1Worldviews on Evidence-Based Nursing, 2019; 1–6.
© 2019 Sigma Theta Tau International

Original Article

The Effect of Distraction Cards on Reducing
Pain and Anxiety During Intramuscular
Injection in Children
Nejla Canbulat Şahiner, PhD ● Ayşe Sonay Türkmen, PhD

Aim: The aim of the present study was to evaluate the effectiveness of distraction cards in re-
ducing pain and anxiety during intramuscular (IM) injection in children aged between 6 and
11 years.

Methods: Sixty children were randomized into two groups, the distraction group and controls.
The children in the distraction group viewed distraction cards during the procedure. The chil-
dren in the control group were allowed to have their family nearby when the routine injection
procedure was performed, but no distraction techniques were employed. Children’s Fear Scale
was used to assess children’s anxiety levels. Pain levels were assessed using the Wong- Baker
FACES pain rating scale via self- reports, which were completed by the children and also by the
parents and observer.

Results: There were significant differences in the self-, parent-, and observer-reported pain
and parent- and observer-reported anxiety levels between the distraction and control groups.

Linking Evidence to Action: Distraction methods, such as distraction cards, should be used as
a nursing intervention to reduce pain and anxiety during IM injection in children. This study
contributes to the literature on nonpharmacologic pain relief methods during IM injection in

One of the most extraordinary phenomena first ex-
perienced in childhood is pain (Cohen et al., 2008;
O’Rourke, 2004; Young, 2005). As such, pain is a qual-
ity improvement measure in many hospitals and even
considered as the fifth vital sign (American Academy of
Pediatrics, Committee on Psychosocial Aspects of Child,
Family Health, Task Force on Pain in Infants, Children,
and Adolescents, 2001). Needle- requiring medical pro-
cedures such as venipuncture and intramuscular (IM)
injections are common and significant sources of pain
for children that cause anxiety, distress and fear (Blount
et al., 2009; Leahy et al., 2008; Uman, Chambers,
McGrath, & Kisely, 2006). Pain experiences in infancy
and childhood may result in long- term changes in phys-
iologic and behavioral responses to pain (Anand, 2001).
The American Academy of Pediatrics and the American
Pain Society recommend that, wherever possible, stress
and pain should be minimized or lessened, even in minor
practices such as IM injection (American Academy of
Pediatrics, Committee on Psychosocial Aspects of Child,
Family Health, Task Force on Pain in Infants, Children,
and Adolescents, 2001). Pain in children can result in

profound long- term physical and psychologic sequelae
if it is not managed quickly and decisively. Therefore,
knowledge of the importance of effective pain control
in children is vitally important for physicians, nurses

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