Pain Management Nursing xxx (xxxx) xxx

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Pain Management Nursing

journal homepage: www.painmanagementnursing.org

Original Article

The Effects of Two Methods on Venipuncture Pain in Children:

Procedural Restraint and Cognitive-Behavioral Intervention Package
Fatma Yilmaz Kurt, RN, PhD *, Aynur Aytekin Ozdemir, RN, PhD y, Selma Atay, RN, PhD z
*
Department of Child Health Nursing, School of Health, Canakkale Onsekiz Mart University, Canakkale, Turkey
y
Department of Nursing, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul, Turkey
z
Department of Fundamentals of Nursing, School of Health, Canakkale Onsekiz Mart University, Canakkale, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Background: Invasive interventions can produce fear, anxiety, and pain in children. This may negatively
Received 30 April 2018 affect the children's treatment and care.
Received in revised form Aim: This study was conducted to determine the effects of procedural restraint (PR) and cognitive-
27 April 2019
behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age.
Accepted 6 September 2019
Design: Quasi-experimental study.
Settings: The study was conducted in the pediatric blood collection service of the hospital in Turkey
between October 1, 2015, and April 1, 2016.
Participants/Subjects: The population of the study consisted of children admitted to the blood collection
service during the study period who met the inclusion criteria.
Methods: The children included in the study were divided into two groups. Group 1 (n ¼ 31) received PR
in accordance with routine clinical practice. Group 2 (n ¼ 30) received the CBIP. The data were collected
by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-
FACES) Pain Rating Scale.
Results: The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of
8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES
score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-
FACES pain scores of the groups (p < .05).
Conclusions: The results of this study showed that the children in the CBIP group had a lower pain level
during venipuncture compared to those restrained for the procedure.
© 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Invasive interventions can produce fear, anxiety, and pain in many negative outcomes may occur in the long term. Healthcare
children. Children and parents may be reluctant to undergo a professionals often pay little attention to the management of pain
medical intervention. This may negatively affect the children's associated with venipuncture and intravenous cannulation, which
treatment and care (Blount, Piira, Cohen, & Cheng, 2006; Uman are widely used interventions. However, increasing evidence exists
et al., 2013). Negative experiences related to medical procedures to indicate that a venous access procedure is a significant source of
have a long-lasting effect on children, which may persist pediatric pain, which must be managed proactively. Nurses should
throughout their life (Taddio et al., 2015). Every child has the right thus focus on the effects of different techniques used or recom-
to be protected from harm (Bruce, 2009). Relieving or preventing mended for use in painful medical procedures on children (Aydin,
pain is one of the primary responsibilities of nurses providing care Şahiner, & Çiftçi, 2016; Canbulat, Inal, & So €nmezer, 2014;
for children. In the case of failure to manage acute pain in children, Czarnecki et al., 2011).
The purpose of procedural pain management is to minimize the
pain, anxiety, and fear related to medical procedures. Pharmaco-
logical and nonpharmacological methods can be used in combi-
Address correspondence to Aynur Aytekin Ozdemir, RN, PhD, Department of nation, as well as alone (Bruce, 2009). Many pain management
Nursing, Faculty of Health Sciences, Istanbul Medeniyet University, Atalar District, techniques exist to ensure the safety and comfort of patients during
Şehit Hakan Kurban St. 34862, Kartal - Cevizli, Istanbul 34700, Turkey.
E-mail address: aynuraytekin25@hotmail.com (A. Aytekin Ozdemir).
painful procedural interventions. One of these techniques is

https://doi.org/10.1016/j.pmn.2019.09.002
1524-9042/© 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
2 F. Yilmaz Kurt et al. / Pain Management Nursing xxx (xxxx) xxx

