.522 98 0.603 NA
sebelum
tindakan
Kecemasan 3.19 1.13 16.76 98 <0.001 3.34
selama
tindakan
Kecemasan 3.17 0.88 17.00 98 <0.001 3.41
setelah
tindakan

Skor nyeri dan kecemasan secara signifikan lebih rendah di

kelompok intervensi dibandingkan dengan kelompok kontrol seperti nilai
pada anak-anak, orang tua, dan perawat pengamat (Tabel 3). Nyeri pra-
prosedur dan kondisi medis lainnya tidak berkontribusi pada kecemasan
pasca-tindakan (Tabel 4).
Tabel 3 Perbandingan Skor Nyeri dan Kecemasan Anak-anak Dalam
Kelompok Intervensi dan Kontrol
Hasil Study Groups Mean Degree of Effect
Pemeriksaan (SD) Freedom size
Kontrol Intervensi t (df) (Cohen’s
(n=52) (n=48) d)
Nyeri
Anak 7.06 3.08 12.08 98 2.43
Orangtua 7.13 3.08 12.34 98 2.48
Peneliti 7.13 3.06 12.33 98 2.47
Ketakutan
Anak 3.17 0.88 17.00 98 3.41
Orangtua 3.19 0.94 14.29 98 2.87
Peneliti 2.94 0.85 13.95 98 2.81

Tabel 4 Peran kecemasan sebelum prosedur, jumlah hari rawat inap, dan
karakteristik umum dari kecemasan setelah prosedur dalam kelompok
intervensi
Dependen Variable : kecemasan setelah tindakan

Faktor Kontrol Koefisien t 95% Cl for B

Beta P-value
Lower Upper

Nyeri -0.269 -0.759 0.452 -0.397 0.180

sebelumnya
Kecemasan -0.257 -1.683 0.100 -0.655 0.060
sebelumnya
Usia -0.321 -0.876 0.386 -0.416 0.165
Jenis Kelamin -0.018 -0.115 0.909 -0.475 0.423
Lama rawat inap -0.181 -1.019 0.315 -0.367 0.121
Percobaan -0.007 -0.045 0.964 -0.502 0.525
Usia ibu -0.059 -0.364 0.718 -0.044 0.064
Pendidikan ibu -0.147 -0.880 0.384 -0.324 0.128
4. PEMBAHASAN

Studi ini menunjukkan bahwa distraksi menggunakan TICK-B

efektif dalam menurunkan tingkat nyeri dan kecemasan pada anak-anak
yang dirawat di rumah sakit, yang dilaporkan baik oleh anak-anak sendiri,
orang tua, maupun perawat pengamat. Studi ini menggunakan teknik
TICK-B untuk pertama kalinya sebagai distraksi berbasis seni pada anak-
anak usia sekolah. Nyeri sering dirasakan selama prosedur yang rutin
dilakukan di rumah sakit, seperti pengambilan darah dan infus. Pada anak-
anak, nyeri dapat menyebabkan ketegangan, rasa takut, dan kecemasan.
American Pain Society merekomendasikan pemberian manajemen nyeri
yang efektif baik sebelum maupun selama prosedur jarum (Czarnecki et
al., 2011). Menurut rekomendasi praktik klinis berbasis bukti, sebagian
besar situasi yang melibatkan nyeri dan kecemasan yang disebabkan oleh
prosedur yang menyakitkan dapat diatasi dengan pendekatan non-
farmakologis (Bergomi et al., 2018).
Menurut hipotesis kami, intervensi seni berdasarkan TICK-B dapat
mengurangi tingkat nyeri dan kecemasan pada anak-anak usia sekolah.
Hasil penelitian pada sebuah uji coba terkontrol non-random menunjukkan
bahwa anak-anak yang menerima terapi seni menunjukkan perilaku yang
kooperatif dan menginginkan intervensi terapi seni untuk prosedur yang
menyakitkan di masa depan. Sebaliknya, anak-anak dalam kelompok
kontrol yang tidak menerima intervensi seni menunjukkan resistensi,
perilaku tidak kooperatif, dan ketakutan selama dan setelah pemasangan
jarum suntik (Shella, 2018). Literatur telah mengonfirmasi efektivitas
intervensi berbasis seni dalam meredakan nyeri dan kecemasan di antara
anak-anak dengan berbagai penyakit.
Pengurangan nyeri yang dirasakan selama prosedur terapeutik
ketika anak-anak aktif berpartisipasi dalam tugas dapat dijelaskan oleh
teori-teori berikut. Teori kontrol gerbang nyeri Melzack dan Wall dapat
menjelaskan bagaimana intervensi berbasis seni memengaruhi persepsi
dan pengalaman nyeri dan kecemasan selama prosedur terapeutik dan
 diagnostik. Dalam teori kontrol gerbang, otak memiliki mekanisme
gerbang saraf yang melepaskan atau menekan persepsi nyeri seseorang.
Selain dari peristiwa dan emosi masa lalu, faktor-faktor psikologis, seperti
kesadaran, juga mempengaruhi persepsi nyeri. Gerbang ini terbuka akibat
stres atau ketika tidak ada aktivitas dan hanya rangsangan yang
menyakitkan untuk difokuskan. Seseorang, oleh karena itu, mengalami
tingkat nyeri yang lebih tinggi ketika gerbang terbuka. Gerbang tersebut
akan tertutup ketika perasaan nyeri berkurang dengan melepaskan
ketegangan, mengurangi aktivitas yang menyakitkan, atau menggunakan
rangsangan yang mengalihkan perhatian.

