In the present study, a picture book on IV catheterization and infusion was created and the behavioral distress of hospitalized school-aged children through participant observations was documented. Based on the results, this kind of intervention could provide an opportunity for the nurses to help the school‐aged children in facing IV catheterization. In addition, this method can improve the children's preparation and reduce their anxiety.
Further, the mean anxiety level was examined by using OSBD_R in four phases. The first phase was performed in the treatment room before any intervention while three other phases were conducted after intervention. The results indicated that the mean anxiety during the phases after intervention in the control group was significantly higher than that of the intervention group. Furthermore, the variations of mean anxiety scores in four phases were significantly different in both intervention and control groups. These variations in the intervention group represented the reduction of anxiety level in the first to fourth phases. However, these variations in control group could represent a gradual increase of anxiety level from the first to third phases and finally a reduction during the last phase.
Among the participants girls included 57.1% and 48.6% of the subjects in the intervention and control groups, respectively. According to the findings, the highest percentage of children in both groups was accompanied by their mothers. Regarding birth order, most of the children under study in both groups were the first child of the family. Regarding the father’s education level, most of them in both groups hold a diploma. As far as mother’s education level was concerned, 37.1% of mothers in the intervention group hold a diploma or they were under diploma while 45.7% of mothers in the control group hold a diploma. In terms of residential area, most of the participants in both groups are living in the city. Exposure to city environment and culture may lead to a better relationship between the parents and the researcher.
Children’s training on various medical procedures in which they are involved constitutes an important nursing intervention which is affected by their expectations and needs. Generally, training aims to enhance patients’ autonomy and independence, and improve health outcomes (18).
The findings indicated that the mean anxiety level in the intervention and control groups is not significantly different. However, the mean anxiety level of the intervention group was significantly less than the control group after orientation intervention in the second and third phases. In addition, the anxiety level decreased in both groups in the fourth phase while it was more significant in the control group, compared to the intervention group. In other words, orientation intervention can control the children’s anxiety during and after the procedure. In this regard, a study applied in 2015 in which concluded that insulin injection anxiety level among the children in the interactive game group involved with orientation toward the disease and insulin therapy was lower during and after the game, compared to the control group (1). In other words, interactive computer games reduced the injection anxiety in the intervention group effectively, which is consistent with the findings of the present study. A study performed in 2007 evaluated children’s anxiety in three phases and reported that professional music played in the medical environment is instrumental for reducing anxiety caused by venipuncture procedure before, during, and after the procedure. Further, children’s anxiety in three phases was lower in the intervention group than that of the control group (28). Furthermore, a research published in 2010 reported that patients, who were exposed to instructive videos before operation, are not different from the control group in terms of anxiety. However, just before operation, the anxiety of the control group increased significantly, compared to the intervention group. Although the reduction was more significant in the intervention group after the operation, a significant reduction in anxiety was observed in both groups, compared to pre-intervention. In addition, the anxiety of the intervention group was lower than that of the control group (17).
It was reported in a study performed in 2013 that the anxiety level of patients undergoing operation before blended education program in both groups was not significantly different. Further, the anxiety level of the intervention group was significantly lower than that of the control group after intervention. However, anxiety level in the second test (releasing time) was not significantly different in both groups (31), maybe due to the lengthy interval between the education and the second post-test. Furthermore, the method, age-range and the performed procedure on the patients were different from the present study.
Based on the results of the present study, the variations of mean anxiety scores before and after intervention were significant in both intervention and control groups. However, these variations represent a decrease in anxiety level in the intervention group and an increase in the control group. In other words, expectedly, the intervention could control and reduce the children’s anxiety undergoing the procedure effectively. However, the anxiety of the control group increased due to the lack of intervention.
The results are consistent with those reported by a research that investigated the effects of Iranian famous puppet “Kolah Ghermezi” (the red hat puppet) on the anxiety of hospitalized children before appendicitis surgery. They reported that the difference of anxiety level was significant before and after intervention in both groups. However, anxiety decreased in the intervention group and increased in the control group. The researchers in the present study believe that the puppets are instrumental for reducing children’s anxiety before operation and their application is highly recommended (32). In addition, a study published in 2013 concluded that children’s storybooks containing operation related issues are effective for reducing the anxiety before the operation among 5 to 11 year-old children, especially 7-year-old girls (22).
It has been suggested that children orientation about the injection procedures through games can considerably reduce their anxiety during the procedure (13). These results are consistent with the findings of the present study. In addition, in 2015 it was reported in study that anxiety decreased considerably among children who underwent interventions through training manual and role-playing the procedure on a teddy bear (33). Further, mean anxiety variations were significant in the control group, which indicated an increase in the anxiety level in this study. According to a research published in 2013 giving information to patients undergoing coronary artery bypasses graft surgery about the surgery procedure and its following care and recovery can considerably reduce their anxiety, which this is in line with the results in the present study. Further, they reported that the mean anxiety level decreased in both groups, compared to pre-operation although the reduction was more significant in the intervention group (34). However, it seems that the reduction of anxiety in the control group is related to the finished operation, which reduces patients’ anxiety automatically.
Furthermore, some studies indicated the positive effects of picture books on decreasing the anxiety of children receiving medical procedure. For example, it was investigated the effects of pre-school children orientation on intravenous placement procedure through picture book and found that the anxiety level increased during intravenous placement procedure compared to the beginning of the procedure although this increment was only significant in the control group and no significant increase was observed among the children in the intervention group (20). It is worth noting that they examined pre-school children while the present study considered the school-aged children. According to Langford, 6 to 12 year-old children acquire logical thinking and their anxiety could be reduced realistically through explanation and briefing before the procedure (35). In addition, using distraction techniques can alleviate anxiety in children during IV placement. The reported distraction techniques include providing educational picture books about injections before its administration, as well as delivering visual and sensory information about the procedure(36).
However, some researchers conducted a study on 4 to 8 year-old children and reported that child’s guardians’ education about anesthesia through pamphlets did not affect the children’s anxiety during anesthesia procedure and the anxiety level increased significantly in both groups after intervention (37). On the contrary, it is believed by another study performed in 1994 that parents can smooth the experience for the children during induction with proper parental preparation, education and counselling, and anesthesia can be induced with no trauma, fear or anxiety (38)..
The inconsistency in the results can be related to different training methods, age range, and procedure type. However, it has been reported that informing the children with the age range of 8–10 with operation and anesthesia through pamphlets could decrease their anxiety although the reduction was insignificant, which is inconsistent with the results of the present study. In addition, the anxiety of the control group increased in the previous studies (39), which is congruent with the results of the present study. The incongruent results of the previous studies could result from the absence of the children’s parents or ineffectiveness of the intervention caused by this absence. Although school-aged children can tolerate parents’ absence more, hospitalization may enhance their needs for security and parental presence (32).
Based on the results, an IV catheterization picture book is effective in decreasing school-aged children's anxiety during and after the intervention. Therefore, the nurses should explain the steps in procedure and their relations. Thus, nurses can play an important role within the framework of the holistic, patient-centered and individualized health care.