cognitive-behavioral intervention. Existing literature recommends studies using the suggestion method alone. They found that the
the use of cognitive-behavioral interventions to minimize the method did not reduce self-reported and observed pain or distress
distress and pain children experience during interventions (Chen, levels in children. On the other hand, the same study reported that
Joseph, & Zeltzer, 2000; Hockenberry, Wilson, Winkelstein, & when the suggestion method was used with distraction in needle-
Kline, 2003; Jay, Elliott, Katz, & Siegel, 1987). A cognitive inter- related painful procedures, the children's self-reported pain was
vention is defined as one in which the patient identifies anxiety and reduced.
negative thoughts related to medical procedures and replaces them Cognitive and behavioral interventions aim to teach parents
with more positive beliefs and attitudes, improving adaptive how to alleviate their children's distress during needle-related
behavior and coping methods (Barlow & Durand, 2015). The procedures (McCarthy et al., 2010). In this study, parents were
cognitive interventions used for procedures include cognitive trained in how to soothe and support their children by holding
distraction, imagery, hypnosis, preparation/information, thought- their hands. The Agency for Health Care Policy and Research and
stopping, coping self-statements, suggestion, memory change, the Public Health Service (1992) jointly recommend that parents
and parent training (Uman, Chambers, McGrath, & Kisely, 2008). A be present with their children during medical procedures. Studies
behavioral intervention is defined as an intervention to reveal have found that the presence of parents during medical procedures
specific behaviors based on behavioral sciences and learning reduces both distress and pain for their children (Bauchner, Vinci,
principles (Barlow & Durand, 2015). They include behavioral Bak, Pearson, & Corwin, 1996; Cavender, Goff, Hollon, & Guzzetta,
distraction, muscle relaxation, breathing exercises, modeling, 2004).
rehearsal, desensitization, positive reinforcement, parent training, Examples of positive reinforcement include positive statements
parent/staff coaching, and virtual reality. Cognitive-behavioral in- and tangible rewards (e.g., toys) after painful procedures (Uman,
terventions can be defined as packages that contain a minimum of Chambers, McGrath, & Kisely, 2008). The reinforcement encour-
one behavioral intervention together with a minimum of one ages the child's coping behaviors during the painful procedure and
cognitive intervention (Uman, Chambers, McGrath, & Kisely, 2008). increases the likelihood of them showing similar behaviors in
Cognitive-behavioral interventions teach effective coping skills identical conditions in the future (Schiff, Holtz, Peterson, &
to reduce the stress and anxiety children experience during painful Rakusan, 2001). In their study, Manne et al. (1990) implemented
procedures (Ellis & Spanos, 1994; Jay, Elliott, Fitzgibbons, Woody, & a behavioral intervention package of parent coaching, distraction,
Siegel, 1995). In a study using the cognitive-behavioral intervention and positive reinforcement for children with cancer during veni-
package (CBIP) to reduce children's distress during a painful med- puncture intervention, whereby they determined that the inter-
ical procedure, the children in the treatment group had a lower vention reduced the children's behavioral distress. In another
score for distress and pain than children in the control group (Jay, study, researchers implemented a package involving preparation,
Elliott, Katz, & Siegel, 1987). In their study, Sikorova and relaxation, distraction, reinforcement, parent involvement, and
Hrazdilova (2011) implemented a psychological consultation eutectic mixture of local anesthetics cream on children infected