5. KESIMPULAN

Berdasarkan hasil penelitian diperoleh rata-rata suhu tubuh pre-test

kompres hangat konvensional adalah 37,830C sedangkan rata-rata suhu
tubuh pre-test kompres hangat teknik tepid sponge adalah 38,040C.
Perubahan suhu tubuh berfluktuasi baik pada teknik kompres hangat
konvensional maupun tepid sponge. Dari uji Different Univariate-General
Linear Model diketahui bahwa teknik kompres hangat konvensional dan
tepid sponge berpengaruh signifikan terhadap perubahan suhu tubuh p =
0,03. Teknik tepid sponge lebih baik digunakan untuk penatalaksanaan
demam pada anak penderita demam tifoid dibandingkan kompres hangat
konvensional karena penurunan suhu tubuh terjadi dalam waktu 5 menit
hingga 30 menit sedangkan penurunan suhu tubuh kompres hangat
konvensional hanya berlangsung selama 15 menit setelah dilakukan kompres.
 6. APLIKASI JURNAL

STANDART OPERASIONAL PROSEDUR

DISTRAKSI BERBASIS SENI (ART THERAPY)
Pengertian Merupakan bentuk terapi yang menggunakan ekspresi
kreatif seperti melukis dan menggambar sebagai alat
untuk membantu anak mengatasi kesulitan emosional,
mengurangi stres dan kecemasan dan distraksi
menurunkan nyeri pada saat prosedur kanulasi
Tujuan 1. Mengurangi tingkat kecemasan dan nyeri pada
anak selama prosedur kanulasi.
2. Memberikan anak ruang untuk mengekspresikan
perasaan dan pikiran melalui seni.
3. Membantu anak merasa lebih tenang dan
terhubung dengan proses perawatan medis

Indikasi Klien yang mengalami kecemasan dan

ketidaknyamanan dalam pelaksanaan prosedur medis
seperti kanulasi
Peralatan 1. Buku gambar, pensil warna, crayon, pensil, spidol.
2. area terapi seni yang nyaman dan ramah anak.
3. peralatan keamanan dan sterilisasi (jika
diperlukan).
4. Buku atau perangkat tambahan untuk panduan

Prosedur Kerja 1. Tahap pra Interaksi

a. Siapkan ruang terapi seni yang nyaman dan

ramah anak
b. persiapkan semua peralatan
c. pastikan klien didampingi terapis
d. Komunikasikan kepada anak dan keluarganya
tentang tujuan dan manfaat terpi untuk
mengurangi kecemasan dan nyeri selama
prosedur kanulasi.

2. Tahap Orientasi

a. Memberi salam dan sapa kepada klien.

b. Ajak klien untuk merasa nyaman dan
memberikan informasi tentang apa yang dapat
klien harapkan.
c. menanyakan ketersediaan dan kesiapan klien
 3. Tahap Kerja
a. Membaca doa
b. Persiapan alat seperti Buku gambar, pensil
warna, crayon, pensil, spidol.
c. Membagikan buku gambar, pensil warna,
crayon, pensil dan spidol.
d. Menjelaskan tema gambar yaitu menggambar
yang terbebas dari kekerasan seperti tumbuhan
dan hewan
e. Setelah selesai menggambar terapis meminta
klien untuk menjelaskan gambar dan makna
gambar yang telah dibuat.
4. Tahap Terminasi
a. Melakukan evaluasi tindakan
b. Berpamitan dengan klien
c. Membereskan alat
d. Mencuci tangan

7. IMPLIKASI TERHADAP KEPERAWATAN

Jurnal ini sangat bermanfaat khususnya bagi keperawatan karena

memberikan kontribusi yang bermakna kaitannya dengan peran perawat
anak untuk berpartisipasi memberikan asuhan keperawatan bagi anak yang
sedang menjalankan prosedur kanulasi. Dengan terapi seni berbasis
distraksi akan memberikan perubahan skala nyeri dan tingkat kecemasan
yang signifikan dan membantu dalam proses pelaksanaan prosedur
kanulasi, Adapun bagi perawat sendiri, hal ini akan membantu perawat
dalam menerapkan terapi alternatif pada anak sehingga bisa lebih efektif.
8. APLIKASI JURNAL DI TEMPAT PELAYANAN

Terapi seni berbasis distraksi efektif untuk menurunkan skala

nyeri dan menurunkan tingkat kecemasan pada anak saat menjalankan
prosedur kanulasi. Untuk penerapannya di tempat pelayanan seperti di
Rumah sakit, sebenarnya bisa dilakukan karena pengadaan peralatan yang
cukup mudah dan tidak merugikan lingkungan sekitar. Hal lain yang perlu
diperhatikan adalah, persiapan alat dan air yang hangat tidak terlalu panas
maupun dingin.
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LAMPIRAN

Original Research

Open Access

Effectiveness of art-based distraction in Belitung Nursing Journal

Volume 8(3), 213-221
© The Author(s) 2022

reducing pain and anxiety of hospitalized https://doi.org/10.33546/bnj.2054

children during cannulation procedure: A

randomized controlled trial
Sherzad Khudeida Suleman1,2* , Akram Atrushi3, and Karin Enskär4
1
Nursing Department, Faculty of Health Sciences, Witten/Herdecke University, Germany

