Yearbook on Journal of the Japan Society of Nursing Research 2013

Factors Associated with Children’s Ineffective Coping Behavior during Blood Sampling
Shiho Sato 1), Yukiko Sato 1), Hitoshi Shiwaku 2)
Key Words :preschool children
blood sampling
coping behavior
preparation

ABSTRACT
Purpose: This study investigated the factors associated with ineffective coping behaviors exhibited bychildren during blood sampling.
Materials and Methods: Coping behavior of 49 children aged 3–6 years was observed based on the Manifest
Upset and Cooperation Scales during blood sampling; their parents responded to a questionnaire before theprocedure. We obtained permission after an ethical examination of the facility with which the researchers
were affiliated.
Results: Children were assigned to ineffective (n = 12) and effective (n = 35) coping behavior groups
based on the Manifest Upset and Cooperation Scales. The children in the ineffective coping behavior groupwere younger than those in the effective coping behavior group (P = 0.013). The child’s tendency toward
ineffective coping behavior before blood sampling and the parent’s prediction was higher in the ineffective
coping behavior group as compared with the effective coping behavior group (P = 0.000). Multiple regression
analysis revealed that the parent’s prediction based on the Manifest Upset Scale was the significant factor
that influenced a child’s coping behavior.
Conclusion: The study findings suggest that it is important to take into consideration a child’s age andbehavior, and the parent’s prediction before blood sampling.

I．INTRODUCTION

study that determined the process that children accepted andacquired during examinations and procedures11). As factorsthat had an influence on children’s coping behavior, thesestudies included stages of development, past pain experience,
explanation prior to blood sampling, and awareness andrelation with the parent4)–10). Although it is revealed that thesefactors lead to much coping behavior, there is no study thatinvestigated the association with ineffective coping behavior(e.g., crying continually and resisting without being proactivein undergoing examinations and procedures; and strongly
expressing anxiety and tension)9). It cannot be said that there
are sufficient studies on related factors in children requiring
more individual nursing intervention and preparation.
Several studies on preparation included practical reports,case reports12)–15), and reports that verified its efficacy2), 16), 17).
It has been reported that preparation leads to decreased
psychological confusion in children16), 17) and is effective forpain relief2). In addition, a guidebook18), care model19)–24), andcheck list25) for preparation were presented to show the meansby which to perform preparation. Under the circumstances, it
is pointed out that an assessment of the child’s backgroundand consideration of their individual needs before performing
preparations are important2), 18). Thus, it is considered thatthe background of children who cannot be proactive inundergoing examinations and procedures, and who cannot
show their effective coping skills, should be clarified.
This study aimed to determine the factors related tochildren who show ineffective coping behavior for blood
sampling, which is conducted more routinely, and often,
becomes a painful experience during painful medical
examinations and procedures. In the study, the subjects
were children aged 3–6 years who were considered tolack the ability to generalize and infer things during theirstages of cognitive development26), and therefore, required
preparation.

Medical examinations and procedures are often associatedwith physical pain or psychological distress. Children cannot
understand the purpose and necessity of examinations andprocedures thoroughly as they have not yet fully developed
their cognitive abilities or verbal abilities. In addition, they
have little experience and coping skills. As a result, children
may have to undergo procedures or medical examinations thatthey cannot accept and that they then resist. Therefore, some
support to improve coping skills and facilitate independent
participation is important for children1).
One way of support is preparation; that is, to explain tochildren who will undergo treatment or examination ina manner suitable to their cognitive development, and toprovide an environment or opportunity that improves
the coping skills of children and their parents. Prior to
examinations and procedures, preparation for children,
who have not yet fully developed their cognitive abilities, isneeded to help them to understand and assent to medical
examinations and procedures in their own way, and to
improve their coping skills1). It has begun to be used actively
in clinical practice and is becoming widely popular inpediatric nursing.
A researcher prepared children who were undergoingblood sampling, and verified that preparation might allow
them to understand and assent to blood sampling, and mightrelieve the pain that the children might feel2). It is a fact thatmany children who still cannot assent to and accept blood
sampling, show ineffective coping behavior, such as crying,resistance, and acting violently.
There are several studies on the coping behavior ofchildren, who undergo painful examinations and procedures,
including blood sampling, studies that determined the actual
situation of such coping behavior3), 4), studies that reported
the factors that influence such coping behavior 5)–10), and a

II．METHODS

1) Yamagata University Faculty of Medicine, School of Nursing2) Tohoku University Graduate School of Medicine, Health Sciences