comprised of cognitive and behavioral interventions on children in with HIV during venipuncture. In this study, a significant reduction
the 5- to 10-year age group during venipuncture. In the study, they in the children's pain and distress levels was found (Schiff, Holtz,
found that the pain levels of the consultation group were lower Peterson, & Rakusan, 2001).
than the control group. Procedural restraint (PR) is the most common approach used to
In the present study, the CBIP included preparation and infor- ensure patient safety and improve treatment success during inva-
mation regarding the procedure as well as cognitive-behavioral sive interventions (Brenner, 2007; Kennedy & Mohr, 2001;
distraction, suggestions (procedure will be less painful, and pro- Tomlinson, 2004). The Joint Commission on Accreditation of
cedure will not damage to your arm, etc.), parent training, and Healthcare Organizations defines PR as “using physical force
positive reinforcement. Information was provided about what directly on the patient to restrict freedom of movement without
might be experienced during the procedure (Zeltzer, Jay, & Fisher, consent of the patient” (American Nurses Association [ANA], 2012,
1989). The American Academy of Pediatrics (2001) states that in- p. 3-4). PR is widely used for painful procedural interventions in
formation about medical procedures must be provided to children pediatric patients, often for inserting or removing a drain or
and parents so they can be prepared for the procedure. A related intravenous cannula or injecting drugs when initiating and ending
review study concluded that pediatric patients were not prepared treatment in children. However, it has adverse physical effects on
adequately for acute medical procedures (Jaaniste, Hayes, & von patients, and may cause fear, anger, anxiety, agitation, resistance,
Bayer, 2007). Harrison (1991) studied a convenience sample of resistance to procedures, and bad temper (Crock et al., 2003;
100 children, aged 6-12 years; children who had been prepared for Ofoegbu & Playfor, 2005; Stacey, Ames, & Petros, 2000).
the venous blood withdrawal procedure found it less painful that No study was found in the literature comparing the effects of PR
those who had not. and behavioral-cognitive interventions on children's pain levels
Distraction is usually defined as a strategy (whether cognitive or during venipuncture. Thus the present study investigated the ef-
behavioral) that draws a child's attention away from detrimental fects of PR, which is not a pain management strategy, and CBIP,
pain stimuli (Sander, Eshelman, Steele, & Guzzetta, 2002). Kleiber which is a pain management strategy (including preparation and
and Harper (1999) reviewed the effect of distraction on the information, cognitive-behavioral distraction, suggestion, parent
distress patterns of children (16 studies) and the children's self- training, and positive reinforcement), on children's pain levels
reported pain (10 studies) during medical procedures. The results during venipuncture.
of the study revealed that distraction reduced children's self-
reported pain in various medical procedures. In a systematic re-
view, it was reported that distraction methods reduced both
needle-induced pain and distress in children and adolescents Research Hypotheses
(Birnie, Noel, Chambers, Uman, & Parker, 2018).
One suggestion researchers have made is that positive verbal H0: There is no difference between the pain scores of children
and nonverbal feedback be given to the child by the nurse receiving PR and the pain scores of children receiving CBIP.
(Emergency Nurses Association [ENA], 2018). In their systematic H1: There are differences between the pain scores of children
review, Uman, Chambers, McGrath, and Kisely (2008) examined receiving PR and the pain score of children receiving CBIP.

Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
 F. Yilmaz Kurt et al. / Pain Management Nursing xxx (xxxx) xxx 3

Materials and Methods questions about their prior experience of invasive interventions,
intravenous (IV) access, and fears about IV intervention.
This is a quasi-experimental study with a treatment group
and a control group; it was conducted in the pediatric blood VAS
collection service of a maternity and children's hospital located The scale is used to measure and monitor the severity of pain. It
in western Turkey between October 1, 2015 and April 1, 2016. The is a 10-centimeter horizontal or vertical line with a statement at
study participants consisted of children between 6 and 12 years each end. The left end of the line states “no pain” or “no pain at all,”
of age who were admitted to the blood collection service during and the right end of the line states “unbearable pain” or “worst
the study period and who met the inclusion criteria. The sample possible pain.” The child is instructed to mark a point on the line
size was determined by a power analysis, which had a 98% test that would accurately represent their pain. The distance of the
power with an effect size of 1.29 at a confidence interval of 95% patient's mark to the left end is measured in centimeters and
and a significance level of .05 for the analysis t test. The sample expressed as the score. The VAS has been used successfully in
included a total of 61 children, 31 in the PR group and 30 in the school-aged children (Wewers & Lowe, 1990).
CBIP group.
The inclusion criteria for the current study required that
participants be 6 to 12 years of age, not have any chronic dis- WB-FACES Pain Rating Scale
eases, congenital or neurological disorders, not have been pre- The scale was developed by Wong and Baker in 1981 and
viously hospitalized for treatment, and have no history of using restructured in 1983. The scale is used to describe pain in children
sedatives, analgesics, or narcotic substances or drugs, and that between 3-18 years of age and includes drawings of six faces that
their parents gave consent to their inclusion in the study. After represent gradually increasing severity of pain, with pain levels
data collection began, seven children in the PR group and five rated from 0 to 5. The leftmost face is a smiley face that represents
children in the CBIP group were dropped from the sample. “no pain,” and the rightmost face is a crying face that represents the
Figure 1 shows the study flow diagram for child enrollment. The “most severe pain.” The child is instructed to choose a face that best
sample group for the study consisted of 61 children selected from expresses how he or she is feeling. The WB-FACES scale is a 0-10
the study population using a random sampling method. The scale, with higher scores indicating less tolerable pain (Mayer,
children were assigned to a sample group based on day of Torma, Byock, & Norris, 2001; Wong & Baker, 1988).
admission. Groups were assigned to even or odd days, which
were decided by drawing lots. CBIP
Researchers used existing literature to configure the CBIP, taking
Data Collection into account children's developmental characteristics. The opinions
of the researchers, three professors specializing in the fields of
The data were collected by the investigators through face-to- pediatric or psychiatric nursing, were then applied, shaping the
face interviews using a questionnaire, visual analog scale (VAS) CBIP into its final form. One of the three researchers, who is also a
and the Wong-Baker FACES (WB-FACES) Pain Rating Scale. nurse with a Ph.D. in the pediatric nursing field with 12 years of
clinical experience, implemented the CBIP with the participants. A
pilot study on the CBIP was conducted on five children. The study
Questionnaire
was recorded on video and later submitted for the expert opinion of
The questionnaire developed by the investigators contained
the team, including professors. Based on these expert opinions, the
identification questions, such as age and gender of the child, and
CBIP took its final form. The children included in the pilot study
were not included in the analysis of the study.
Assessed for eligibility (n=75)
The cognitive interventions in this package include preparation
and information regarding the procedure, cognitive distraction,
Excluded (n=2) suggestions (procedure will be less painful, etc.), and parent
Parents declined to participate
training. The behavioral interventions include positive reinforce-
ment and behavioral distraction.
n=73
Randomly allocated and incluted
in final analysis  Preparation and information on the procedure: The investigator
conducted an interview with the child and parents prior to the
procedure. This interview was intended to provide information
n=35 n=38 (appropriate for the child's age) on how the procedure was
CBIP Group PR Group
performed, how long it would take, and how the child should
behave. The investigator then answered any questions the child
Loss of CBIP group (n=5) Loss of PR group (n=7)
(due to the parent/child was (due to the parent/child was
might have.
withdrawn from the study) withdrawn from the study)  Cognitive distraction: After the child was informed about the
procedure, the investigator asked the child questions not related
Venipuncture with CBIP Venipuncture under normal to the procedure while it was in progress to draw the child's
(n=30) routine (with PR) (n=31) attention to another subject.
 Suggestions: The investigator used verbal and nonverbal
VAS and WB-FACES Scored VAS and WB-FACES Scored communication techniques (eye contact, speaking a calm tone of
voice, etc.) and made suggestions before starting the procedure
to make the child feel they were supported (suggesting that the
VAS and WB-FACES
procedure will be less painful, and procedure will not damage to
Scored Compared your arm, etc).
 Parent training: The investigator included the parents in the
Figure 1. Flow of study. preparation and information interview prior to the procedure

Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
4 F. Yilmaz Kurt et al. / Pain Management Nursing xxx (xxxx) xxx