2
Nursing College, Duhok University, Kurdistan Region, Iraq

3
Pediatric Unit, College of Medicine, Duhok University, Kurdistan Region, Iraq

4 Department of Women’s and Children’s Health, Uppsala University, Sweden

Abstract
Background: Peripheral venous cannulation (PIVC) is one of the most common needle procedures
associated with the therapies of pediatric patients, which causes pain and anxiety in children. Trace
Image and Coloring for Kids-Book (TICK-B) is one of the arts-based interventions to relieve pain and
anxiety, but none of the existing studies use the TICK-B to decrease children’s pain intensity and
anxiety levels during PICV.
Objective: This study aimed to investigate the effectiveness of the Trace Image and Coloring for Kids-
Book (TICK-B) in decreasing children’s pain and anxiety during PIVC.
Methods: A parallel, randomized, double-blind controlled trial was used in this study. Children aged 6–
12 years were randomly allocated to one of two groups: intervention or control. The intervention
group (n = 48) received the TICK-B during the PIVC, compared to no intervention in the control group
(n = 52). The children, their parents, and an observer nurse rated outcomes 1-2 min after completion of
the procedure. The patients in both groups were similar in age, gender, duration of hospitalization,
injections, mother’s age, and education. Faces Pain Scale- Revised (FPS-R), Children’s Fear Scale
*Corresponding author: (CFS), and Visual Analog Scale (VAS) were used to measure pain and anxiety. Paired and
Sherzad Khudeida Suleman, BSN, MSN
Nursing Department, Faculty of Health
independent t-tests were used for data analysis.
Sciences, Witten/Herdecke University, Results: Patients in the intervention group reported significantly reduced pain levels than those in the
Alfred-Herrhausen-Straße 45, 58455 Witten,
Germany | Nursing College, Duhok control group (p <0.001), as reported by children (3.08 vs. 7.06), parents (3.08 vs. 7.13), and the
University, Zakho Street 38 Duhok 01006 observer nurse (3.06 vs. 7.13), respectively. Anxiety levels were also significantly lower among
Kurdistan Region, Iraq
E-mail: sherzadkhudeida@uod.ac patients in the intervention group than in the control group (p
<0.001), as reported by children (0.88 vs. 3.17), parents (0.94 vs. 3.19), and the observer
Article info:
Received: 16 February 2022 nurse (0.85 vs. 2.94), respectively.
Revised: 18 March 2022 Conclusions: TICK-B is an effective technique for reducing children’s pain and anxiety during PIVC.
Accepted: 26 April 2022
TICK-B is a simple, inexpensive, and effective technique that nurses can use to decrease the levels of
This is an Open Access article distributed under
the terms of the Creative Commons pain and anxiety of pediatric patients during intravenous cannulation.
Attribution-NonCommercial 4.0 International License, which
allows others to remix, tweak, and build upon the work non-
commercially as long as the original work is properly cited.
The new creations are not necessarily licensed under the
identical terms. Keywords
E-ISSN: 2477-4073 | P-ISSN: 2528-181X anxiety; cannulation; children; distraction; distress; pain; hospitalization
Background
Peripheral intravenous cannulation (PIVC) is an
invasive procedure in which a catheter is inserted
through a patient’s skin into the lumen of a
peripheral blood vein. This causes children severe
pain and increases the anxiety of children and
caregivers (Smith et al., 2007). It is a common
stressful procedure for children, and nearly all
pediatric patients have an experience with PIVC
(Zingg & Pittet, 2009). This technique is mainly
recommended for administering solutions,
medications, blood, or blood products to pediatric
patients (Doyle & McCutcheon, 2015).
If not managed quickly and decisively, the pain
experienced by children can have long-term
physical and psychological implications, such as
needle phobia, avoidance of medical care, and a
lack of cooperation during future medical
procedures. Therefore, it is advisable to manage
pain proactively during the insertion of the cannula
or venous access (Kennedy et al., 2008). Reports
show that relief of pain during painful procedures
is an important responsibility of pediatricians,
nursing staff, and other health personnel (Wong et
al., 2012). The WHO affirms that pain relief is a
fundamental
human right (Daher, 2010). Therefore, it is
significant to explore the most effective forms of
pain management (Koller & Goldman, 2012;
Uman et al., 2013).
The nurses are responsible for managing the
pain and anxiety of patients as the most crucial
results of painful procedures. It is the
responsibility of pediatric nurses to anticipate,
recognize, and evaluate pain and to implement
interventions before, during, and after procedures.
In order to treat pain effectively, Both
pharmacologic and nonpharmacologic approaches
have been strongly recommended in research
studies and clinical guidelines (Czarnecki et al.,
2011; Taddio et al., 2010).
A usual pharmacological strategy is the use of a
topical cream to reduce pain resulting from
medical procedures (Trottier et al., 2019). But
