The Work for Distractions during the Procedures ofBlood Sampling and Securing Vascular Access
Shinobu Kubota*
Ayako Naka** ・ Misa Kameda** ・ Megumi Shimizu** ・ Remi Kinoshita**
Keiko Yano*** ・ Keiko Mano****1. Introduction
For children, hospital experiences are often associated with painful, fearful and unknown eventsand they tend to feel anxieties and distresses. I have been working for children as a children’s nurse
in a pediatric ward for four years. Since my occupation was seen as a type of children’s nurse thatwas nothing to do with medicine, I was not able to involve in situations where children underwent
medical treatments.
Last year, I took training courses for Hospital Play Specialist (hereinafter referred to as HPS) in
order to learn the methods and the importance of preparations and distractions in the pediatricenvironment.
After I completed the courses, I set my goal to create an environment where children can takemedical treatments positively. To achieve that goal, I would like to work together with doctors,
nurses and other children’s nurses in the ward to become a representative of children. I would like towork as a bridge between children and healthcare professionals especially in cases where children
underwent possible fearful treatments such as taking blood and securing vascular access. In thisarticle, distractions practiced based on the philosophy above were reported and reviewed. The
further issues were also discussed.
2. Method
1) The contents of the HPS training courses were reported to other healthcare staffs.


I asked for their cooperation at the time when distractions were practiced. Initiallydistractions would be held during blood sampling and securing vascular access.
2) A shift schedule was made among children’s nurses at the time of blood sampling

As one of their duties, a children’s nurse would attend and practice distractions during blood

sampling. The duty rotated on a weekly basis.


A children’s nurse in charge would check the name of a child and of an attending nurse.

Because the blood sampling had often been taken already when a children’s nurse entered thetreatment room, the name of an attending children’s nurse was placed in the treatment room inorder to get HPS work entrenched in practice. Nurses in the treatment room were asked to call an
attending children’s nurse before the treatment.
3) Learning sessions on preparation and distraction were held in the ward.
4) Through practicing preparations, we elicited cooperation from doctors and nurses

Practicing a blood sampling without restraining a child and allowing a parent to accompany

during the practice were requested to an attending doctor

Presentations on preparation and distraction were provided to healthcare staffs to elicit theirunderstanding and interest in those practices. We asked staff to work together.
3. Result1）Distraction from the perspective of the number of intervention
The number of distraction interventions practiced between April 2014 and November 2014 was
518 cases in total (Figure 1); 101 out of 283 children in total received distraction several times. The
breakdown of ages shows that infants received distraction the most. Since behaviors of infants
vary from showing no interest to crying loud, it tends to be considered that infants who seem
indifferent do not need distractions. It has been seen, however, that infants change their facial
expressions when they are given distractions and some stop crying. Accordingly it is important toprovide distraction even to infants showing no interest since distraction may work as a preventionof possible trauma from pain/fear associated medical treatments.

Figure 1．Age distribution of the number of distraction intervention
Ages of toddlers are the second most in the figure. Though toddlers start showing their wills andwishes, it is still difficult to communicate with others precisely during those years. Toddler years arealso times when anxiety and fear are increasing in one’s mind. HPS has a role representing
children’s will so that HPS must pay constant efforts to apprehend children in order to alleviate theiranxiety and distress. Our everyday mission is, therefore, to understand one’s favorite types of playthrough close communication with the child, and eventually to build a trusting relationship.
2) The method of selection of distraction tools
To practice distraction, we prepared toys and playthings grouped in accordance with age. Those toys
and playthings included popular character goods and sensory toys. Table 1 indicates toys that drew a
lot of attention from children during blood sampling practice. During blood sampling, we also
prepared some short movies such as ANPANMAN and Tom and Jerry. We asked parents what kindof toys and cartoon characters their children liked beforehand. Parents and children were then able
to select what they wanted to play before the treatment.
Table 1．List of Distraction Tools

A.

During blood sampling procedures

Picture 1: (5 year-old)
5~10 minutes prior toblood sampling, the childcame into the treatment
room and started playing
games.

Picture 2：(5 year-old)Placed toys in front of achild and let him/her choose
what to play.

