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6/01 c:/CIRCJDateDue.p65-p. 15

Development of a Pamphlet to Reduce Anxiety
And Fear in Children Requiring Injections

BY

Lisa M. Vigneau

A Scholarly Project
Submitted To
Michigan State University
in partial fulfillment of the requirements
for the degree of

Master of Science in Nursing

College of Nursing

1999

ABSTRACT

Development of a Pamphlet to Reduce
Anxiety and Fear in Children Requiring Injections

BY
Lisa M. Vigneau

To children the health care environment is a strange
and scary place that often evokes feelings of fear and
anxiety. One event contributing to a great amount of fear
and anxiety in children is an injection. Injections are a
common and necessary part of maintaining health in children
therefore the fear and anxiety they lead to creates an
obstacle for pediatric health care providers to overcome.

A child who exhibits injection related fear and anxiety
often demonstrates negative behaviors. Despite these
negative effects and the growing literature addressing the
problem of this fear and anxiety, little has been published
to evaluate and recommend methods of intervention.

The focus of this project is the development of a
pamphlet containing recommended interventions health care
providers can use with children requiring injections to
reduce the amount of fear and anxiety they experience. A
discussion of the background of the problem and relevant
literature is included. The result of the project is a
pamphlet, reference chart, and a parent education handout to
be used by providers of pediatric care to assist children in
experiencing decreased levels of injection related fear and

anxiety.

ACKNOWLEDGMENTS

I wish to extend my sincere appreciation to the members
of my committee for their continued support and
encouragement throughout the completion of my project. A
huge thanks to my chairperson, Kathy Dontje, NSN, RN, for
her guidance and support of my ideas from the initiation of
my project through the final draft. I also extend a great
deal of thanks to my other committee members, Patty Peek,
MSN, RN and Linda Spence, PhD, RN, for their input,
guidance, and their expertise with children. Thanks to all
for the cheerful words and constant encouragement.

I would also like to extend my gratitude to my family
and friends for their encouragement and support throughout
this project and the entire graduate school experience. I

never would have made it alone!

iii

TABLE OF CONTENTS-

INTRODUCTION . . . . . .
Background . . . . J . .
Problem Statement . . . .
Purpose Statement . . . .
Conceptual Definitions

Children . . . . .

Anxiety . . . . .
Fear . . . . . . .

Conceptual Framework . .
Developmental Framework .

Review of Literature
Information . .
Distraction . .
Play . . . . . .
Parental Presence .
Topical Skin Anesthes
Control . . . . . .

Project Development .

Methodology . . . .
Target Audience . .
Evaluation . . . . .

Implications for Advanced
Implications for Research
Implications for Education
Conclusion . . . . . . .
LIST OF REFERENCES . . .

Appendices . . . . . . .

o o o o o o o o o o o
O I O O O O O O O O O
o o o 6 o o c Q o o o
o o o o o o o o o o o
o o o o o o o o o o o
O O O O O O O O I O O
O O O O O O O O O O O
O O O O O O O O O O O
O O O O C O O O O C O
o o o o o o o o o o o

ia O O O O O O O O 0

Practice Nurse (APN)

iv

shah-huh U

01

11
13
16
17
18
19
21

22
22
24
24
25
27
29
31
32

35

Figure 1:

Figure 2:

Figure 3:

LIST OF FIGURES

The Roy Adaptation Model of Nursing . . . .

Application of Roy Adaptation Model to
PrOj act 0 O O O O O O O O O O O O O O O 0

Integration of Piaget's Theory of Cognitive
Dave 1 opment O O O O O O O O O O O O O O O

INTRODUCTION

Background

To children the health care environment is often a
strange and scary place. Visits to a health care setting
may lead to intense feelings of anxiety and fear in
children. This fear and anxiety is usually the result of
previous encounters with painful procedures, a strange
environment, a feeling that they have lost control over the
situation, and separation from their parent (Melamed,
Klingman, & Siegel, 1984). In the primary care setting, the
event that produces a great amount of fear and anxiety for
children is an injection.

Due to the need to immunize children against various
illnesses injections are common events during childhood.
Multiple studies have shown a relationship between
injections and intense feelings of fear and anxiety in
children (Abbott & Fowler-Kerry, 1995; Polillio & Riley,
1997). Fear of getting an injection is the third greatest
fear reported by children (Boon, Humphrey, van den Heuvell,
& van de Weil, 1992; Broome & Endsley, 1987; Polillio &
Riley, 1997). The prevalence of this injection related fear
and anxiety is an area of increasing interest among

researchers. To date, many studies have looked at the

1

prevalence of injection-related anxiety and the effect this
anxiety and fear have on children (Biddinger 1993; Broome &
Hellier, 1987; Polillio & Kiley, 1997; Ross, 1984).
Injection related fear and anxiety was found to be a common
problem among children. This fear and anxiety often relates
to the anticipated pain of the injection or the common
childhood misconceptions related to bodily intrusion and
mutilation. Injection related fear and anxiety might result
in negative effects such as an increase in pain perception,
physical resistance, and uncooperative behaviors (Abbott &
Fowler-Kerry, 1995). A child who is extremely upset by the
injection experience may have such extreme behaviors that
the parent may choose to avoid the experience in the future.
The child that misses the necessary injections is at risk
for developing a potentially serious illness. By
intervening during the injection process an Advanced
Practice Nurse (APN) has the potential to decrease the
child‘s fear and anxiety resulting in fewer negative
effects. It may be necessary for the APN to intervene with
the parent as well. Parents have an impact on the way
children deal with the injection experience (Blount, Davis,
Powers, & Roberts, 1991). Educating parents about methods
to help their child effectively cope with an injection may
lead to a lower level of fear and anxiety in the child.
Problem Statement
Anxiety has been linked with various negative effects