children may experience pain and distress because
of these creams (Gold et al., 2006). due to possible
side effects. These creams have physiological
effects with no impact on psychological
perspectives, such as patients’ attitudes, while
non-pharmacological methods help break the
vicious cycle between pain and anxiety by
controlling children’s pain and anxiety (Tick et al.,
2018). Non- pharmacological methods are used
because they are simple, easy to use, saves time,
have no side effects, enhance interaction, and
promote an individual sense of control over
anxiety and pain (Short et al., 2017).
For these reasons, non-pharmacological
approaches are generally recognized as alternative
techniques, which may be used separately or in
pair with pharmacological approaches to treat pain
and anxiety and establish a sense of control over
fear in children (Uman et al., 2013). Distraction
techniques move children’s attention away from
uncomfortable stimulation to more engaging or
pleasant stimulation. They are easy-to- administer,
inexpensive, and effective ways to decrease pain
and anxiety levels (Koller & Goldman, 2012).
As a non-pharmacological technique,
distraction is one of the most effective ways to
reduce anxiety and pain. There are two kinds of
distraction: active distraction and passive
distraction (Aydin et al., 2016; Inan & Inal, 2019).
Active distraction encourages children to take part in
certain assignments during the procedure by
stimulating one or more of their senses and engaging
their skills during painful procedures. In contrast,
with passive distraction, the children are not
involved in activities during the therapeutic
procedures. Passive distraction only activates their
visual and/or auditory senses (Aydin et al., 2016;
Inan & Inal, 2019). The benefits and effectiveness of
distraction are documented through parent-child
and/or observer reports on reducing pain, distress,
and anxiety (Uman et al., 2013). Art therapy is a
useful method of distraction. This method supports
children in coping with stress before, during, and
after medical procedures (Galvez et al., 2021;
Woodgate et al., 2014).
Arts-based interventions have been reported to
relieve pain and anxiety in children with a variety of
different diseases and a variety of situations, such as
children with cancer (Abdulah et al., 2019) and
hospitalized children (Shella, 2018). The Trace
Image and Coloring for Kids-Book (TICK-B) may
be superior to other distraction interventions because
many distraction techniques require training, are
expensive, unattractive to children, complex to
apply, and impractical, such as computer-related
games, virtual reality, and electronic distraction.
These factors hinder the widespread application of
 distraction methods in hospitals. In many clinical
settings in developing countries, children do not
receive any pharmacological or non-
pharmacological interventions to decrease pain
and anxiety levels. To date, to our knowledge,
there are no studies on using the TICK-B as an
art-based distraction to reduce children’s pain
intensity and anxiety levels during PICV in the
published research. The TICK-B technique is an
art base-intervention easily applied by nurses. It
does not require training or have adverse effects
during medical procedures, and it is a cost-
effective and attractive technique. For these
reasons, in this study, we examined the
effectiveness of the TICK-B in decreasing the
pain and anxiety of hospitalized children during
PICV. We hypothesized that children who
received the TICK-B would have a significantly
lower level of pain and anxiety.
Methods
Study Design
This was a parallel, randomized, double-blind
clinical trial conducted on pediatric patients.
Patients who required the PIVC procedure were
randomly assigned into two groups: the
intervention group and the control group.
aged 6–12 years old of both genders who required
PIVC. We received consent from the children’s
parents. Patients were excluded from the study
based on having a chronic disease, being
unconscious, being neuro- developmentally
delayed (diagnosed through parental reporting),
being unable to communicate verbally, having a
hearing or sight impairment, or having taken an
analgesic within the past 6 hours. The general
characteristics of both groups of patients and their
parents were similar.
We determined the sample size based on the
G*power program (Faul et al., 2007). The pain
level of the first five cases in the control group was
assessed by the observer, and the mean value and
standard deviation of these five cases were
measured accordingly. The obtained score was
6.53 (SD = 1.5). We believed the intervention
would have a large effect on pain in this study.
Therefore, we assumed this value could decrease
to 5.53 (SD = 0.85) after the intervention. The
effect size was 0.820, two tails, α 0.05, and power
(1-β), 0.95 was considered using the two
independent groups. The required number of
patients in each group was 40, but we increased
our sample size by around 50% to avoid missing
information due to possible technical issues. In
addition, cases were