Picture 3：Blood
sampling while being
held in arms (2year-old). The childseemed comfortable andwas watching a movie

Picture 4:(5year-old)

The child was so focused on playingthat she was no longer disturbed
with blood sampling. She took thetreatment at peace.

Picture 5: Medical Play（5year-old）
She was interested in a syringe toy that wasclosely resembled to the real apparatus. She
expressed her feelings by repeating her medical
experience with the syringe. She seemed relievedftl i3) Case example of distraction
Case 1: A-kun, 3-year-old male (delay in development, Down’s syndrome)
A nurse was carrying A-kun when they entered the treatment room. In the treatment room, I
offered to hold him in my arms. Considering the boy’s characteristics and his mood at that moment, I
found it was better that he continued to be held while he took blood sampling. After having received
permission from his doctor, A-kun underwent blood sampling while being held gently in my arms. As
a result, he completed the treatment without crying. A nurse who came into the room talked to me
that A-kun had experienced forcefully taken blood sampling in the previous day since he cried hard
and resisted aggressively.
Some days later, another blood sampling was scheduled for A-kun. A nurse carried him to thetreatment room. He was then crying intensively on a bed where he was placed in the spine posture. I
explained to a doctor and attending nurses about how his previous blood sampling went. I, then,suggested holding K-kun in my arms again during his blood sampling. After having received
permission from the doctor, I held K-kun gently in my arm. Soon he stopped crying and started
watching movies and observing toys. Eventually he took the treatment while he was held. He went
through the treatment without crying or refusing the procedure.
Case 2: B-chan, 5-year old female (eating disorder)
B-chan had disturbed eating behavior and was smaller than children in her age. There were somefamily problems in her family. Her linguistic development seemed delayed but had never been
diagnosed as any delay in development. Her behaviors indicated a lack of sociability with someegocentric attitudes.
Before our intervention, B-chan was often crying on a bed where she was placed in thespine posture during blood sampling. She had mood-swings. Once she said “no”, she would refuse
everything after that. Because of such characteristics and through our everyday observation on her,