and instructed them to provide support to the child (standing interview, the child sat on the venipuncture procedure seat alone,
with the child, holding his or her hand, etc.). with the support of a parent and the investigator. The child was
 Behavioral distraction: The investigator suggested various introduced to the investigator prior to the procedure. The nurse
distraction techniques for the child during the procedure (e.g., answered any questions the child might have. The parent sat on the
counting, singing a song, reading a poem, or answering ques- seat next to the child and held his or her hand for support. The
tions). The technique chosen by the child was used during the blood was collected by the nurse when the child indicated he or she
procedure. was ready for the procedure. During the procedure, the investigator
 Positive reinforcement: After the procedure, the investigator used the stages of CBIP (cognitive distraction, suggestions, behav-
encouraged the child with positive feedback (positive rein- ioral distraction, and positive reinforcement). The children assessed
forcement) about the child's successful coping ability during the the pain they experienced during the procedure using VAS and WB-
procedure (“Well done!” “You were very brave!” etc.). FACES. The process of the CBIP group lasted approximately 10-
15 min.
Intervention
Analysis
For the pediatric blood collection procedure, a volunteer nurse
with a minimum of 5 years of experience performed the veni- Statistical analyses were performed using the Statistical Package
puncture. The nurse did not have any conflict of interest. The for the Social Sciences software program (SPSS Inc., Chicago, IL,
clinical decision to perform venipuncture was made by a pediatri- USA) for Windows (version 18.0). Descriptive statistics were
cian. The venipuncture was performed in accordance with the expressed as percentage, mean, and standard deviation. The PR
procedures of the blood collection service using a 22-gauge needle group and CBIP group were compared using the c2 test and inde-
with a phlebotomy seat specifically prepared for children. No pendent t test. Significance was assessed at the level of p < .05.
pharmacological pain relief method was administered before,
during, or after the venipuncture. The post-procedure pain of each Ethical Considerations
child was assessed by VAS and WB-FACES.
Before conducting this study, we obtained approval from the
PR Group (n ¼ 31) ethical committee of the Medical School of Çanakkale Onsekiz Mart
The children in this group were restrained during the veni- University (dated December 21, 2015, number 2015/17-02), and
puncture procedure in accordance with the routine practice of the obtained official permission from the other relevant authorities.
blood collection service. The younger children sat on their parent's The purpose of the study was explained to all the parents of the
lap while the parent restricted the child's movements. The parent children included in the study, who then returned an informed-
placed the child's leg between their legs to constrict them. The consent form to participate. Additionally, the children were pro-
other (nonvenipuncture) arm was held by the parent to restrict vided with information on the study to obtain their verbal consent.
movement. The older children sat on the seat, and their arms, and
legs when needed, were restrained by the parent or auxiliary staff. Results
The blood was collected by the nurse. After the procedure, the
children assessed the pain experienced during the procedure using The mean age of children in the PR group was 8.32 ± 2.07 years,
VAS and WB-FACES. The process for the PR group lasted approxi- and the mean age of children in the CBIP group was
mately 5-7 minutes. 8.37 ± 1.77 years. Of the children in the PR group, 87.1% had prior
experience with venipuncture, compared to 90% of children in the
CBIP Group (n ¼ 30) CBIP group. Of the children receiving PR, 44.4% had previously
All the stages of CBIP were used by the investigator for the experienced venipuncture once, compared to 51.9% of children
children and parents in this group. The pre-procedure interview receiving CBIP. The children in the PR and CBIP groups were
with children for preparation and information about the procedure compared for variables including age, gender, experience of IV in-
was carried out in a room next to the procedure room. After this jection, number of IV injections, and fear of injection. There were no

Table 1
Comparison of Groups According to the Children's Descriptive Characteristics and Venipuncture-related Characteristics

Characteristics PR Group (n ¼ 31) CBIP Group (n ¼ 30) Test p

n (%) n (%)

Age* (y) 8.32 (2.07) 8.37 (1.77) t ¼ 0.089 .929

Gender c2 ¼ 0.807 .369
Female 17 (54.8) 13 (43.3)
Male 14 (45.2) 17 (56.7)
Venipuncture experience c2 ¼ 0.126 .722
Yes 27 (87.1) 27 (90.0)
No 4 (12.9) 3 (10.0)
Number of venipuncture experiences c2 ¼ 0.913 .634
1 12 (44.4) 14 (51.9)
2 7 (25.9) 8 (29.6)
3 8 (29.6) 5 (18.5)
Fear of venipuncture c2 ¼ 1.991 .158
Yes 18 (58.1) 12 (40.0)
No 13 (41.9) 18 (60.0)

PR ¼ procedural restraint; CBIP ¼ cognitive-behavioral intervention package; SD ¼ standard deviation.