on children. Anxiety has been shown to increase pain

2

perception, which in turn increases fear and anxiety levels
thereby creating a vicious cycle (Fowler-Kelly & Lander,
1987; McGrath & DeVeber, 1986; Polillio & Riley, 1997).
Anxiety and fear may also lead to the following:
uncooperative behavior, physical resistance which increases
the risk of accidental injury to the child, a physiologic
response such as tachycardia, and possibly even avoidance of
the health care setting (Harrison, 1991; Polillio 8 Riley,
1997). Despite the growing literature that shows the
prevalence of anxiety and fear as a problem, very little has
been published in regards to interventions a provider can
utilize to help decrease fear and anxiety in children
requiring injections.
Purpose Statement

The purpose of this project is to develop a set of
interventions that can be used by primary care providers to
decrease fear and anxiety in children receiving injections.
Each intervention is matched with the appropriate age group
that would benefit from the use of the intervention. The
provider can then refer to the recommended interventions for
a child of a specific age to determine how to assist in
decreasing the level of fear and anxiety. The goal of the
intervention set is to provide health care providers with a
quick, easy, and inexpensive way to help children experience

a reduced level of fear and anxiety related to injections.

Conceptual Definitions

Children

The project interventions are designed to be used with
children between birth and eighteen years of age. This is a
large age range that encompasses various stages of
development. Piaget's theory of cognitive development
(1969) is used as a guideline for determination of
appropriate interventions for the children depending upon
their stage of cognitive development.
Anxiety

The literature identifies the concept of anxiety as a
common phenomenon but often fails to define the concept.
The definition derived for this project considers anxiety as
an undefined fear or a painful uneasiness of the mind due to
a vague, nonspecific threat (Biddinger, 1993; Roy & Andrews,
1991).
Fear

The concept of fear is not well differentiated from
anxiety or distress in the literature. Like anxiety, fear
relates to a perceived threat to an individuals personal
security. The major difference is that fear relates to a
defined event or threat such as an injection. For this
project fear is defined as an emotional reaction to a real
or unreal threat or danger that the child believes is

capable of causing harm to one's self (Whaley & Wong, 1991).

Conceptual Framework

The Roy Adaptation Model of Nursing (Roy 8 Andrews,
1991) can be used by the APN as a basis for addressing the
problem of injection related fear and anxiety in children.
The goal of nursing, according to Roy, is to help an
individual adapt to the environment by processing and
managing the environmental stimuli (Roy & Andrews, 1991).

In the Roy Adaptation Model there are two types of stimuli
that a person must process in order to adapt to the
environment, focal and contextual (see figure 1).

Focal stimuli are defined as any internal or external
stimuli that immediately confront an individual. The focal
stimuli involve an internal change in an individual or an
external change in the environment. The contextual stimuli
are all the other internal and external stimuli that
contribute to the situation at hand. The contextual stimuli
may accentuate the impact of the focal stimuli. The
contextual stimuli have a large impact on how the individual
processes the situation involving the focal stimuli. The
presenting stimuli are processed through the use of the
individual's coping mechanisms and the result is a response
of either adaptation or maladaptation.

Coping mechanisms are thought of as both innate and
learned methods of responding to one's changing environment.
Individuals are born with minimal coping mechanisms.
Additional coping mechanisms are learned throughout

development as the child is faced with unfamiliar stimuli in

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the environment. An individual with appropriate coping
mechanisms is likely to respond by adapting to the
environmental stimuli. This concept is consistent with the
American Nurses Association's definition of nursing with the
focus on the human responses to actual or potential problems
(Roy & Andrews 1991). The response proposed by Roy is
either an internal or external reaction to the specific
situations faced by an individual. To assist an individual
in achieving a successful adaptation response, interventions
must modify stimuli or assist the individual with
development and recognition of coping mechanisms.

In relation to this project, an anxious and fearful
child is faced with an impending injection with a needle
(focal stimuli) as well as multiple contextual stimuli, such
as expected pain and strange people. The child must rely on
his or her own coping mechanisms to process the stimuli and
develop a response to the situation (see figure 2).

Since it is not practical for a health care provider to
intervene by eliminating the stimuli (needle or injection),
the focus is on helping the child develop or recognize
coping mechanisms to assist in managing stimuli. A child
with coping mechanisms that enable the successful processing
of stimuli has decrease in the amount of fear and anxiety
experienced (adaptation). On the other hand, a child with
ineffective or fewer coping mechanisms is unsuccessful at
processing stimuli and the result is likely to be an

increase in fear and anxiety (maladaptation). A child who

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is able to develop coping mechanisms and successfully cope
with injections hopefully will experience less anxiety, less
pain, less fear, is more cooperative, and is less likely to
resist future visits to the health care setting for
injections. As a result, the goal of nursing as defined by
Roy is met since the child has successfully adapted to the
environmental stimuli.