1. Terminology: operational definitions

Corresponding author. Tel.: +81 23 628 5453.
E-mail address: s.shiho@med.id.yamagata-u.ac.jp (S. Sato)In this study, the coping behavior of children undergoing

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This paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Yearbook on Journal of the Japan Society of Nursing Research 2013

The sex, age, and names of diseases for the children weretranscribed as basic attributes from their medical records.
We also observed the measurement of the blood sampling
time, staff in charge of the puncture, number of punctures,
posture during punctures, and participation the parent when
the blood sampling was performed during this survey.

blood sampling was defined as the response and behavior tophysical pain and psychological distress that were observed
when children underwent blood sampling. These were
measured by the degree of the child’s cooperation during
blood sampling and by the degree of the child’s emotions.
In addition, “ineffective coping behavior” was defined as
the following coping behavior of children undergoing blood
sampling: the physical pain of children who resist and are
not proactive in undergoing blood sampling; and the reaction
and behavior of children who strongly showed psychologicaldistress, such as anxiety or fear.

(2) Coping behavior

For evaluation, children’s coping behavior during blood
sampling was objectively measured using the two existing
scales: the Manifest Upset Scale16) and Cooperation Scale16).

2. Subjects① Manifest Upset Scale

Subjects were children aged 3–6 years, who underwent
blood sampling in the pediatrics outpatient department ofa university hospital in the prefectural capital in the Tohoku
district, and their parents. The children and their parents
who consented to cooperate in the survey were included inthis study. Considering that the stages of development might
influence coping behavior, developmentally disabled children
were excluded from the subjects.

The Manifest Upset Scale, which was derived from
Wolfer’s28) scale and partially modified by Koseki16), was used
to evaluate the degree of children’s anxiety and fear towards
blood sampling. A single-item questionnaire scored on a scaleof 1, 3, and, 5 points was used; the higher the score, the higher
the level of psychological confusion, including anxiety andfear, in the child.

3. Data-gathering period② Cooperation Scale

Data were gathered from June to September 2009.

The Cooperation Scale, which was derived from Wolfer’s28)
scale and partially modified by Koseki16), was used to evaluate
the degree of cooperation during blood sampling. A singleitem questionnaire scored on a scale of 1, 3, and, 5 points
was used; the higher the score, the higher the level of noncooperative behavior from the child.

4. Data-gathering method

This study was conducted via participant observation anda questionnaire survey using a scale to measure children’s
coping behavior. Children’s coping behavior until entering
the blood sampling room and during blood sampling wasobserved via the participant observation method. Before
blood sampling, a questionnaire survey was undertakenby their parents. Children’s coping behavior was classified
into effective and ineffective groups based on the behavior
observations of the children during blood sampling. Related
factors were examined based on the questionnaire survey by
their parents and based on the behavior observation of thechildren up until entering the blood sampling room. After
having obtained subjects’ consent before blood sampling, we
asked their parents to fill out the questionnaire and observed
the children’s behavior.

(3) Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)

Behavior associated with pain was objectively measured
using a scale developed by McGrath et al.29) to measure
behavior associated with pain due to needle puncture orother instruments. In this scale, the behavior was observed
according to the following six parameters: cry, facial, childverbal, torso, touch, and legs. Each item included three to six
kinds of behavior, and scoring was defined respectively inorder to score each subject’s behavior in the range of 4 to
13 points; the higher the total score of all of the items, thestronger the pain.

5. Materials

b. Observed children’s coping behavior until they enter blood
sampling rooma. Observed children’s coping behavior during blood sampling

For the purpose of objectively measuring children’s
behavior, the researchers conducted participant observationfrom the time when a child predicted he/she was to undergo
blood sampling or from the point in time when a child wastold to undergo blood sampling until entering the blood
sampling room. This was done using the two scores of the
Manifest Upset Scale16) and the Cooperation Scale16).