*
Mean (SD).

Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
 F. Yilmaz Kurt et al. / Pain Management Nursing xxx (xxxx) xxx 5

Table 2
Comparison of Mean Pain Scores of Children in the PR and CBIP Groups

Scale PR Group (n ¼ 31) CBIP Group (n ¼ 30) Test p

Mean (SD) Mean (SD)

VAS 5.90 (3.22) 2.43 (2.02) t ¼ 5.007 .000

WB-FACES Pain Rating Scale 8.70 (2.22) 2.80 (2.49) t ¼ 9.769 .000

PR ¼ procedural restraint; CBIP ¼ cognitive-behavioral intervention package; SD ¼ standard deviation; VAS ¼ visual analog scale; WB-FACES ¼ Wong-Baker FACES.

statistically significant differences between the groups (p > .05; factors (Aydin, Şahiner, & Çiftçi, 2016; Canbulat, Inal, & So€nmezer,
Table 1). 2014; Crevatin et al., 2016; Karakaya & Go €zen, 2016). The current
Table 2 compares the mean of pain scores for children in the PR study compared children by their defining characteristics and
and CBIP groups. The children who were restrained for the pro- found that both groups were similar in terms of these variables
cedure had a mean VAS score of 5.90 ± 3.22, and mean WB-FACES (p > .05). It is important that groups be similar in terms of variables
score of 8.70 ± 2.22. The children receiving CBIP had a mean VAS with the potential to affect a child's perception of pain and reaction
score of 2.43 ± 2.02, and a mean WB-FACES score of 2.80 ± 2.49. level in order to show the effects of the two methods used during
There was thus a statistically significant difference between the the venipuncture procedure.
mean VAS and WB-FACES score for the groups (p < .05; Table 2). This study investigated the effect on pain of two methods, PR
Of children receiving CBIP, 23.3% had a VAS score of 0, and 60% and CBIP, used with children during venipuncture. The results
had a score of 1-4, whereas 16.1% of restrained children had a score showed that children restrained for the procedure had a statisti-
of 5-7 and 41.9% had a score of 8-10. Of children in the CBIP group, cally significant higher mean pain score than children in the CBIP
43.3% had a pain level of “hurts a little bit/hurts little more” ac- group (p < .05). This finding corroborates the hypothesis that dif-
cording to WB-FACES. Of children in the PR group, 64.5% reported a ferences exist between the pain score of children receiving PR and
pain level of “hurts worst” (Table 3). the pain score of children receiving CBIP. No study in the literature
compared the effects of PR and behavioral-cognitive interventions
on children's pain levels during painful procedures. However,
Discussion
previous studies in the literature suggest alternative practices other
than PR (Brenner, 2007; Folkes, 2005; Masters, 1998). The previous
The American Society for Pain Management Nursing states that
studies reported that the use of PR with children was not useful and
individuals subjected to a painful procedure have the right to have
caused them to experience a high level of stress (Brenner 2007;
their pain managed in the most appropriate manner before, during,
Martinez, Grimm, & Adamson, 1999; Masters, 1998; Mohr,
and after the procedure. It also stresses that a plan must be
Mahon, & Noone, 1998). The children reported that they experi-
developed to relieve pain and anxiety prior to a painful procedure
enced distress more than pain during treatments and medical
(Czarnecki et al., 2011). In addition, the American Academy of Pe-
procedures performed using PR (Folkes, 2005; Robinson & Collier,
diatrics (AAP, 2001) emphasizes that pain related to medical and
1997). PR causes children to feel a loss of control and as if they
nursing procedures in children can be substantially reduced or
are being punished, as well as fear, anxiety, and insecurity (Demir,
prevented; pharmacological and nonpharmacological approaches
2007). PR may cause physical and psychological damage to children
are recommended (Schechter et al., 2007).
before, during, and after the procedure (McGrath, Forrester, Fox-
It has been reported that during procedural interventions, a