Developmental Framework

Piaget's Theory of Cognitive Development guides the
application of the proposed interventions (Biddinger, 1993;
Whaley & Wong, 1991). It is recognized that a child's
coping mechanisms, fears, and one's ability to adapt are
influenced by the child's stage of cognitive development
(Biddinger, 1993; Whaley & Wong, 1991). According to
Piaget, one's cognitive ability enables the individual to
adapt to the environment. It is also thought that an
individual's behavior allows one to establish and maintain
equilibrium with the environment.

Children progress through Piaget's four stages of
thinking to achieve logical thought. The sensorimotor stage
occurs between birth and age 2. Simple learning involving
repetitive behaviors, play, and imitation represents this
stage. Sensations, curiosity, and experimentation guide
these children in their learning. Toward the end of this
stage the child begins to perceive a basic understanding of

cause and effect and develops a minimal sense of object

permanence. Most fear and anxiety in this stage is related
to stranger anxiety and the absence of a parent.

According to Piaget, the child progresses into the
preoperational stage from age 2 to age 7. The child in this
stage is quite egocentric. The child sees no point in
another person's point of view and can not reason beyond the
observable. Language and symbols are used in this stage to
represent the child's environment. Their thinking is guided
by imagination, play, questioning, and interaction with
others. These children still experience stranger anxiety
and fear the absence of a parent. At this stage of
development children begin to fear medical experiences and
may develop misconceptions related to medical events. It is
also in this stage that children begin to associate specific
events with pain and develop anxiety or fear related to the
event.

Between ages 7 and 11 a child is in the concrete
operational stage of Piaget's developmental theory. The
child develops logical thinking and is able to classify and
sort thoughts in order to solve a problem. In this stage
the child can manage more than one situation at a time.
Children begin to see another person's point of view as
relevant and their line of thinking becomes more socialized.
These children have intense fear and anxiety in regards to
being hurt. It is quite common at this stage for a child to
attempt to hide their feelings of fear and anxiety from

others.

10

The final stage of Piaget's theory of cognitive
development occurs from age 12 until 15 and is referred to
as formal operational. The child begins to utilize abstract
thinking and is able to consider abstract or philosophical
matters. The child is flexible in thinking and adapts more
easily to variations in thinking. This child may confuse
ideal concepts with practical. The child no longer fears
parental absence during the exam and does not experience
stranger anxiety. The child may experience a greater level
of anxiety if the parent is present. This child's greatest
fear is related to the unknown and being injured. It is
important to note that all individuals do not reach the
formal operational stage of cognition.

It is important that the child's developmental stage is
considered when determining age appropriate interventions.
The identification of a developmental stage is entered into
the Roy Adaptation Model as a stimulus that impacts a
child's ability to adapt to the environment (see figure 3).

Review of Literature

The available literature relating to childhood fear and
anxiety surrounding injections is quite limited. The search
for relevant literature is complicated by the lack of
differentiation between fear, anxiety, and distress. The
three concepts are used interchangeably to represent the
phenomenon children experience related to injections. The
phenomenon referred to as fear, anxiety, and distress is

generally exhibited by an uncooperative child, crying, loss

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12

of control, physical resistance, a sense of panic, muscle
tension, rapid breathing, and an increase in heart rate
(Boon, Humphrey, van den Heuvall, 8 van de Niel, 1992;
Bournaki, 1997; Harrison, 1991).

In the interest of clarity this phenomenon will be
referred to as fear and anxiety throughout the remainder of
the project. By observing children during the injection
process, it was found that children experience varying
levels of anxiety and fear with the younger children
demonstrating consistently higher amounts of anxiety and
fear, (Boon, Humphrey, van den Heuvall, 8 van de Niel, 1992;
Bournaki, 1997; Broome 8 Hellier, 1987). Various other
studies (Abbott 8 Fowler-Kerry, 1995; Cohen, Blount, 8
Panopoulos, 1997) acknowledge the presence of fear and
anxiety in children receiving injections, but the focus is
on identifying interventions to reduce the amount the child
experiences. The remainder of the literature review is
dedicated to the specific interventions that are designed to
decrease the amount of fear and anxiety children experience.
Information

Children's fear and anxiety is often related to
misconceptions they have developed about the impending
event, the injection (Harrison, 1991; Melamed, Klingman, 8
Siegel, 1984). These misconceptions lead to varying levels
of threat depending upon the child's stage of development
(Biddinger, 1993). By providing children four years old or

older with honest information that is appropriate to their

13

stage of cognitive development the provider can clarify

misconceptions and assist in decreasing the level of fear

and anxiety. It is difficult to make recommendations for

this intervention with children under four years old since

studies have focused on the effect information has on

anxiety and fear in children ages four and older. According

to Biddinger (1993), Harrison (1991), and Melamed, Klingman,

8 Siegel (1984), providing four to twelve year old children

with honest information about the injection experience

resulted in a decrease in fear and anxiety as a result of

the following factors:

1. An increasing sense of control and mastery related to
the event.

2. A decrease in misconceptions related to injections.

3. The ability to anticipate the event and expect the
sensory input.

4. An understanding of the importance and purpose of the
injection information.

Several researchers have recommended providing children
with information prior to an injection. According to
Biddinger (1993), providing accurate information about
injections allows the child to experience less fear and
anxiety, a decrease in resistive behaviors, and helps the
child cope with the event. In order for information to be
successful it must be honest, appropriate to the development
of the child, and include sensory information (Biddinger,

1993; Carpenter, 1992; Harrison, 1991; Melamed, Klingman, 8

14

Siegel, 1984). A paper by Melamed, Klingman, and Siegel
(1984) summarized various recommendations pertaining to
providing injection related information and concluded that
children provided with information about what they would
feel, see, and hear were able to cope while experiencing a
decrease in anxiety and fear. Biddinger (1993) provides the
following examples of developmentally appropriate ways to
provide a child with information related to injection:

1. Sensorimotor (2-7 years old)- benefit from play and
demonstration that is accompanied by simple verbal
explanation.

2. Concrete Operational (7-11 years old)- Best approach
may be the use of a picture book that addresses the
importance of injections and portrays a cooperative
child receiving an injection.

3. Formal Operational (12-15 years old)- Information
should be in the form of a verbal explanation related
to the injection experience.

The literature available in relation to providing
information to children about the injection experience
outlines the benefit of information for children over two
years old. Information can assist the child in experiencing
a lower level of fear and anxiety.

It may also be beneficial to provide information about
injections to the parents. Parental education is important
since a parent's approach to the injection experience may

impact the child's ability to cope (Immunization is Basic,

15

1995). Beginning at the first visit requiring injections,
parents should be provided with suggested methods to help
their child deal with injections. The information can be
reviewed periodically during subsequent visits. Informed
parents are able to support their children during the visit,
which may aid in decreasing the amount of anxiety and fear
experienced during the injection process (Biddinger, 1993).
One example of an injection related information handout for
parents is included in Appendix C. This handout advises
parents on appropriate and inappropriate ways to help their
children through the injection experience such as avoiding
threatening children with injections and rewarding the child
after the shot for a job well done.
Distraction

Distraction of the child has been found in research to
be a relatively inexpensive and easy to utilize intervention
that can decrease fear and anxiety in children (Cohen,
Blount, 8 Panopoulos, 1997; Fowler-Kelly 8 Lander, 1987;
Vessey, 1995). A study by Cohen, Blount, and Panopoulos
(1997) utilized a selected cartoon video to distract
children ranging from four to six years old throughout the
injection experience. Distracted children were able to cope
better with the injection. These children also experienced
a 50% decrease in their level of fear and anxiety while
requiring less restraint during the injection than did the
non-intervention group. The children in the intervention

group reported a 2.7 point decrease on a five point pain

16

scale. Fowler-Kelly 8 Lander (1987) found distraction with
music to result in a significant decrease in the anxiety and
fear the child experienced. The sample consisted of 200
children between 4.5 and 6.5 years old who were receiving
regular immunizations. These children listened to
children's music through headphones and reported scores of
up to 1 point less than the control group on a four point
pain scale. It is noted that the older children benefited
more from musical distraction while the younger children
were best distracted by the cartoon video. Younger children
can also be distracted by puppets and toys during the
injection process as a means of decreasing fear and anxiety
(Vessey, 1995). Because this intervention is effective,
inexpensive, and easy to utilize it has the potential to
have a great impact on children's level of fear and anxiety.
Play

The literature available in relation to play as an
intervention to decrease fear and anxiety is sparse. Young
and Fu (1988) conducted a study that utilized needle play
with four to seven year old children receiving injections.
The findings included a significant decrease in fear and
anxiety with the participants as demonstrated by lower pulse
rate, lower self-reporting on a pain scale and a lower
observed anxiety and pain rating by the participants. By
allowing the child to be exposed to and handle the syringe
and needle, the child will become familiar with the objects

when exposed to them in the future. This familiarity

17

results in a decreased level of fear and anxiety. Whaley

and Wong (1991) and Wong (1993) recommend the following

forms of play to lessen the anxiety and fear children two
years and older experience related to injections:

1. ‘Let the child handle equipment (real or fake); let the
child give pretend injection to a stuffed animal or a
doll.

2. Have syringes decorated as animals, people, or
creatures for the child to play with and take home with

I them.

3. Have a magic target on child's body where the injection
will be given; cover spot with decorative Band-Aid.

4. Give reward for cooperation and bravery (i.e. sticker,
pencil).

By incorporating play related to the source of
impending pain the child becomes “acquainted” with the
equipment and sees the experience as less threatening which
leads to a lower level of fear and anxiety.
BarentaLEresonoe

The presence of a parent during an injection is well
studied in relation to decreasing fear and anxiety
experienced by the child. Much of the research is
inconclusive in the recommendation of parental presence due
to inconsistent results. A report by Blount, Davis, Powers,
and Roberts (1991) critically reviewed various researchers
recommendations in relation to parental presence and found

that some children experienced a greater increase in fear

18

and anxiety when parents were present and others experienced
an increase if parents were absent. The only consistent
finding in this area of research was that older children
experienced a lower level of anxiety and fear if the parent
was absent. .The younger children tended to experience an
increase in fear and anxiety when the parent left the room
than they did as a result of the injection. Based on the
inconclusiveness of the results, Blount, Davis, Powers, and
Roberts (1991) and Broome and Endsley (1989) recommended
that the parent remain in the room to support the child
unless the child requested that they leave. The parent may
help by distracting the child or offering emotional support
during procedure. It was thought that this would lead to
the greatest chance in decreasing the level of fear and
anxiety experienced by the child.
Wow