Using the Manifest Upset Scale and Cooperation Score(participant observation method) developed by Koseki16),
children’s coping behavior during blood sampling wasobserved. These two scores were widely used as anobservation method to assess children’s coping behavior inprevious studies18), 27). The period from entering the blood
sampling room to just before needle puncture for blood
sampling was defined as stage I. The period from needle
puncture to removal of needle was defined as stage II. The
period from removal of the needle to leaving the blood
sampling room was defined as stage III. Each coping behavior
in these phases was evaluated.

c. Questionnaire by parents(1) Demographic and child’s background data

To examine the children’s background regarding painful
medical procedures, the parents were asked to answer thefollowing items on the questionnaire: past blood sampling(1) Demographic background data of the children

14This paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Yearbook on Journal of the Japan Society of Nursing Research 2013

experience; number of experiences of blood sampling; timesince the last blood sampling; experiences of strong pain,
except blood sampling and vaccination; and hospitalization
experience.

of coping behavior during blood sampling as the dependent
variable. The Statistical Package for the Social Science (SPSS)
17.0J for Windows was used for the statistical analysis.
III．RESULTS(2) Prediction of their child’s behavior

1. Demographic data and coping behavior data during blood
sampling

The parents were asked to predict their child’s coping
behavior before blood sampling. Both the Manifest Upset
Scale and Cooperation Scale were used for the predictedbehavior.

Of the 49 pairs of children and their parents who wereasked to participate in the survey, all of them gave theirconsent to the survey. The following two children and theirparents were excluded from the analysis: a child with adevelopmental disease, which was found after the request
for the survey; and a child who underwent an additional
medical procedure other than blood sampling. The remainder(47 pairs; 95.9%) was targeted for the analysis. The mean
age ± standard deviation (SD) of the children as the subjects
was 4.8 ± 1.1 years old. All of them (26 boys, 55.3%; 21 girls,
44.7%) had experienced blood sampling in the past (Table1). Mothers accounted for more than 80% of the parents in
attendance (Table 2). The parents’ state anxiety mean score
related to the blood sampling of their children was 42.0 ± 8.5(mean score ± SD) points (Table 3).
Table 4 shows the situation of blood sampling during thesurvey. The mean ± SD of the blood sampling time was 4.4 ±2.7 minutes. Blood sampling was performed by a pediatrician
and nurse in charge of the treatment in the pediatrics
outpatient treatment room in this hospital. Adhering toeach child’s request as much as possible, it was determined
whether a child was to be punctured in a supine position or
sitting position. The parents were allowed to enter the blood
sampling room and could watch over their child on the side or(3) The State-Trait Anxiety Inventory (STAI) 30)

The scale developed Spielberger et al. was used to measure
the degree of parent’s anxiety. This scale can measure bothstate anxiety and trait anxiety. In this study, we used only
the state anxiety scale to understand the parent’s anxiety forblood sampling of their children. This scale consisted of 20
questions to be scored in the range of 20 to 80 points; thehigher the total score, the stronger the anxiety.
6. Ethical considerations

We submitted the research design to the ethics committeeof Yamagata University Faculty of Medicine and the ethics
committee of the university hospital where the survey was
performed. This study was approved by these ethical review
boards. The participants were informed of the purposeof the survey. In addition, the following information wasgiven to the subjects verbally and in writing: cooperation
to undertake the survey was voluntary. A subject could
withdraw from participation in the survey at any time, andwithdrawal from or refusal to take part in the survey would
result in no medical disadvantage. The obtained information
would never be used for any purpose other than the study.
Personal information would remain anonymous and will not
be able to be connected to the source code. The results ofthe survey would be presented after being processed, so that
subjects cannot be identified individually. Information, suchas diagnoses, would be obtained from medical records. Of allthese participants, only the children and their parents who
provided consent to participate in the study were includedin the survey. The written consent was obtained from thechildren’s parents after having verbally obtained the consent
from both the children and their parents.

Table 1. Demographic data of the children (n=47)
Mean (SD)n(%)

Age (years)
4.8 (1.1)
Sex
Boy
Girl
Experiences of blood samplingYesNo

26 (55.3)
21 (44.7)

47 (100.0)
0 (0.0)

Table 2. Demographic data of the parents (n=47)

7. Analysis

MotherMother and father
GrandmotherGrandparent
total

The children were assigned to the effective group or the
ineffective group based on the children’s coping behavior
during the blood sampling. The related factors of the twogroups were compared regarding the following items: ageof children, children’s past pain experiences, explanation
prior to blood sampling, children’s behavior until entering
the blood sampling room, parent’s anxiety, and parent’s
prediction regarding blood sampling.
A Mann–Whitney U test (exact test) was used to assess thedifferences between the two independent groups. Fisher’s
exact test was used to assess proportional differences. To
measure the degree of impact of the related factors, a multiple
regression analysis was performed with the above-mentioned
related factors as independent variables and with the scoren(%)

40 (85.1)
5 (10.6)
1
(2.1)
1
(2.1)
47 ( 100.0)