Samples/Participants
The patients from the medical ward of the Heevi
pediatric teaching hospital in the city of Duhok,
Iraqi Kurdistan, were recruited between
November 2019 and February 2020. The Heevi
pediatric teaching hospital is the only pediatric
hospital to treat medical, emergency, and surgical
conditions in Duhok. The hospital has a CCU,
NICU, operation unit, reception unit, and
medical, emergency, and surgical wards.
The patients’ baseline information was
assessed according to the eligibility criteria by the
first author. In addition, the medical records of
the patients were checked for the eligibility
criteria. Accordingly, the eligible patients were
randomly allocated to either the intervention or
control group. The study sample included
patients admitted to the pediatric medical ward
widely available at the hospitals, and the
intervention was easily conducted with a short
follow-up time. Accordingly, these two factors
allowed us to raise our sample size.
In the randomization process, the names of the
patients who required the PIVC procedure were
recorded on a pre- designed form. Simple
randomization was conducted using an envelope
technique. Opaque sealed envelopes containing
information assigning patients to either the
intervention or control group were given to the
patients. The patients, nurses, and parents were
blind to the groupings due to the opaque sealed
envelopes. The observer nurse who measured pain
and anxiety levels was unaware of the groups’
assignments. To reduce measurement bias, we did
not allow the observer nurse to enter the room until
the procedure ended. In addition, the nurse was
masked as to whether the intervention was applied
or not applied to a patient. We also coordinated
with the head nurse of the medical ward so that no
one would be allowed to enter the room and
interrupt the procedure.
The patients were asked to select one of these
envelopes. Of 110 invited patients, ten declined to
take part in the study. The patients who agreed
to participate in the study were
randomly assigned into the groups. The
intervention group included 48 patients, while the
control group included 52 patients. To apply the
allocation concealment, we selected one child
randomly from each room for either inclusion in
the experimental or control group. We asked the
nurses to bring the patients to a special room for
the study purpose (The intervention was not
performed in the same room as the child admitted).
The child selected an opaque pocket for either
inclusion in the experimental or control group.
This technique helped us avoid allocation bias
since the patients did not know what had been done
to other patients. Also, the rooms were separated
from each other, and patients were not aware of the
situation of the other children. In terms of
information bias, the patients were not aware of the
situation of other patients either in the ward or
room.
The children did not know that we were
comparing their pain and anxiety levels with
another group. We also asked the clinical nurse and
parents not to inform their children about the
intervention. Therefore, the children were
completely blind to the goals of the intervention
(see flow chart in Figure 1).
Figure 1 Flow chart of participants' recruitment
Intervention image to be colored during the cannulation
TICK-B was developed through the following two procedure. At this time, the first author started to
phases: Firstly, we consulted two child apply the intervention simultaneously with the
psychiatrists to obtain the types of images that venipuncture procedure. Then, the clinical nurse
must be included in the TICK-B tool. The started to perform the PIVC procedure. The observer
psychiatrists gave us some hints about the effects nurse and the children’s parents were hidden for
of the images on the children’s behavior and accurate study purposes to avoid behavioral changes
mental status. They advised us that the image must during and after the procedure and to avoid
be desirable and immersed with the nature measurement bias. Parents were allowed to remain
perspectives and be free from the violent features.with the children during the cannulation to
The pictures of the pets, such as rabbits and standardize the cannulation procedure, and the
flowers, are considered convenient images. cannula was placed on the left hand of each child. The
In the second phase, we contacted the method of pain relief (distraction) was continued
professional art teachers at three elementary until the procedure was completed. Our TICK-B
schools for children in different geographic areas.technique was tested with ten children in a pilot
We asked them to draw convenient images based study to assess TICK-B applicability. Examples of
on the advice of the psychiatrists. The teachers coloring images can be seen in Figure 2.
made several images at this phase. Then, the For the control group, the patients received routine
images were presented to the psychiatrists and the hospital care during cannulation procedures. They
researchers to select the most appropriate pieces did not receive a TICK-B intervention or any other
for inclusion in the TICK-B. kind of distractions as non- pharmacological or
The first author initiated the TICK-B pharmacological approaches. In addition, the child’s
intervention between 2 and 3 minutes before the mother was allowed to be presented during the
procedure and continued until the cannulation cannulation procedure as recommended by clinical
procedure was completed. The TICK-B was guidelines.
implemented by the first author, a Ph.D. student in
pediatric nursing, but all of the outcome Data Collection
evaluations were conducted by the observer nurse, The children were asked to report outcomes after the
the parents, and the children. The observer nurse, 1–2- minute-long procedure ended. The children
who had experience in child health nursing for rated their pain and anxiety levels based on the
eight years, was trained by the researcher to assess Faces Pain Scale-Revised
pain and anxiety. The nurses made the decisions
on the PIVC procedure in the pediatric wards on
the same day. The clinical nurse who performed
the PIVC procedure had over ten years of
experience in child health care. For that reason, we
did not educate the nurse about the PIVC
procedure.
Peripheral vein cannulation was performed by
the same nurse practitioner for all pediatric
patients. The child was taken to a quiet place in the
ward and sat at a table. Two to three minutes
before beginning the procedure, the first author
interacted with the child to gain the child’s
confidence, cooperation, and friendship during the
TICK-B intervention. Then, the book was handed
over to the patient, instructed to choose a preferred
(FPS-R) and Children’s Fear Scale (CFS). The
observer nurse and parents used the visual
analog scale (VAS) to measure anxiety levels
and pain intensity in children. We were permitted
to use these tools, and they were very easy to use
since they were pictures and did not require
translation into another language. The pain and
anxiety levels were separately evaluated by
assessors, including children, parents, and the
observer nurse. The assessors were masked from
each other in this study to avoid possible
measurement bias. The observer nurse had no
personal conflicts or financial interest in the
study.