Young, & Huff, 2002). If excessive force is used during the PR,
child's pain and reaction level is affected by the type of procedure
children may experience pain, injury, and speech disorders. The
(Rawe et al., 2009) as well as the child's character, experience with
potential psychological effects may include emotional distress,
pain, and physical, psychological, and social factors (Marsac & Funk,
poor coping skills, phobia, and difficulty in communicating with
2008). Studies exist demonstrating that a child's pain level is
healthcare professionals (Brenner, Treacy, Drennan, & Fealy, 2014).
affected by factors such as gender, experience, and fear of injection
The literature demonstrates that the use of cognitive-behavioral
(Windich-Biermeier, Sjoberg, Dale, Eshelman, & Guzzetta, 2007),
interventions in children, such as distraction, play therapists, the
but there are also studies showing pain level is not affected by these
use of parents, improved pain relief, and behavioral interventions
may result in less physical restriction (Dorfman, 2000; Huff &
Table 3 McGrath, 2003; McCarthy, Cool, & Hanrahan, 1998; Piira, Sugiura,
Comparison of PR and CBIP Groups According to the Distribution of Children's Pain Champion, Donnelly, & Cole, 2005; Tomlinson, 2004; Willock,
Scores Richardson, Brazier, Powell, & Mitchell, 2004). Cognitive-
Scale Pain Levels PR Group CBIP Group behavioral interventions contribute to relaxing children and par-
(n ¼ 31) (n ¼ 30) ents during painful procedures, creating a better understanding of
n (%) n (%) the child's condition and cooperation, and eliminating the need for
PR. In the study by Schiff, Holtz, Peterson, and Rakusan (2001),
VAS
0 points 2 (6.5) 7 (23.3)
cognitive-behavioral strategies were used for routine venipuncture
1-4 points 11 (35.3) 18 (60.0) procedures in HIV-positive children (n ¼ 43), and their effect on
5-7 points 5 (16.1) 5 (16.7) procedural pain was examined. The study demonstrated the
8-10 points 13 (41.9) - (-) effectiveness of using a multicomponent pain management inter-
WB-FACES Pain Rating scale
vention comprised of cognitive-behavioral interventions for
No hurt 1 (3.2) 9 (30.0)
Hurts little bit/hurts little more - (-) 13 (43.3) reducing pain and anxiety in children. The effect of cognitive-
Hurts even more/hurts whole lot 10 (32.3) 8 (26.7) behavioral interventions on venipuncture-/IV insertion-related
Hurts worst 20 (64.5) - (-) procedural pain in children was examined through randomized
PR ¼ procedural restraint; CBIP ¼ cognitive-behavioral intervention package; controlled studies. Cavender, Goff, Hollon, and Guzzetta (2004)
VAS ¼ visual analog scale; WB-FACES ¼ Wong-Baker FACES. investigated pain, fear, and distress in children in the control

Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
6 F. Yilmaz Kurt et al. / Pain Management Nursing xxx (xxxx) xxx

group and a treatment group using parental positioning and Brenner, M. (2007). Child restraint in the acute setting of pediatric nursing: An
extraordinarily stressful event. Issues in Comprehensive Pediatric Nursing, 30(1-
distraction in children aged 4 to 11 years (n ¼ 43). In this study, the
2), 29e37.
treatment group's fear score was lower, but there were no statis- Brenner, M., Treacy, M. P., Drennan, J., & Fealy, G. (2014). Nurses’ perceptions of the
tical differences between the two groups. Despite this finding, an practice of restricting a child for a clinical procedure. Qualitative Health
association between pain and fear was determined. Jay, Elliott, Katz, Research, 24(8), 1080e1089.
Bruce, E. (2009). Management of painful procedures. In A. Twycross, S. Dowden, &
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Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002
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Please cite this article as: Yilmaz Kurt, F et al., The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-
Behavioral Intervention Package, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2019.09.002