Table 3. Parents’ anxiety and prediction of
their child’s behavior (n=47)
Parent’s state anxiety (STAI)
Parent’s prediction
Manifest upset scale
Cooperation scale

15
This paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Mean (SD)
42.0 (8.5)

Median (range)
3 (1-5)3 (1-5)

Yearbook on Journal of the Japan Society of Nursing Research 2013

Table 4. Situation of blood sampling (n=47)
Mean (SD)
Blood sampling time (min)Performed blood sampling
Doctor
Nurse
Number of punctures
Once
Twice
Posture during punctures
SupineSitting
Relation of the parent
Intervene in the treatment
Watch overNothing

4.4 (2.7)

Table 5. Children’s coping behavior during blood sampling (n=47)n(%)

Median (range)

Manifest Upset Scale
Stage I
Stage II
Stage III
Cooperation Scale
Stage I
Stage II
Stage IIICHEOPS
Stage I
Stage II

44 (93.6)
3 (6.4)43 (91.5)
4 (8.5)21 (44.7)
26 (55.3)
28 (59.6)
17 (36.2)2 (4.3)

1 (1- 5)
1 (1- 5)
1 (1- 5)
1 (1- 5)
1 (1- 5)
1 (1- 5)8 (6-13)8 (6-13)

Stage III

6 (6-10)

Table 6. Comparison of the sex and diseases between ineffective and effective groups (n=47)

Sex
Boy
Girl
Diseases
Endocrine, nutritional and metabolic diseases
Neoplasms
Diseases of the genitourinary systems
Diseases of the blood and blood-forming organs and certain disorders
Diseases of the musculoskeletal system and connective tissue
Diseases of the nervous system
Unidentified
Fisher’s exact test

encourage him/her by holding his/her hands, and they werein a situation to be able to intervene in the treatment during
the blood sampling. In this study, 28 parents (59.6%) entered
the blood sampling room together with their child during
the blood sampling. While the children underwent the blood
sampling, they received some interventions, such as being
held in parent’s arm or holding the other hand (the hand thatwas not used for blood collection) while being encouraged
by each parent.
Table 5 shows the children’s coping behavior during blood
sampling, which was obtained via the participant observation
method. The median score on the Manifest Upset Scale score(range) for stage I to III was 1 (1–5) point. Additionally, themedian Cooperation Scale scores (range) for stage I to III was
1 (1–5) point. The mean scores of behavior for pain (range)
using the Children’s Hospital Eastern Ontario Pain Scale(CHEOPS) were as follows: stage I, 8 (6–13) points; stage II,
8 (6–13) points; and stage III, 6 (6–10) points. This tended toincrease between entering the blood sampling room and theremoval of needle and decrease after the removal of needle
and during stage III.
No generalized standard is currently available to classify
the groups as effective and ineffective. Thus, in this study,
we examined the classification of the groups with pediatricnurses, and then, classified the children based on their
Manifest Upset Scale scores and Cooperation Scale scoresobtained from the observation during the blood sampling.
To observe coping behavior through the course of the blood

Ineffective groupn(%)

Effective groupn(%)

5 (41.7)
3 (25.0)
2 (16.7)
1 (8.3)0 (0.0)0 (0.0)1 (8.3)

11 (31.4)
8 (22.9)
7 (20.0)
4 (11.4)
1 (2.9)1 (2.9)3 (8.6)6 (50.0)
6 (50.0)

20 (57.1)
15 (42.9)

P-value.744.990

sampling, the period of blood sampling was classified into
three stages. However, in order to understand the children’s
behavior during blood sampling in detail, we calculated thetotal score for the Manifest Upset Scale and Cooperation Scalefrom stage I to stage III, and confirmed the distribution. As aresult, since there was a bimodal score distribution, the cutoff was defined at 18 points (the total score). Twelve children
with 18 points or more (6 boys, 6 girls) and 35 children with
17 points or less (20 boys, 15 girls) were assigned to theineffective group and effective group, respectively (Table 6).
After comparing the two groups on behavior for pain during
the blood sampling based on CHEOPS, there was a significant
difference observed. The CHEOPS scores of the ineffective
group were higher than those of the effective group, and in
the behavioral observation for pain, behaviors such as crying
and acting violently were found. Therefore, it was shown that
this group classification was appropriate (Table 7).
On classifying the children’s diseases based on ICD-1031), in
both the groups, endocrine nutritional, and metabolic diseases
were most common, followed by neoplasms, and diseases of
the genitourinary systems (Table 6). In a comparison of sex
as well as disease type between the ineffective and effective
groups, there were no differences found.
2. Comparison of ineffective and effective coping behavior
groups16

