Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction

Izabel Cristina Santiago Lemos, Luanna Gomes da Silva, Gyllyandeson de Araújo Delmondes, Adamo Xenofonte Brasil, Paula Laysa Freitas Santos, EmilianaBezerra Gomes, Kelly Vanessa Le...

American Journal of Nursing Research

Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction

Izabel Cristina Santiago Lemos1, Luanna Gomes da Silva1, Gyllyandeson de Araújo Delmondes1, Adamo Xenofonte Brasil1, Paula Laysa Freitas Santos1, EmilianaBezerra Gomes1, Kelly Vanessa Leite Gomes da Silva1, DayanneRakelly de Oliveira1, Joseph Dimas de Oliveira1, George Pimentel Fernandes2, Marta Regina Kerntopf1,

1Departamento de Enfermagem, Universidade Regional do Cariri, Crato, Brasil

2Departmento de Educação, Universidade Regional do Cariri, Crato, Brasil


The instructional therapeutic play (ITP) is responsible for the child´s preparation to perform procedures such as venipuncture, reducing anxiety, fear and pain in hospitalized children undergoing painful procedures. Thus, the aim of this study is to evaluate the effectiveness of ITP to the management of pain when performing peripheral venipuncture or handling of the venous access in preschool and schoolchildren. The research is analytical, exploratory and quantitative. To measure the pain of children the Faces Pain Scale (FPS) was used. For data analysis, the Wilcoxon test was used. Before the sessions, 28.6% reported the pain score “1” or absence of pain. After the sessions, 71.4% of the sample indicated the same score. Another important issue before the ITP sessions, the score was“4”, which expresses intense pain. After the sessions, 100% of children who have been assigned this face, showed improvement in pain patterns. Thus, the findings of this study corroborate previous studies that show ITP as an important tool in relieving pain presented by hospitalized children, subjected to intrusive and stressful procedures.

Cite this article:

  • Izabel Cristina Santiago Lemos, Luanna Gomes da Silva, Gyllyandeson de Araújo Delmondes, Adamo Xenofonte Brasil, Paula Laysa Freitas Santos, EmilianaBezerra Gomes, Kelly Vanessa Leite Gomes da Silva, DayanneRakelly de Oliveira, Joseph Dimas de Oliveira, George Pimentel Fernandes, Marta Regina Kerntopf. Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction. American Journal of Nursing Research. Vol. 4, No. 1, 2016, pp 1-5.
  • Lemos, Izabel Cristina Santiago, et al. "Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction." American Journal of Nursing Research 4.1 (2016): 1-5.
  • Lemos, I. C. S. , Silva, L. G. D. , Delmondes, G. D. A. , Brasil, A. X. , Santos, P. L. F. , Gomes, E. , Silva, K. V. L. G. D. , Oliveira, D. D. , Oliveira, J. D. D. , Fernandes, G. P. , & Kerntopf, M. R. (2016). Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction. American Journal of Nursing Research, 4(1), 1-5.
  • Lemos, Izabel Cristina Santiago, Luanna Gomes da Silva, Gyllyandeson de Araújo Delmondes, Adamo Xenofonte Brasil, Paula Laysa Freitas Santos, EmilianaBezerra Gomes, Kelly Vanessa Leite Gomes da Silva, DayanneRakelly de Oliveira, Joseph Dimas de Oliveira, George Pimentel Fernandes, and Marta Regina Kerntopf. "Therapeutic Play Use in Children under the Venipucture: A Strategy for Pain Reduction." American Journal of Nursing Research 4, no. 1 (2016): 1-5.

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1. Introduction

Since the mid-50s, researchers have woken up to the need to investigate the reactions of the child before the hospitalization process paying attention to the peculiar characteristics and child development process, understanding that the adaptive mechanisms of the child usually affect an ineffective management of the hospitalization process [1, 2].

The children in hospitalization expressed feelings of anger, fear, insecurity, anxiety, guilt, hopelessness and deep loneliness exacerbated by factors such as distance from their everyday routine and the insertion into a new environment, with unknown people, who become the protagonists of care actions [3].

Also, during hospitalization children are subjected to different painful procedures without understanding, for sure, how they are running, for what purpose and why they must experience them [4].

Among these procedures, there is venipuncture as the procedure in which children in hospitalization process most commonly are submitted to sample collection or administration of intravenous medication [5].

In this regard, it is stressed that the adverse feelings experienced by children undergoing repeated venipuncture may interfere with the course of their growth and development, noting that some feelings expressed by the child submitted to venipuncture are fear, anxiety, aggressive behavior and pain [6].