Figure 2 Examples of photos of children’s coloring book

Instruments
The general features of the patients—including
age, gender, hospitalization, frequency of
injections, parents’ age, and educational status—
were recorded using a pre-designed
questionnaire.
Pain in children (self-assessment): Faces Pain
Scale- Revised (FPS-R) was used to measure
pain severity. The FPS-R ranges from 0 to 10
and illustrates degrees of pain with six cartoon
expressions ranging from “no pain” to “very
painful.” The children were encouraged to select
the face that was compatible with their pain
severity. The FPS-R scale is unique and has
been proven to be reliable in assessing pain in
children (Thong et al., 2018).
Anxiety in children (self-assessment): To
measure anxiety in children, the Children’s Fear
Scale (CFS) was used. This tool was applied to
measure the fear of children aged 5 to 10 years
during painful procedures. It includes
illustrations of 5 faces placed equally on a
horizontal plane. The CFS faces
 each express a different level of anxiety. On the
far left of the scale, there is a face marked with the correlation and linear regression. We didn’t have
number 0, representing an expression of no anxiety
at all, and on the far right, there is a face marked
with the number 4, marked with the greatest level
of anxiety. The CFS is a viable and reliable
instrument for measuring procedural anxiety in
school-aged children (McMurtry et al., 2011).
Anxiety and pain (proxy assessment): The
observer nurse and parents assessed the children’s Ethical Considerations
state of pain and anxiety using a Visual Analog
Scale (VAS). When the VAS score is 0, no pain is
felt, and when it is 10, the most severe discomfort
is experienced. After the cannulation was
completed, the observer nurse and parents reported
their assessment of the levels of anxiety and pain
on scales from “no anxiety” to “greatest anxiety”
and “no pain” to “worst pain.” The VAS is a valid
and reliable scale. Therefore, it is commonly used
for measuring outcomes of painful procedures in
children 8–18 years of age (Bailey et al., 2012).
Data Analysis
The general features of all pediatric patients in the
study were demonstrated in mean (Sta. deviation)
or no (%). Independent t-tests or Pearson Chi-
Square tests were performed to assess the
homogeneity of patients in both groups. A
comparison of pain and anxiety levels between the
intervention and control study groups was
conducted using an independent t-test in “per-
protocol” analysis. We didn’t have measurements
for the few cases that were lost to follow up in the
study. Comparisons of pain and anxiety over time
between the study groups were conducted with a
paired t-test. The anxiety and pain levels were
compared between the intervention and control
groups using an independent t-test. Also, the
correlation between fear and pain and the role of
children’s characteristics and previous
pain on later fear was investigated using bivariate
measurements for the outcomes of the few cases
that were lost to follow-up in the study. A p-value
of less than 0.05 was deemed a significant level of
difference. For the statistical analysis, IBM SPSS
Statistics for Windows was used (Version 25.0;
Armonk, NY, 2017).
This paper was part of a PhD program. Ethical
approval was given by the Division of Scientific
Research, Directorate of Planning, Duhok General
Directorate of Health in Duhok on September 10,
2019 (registration number 10092019-6). The grant
to publish the results of this study was obtained on
August 23, 2020 (reference number 20072020-3).
Administrative approval was also received from
Heevi Hospital. According to the terms of the
Declaration of Helsinki, informed written consent
was gained from the parents of all children before
enrollment in the study. We did not perform any
harmful intervention on the patients in this study.
Results
The authors considered 120 children for inclusion in
this study,
110 of whom were eligible and participated; ten
were not included because they were too young. Of
the 110 included in this study, the parents of ten of
them declined the procedure: seven patients in the
intervention group and three in the control group.
The patients in both study groups were similar in
age, gender, number of injections, maternal age,
and education (Table 1).
 Table 1 Comparison of general features between the control and intervention groups

Study groups Statistic value p-value

Patients’ characteristics
Control (n = 52) Intervention (n = 48) (Chi Square/t/Fisher) (two-sided)
Age (year); Mean (SD) 7.98 (1.96) 7.79 (1.78) 0.998 0.321a
Hospitalization day; Mean (SD) 3.38 (1.05) 3.33 (1.04) 0.245 0.807a
Number of injection attempt; Mean (SD) 1.13 (0.34) 1.23 (0.42) -0.954 0.342a
Mother age (year); Mean (SD) 40.98 (3.97) 40.46 (4.31) 0.631 0.530a
Gender; no (%)
Male 25 (48.1) 24 (50.0) 0.037 0.848b
Female 27 (51.9) 24 (50.0)
Mother’s education; no (%) 1.175 0.907c
4 (7.7) 4 (8.3)
Illiterate
25 (48.1) 19 (39.6)
Primary school grad.
14 (26.9) 16 (33.3)
Secondary school grad.
4 (7.7) 5 (10.4)
High school grad.
5 (9.6) 4 (8.3)
College grad.
a
An independent t-test, b Pearson Chi-squared test, and c Fishers’ exact test were performed for statistical analyses

The patients in the intervention group reported a (t = 17.00; p < 0.001) with a medium effect size
significantly lower level of pain during the (3.41). The patients in the intervention and control
procedure (t = 11.37; p < 0.001) with a medium groups had similar anxiety and pain levels before
effect size (2.27) and after the procedure (t = starting the cannulation procedure (p > 0.05). The
12.08; p < 0.001) with a medium effect size (2.43) study did not find statistically significant
compared to the patients in the control group. The differences in pain and anxiety over time in the
same pattern was observed for anxiety during the control group, while pain and anxiety levels
procedure (t = 16.76; p < 0.001) with a medium decreased significantly over time in the
effect size (3.34) and after the procedure intervention group (Table 2).
 Table 2 Comparison of pain and anxiety scores between intervention and control groups

Study groups Degree of

p-value Effect size
Pain and anxiety Control Intervention t freedom (df)
(two-sided) (Cohen’s d)
(n = 52) (n = 48)
Previous pain 7.13 (1.78) 7.00 (1.75) 0.381 98 0.704 NA
Pain during procedure 7.12 (1.75) 3.27 (1.64) 11.37 98 <0.001 2.27
Pain after procedure 7.06 (1.68) 3.08 (1.59) 12.08 98 <0.001 2.43
Anxiety pre procedure 3.25 (0.59) 3.19 (0.60) 0.522 98 0.603 NA
Anxiety during procedure 3.19 (0.59) 1.13 (0.64) 16.76 98 <0.001 3.34
Anxiety after procedure 3.17 (0.64) 0.88 (0.70) 17.00 98 <0.001 3.41
a
an independent t-test was performed for statistical analyses
Pain and anxiety levels were measured by WBFS, VAS, and CFS, respectively