The following items were compared between the ineffective

This paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Yearbook on Journal of the Japan Society of Nursing Research 2013

and effective groups: age of children, previous blood sampling
experience and hospitalization experience, explanations
prior to blood sampling, children’s behavior until entering
the blood sampling room, the parent’s prediction regarding
blood sampling of their children, and the parent’s anxiety.

b. Children’s past experience regarding blood sampling, pain,
and hospitalization (Table 9, 10)

All the study’s children had experienced blood sampling in
the past. Above all, regarding the number of blood samplings,
31 times or more was the most common in both groups.
Regarding the period of time since the last blood sampling,less than one month was the most common, followed by lessthan three months; the children in both groups experienced
blood sampling routinely. There were three children (6.4%)
and seven children (14.9%) in the ineffective and effective
group, respectively, who experienced strong pain other thanduring blood sampling and vaccination. Most of the children
had experienced hospitalizations. On comparing the numberof past blood sample experiences, the time of the last blood
sampling, experience of strong pain except for blood sampling
and vaccination, and hospitalization experience between theineffective and effective groups, there was no significant
difference.

a. Age (Table 8)

The mean ages of the ineffective and the effective groups
were 4.1 years and 5.0 years, respectively. In the comparison
between the two groups, there was a significant difference (P= 0.013) and the ineffective group was significantly younger
than the effective group.
Table 7. Comparison of the CHEOPS score between ineffective
and effective groups (n=47)

CHEOPS score
Stage I
Stage II
Stage III

Ineffective group(n=12)Median
11.0
12.0
9.0

Mean
11.0
11.7
8.7

Effective group(n=35)

P-value

7.0
8.0
6.0

.000
.000
.000

Median

Mean
7.3
7.7
6.3

c. Explanations before blood sampling (Table 11)

There were 11 children (23.4%) and 26 children (55.3%)
in the ineffective and effective groups, respectively, who were
given explanations about the blood sampling by medical staff
or their parent. In comparing the presence or absence of
explanations before blood sampling between the ineffective
and effective groups, no significant difference was found.

Mann–Whitney U test (exact test), CHEOPS is the children’s hospitalof eastern ontario pain scale.

d. Children’s coping behavior until they enter blood samplingroom (Figure 1)

Table 8. Comparison of the age between ineffective andeffective groups (n=47)

Age (years)

Ineffective group(n=12)Median
4.0

Mean
4.1

Effective group(n=35)MedianMann–Whitney U test (exact test)

5.3

Mean
5.0

In the comparison of the children’s behavior until entering
the blood sampling room, between the ineffective andeffective groups, there was a significant difference both in the
Manifest Upset Scale score (P = 0.012) and the Cooperation

P-value.013

Table 10. Comparison of the experiences of strong pain andhospitalization experience between ineffective
and effective groups (n=47)

Table 9. Comparison of the previous blood sampling experience
between ineffective and effective groups (n=47)
Number of experiences ofblood sampling
1- 5
6-10
11-20
21-30
31 or more
No answer
Time since the lastblood sampling
1 week or less
1 month or less3 months or less
6 months or less
1 year or more
No answer
Fisher’s exact test

Ineffective group Effective groupP-valuen(%)n(%)
0 (0.0)3 (25.0)
3 (25.0)
1 (8.3)5 (41.7)
0 (0.0)4 (11.4)
3 (8.6)9 (25.8)
3 (8.6)
14 (40.0)
2 (5.7)0 (0.0)8 (66.7)
2 (16.7)
1 (8.3)1 (8.3)3 (8.6)15 (42.9)
8 (22.9)
4 (11.4)
3 (8.6)0 (0.0)Experience of strong pain
Yes
No
Hospitalization experience
Yes
No

.608

Fisher’s exact test

Ineffective group Effective groupP-valuen(%)n(%)
3 (25.0)9 (75.0)

11 (91.7)
1 (8.3).700

31 (88.6)
4 (11.4).764

Table 11. Comparison of the explanations prior to blood sampling
between ineffective and effective groups (n=47).879

Explanations
Yes
No

2 (5.7)

Fisher’s exact test

Ineffective groupn(%)
11 (91.7)
1 (8.3)17This paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Effective groupn(%)
26 (74.3)
9 (25.7)