The knowledge that an impending injection will be
painful often leads to fear and anxiety in children. A
method to decrease or eliminate this pain is likely to
result in less anxiety and fear associated with the
injection. One method to decrease this pain is through the
use of a topical skin anesthetic such as EMLA cream or a
topical refrigerant anesthetic, (Abbott 8 Fowler-Kelly,
1995; Halperin, Korin, Attias, Pellegrini, Greenburg, 8
Wyss, 1989).

An initial study in this area utilized EMLA cream with

children receiving injections. The children, ages 4-8, were

19

asked to rate their pain level on a ten point pain scale
with lower scores correlating with less pain. The children
who used EMLA cream reported mean scores of 1.9 compared to
a score of 5.6 in the control group revealing a significant
difference. The cream numbs the skin therefore the children
who utilized the cream experienced less pain, fear, and
anxiety than those who used no cream (Halperin, Korin,
Attias, Pellegrini, Greenburg, 8 wyss, 1989). A major
limitation to this intervention is the requirement of a one-
hour time period for the cream to have the anesthetic
effect. This reduces the usefulness of the intervention
with injections because it requires too much time but the
intervention may remain useful for blood draws. EMLA cream
may also be useful in infants if applied before the visit to
both thighs allowing adequate time to numb the skin. The
injection sites are effectively anesthetized in order to
reduce pain that may be experienced from the impending
injections.

A more recent study by Abbott 8 Fowler-Kelly (1995)
found that by using a topical refrigerant anesthetic such as
Ethyl Chloride or Flouri-Methane, the child reported
approximately 20% lower pain scale scores as compared to the
placebo group. The children also experienced less fear and
anxiety related to the injection. This aerosol product is
very convenient because it effectively anesthetizes the skin
within 15-30 seconds of application, which decreases the

pain of injection and decreases the associated anxiety and

20

fear, (Drug Facts and Comparisons, 1999). It is a quick,
inexpensive, and easy to utilize intervention to assist
children in experiencing a reduction in fear and anxiety due
to a reduction in associated pain (GeBauer, 1994).
Control

Multiple research studies reported that the child
receiving injections experiences a loss of control that
results in an increase in fear and anxiety (Carpenter, 1992;
Hobbie, 1989; McDonnell 8 Bowden, 1989; Melamed, Klingman, 8
Siegel, 1984, Ross, 1984). This loss of control is the
guiding factor for the development of multiple intervention
to reduce fear and anxiety related to injections. The goal
is to return a sense of control to the child in order to
reduce anxiety and fear. In a related paper by Robbie
(1989) the importance of using relaxation as a means of
restoring control was discussed. The impact of relaxation
is recognized also by Wong (1993) as a self-controlled
method to decrease fear and anxiety levels. The relaxation
intervention requires the child age seven and older to
concentrate on breathing while assuming a comfortable
position. The result is a state of relaxation and a sense
of control over the situation. This controlled breathing,
relaxation intervention must be taught to the child and
practiced in order for it to be effective. By restoring the
child's sense of control, the provider is able to help the
child experience a decrease in fear and anxiety. Teaching

children relaxation as a means to instill control is a time

21

consuming intervention but the advantage lies in the child's
ability to continually use the intervention when faced with
other sources of fear and anxiety. Due to time constraints,
this intervention may be reserved for those individuals who
experience extreme fear and anxiety due to the increased
risk of avoiding the health care setting or children who for
whatever health reason will require many injections or blood
draws.

The review of literature, although limited, reveals
multiple interventions to aid in the reduction of fear and
anxiety in children requiring injections. By utilizing the
interventions that are appropriate to a child's
developmental level, a provider is able to help the child
cope with the injection. The goal of the interventions are
to reduce the levels of fear and anxiety a child experiences
in relation to an injection while helping them effectively
adapt to the experience.

Project Development
Mothodoloox

The proposed interventions are presented in the form of
a written, educational pamphlet. The content was obtained
from related literature that was discussed in the previous
sections of this paper. Pamphlet's are cost effective and
time-efficient methods to convey important information
(Wilson, 1996). The pamphlet was chosen as a form of
written education because the desired information can be

easily distributed and presented in a clear, concise, and

22

consolidated manner (Bernier 8 Yasko, 1991; Venabi 8 Ferris,
1995). The important information is organized and presented
in an appealing way that is quick and easy to read (Venabi 8
Ferris, 1995). Health care providers have demanding
schedules that do not allow excess time to decipher the
contents of lengthy written materials.

An educational pamphlet is a short, concise way to
organize the important information related to the proposed
interventions. The pamphlet will include a brief
description of each intervention and recommendations on how
to implement the interventions into one's own practice
(Appendix A). The interventions that the provider should
use vary depending upon the developmental level of the
child. Since the pamphlet is not convenient to use if it
must be referenced for every child, a quick reference chart
is included with the pamphlet (Appendix B). This chart is
organized according to age (developmental level) and matched
with the appropriate interventions. The goal is for the
provider to read the pamphlet and then, as a child presents
for an injection, the provider can refer to the chart to
determine which interventions are appropriate for that
child. The health care provider also receives a printed
compilation of recommendations for parent education to be
distributed beginning at a child's first visit.