It is worth mentioning that in Gomes et al. research[7], aimed to describe the emotional consequences related to peripheral venipuncture in hospitalized children, the authors stress that one of the aspects that can determine the level of emotional hospitalization consequences in children is the pain that they can support.

However, the expression of pain is multifaceted, involving sensory, emotional, cognitive and cultural elements. Once the children express the painful feeling, this signal must be received and decoded by the health professional and, he must be able to meet this demand of pharmacological or non-pharmacological way, according to the therapeutic resources recommended by the literature [8].

Regarding non-pharmacological therapies for pain management, there is music, art, guided imagery, massage, use of toys, among other modalities [9].

Toys can be the normative or therapeutic type. Thus, toys are normative when they build spontaneous activities without pre-defined objectives. In the case of therapeutic play (TP), there is a structured game, following the principles of therapy play, with specific objectives to be achieved [10, 11].

Thus, there are three types of therapeutic plays. One allowing the emotional discharge, or the drama therapeutic play (DTP); other one enabler therapeutic play (ETP) of physiological functions, used usually in cases where the child shows regressive behavior for the age and; another one for instructional therapeutic play (ITP), operating for the children preparation to perform procedures such as venipuncture [12].

In Brazilian literature, the use of ITP is highlighted because of its relevance to clinical practice and being considered an important intervention to reduce anxiety in hospitalized children undergoing painful procedures[13].

Thus, this study aims to evaluate the effectiveness of ITP for the management of pain when doing peripheral venipuncture or handling of venous access for medication infusion in preschool and schoolchildren, comparing to pain by children before and after the sessions with instructional therapeutic play (ITP).

2. Materials and Methods

This study is characterized as an exploratory analytical research with a quantitative approach.

The research was conducted in a private hospital, membership to the Unified Health System (UHS), located in the city of Crato, state of Ceará, Brazil. The hospital where the study was conducted is considered a reference for 12 municipalities in the region. The research was conducted from October 2011 to September 2012. The data collection was between April and July 2012.

The research population consisted of hospitalized preschool children (3-6 years old) and schoolchildren (7-12 years old). The inclusion criteria in the sample were children hospitalized for at least 24 hours; undergoing the procedure and/or management of access for peripheral venipuncture, either for drug administration or sample collection; children who had behavioral changes arising from the anxiety and fear related to that procedure, with typical manifestations of Hospitalism (crying, refusal of the procedure, motor restlessness).

Exclusion criteria were the children unable to manipulate objects while TP sessions, children under anesthetic effect, during the immediate postoperative period and children with allopsychic disorientation such as cerebral palsy and autism.

The research participants were contacted in their pediatric unit, where the Therapeutic Play sessions were Therapeutic Play (TP). The final sample consisted of 21 children in the hospitalization unit, and the number of admissions/month established the calculation of the sample.

The first phase was for data collection from the medical records, characterizing the children according to gender, age, length of hospitalization, pathology, medications schedule – for observation - and the general condition of the child.

Those professionals responsible for drug administration were asked about which children had clear anxiety, fear or tension on the peripheral venipuncture procedure. When the need to perform ITP session was noticed, the child was selected as a possible research subjects, however, protecting his right to refuse to participate.

In the second phase of data collection, the child was observed during the peripheral venipuncture procedure or intravenous medicine infusion (IV) - performed by unit staff. It is noteworthy that the simple handling of access for members of the nursing team can characterize an anxiety and stress crisis for the child and caregivers.

Therefore, reactions and behaviors of the research participants were registered, according to the behavioral parameters for expression of pain in children, in the form of a checklist [14]. This resource was necessary to compare the child´s self-report of pain with the behavior shown during the sessions.

Thus, after the procedure, it the Faces Pain Scale (FPS) [15] with 06 faces was delivered to the child assesses the intensity of pain (Figure 1).

In EF, the children indicate the intensity of their pain according to the mime represented in each cartoon face. It is stressed that this scale was given to the children before the use of ITP, right after the venipuncture or management access to the infusion.

Subsequently, we demonstrated for the child how to perform venipuncture technique, through an ITP session.

To perform the ITP sessiocol [16], with the following materials: doln, we used the Martins, Ribeiro, Borba and Silva protols, cotton, 70% alcohol, scalp; syringe; tape and procedures gloves.

When finishing the demonstration, we invited the child to show the procedure in the doll, and we encouraged to express their doubts, fears and clarify what they did not fully understand.