P-value.414Yearbook on Journal of the Japan Society of Nursing Research 2013
Ineffective group
P= .000

Effective group

4
P= .000

P= .001
Score (Median)

3

4.0
（4.0）

2

3.0
（3.8）

3.0
（2.7）

P= .012

1

0

1.0
1.0
（2.0） （1.2）

1.0
（1.2）

1.0
（1.9）

1.0
（1.9）

Manifest upset scale

Cooperation scale

Manifest upset scale

Cooperation scaleChildren’s behavior until entering the blood sampling room

Parent’s prediction

Mann–Whitney U test (exact test), Score: Median (Mean)

Figure 1. Comparison of the children’s behavior until entering the blood samplingroom and parent’s prediction of their child’s behavior between ineffective
and effective groups.
Table 14. Classification of the children’s behavior up until
entering the blood sampling room (n=47)

Table 12. Comparison of the parent’s anxiety between
ineffective and effective groups (n=47)

Parent’s anxiety

Ineffective group(n=12)Median
40.5

Mean
42.8

Mann–Whitney U test (exact test)

Effective group(n=35)Median
41.0

Mean
41.7

P-value

Ineffective behavior.651

Effective behavior
total

Table 13. Factors associated with children’s coping behavior
during blood sampling (n=47)
Variable

Parent’s prediction(manifest upset scale)R
R2
Adjusted R2

β

.761

.761
.579
.569

4 (33.3)

8 (66.6)

12 (100.0)

3

(8.6)

32 (91.4)

35 (100.0)

Total
n(%)

7 (14.9)40 (85.1)

47 (100.0)

Table 15. Classification of the parent’s prediction (n=47)

P-value.000

Ineffective prediction
Effective prediction
total

Multiple regression analysis used the children’s coping behavior
during blood sampling as the dependent variable (stepwise). β isthe standardized coefficients.

Ineffective group Effective group
n(%)
n(%)

Total
n(%)

12 (100.0)

13 (37.1)

25 (53.2)

12 (100.0)

35 (100.0)

47 (100.0)

0

(0.0)

22 (62.9)

22 (46.8)

children (Table 12)

Scale score (P = 0.001); both of the scores for the ineffective
group were higher than those for the effective group.

The mean scores of the parents’ state anxiety related to theblood sampling of their children were 42.8 and 41.7 points in
the ineffective and effective groups, respectively. According to
the STAI32), although a score of 42 points or less was judged
as normal and 42 points or more was judged as high, nostatistically significant difference was found on comparing
the two groups.

e. Parent’s prediction of their child’s behavior (Figure 1)

In the comparison of the children’s coping behavior
that was predicted by the parents, between the ineffective
and effective groups, there was a significant difference
both in the Manifest Upset Scale score (P = 0.000) and the
Cooperation Scale score (P = 0.000); the Manifest Upset Scale
and Cooperation Scale scores were higher in the ineffective
group than the effective group.
f. Parent’s anxiety related to the blood sampling of their

Ineffective group Effective group
n(%)
n(%)

3. Factors associated with children’s coping behavior during
blood sampling18

To examine the degree of impact of the factors associatedThis paper was published at “the Japan Society of Nursing Research” Vol.34 No.4 in 2011.

Yearbook on Journal of the Japan Society of Nursing Research 2013

with children’s behavior during blood sampling, a multiple
regression analysis using the stepwise method was
performed. Scores on coping behavior during blood sampling
was the dependent variable and age, past blood sampling
experience, hospitalization experience, the presence orabsence of explanations prior to blood sampling, children’s
behavior up until entering the blood sampling room(based on the Manifest Upset Scale and Cooperation Scalescores), parent’s prediction (the Manifest Upset Scale andCooperation Scale scores), and the parent’s anxiety were theindependent variables (Table 13). As a result, the multiple
correlation coefficient was 0.761, and the adjusted coefficientof determination was 0.569; 56.9% of the coping behavior
during blood sampling were explained by “the parent’s
prediction” (Manifest Upset Scale score).

confusion associated with blood sampling. For preparation,
it is important that it be performed in a way that is suitableto each child’s cognitive ability1). Additionally, there are not
only studies showing an approach as per stages of cognitive
development18), 25) described by Piaget26), 33), but also a study
according to the category for age, such as for 2–5 year olds
and 5–7 year olds. However, in this study, younger children
even in the latter half of early childhood were included in
the ineffective group and were unable to show effective
coping behavior. Taking in account these results, for younger
children, especially 3 to 4-year-old children, it was understoodthat it was necessary to perform preparations with words
chosen according to the cognitive ability of each age and withthe contents featuring specific coping methods so that they
could demonstrate effective coping behavior.