A parent education handout should be utilized to guide
parents in dealing with the injection process. Parents are

often anxious when their child requires an injection. The

23

parents anxiety is often noticed by the child causing the
child to experience an increased level of anxiety and fear
related to the injection experience (Broome 8 Hellier, 1987;
Cohen, Blount, 8 Panopoulus, 1997). The provider can
utilize a parent education handout beginning with the
child's first visit to the healthcare setting. To achieve
the greatest effect the information should be reinforced at
every visit. Helping parents learn to assist their children
in coping positively with the injection experience will
result in a lower level of fear and anxiety in the child
(Cohen, Blount, 8 Panopoulus, 1997).
W

The pamphlet is designed to be used by health care
providers in any primary care setting including clinics,
private offices, and health departments. It is recognized
that it is often a person other than the provider that
administers the injection. Since it is not practical to
determine who is responsible for administering injections in
various settings the recipient of the pamphlet will be the
provider. The pamphlet will be distributed to health care
providers working with a pediatric population. The desired
outcome is the provider instructing the office staff on the
proposed interventions, and overseeing the implementation of
these interventions when children receive injections.
Exalnation

The proposed interventions must be utilized in order

for this project to be successful in reducing a child's

24

level of fear and anxiety. The effectiveness of the
interventions on decreasing fear and anxiety must also be
evaluated. The pamphlet will be subjected to a peer review
to determine readability and appropriateness of content
prior to printing. As a method of evaluating the utility
and effectiveness of the proposed interventions a simple
“pilot" study will be conducted.

Twenty providers of pediatric health care will be
randomly selected from the community directory. The
pamphlet and intervention reference chart will be
distributed to these providers. After two weeks, a follow-
up letter with an evaluation form will be sent to the
providers. The evaluation form is designed to determine if
providers: a) read the pamphlet, b) saw a need for the
interventions, c) implemented the intervention into their
practice, d) noticed any change in the amount of fear and
anxiety their patients experienced, and e) have any
comments, suggestions, or recommendations to offer. After
reviewing the returned evaluation forms any necessary
revisions will be made to the intervention set/pamphlet.
The pamphlet will then be made available to any provider
that desires to utilize the interventions in practice,
possibly by placing on the World Wide Web.

Implication for Advanced Practice Nurse (APN)

Since the introduction of immunization, injections have

become a necessary and regular part of routine office visits

during childhood. These injections are necessary to help

25

prevent children from developing serious illnesses. It is
necessary for parents to bring children to the primary care
office or clinic for the required immunizations. Children
often experience high levels of fear and anxiety related to
injections. These children exhibit uncooperative behaviors
including crying, kicking and physical resistance, which may
increase the chance of injury to the child during injection.
These behaviors lead to a higher level of fear and anxiety
and may actually increase the pain perception related to the
injection. It is these reasons that may lead parents to
choose to skip the visit rather than deal with the “hassle”
and subject their child to the unpleasant experience,
(Abbott 8 Fowler-Kerry, 1995). By utilizing the
interventions that are recommended in the pamphlet the APN
can assist the child in experiencing a lower level of fear
and anxiety. Parents are less inclined to avoid the visits
that involve injections if the child is less anxious or
fearful. As a result these children will receive the
required injections and are less likely to develop a
serious, preventable illness.

The APN can utilize the interventions recommended in
the pamphlet to help children deal with injections in a
positive way. The interventions help children experience
less pain, less anxiety, and lower levels of fear related to
the injections. These interventions are inexpensive and
easy to utilize therefore it is practical for the APN to use

them in a primary care setting. The impact has the

26

potential to be widespread since these strategies may be
used by children who are faced with anxiety or fear in
another situation.

Implications for Research

The existing literature involving children and
injections recognizes that injections are associated with
high levels of fear and anxiety. The literature in the area
of children's pain is beginning to increase but the deficit
remains in the literature on strategies to decrease this
pain. The available literature in relation to childhood
injections and the associated fear and anxiety is minimal
and quite outdated. The primary implication of this project
is the identification of a common problem (injection-related
fear and anxiety) that has very little existing research
that addresses it.

New studies need to be initiated to address methods to
decrease injection-related fear and anxiety. These studies
may expand upon the current interventions or introduce new
interventions to assist children in experiencing lower
levels of fear and anxiety related to injections. One focus
of future research could look at the interaction of parental
involvement and distraction to determine if parents may be
helpful in reducing the child's fear and anxiety. Another
area of interest may investigate the incorporation of play
with information in order to have a greater impact on
reducing injection-related fear and anxiety. Future

research could also do a more complex study looking at the

27

effectiveness of topical anesthesia. This could be done by
doing a two phase study that involves utilizing the
anesthetic with one injection and at the time of the next
injection offering the child a choice to use or refuse.

This may give some insight on whether the child actually
felt a decrease in injection pain. By expanding the
available literature base, a more comprehensive intervention
set can be recommended. More evidence available to support
the interventions would make providers more likely to
utilize the interventions leading to a greater impact on the
problem.