In the third phase, we conducted a new ITP session. This time, the responsible members of the nursing staff developed the session before the peripheral venous puncture procedure, exchange or handling of the access for medicine infusion. The child then was again observed systematically during the procedure, and their reactions were recorded. Finishing the third step, the EF was again given to the child, for comparative purposes, after venipuncture or management of access to the infusion.

The Statistical Package for Social Sciences (SPSS) was also used, and the Wilcoxon test was adopted to measure the changes in pain scores, a statistical technique non-parametric descriptive and inferential.

An Informed Consent Form (ICF) was provided to the research participants, and the Free and Clear Consent Term (CCT) was given to the children´s caregivers. The Custodian Agreement was also used to handle the institution´s records.

During the development of the research, all the requirements of the Guidelines and Regulations of Research Involving Human Beings, regulated by Resolution 466/12 of the National Health Council. Therefore, the research was submitted to Brazil Platform for analysis by the ethical aspects, being approved under opinion number 738,365.

3. Results

3. 1. Sample Characterization

According to the data analysis, it was observed that the sample consisted mostly of pre-school children aged from three to six years old, representing 52.38% of the final sample. The rest, 47.62% were schoolchildren aged from seven to eleven years old.

Females prevailed among the school population and in the preschool population children, being 61.90% of the total sample.

3.2. Influence of Instructional Therapeutic Play about Pain in Preschool and Schoolchildren Submitted to the Management or the Performance of Peripheral Venous Puncture

According to Table 1, the sessions held with the ITP had a significant influence on pain scores presented by the children.

The pain was scored from the Faces Pain Scale (FPS), with the gradation established as follows: “1” indicates no pain (corresponding to the 1st face) and “6” indicates the maximum pain (corresponding to the 6th face).

Table 1. Pain scores indicated by the children during the performance or management of the peripheralvenous puncture, before and after the ITP session. Crato, 2012

Before the sessions, 28.6% of the sample mentioned the pain score as “1” or absence of pain. 83.33% of them were preschoolers. After the sessions, 71.4% of the sample indicated that perception of pain.

Another score before the ITP sessions was “4”, which expresses intense pain. After the sessions, 100% of children assigned this face, showed improvement in pain pattern, and 50% migrated to score “1”.

Also before the ITP, 14.3% of the sample complained of severe pain, or the score of “5”, 100% schoolchildren. After the sessions, this rate was reduced to 4.8% and 9.5% indicated the score “1”.

It is worth mentioning that before the application of ITP, 4.8% said the pain score was “6” or maximum pain, but after the sessions, this score was not scored.

Also conducting a comparison between the pain scores submitted by the same child, indicated in Table 2, the conclusion was the use of ITP enabled to reduce the pain score in 61.70% of the children participating in the research, 61.5% are schoolchildren.

Table 2. Comparison the pain scores submitted by the same child before and after the ITP session. Crato, 2012

4. Discussion

In Sabino and Almeida research [17] performed with cancer patients, pain scores were compared submitted by the same child before and after therapeutic play session considering different body parts like chest, upper limbs, lower limbs and head. In this study, the Wilcoxon test was used, and it was observed that 12 or 75% participants had lower scores after the TP session.

According to Kiche and Almeida [18] research findings, seeking to compare the reactions expressed by the child during dressing change before and after emotional preparation with instructional therapeutic play, 97.05% of the sample showed a reduction in pain scores and only 2.95% said that the score remained the same.

In this context, in the study of Medeiros; Matsumoto; Ribeiro and Borba [19], the authors pointed out that the use of drama in pediatric services to simulate a difficult and painful situation, while the therapeutic play sessions is not intended to supplant necessarily the painful sensation, - present and real - but it is bearable for the child.

Thus, the research presented corroborate the findings of this study, pointing to the ITP as a tool for pain relief in hospitalized children. However, it is noteworthy that there is not a reliable reference established, but relative since the situations presented is not consistent with the assessment of the procedure or management of peripheral venous puncture[17, 18].

In this study, schoolchildren were included. The research conducted in the implementation of ITP, address only the preschool children since their greater difficulty in understanding and coping mechanisms deficit when compared to schoolchildren[19].

Therefore, it was observed that before and after the sessions of ITP, the Faces Pain Scale was more assimilated for the purpose, by the schoolchildren. They understood more clearly the changes in pain scores and could dissociate the pain of subjective feelings, such as anxiety for wanting to return home, to school and the fear related to the procedures[20, 21].

This situation can be one of the reasons for the major improvement in pain scores variation in the schoolchildren (61.53%) compared to preschoolers (38.47%).

Another existing limitation is in the field of publications aimed at the use of ITP. Indeed, there is still a huge gap of knowledge associated with the effectiveness of non-pharmacological therapeutic tool in the control or management of pain in hospitalized children undergoing several intrusive procedures [17].

