Blood sampling or vaccination (herein referred to as a needle procedure) is a general medical procedure that children commonly undergo. However, a drawback of this procedure is the pain associated with the needle puncture. If the pain caused by the needle puncture is not adequately treated, children’s fear of medical care may intensify in adulthood [1]. Children who are hospitalized in pediatric intensive care units have greater control over their health; however, they have a greater fear of medical care than those who have no such control [2]. Further, children who are not properly treated for pain during circumcision experience more pain during vaccination than those who have not been circumcised [3].
Local anesthesia has been used effectively for pain relief in procedures involving skin punctures, such as blood sampling [4–8]. Although one study reported on pain relief interventions in Japan using either a pharmacological or psychological approach to pain management [9], it is not standard procedure to use pharmacological agents to relieve pain at the puncture site for children undergoing needle procedures [10, 11].
Notably, the effects of local anesthetics and nonpharmacological methods have been tested. Methods include distraction intervention [12–17], combined cognitive-behavioral therapy [18, 19], hypnosis [20, 21], preparation or information [22, 23], breathing [24, 25], and suggestions that a placebo cream might help the needle to hurt less [26]. Pain and distress are the primary outcomes when evaluating these non-pharmacological interventions, and their effectiveness is determined by reducing these two unpleasant feelings. Therefore, using effectiveness indicators that can measure the reduction of negative states, such as pain and distress, are essential for evaluating the efficacy of such interventions. Moreover, it is important to have indicators that can measure the positive effects of the interventions, because such effects may enhance children’s feelings of self-efficacy and self-esteem. Self-efficacy refers to an individual’s subjective perception of their capability to perform in a setting or attain desired results [27]. Self-esteem refers to the degree to which the qualities and characteristics of one’s self-concepts are perceived to be positive [28]. By assessing the positive effects of interventions on children who undergo painful medical procedures, it is possible to convey the assessments to the children themselves. This will foster their ability to predict the outcome of a procedure and enhance their sense of self-efficacy when they undergo similar experiences. Further, nurses’ direct praise for a child’s achievement regarding their behavioral performance can strengthen a child’s sense of accomplishment. Therefore, assessing the positive effects of interventions on children who undergo painful medical procedures may enhance their self-esteem and self-efficacy.
This study focused on the Japanese word “ganbatta” as a positive variable to evaluate children’s behaviors during needle procedures. In Japan, the expression “ganbatta” is often used by adults to praise children and by children to evaluate their own behavior. Similarly, the term is often used by parents and healthcare providers to praise children who undergo a medical procedure and by children regarding their self-evaluation. The word “ganbatta” is the past tense of the verb “ganbaru,” which means (1) to persist in self-will, (2) to strive and persevere to the utmost, and (3) to occupy a certain place and not move [29]. When used to praise children who have received medical care, the term is primarily used in the sense of the second definition. Non-Japanese authors have defined “ganbatta” and “ganbaru” in several ways. Linhart and Frühstück [30] describe the “ganbaru” spirit as an ethos of overachievement and superhuman effort that goes beyond simply doing one’s best. Zeng [31] observes that the “ganbaru” expression is so commonly used that it has become a cliché in “ema” (Japanese wooden prayer plaques). The word “ganbatta” also includes the meaning of “taking on a challenge” and describes a person who seeks to overcome their existing condition and accomplish goals through a change of attitude [32]. These definitions suggest that the term “ganbatta” has unique and complex meanings.
A previous study has qualitatively analyzed behaviors associated with the “ganbatta” concept in young children who undergo needle procedures [33]. Using factor analysis, 5 factors containing 25 items assessing behaviors associated with “ganbatta” have been identified [34]. The specific factors are as follows. Factor 1: Proactive participation (seven items), Factor 2: Sense of relief and joy after needle removal (six items), Factor 3: Negative emotional expression (four items), Factor 4: Information-seeking (five items), and Factor 5: Moving on from the needle procedure (three items).
Factors 1, 3, 4, and 5 are related to overcoming a difficult situation, whereas Factor 2 results from the after effects of such a process. Therefore, evaluating behaviors associated with the concept of “ganbatta” can provide information about a child's sense of achievement regarding their behavioral performance as well as verbal persuasion, which may help increase their self-efficacy and self-esteem. Moreover, we believe that this information can be used as an indicator to allow others to objectively evaluate whether an intervention has been effective.
This study targeted children aged 3–7 years. Since children at this age are in an early stage of cognitive development, they may not be able to objectively grasp what a needle procedure entails, or appropriately evaluate their own conduct during the procedure. Therefore, healthcare providers and parents must evaluate these behaviors on their behalf.
This study simplified the 25-item Ganbatta Scale [34] to objectively evaluate behaviors associated with “ganbatta” in young children aged 3–7 years who undergo needle procedures in a clinical setting. This study conducted a survey among pediatric nursing staff members. Using the Ganbatta Scale, more practice-based and appropriate items could be selected when collecting data from the clinical nurses who used the scale. This study reduced the number of scale items because having many items took too much time to answer in a clinical setting or were too difficult to memorize. Therefore, this study developed a simplified version of the scale with fewer items and higher goodness-of-fit (i.e., Ganbatta Scale-Short Form: GS-SF) to obtain faster and more accurate answers immediately following a needle procedure.
Study Objective
This study aimed to develop a simplified version of the scale (i.e., the GS-SF) to objectively evaluate the behaviors associated with the concept of “ganbatta” in young children aged 3–7 years who undergo a needle procedure.