A researcher with adequate resources could evaluate the
effectiveness of this project by studying the intervention
set with children receiving childhood immunizations.
According to Fowler-Kerry and Lander (1987) a bad experience
with an injection during the early years of life may cause a
child to experience a greater level of fear and anxiety
related to future injections. One approach to help children
avoid this would be the aggressive use of the intervention
set with children and parents beginning at the first visit.
This involves providing the parent with sufficient
information and utilizing the recommended age appropriate
interventions with the child receiving the injection. The
researcher would follow the child from the first shot
through completion of their pre-kindergarten shots to
determine if the intervention group experienced a decreased

level of fear and anxiety as compared to the control group.

28

The above study is limited by the extensive time and
monetary requirements involved in completing the study. An
alternate approach would be to study each intervention
independently. This could be done in an urban area by
randomly selecting pediatric providers and then randomly
assigning their patients population to one of the
interventions. The researcher would then evaluate the level
of fear and anxiety and the associated change in levels
experienced among the various interventions groups. This
design would enable the researcher to gain a better
understanding of the impact of each individual intervention
as compared to the entire intervention set.

Implications for Education

Providers continually interact with children and
parents during routine primary care visits. Injections are
a routine part of these visits and the way that the provider
approaches the injection experience may greatly impact the
way that the child and parent respond to the experience.
Educating providers about methods to decrease injection
related fear and anxiety is essential. The interventions
that are recommended in this pamphlet can assist the
provider in helping the child cope with the injection
experience. If the experience is less stressful the level
of trust between the provider and the child or parent is
greater. The pamphlet includes descriptions of the
interventions and the appropriate age group that benefits

from the intervention. The pamphlet is used as an

29

educational tool to teach primary care providers how they
can help make the injection experience less fearful or
anxiety provoking for children.

Parental education is also an important implication of
this project. The parent education handout that is
distributed to providers is used to educate parents who
accompany their child during an injection. Using the
handout provides an easy, inexpensive way to get important
information to parents and potentially make a big difference
in the way children perceive injections. The handout
contains recommendations for parents to make the experience
more positive which enables the child to experience less
fear and anxiety. The result is a more positive and
pleasant experience for the parent, child, and provider and
enhances the existing relationship between all parties.

Health care providers and office staff must be aware of
this problem and the potential ways to intervene in order to
have an impact. The best way to educate these individuals
is to incorporate the information into the curriculum.
Physicians, APN's, registered nurses, and medical assistants
all have some sort of formal education that could
potentially include education on these interventions and how
they can reduce a child's level of injection-related fear
and anxiety. If the information is not included in the
curriculum it could be disseminated in the form of a staff

inservice in the practice setting. This would ensure that

30

all staff members were aware of methods they could use to
decrease a child's injection-related fear and anxiety.
Conclusion

The proposed interventions are easy to use,
inexpensive, and require little time to implement.
Providers can use these interventions for all children
requiring injections to decrease the anxiety and fear they
experience. Decreasing injection related fear and anxiety
results in a child that is less likely to experience
negative effects such as increased pain perception or
uncooperative behaviors. Lower levels of fear and anxiety
also decreases the chance of a parent and child avoiding the
experience all together and increases the likelihood that
the child is receiving the required childhood injections.
The result is an improvement in the child's overall state of

health, which is consistent with the goals of primary care.

31

LI ST OF REFERENCES

 

LIST OF REFERENCES

Abbott, K. 8 Fowler-Kerry, S. (1995). The use of a
topical refrigerant anesthetic to reduce injection pain in

children. 1onrnal_of_2ain_5¥nntom_nanaoementl_lo. 584-590-

Bernier, M.J. 8 Yasko, J. (1991). Designing and
evaluating printed educational materials: Model and

instrument develOPment- 2atient_Ednoation_and_connsolinol
18. 253-63.

Biddinger, L.A. (1993) Bruner's theory of instruction
and pre-procedural anxiety in the pediatric population.
Issnes_in_Comorohensixe_2ediatrio_Nnrsinnl_1o. 147-154.

Blount, R.L., Davis, N., Powers, S.W. 8 Roberts, M.C.
(1991). The influence of environmental factors and coping
style on children's coping and distress.

Rexiowl_11, 93-116.

Boon, C.M.J., Humphrey, G.B., van den Heuvell, C.L., 8
van de Wiel, H.B.M. (1992). The occurrence of high levels of
acute behavioral distress in children and adolescents
undergoing routine venipuncture. Pediatricsl_2fl(1)p 37-91-

Bournaki, M.C. (1997). Correlates of pain-related
responses to venipunctures in school-age children. Nursing

Researohl_io(3). 147-154.

Broome, M.E. 8 Endsley, R. C. (1989). Maternal presence,
childrearing practices, and children's responses to an

injection. Besoaroh_in_Nnrsin9_and_Healthl_lz 229- 235.

Broome, M. E. 8 Hellier, A. P. (1987). School-age
children's fears of medical experiences.

Comorehensixe_Podiatrio_Nursinol_lo, 77-86.