On the other hand, there are several studies that evaluate the behavioral patterns of the child after the sessions, but not including the pain [22, 25].

Something that can explain this is the very difficult to assess pain in children. Although there are some scales applied in pediatric research, there are restrictions regarding the real effectiveness of these measurement instruments, in particular because they use self-reported pain intensity of the child, not being effective as accurate when considering those children under six years old[26].

However, in the international publications, it was possible to find studies that sought to assess pain in hospitalized children using non-pharmacological treatments, in general, performed by Wong/Baker scale, the same scale applied in this study [27, 28].

For example, in the study of Bertini et al.[29] the researchers sought to investigate the possible positive effects of the presence of a clown in a pediatric unit.

The researchers assessed both the clinical course of the disease, as some physiological parameters and pain. Aspects were observed as systolic and diastolic blood pressure; respiratory and heart rate and temperature, beyond the parameters of pain self-assessment, where once again, the Wong/Baker scale was used.

The research results indicated that in addition to promoting the improvement of the symptomatology of the disease, the use of humor was able to reduce statistically the sensation or perception of pain in children in the experimental group [29].

In the Bertonthesis [30] Wong/Baker scale was also used to assess the effect of music on anxiety and pain in children undergoing medical procedures (invasive and non-invasive). The results of this research were satisfactory, indicating that children who received intervention with the use of music expressed less aversive behaviors to the procedures and a significant reduction in pain sensation.

Thus, despite the existing limitations for measuring pain in children, the Wong/Baker scale is a viable option to conduct studies that address this goal, especially when considering affective aspects of pain, with non-pharmacological therapies acting [31, 32].

When the expression of pediatric pain in its different nuances is undertreated or neglected by the professionals, it can result in serious consequences for child development. Thus, pediatric hospital services must have an effective role in the identification, treatment and management of pain, using pharmacological and non-pharmacological therapies [33].

In the case of ITP, being considered a non-pharmacological tool for pain management, the systematic application of therapeutic play sets propitiatory means of child’s cooperation in achieving the hospital’s routine procedures and adherence to the therapeutic plan. It is a communication tool between the professional and the child and helps the formation of links between health professionals and hospitalized children [34].

For these reasons, there is the need for systematic sessions with therapeutic play to help the child coping with the emotional and physical pain resulting from hospitalization or carrying out intrusive procedures [35].

When highlighting the systematic use of therapeutic play, it encompasses not only the aspect of regularity but also the use of national and international validated protocols for the application of this resource of pediatric care.

Unfortunately, the routine of pediatric hospitalization units for the nursing staff usually affects a limited time for the regular enforcement activities that are not linked to drug therapy [36, 37, 38].

Regarding the use of validated protocol for ITP sessions, there are currently only two protocols published in Portuguese, aiming at the venipuncture procedure and the surgical procedure of adenotonsillectomy, both addressing the age group of preschoolers [16, 39].

This shortage of protocols may affect the effectiveness of developed sessions. It is necessary to adapt existing protocols, seeking to perform ITP sessions for other procedures and other age groups. Unfortunately, in everyday practice, many professionals perform these sessions in an uncoordinated manner, irregular and only empirical. Some of them not even use toys to clarify hospital procedures [40].

For the effective and systematic use of ITP, it is still necessary to promote the continued training of the future health professionals and those already working in the pediatric hospitalization units, particularly the nursing staff. These professionals deal daily with the invasive and painful procedures, which can arouse feelings of fear, denial, disgust, anxiety and pain in hospitalized children [16].

Thus, based on the benefits related to the use of therapeutic play for pediatric care, it is indeed imminent the construction and consolidation of joint actions that enable the systematic practice with therapeutic play sessions in its different modalities, for children expressing this need [35].

5. Conclusions

This research evaluated and compared the pain presented by the children, on using the ITP that can be used as an effective therapeutic tool in the management of pain and anxiety in preschool and schoolchildren that submit or have submitted invasive procedures such as venipuncture.

According to the data analyzed, the use of ITP, in fact, had a significant influence on pain scores submitted by hospitalized children, with 60.9% of the sample reported that the pain decreased after the completion of the ITP sessions.

Corroborating with the literature checked, we believe that the use of ITP is a relevant intervention on health team practice working in pediatric units.

However, it is necessary to promote continuous training to the professionals working in pediatric units, helping on not only the technical side but the theoretical reinforcement of the benefits found with the use of different modes of TP to demystify and break preconceived ideas to the use of this intervention.


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