Pain and anxiety scores were significantly lower in procedure pain and other medical conditions did not
the intervention group compared to the control contribute to post-procedure anxiety (Table 4).
group as evaluated by children, parents, and the
observer nurse (Table 3). Pre-
Table 3 Comparison of pain and anxiety scores of children in the intervention and control groups with different examiners

Study Groups Mean (SD)

Degree of Effect size
Outcome measurements Control group Intervention group t
freedom (df) (Cohen’s d)
(n = 52) (n = 48)
Pain
Child reported 7.06 (1.68) 3.08 (1.59) 12.08 98 2.43
Parent reported 7.13 (1.70) 3.08 (1.56) 12.34 98 2.48
Observer reported 7.13 (1.69) 3.06 (1.60) 12.33 98 2.47
Fear
Child reported 3.17 (0.64) 0.88 (0.70) 17.00 98 3.41
Parent reported 3.19 (0.84) 0.94 (0.72) 14.29 98 2.87
Observer reported 2.94 (0.80) 0.85 (0.68) 13.95 98 2.81
The p-value of the pain and anxiety was p < 0.001 for all comparisons Pain
and anxiety were measured by WBFS, VAS, and CFS, respectively

Table 4 Role of before procedure anxiety, hospitalization day, and general characteristics of after procedure anxiety in the intervention group

Dependent variable: Anxiety after the procedure

Controlling factors Standardized 95% CI for B
t p-value
Coefficients Beta Lower Bound Upper Bound
Previous pain -0.269 -0.759 0.452 -0.397 0.180
Previous anxiety -0.257 -1.683 0.100 -0.655 0.060
Age -0.321 -0.876 0.386 -0.416 0.165
Gender -0.018 -0.115 0.909 -0.475 0.423
Hospitalization days -0.181 -1.019 0.315 -0.367 0.121
Attempt 0.007 0.045 0.964 -0.502 0.525
Mother age 0.059 0.364 0.718 -0.044 0.064
Mother education -0.147 -0.880 0.384 -0.324 0.128
The linear regression was performed for statistical analyses

Discussion cannulation. In children, pain may cause tension,

fear, and anxiety (Gold et al., 2006). The American
This study demonstrated that distraction using the Pain Society recommends providing effective pain
TICK-B is effective in lowering pain and anxiety management both before and during needle
levels in hospitalized children reported either by procedures (Czarnecki et al., 2011). According to
the children themselves, parents, or observer evidence-based clinical practice recommendations,
nurse. This study used the TICK-B technique for most situations involving pain and anxiety induced
the first time as an art-based distraction in school- by painful procedures can be managed with non-
aged children. Pain is often felt during procedures pharmacological approaches (Bergomi et al.,
routinely conducted in hospitals, such as 2018).
phlebotomies and peripheral intravenous
According to our hypothesis, art intervention
based on the TICK-B could reduce the levels of
pain and anxiety in school- aged children.
Consistent with our study, a nonrandomized
controlled trial showed that children who
received art therapy exhibited cooperative
behavior and desired art therapy intervention for
future painful procedures. In comparison, the
children in the control group who did not receive
art intervention showed resistance, uncooperative
behavior, and fear during and after lumbar
insertion and marrow aspiration (Shella, 2018).
The literature has confirmed the effectiveness of
art-based interventions in relieving pain and
anxiety among children with various diseases.
Children’s fear of medical procedures
decreases when they actively participate in a task
during therapeutic interventions. It seems that
the active participation of the children increases
their tolerance toward the pain posed by medical
interventions (Aydin et al., 2016; Inan & Inal,
2019).
The reason for this increased tolerance may be an
altered perception of pain in the children.
The pain relief experienced during therapeutic
procedures when children actively participate in a
task may be explained by the following theories.
Melzack and Wall’s gate-control theory of pain,
suggested in 1965, may explain how art-based
intervention affects the perception and experience
of pain and anxiety during therapeutic and
diagnostic procedures. In the gate-control theory,
the brain has a neural gate mechanism that releases
or suppresses an individual’s perception of pain. In
addition to past events and emotions, psychological
factors, such as awareness, also influence pain
perception. The gates open due to stress or when
there is a lack of activity and only a painful
stimulus to focus. An individual, therefore,
perceives a higher degree of pain when the gates
are open. The gates close when the feeling of pain
is reduced by relaxing the person, diminishing the
painful activity, or using a distracting stimulant
(Melzack & Wall, 1965).
There are different logical interpretations of the
distraction’s function. One of the earliest scientific
principles for treating pain transmission is the gate
control theory. According to the theory, the central
nervous system modifies the experience of pain,
and so cognitive attention can influence pain
processing and perception (Melzack & Wall,
1965). This effect may be analyzed neuro-
psychologically, as certain areas of the brain are
less active during distracting tasks (Seminowicz &
Davis, 2006).
A second explanation, one in harmony with
gate-control theory, can be found in limited
attentional capacity theory, which proposes that
the resources available to process pain are fewer if
some attention is devoted to a distracting job
(Gutiérrez-Maldonado et al., 2012). Attention
plays an essential role in the perception of
children’s pain during painful procedures. In this
regard, the children’s pain increases when there is
no distraction task during the therapeutic
procedures. We believe that TICK-B has played a
distraction role in reducing the children’s attention
to the painful procedures.
A third explanation is offered by the behavioral
concept a distraction introduces a stimulus with
prior positive associations (e.g., a favorite game),
stimulating behaviors that do not correspond to the
behaviors of someone in pain (e.g., smiling in a
film), and strengthening painless reactions
(Pancekauskaite & Jankauskaite, 2018). The most
common pain management strategy used on children
is controlling their attention by engaging in pain-
distracting conversations or activities. We
hypothesize that distraction involves a competition
for attention between sensory pain and another
activity. In accordance with the literature, the TICK-
B reduces pain by providing distracting tasks for
children.
Distractions may decrease the stress caused by
therapeutic procedures in children and enable
children to be more tolerant of pain. In this regard,
children may become more relaxed, satisfied, and
active and allowing nurses to concentrate on
delivering high-quality care better. In addition,
during distraction tasks, children’s domain raises
awareness of the self and others. This awareness
assists children in coping with stress and traumatic
experiences (Dalley & McMurtry, 2016).
Effective coping is associated with managing a
situation’s demands or controlling emotions by
gaining a sense of physical and psychological well-
being (Folkman & Lazarus,
 1984). In pediatric psycho-oncology, One of the Conclusion
most crucial research areas was how to help
The TICK-B art-based distraction technique was
children deal with therapies, particularly invasive
found to be an effective method in reducing the
medical procedures (Askins & Moore, 2008).
anxiety and pain of children during and after a
Gloria Martinez-Ayala, a psychologist, claims
cannulation procedure. In addition, the distraction
that art- based intervention activates several
technique can be used safely and does not
regions of the brain. The potential effects of art
adversely affect the success of the cannulation
therapy include the diminishment of symptoms
procedure. More research could be carried out to
associated with stress, minimization of anxiety
investigate whether the TICK-B is effective in
and depressive moods, conflict resolution,
diverse clinical settings across various age groups
increased quality of life, and visual thinking
and cultures.
(Caddy et al., 2012). In addition, the associated
relaxation and mindfulness modulation lower the
Declaration of Conflicting Interest
activity of the amygdala is a key component of The authors declared no potential conflicts of interest concerning the research,
the brain involved in managing emotions affected authorship, and/or publication of this article.