4. Children’s coping behavior up until entering the blood
sampling room, parent’s prediction, and children’s coping
behavior during blood sampling

2. Children’s coping behavior until entering blood sampling room

For the children’s behavior until entering the blood
sampling room, the Manifest Upset Scale and Cooperation
Scale scores were significantly higher in the ineffective
group compared to the effective group. Considering theresults, it can be seen that the children who could not show
coping behavior well during blood sampling expressed
uncooperative and restless behavior before the blood
sampling and before having entered the blood samplingroom. In addition, the risk that the children who showed
uncooperative and restless behavior before entering theblood sampling room might be included in the ineffective
group was 2.9 times higher than the effective group. Given
the above, in the assessment of preparation, it is important toobjectively evaluate the children’s behavior until entering theblood sampling room. For children who show uncooperativeand restless behavior before entering the blood samplingroom, preparation according to each child’s characteristics
and response is thought to be necessary; for example, securesufficient time for getting ready psychologically before blood
sampling and then perform the preparation.

The children’s behavior until entering the blood samplingroom was classified into the ineffective or effective groups,
such as coping behavior during blood sampling (Table
14). This classification was based on consultation with thespecialists in childcare. The scores were calculated based on
the classification of the children’s behavior up until blood
sampling. Summed scores of six or more on the Manifest
Upset Scale and Cooperation Scale were defined as ineffective,
and fewer than six was defined as effective. As a result of thisclassification, of the seven children who showed ineffective
coping behavior before entering the blood sampling room,
four children were in the ineffective group; of the 40 children
who showed effective coping behavior before entering theblood sampling room, 32 children were in the effective group.
The risk ratio that the children, who showed behaviors that
demonstrated that they would not cooperate and calm down
before entering the blood sampling room, could be includedin the ineffective group was 2.9 times higher than the effective
group.
As with the above classification, children’s coping
behavior that was predicted by parents was also classified
into ineffective and effective (Table 15). There were 25
children (53.2%), who were predicted to show ineffective
coping behavior (ineffective prediction), while 22 children(46.8%) were predicted to show effective coping behavior.
Of the children who were predicted to show ineffective
coping behavior by their parents, 13 children belonged to theeffective group. On the other hand, all of the children who
were predicted to show effective coping behavior by theirparents belonged to the effective group.

3. Parent’s prediction

For the parent’s prediction, the Manifest Upset Scale
and Cooperation Scale scores were significantly higher in
the ineffective group compared to the effective group. The
parents of the children in the ineffective group predicted that
their children’s behavior during blood sampling might show
stronger psychological confusion and uncooperative behavior
than the effective group. Furthermore, from the results of themultiple regression analysis, 56.9% of the coping behaviors
during blood sampling were explained by the parent’s
prediction of the Manifest Upset Scale score. In the parent’s
prediction, it is influenced especially by the prediction of
the degree of emotion. Therefore, it can be seen that thechildren’s behavior during blood sampling may be predictedby allowing parents to predict their children’s behavior using
the Manifest Upset Scale score before the blood sampling. In
the parent’s prediction, we could not calculate the risk ratio
for the ineffective group. Of the children who were predicted
to be effective, no child belonged to the ineffective group.
Considering these results, it can be seen that the parents
might predict their child’s behavior precisely. As Lee et al.34)
described, information from the mother would be the mosteffective for prediction of children’s responses to painful

IV. DISCUSSION
1. AgeIn the ineffective group, the children were significantly
younger compared with the effective group, and the results
were similar to previous studies5)–7). Mikami et al.27) reported
that the age of the children as well as their cognitive
development led to cooperation behavior for blood sampling
as well as recovery from psychological confusion. This reportsuggested that preparation involving the cognitive domain
might improve coping skills for pain and psychological
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Yearbook on Journal of the Japan Society of Nursing Research 2013

medical procedures. Takeda6) described that information fromthe mother would be useful to predict each child’s reaction
and behavior towards blood sampling, and to understand its
meaning. Similar results were obtained in this study, whichsuggested that prediction by the parents understanding thecharacteristics of their child well was extremely effective inthe scene that they have experienced.