we thought it was important to make her mentally prepared for the forthcoming event. We decided
that I would be involved in the treatment procedure by letting her choose her favorite way to takethe treatment. Though she changed her “favorite way” depending on a day, often she chose to takeblood sampling in a sitting position. Eventually she told to a doctor “I would like to do it in a sitting
position” and showed her arm by herself. The doctor and nurses started to respect B-chan’s will andnaturally let her undergo blood sampling in a sitting position. B-chan was then no longer disturbed
with the treatment and took it positively while playing.
Case 3: C-chan, 3 year-old female
C-chan was held in her mother’s arm and came in front of the treatment room. Once she heard“blood sampling” she started crying and exclaimed that “I hate the treatment room” “I want to bewith my mum”. Such her behaviors were not seen during her playtime. From her behavior at thetreatment room, we thought that it would be better if her mother accompanied C-chan during blood
sampling procedure. After having received permission from a doctor, we talked to C-chan that she
would be able to stay with her mother during blood sampling. She stopped crying. Though she said
“it hurts”, she completed blood sampling on her mother’s lap.
When C-chan was crying loud, we asked her mother about the behaviors of C-chan during theprevious blood sampling. The mother told us that C-chan couldn’t tolerate even just hearing words“blood sampling” and “the treatment room” and she started crying. It was considered that
C-chan associated those words with a separation from her mother and the feeling of fear. When we
received information that securing vascular access for intravenous drip would be practiced in twodays, we had a talk with C-chan and her mother. At that point, we had not received permission froma doctor that the mother was able to accompany C-chan during the treatment, we asked C-chan if we
could accompany her; “Can we hold you in the treatment room?” “Let’s play together there”.
C-chan replied to us “I prefer mum”. When we explained that her mother would take her to thetreatment room and we would stay with C-chan in the room, she understood.
On the day of the treatment, C-chan came to the treatment room with her mother. Though she
started crying, she came to be held to HPS when HPS stretched her arms toward C-chan.
C-chan requested to a doctor for a puncture site by saying “It hurts here, so put the needle there
instead”. During the procedure of securing vascular access, C-chan showed some interest in DVD
and children’s books even though she was crying and calling her mother. Though with tears
C-chan bravely completed the treatment. Later, though C-chan still cried when she heard the term
“blood sampling” “examination”, she became able to undergo medical treatments on someone’s lap orin someone’s arms while playing and talking about what she was interested in.
Case 4: D-kun, 5 year-old malePreviously D-kun was placed on bed forcefully in a spine posture while taking a medical
treatment since he refused to take it with tears and tried to resist it. The intervention of HPS wasprovided when D-kun was about to take blood sampling for the 3rd time. While he was watching his
favorite DVD, he was saying to him “I’ll give it a try!” Then he was entering the treatment room.
Though he showed his arm to a doctor, he pulled it back and said to the doctor “Wait a second”. Soon
after he started refusing by saying “I don’t want to do it!” and we decided to take a break for a while.
When HPS asked him what he did not want to do, he replied to us “I’m afraid of needles”. We
indicated our understanding to him and praised him for facing it bravely by showing his arm byhimself. He was smiling. After a while he was saying “I’ll give it a try again”.
Later HPS visited to his room and suggested a treatment where D-kun did not see the needle inorder for him to reduce the fear against needles. D-kun still preferred to see and he even decided
when to take blood sampling based on his other schedule of the day. He entered the treatment roomand sat in a chair in a positive manner though he seemed nervous. When his doctor said to
D-kun that he would start the blood sampling on the count of three, D-kun disagreed by saying “thatis too fast”. I suggested to him that we slowly count ten so that there will be enough time for him to
get ready. He, then, completed the treatment without pulling back his arm.
On the following day, securing vascular access was scheduled. D-kun tried to divert his attention
by talking about DVD with children’s nurses that he chose beforehand. When he started feelinganxious, we asked if he wanted to count ten. Though talking in a low voice, he started counting to ten
and made himself ready for the procedure. Once the blood sampling was complete, the doctor
thanked him and praised him for his courage and efforts. D-kun seemed to acquire some confidence
in the situation.
4. Discussion
It seemed that the child gained a certain confidence to go through the next treatment afterparticipating in the medical procedure on his own initiative through distractions. Having seen theeffects of distraction interventions “a child did not cry” or “blood sampling and securing vascularaccess went rather smoothly”, healthcare staffs began to request HPS to practice interventions. That
indicates that distraction intervention is becoming recognized in our ward. Further, doctors now try
not to hold a child forcefully when they practice blood sampling and other treatments. For somecases however, children are still restricted during medical treatments for “safety reasons”. Nurses
who attended our seminar once told us that they weren’t able to press firmly to a doctor even theyfelt there were some unnecessary restrictions imposed on children. We would like to improve suchsituation by telling doctors “children were able when they were given appropriate conditions”.
Though the number of cases where parents can accompany during their child’s medical treatment
such as blood sampling and securing vascular access are increasing, such procedure is not yet
acknowledged enough and children are still forcefully separated from their parents in some casesand some get really upset and cry. When children are upset, they do not show any interest in toys.
When children are with their parents whom they have an established trusting relationship with,they come to gain courage to go through medical treatments along with distraction intervention. One

of our future tasks shall be, therefore, by becoming children’s representative to convey their voice tohealthcare professionals, to establish an environment where children can undergo medical
treatments without having unnecessary distresses.
5.Conclusion
The total number of distraction interventions that was practiced between April 2014 andNovember 2014 was 518 cases. To achieve the number of interventions, not only HPS but also
doctors and nurses had worked together. By studying the cases, we realized that many children
went through blood sampling and securing vascular access repeatedly. In this study, we reviewed
these cases by reflecting regular procedures of medical treatments. The fundamental changes
made through our distraction interventions seemed to encourage children to go through the
medical treatments and to alleviate anxieties and fear. It is however, that issues to be resolved
were revealed through our study at the same time and our harder work with other healthcare
professionals toward children in order to reduce their distresses is surely required.
＜References＞
Chika Mastudaira (2010). Introductory of Hospital-Play, Kenpakusha Press, 2010.
Chika Mastudaira (2012). Practical Use of Hospital-Play, SOUHEKI-SHA