by stress (Taren et al., 2015). We believe that the

reduction in pain and anxiety experienced during Funding
The authors have no funding to disclose.
art-therapy intervention is due to this kind of
activation in the brain.
Acknowledgment
The strengths of this study include the The authors would like to thank the staff at Heevi Pediatric Teaching Hospital for
performance of randomization, the recruitment their kind support. In addition, we would like to present our deep thanks to the
observer nurse and her kind cooperation and support
of a control group, the use of simple pain and
fear assessment tools, practical art-based
intervention, blinding, and allocation
concealment. However, the study was not free
from limitations. To reduce the reporting bias of
the parents, the outcomes were also reported by
two other assessors. In addition, we included
school-age children in this study, limiting the
applicability of the TICK-B to this age group.
Furthermore, we recruited patients from a single
site and a singles ward.

Implications for Nursing Practice

An essential role of pediatric nurses during
painful interventions is to improve nurse-child
collaboration by reducing the emotional and
physical impact of medical interventions through
non-pharmacologic approaches. As an art-based
distraction, the TICK-B is a non-pharmacologic
technique and an enjoyable activity that helps
distract children and decrease levels of pain and
anxiety during cannulation. Nurses can use the
TICK-B as a simple, cost-effective, and
convenient technique to manage pain and anxiety
in children.
with interest in the financial declaration. We also thank all the families and Dalley, J. S., & McMurtry, C. M. (2016). Teddy and I get a check-up: A pilot
children who have participated in this research. And thank you to Prof. educational intervention teaching children coping strategies for managing
Margareta Halek, Witten/Herdecke University, and Mr. Deldar Morad, Dohuk procedure-related pain and fear. Pain Research and Management, 2016.
University, for support in reviewing our manuscript. https://doi.org/10.1155/2016/4383967

Doyle, G. R., & McCutcheon, J. A. (2015). Clinical procedures for safer patient care.
Authors’ Contributions Victoria: BCcampus.
All authors have equal contributions to the conception or design of the work,
Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G* Power 3: A flexible
the acquisition, analysis, or interpretation of data for the work, drafting of the
statistical power analysis program for the social, behavioral,
work or revising it critically for important intellectual content, and final approval
of the version to be published and accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.

Authors’ Biographies
Sherzad Khudeida Suleman, BSN, MSN is a PhD Student in the Nursing
Department, Faculty of Health Sciences, Witten/Herdecke University, Germany.

Akram Atrushi is a Consultant Pediatrician, Professor at the College of Medicine,

Duhok University, Kurdistan Region, Iraq.

Karin Enskär, RN, BSN, MSN, PhD of Nursing Science is a Professor at the
Department of Women’s and Children’s Health, Uppsala University, Sweden.

Data Availability
The study data can be seen in the following link:
https://drive.google.com/file/d/11cDFqBLCD_sc_zR85gEfI1U4ovWxKne-

/view?usp=sharing

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Cite this article as: Suleman, S. K., Atrushi, A., & Enskär, K. (2022).
Effectiveness of art-based distraction in reducing pain and anxiety of
hospitalized children during cannulation procedure: A randomized controlled
trial. Belitung Nursing Journal, 8(3), 213-221.
https://doi.org/10.33546/bnj.2054