age, coping behavior until entering the blood sampling room,and the parent’s prediction. It is thought that each child’scharacteristics could be understood and preparations madeaccording to each child’s individual needs. This could beachieved by collecting information prior to the blood sampling
procedure about age, coping behavior until entering the blood
sampling room, and the parent’s prediction. Specifically, foryoung children, children who demonstrated rejecting andrestless behavior until entering the blood sampling room,and children who were predicted to show ineffective coping
behavior during blood sampling by each parent, we thinkthat it is necessary to secure a time to perform preparations
before blood sampling. It is important that the contents ofthe preparations address their individual needs: preparation
include information about effective coping behavior forchildren who show poor cooperation, and distraction andplay for children who show emotionally restless behavior. In
the future, it will be necessary to develop an assessment sheetthat is specifically available, including these related factors,
and to examine the use of the sheet and the implementation ofsuch preparations according to each individual child’s needs.

4. Child’s past blood sampling experiences, hospitalization
experiences, explanations before blood sampling and parent’s
anxietyIn this study, no difference between the ineffective groupand the effective group was found in the child’s past blood
sampling experience, hospitalization experience, presenceor absence of explanations prior to blood sampling, and theparent’s anxiety. Takeda6) reported that past blood sampling
experience was an important factor for children in predicting
and evaluating blood sampling, and that mothers’ anxiety
promoted children’s anxiety and influenced their behavior.
In addition, according to Nishimura et al.7), children, who
had experienced hospitalization and had the opportunity
to prepare psychologically, showed relatively more coping
behavior. The factors indicating no difference in the itemsin this study were seen as follows: the subjects included thechildren who had experienced blood sampling repeatedly
and the children who empirically understood that blood
sampling was always performed when visiting a hospital;
thus, the parents of such children had no major anxiety about
the blood sampling of their child. For explanation prior toblood sampling, on account of the burden of the questionnaire
and the time before blood sampling, we were not able tounderstand the content of the explanation in detail in thisstudy. These were not related in the children who had alreadyexperienced blood sampling and their parents. However,for the children who will undergo a first blood sampling in
the future and the children who have poor blood sampling
experience, it is considered necessary to investigate andexamine the content of such explanations more deeply. For
children’s coping behavior for procedures, no standard of
ineffective coping behavior that has been generalized andstandardized is currently found. We classified the children’s
coping behavior into the two groups based on the score
distribution of coping behavior in this study and analyzed
it. It can be thought that there might be no difference inthese items because of the classification of these scores.
Accordingly, it was thought to be necessary to examine these
items including the score category that would be able to begeneralized in the future.

V. Conclusion

Children, aged 3–6 years, who were undergoing blood
sampling in an outpatient department, were classified into
an ineffective group and an effective group based on thechildren’s coping behavior during blood sampling. The groups
were compared and the related factors were examined. As aresult, the following was found:
1. Compared to the effective group, the children in theineffective group were significantly younger.
2. For children’s behavior until entering the blood samplingroom, the Manifest Upset Scale and Cooperation Scale scores
were significantly higher in the ineffective group than in theeffective group.
3. The parent’s predictions, before blood sampling, for the
Manifest Upset Scale and Cooperation Scale scores weresignificantly higher in the ineffective group than in theeffective group.
4. For effect factors of the children’s behavior during blood
sampling, the parent’s prediction of the Manifest Upset Scalescore before blood sampling was extracted.
5. For children undergoing blood sampling, it is important
to know the age of the children, the children’s behavior until
entering the blood sampling room, and the parent’s prediction
before blood sampling. It was suggested that the assessmentof these data might lead to particular preparations.
ACKNOWLEDGMENTS

5. Limitations of the study and future tasks

The authors are grateful to those subjects who participatedin this study. We would also like to sincerely thank thepediatric doctors and nurses at the university hospital for
their kind cooperation in this study. This study was supported
by a Grant-in-Aid for Young Scientific Research (Start up),2008-2009, No. 20890026, from the Japan Society for the
Promotion of Science. We presented our research results
at the 36th Annual Meeting of the Japan Society of Nursing
Research in Okayama, 2010.

Considering that the survey was performed in a university
hospital, that all of the subjects had experienced blood
sampling, and that some subjects repeatedly underwent blood
sampling, we cannot say that the results of this study apply tochildren who will experience blood sampling for the first timeand children who have poor blood sampling experiences. This
study had a small sample size and, therefore, it is necessary toincrease the number of the subjects to increase the reliability
and validity in the future.
This study suggested that the factors related to ineffective
coping behavior during blood sampling of children included
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Yearbook on Journal of the Japan Society of Nursing Research 2013

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