Cohen, L.L., Blount, R.L. 8 Panopoulos, G. (1997).
Nurse coaching and cartoon distraction: An effective and
practical intervention to reduce child, parent, and nurse

distress during immunizations. lonznal_of_2ediatz1g
Psxoholooxl_22(3), 355-370.

Drug Facts and Comparisons (53rd Ed.) (1999). St.
Louis, MO: Facts and Comparisons.

GeBauer, CO. -

(1994). Prescribing information. Cleveland, OH: GeBauer
CO.

32

Fowler-Kerry, S. 8 Lander, J.R. (1987). Management of
injection pain in children. Pa1n1_1n, 169-175.

Halperin, D.L., Koren, G., Attias, D., Pellegrini, E.,
Greenburg, M.L. 8 Wyss, M. (1989). Topical anesthesia for
venous, subcutaneous drug reservoir and lumbar punctures in

children. Pediatriosl_81(2), 281-284.

Harrison, A. (1991). Preparing children for venous
blood sampling. Pa1n1_15, 299-306.

Hobbie, C. (1989). Relaxation techniques for children

and young Peeple. Jonrnal_of_Redistrio_noalth_Caroi_3. 83-
87.

McDonnell, L., 8 Bowden, M.L. (1989). Breathing
management: A simple stress and pain reduction strategy for
use on a pediatric service.

Podiatrio_Nursingl_12. 339-344.

McGrath, P.A. 8 DeVeber, L.L. (1986). Helping children
cape with painful procedures. Amorioan_lournal_of_Nnrsino1
November, 1278-1279.

Melamed, B. G., Klingman, A. 8 Siegel, L. J. (1984).

Childhood stress and anxiety. In_Cogn1t1ye_flehay1gr_1hezany
w1th_§h11dren1 New York, NY: Plenum Press. '

Michigan State University (1995). Immnn1zat1on_1s
Bas1g. Michigan State Extension Program. East Lansing, MI.

Moore, K. E., Geffken, G. R. 8 Royal, G. P. (1995L
Behavioral interventions to reduce child distress during

self-injection. £11n1gal_2ed1atr1gs1 October, 530- 534.

Polillio, A.M. 8 Kiley, J. (1997). Does a needleless
injection system reduce anxiety in children receiving

intramuscular injections? Ped1atr1g_flnrs1ng1_21(1), 46-49.

Ross, D. M. (1984). Thought-stopping: A coping strategy
for impending feared events. Issues_1n_ggmprehen§1yg

Eediatrio_Nursin91_l 83-89.

Roy, C. 8 Andrews, H. A. (1991).

Tho_Bo¥_Adantotion
Nodel1_The_definitixe_statement1 Norwalk CT: Appleton &
Lange.

. Venabi, M. 8 Ferris, L. (1995). Improving written
patient education materials: A review of evidence. Health

Ednoation_1ournalr_54.99-106.

Vessey, J.A. (1995). Developmental approaches to
examining young children. Ped1atr1g_flnrs1ng1_z1(1), 53-56.

33

Whaley, L. F. 8 Wong;, D.L. (1991). unrs1ng_gaze_gfi
Infantfi_nnd_£hildzfin1 (4 Ed.) St.Louis, MO: Mosby-Year
Book, Inc.

Wilson, F.L. (1996). Patient education materials nurses

use in community health. _Hostorn_Jonrnal_of_Nnrsin91_18(2).
195-205.

Wong. D-L- (1993). Essentials_of_Podiatrio_Nnrsino (4th
Ed.) St. Louis, MO: Mosby-Year Book, Inc.

Young, M. R. 8 Fu, V. R. (1988). Influence of play and
temperament on the Young child's response to pain.

Children_s_Health_Carol_lo(3). 209-214-

34

 

APPENDIX A
Pamphlet
“Methods to Reduce Injection-Related Fear

and Anxiety in Children”

 

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36

APPENDIX B
Chart
“Recommended Age Appropriate Interventions

to Reduce Injection-Related Fear and Anxiety"

 

 

 

 

 

 

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37

Appendix C
Parent Education Handout

“Helping Your Child Cope With Shots"

Helping Your Child
Cope With Shots

Here are suggested ways to help
your child deal with fears
about injections.

I! Put your own fear and anxiety
about shots aside- do not talk
about your fear of shots in front
of your child.

I: Discuss what will happen at the
doctor’s office. Play act before
the appointment by using
cotton balls, band-aids, and toy
medical equipment.

fl Explain that shots help keep
children from getting sick.

II NEVER threaten your child with
a shot, such as “if you don't
behave the nurse will give you
a shot‘. Doctors and nurses
are “good guys” that help us
stay well.

ll Offer reassurances and support
to your child. Hold childs hand,
have them sit on your lap, bring
a familiar item such as a teddy
bear or blanket

 

Distract the child as the shot is
given. Use a puppet or just ask
the child to blow out imaginary
birthday candles. '

Congratulate your child for
being brave and do not scold
him/her for crying.

Let child know you are proud of
him/her- do not say the shot
didn’t hurt since it does hurt!

Reward your child with a
pleasant activity after the visit.
Make it fun and let the child
choose if possible. This retums
their sense of control that is
alien lost during the injection
process.

Involve siblings in a
supportive manner- do not
allow them to tease the child.

Miran-Warren 1'. Basic, “dig-n
000mm Frown. (1995).

 

 

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