Using the Theory of Unpleasant Symptoms to Ascertain ...



Using the Theory of Unpleasant Symptoms to Ascertain Evidence Based Nursing Interventions to Decrease the Pain, Anxiety and Fear of Immunizations

Bonnie Sawyer-Banda

University of Central Florida

Abstract

The pain of childhood immunizations causes anxiety and distress to children, their parents and the health care providers that must administer them. Some of those children become “needle phobic” adults because of painful immunization experiences. Subsequently, they avoid seeking medical and dental care because of this fear. Many parents do not get their children immunized because of the pain the child must endure. This trend can cause a public health nightmare when outbreaks of vaccine preventable illnesses occur. Using the theory of unpleasant symptoms, this paper will explore evidence based interventions that can assist nurses and other health care providers in finding inexpensive and quick methods to decrease pain, fear and anxiety when administering immunizations and performing other needle procedures in infants, children, adolescents and adult populations.

Background

Immunization development and administration has saved innumerable lives and prevented untold suffering around the world. Unfortunately, most vaccines require a shot or needle puncture to be introduced into the body. According to the World Health Organization (WHO), about 16 billion injections are given each year in developing countries. Five percent (5%) or 800 million of those injections are given to children as immunizations (2000). The state of Florida follows the Center for Disease Control (CDC) guidelines for immunization requirements. According to these guidelines, a child will receive at least 21 injections by the time he/she reaches the age of 5 years.  If the parent chooses to have the child immunized against the seasonal flu, add 6 more injections to the series (2011).

The pain anticipated by children who are going to receive immunizations causes distress and anxiety for the child as well as for the parent of the child and the health care provider. The fear of needle procedures is so severe in 10% of the population that it is classified as “needle phobia” (Taddio, 2008).  The cognitive beginning of this phobia can be traced back to childhood immunizations for many of those afflicted (Gaskell, Binns, Heyhoe, and Jackson, 2005). The fear of needles can lead to the avoidance of medical care, dental procedures, blood donations, poor immunization compliance and poor management of diabetes (Taddio, 2008). Many children are so preoccupied with the possibility of receiving an injection at the clinic, that health teaching and assessment opportunities are limited (Schechter, Zempsky, Cohen, McGrath, McMurty and Bright, 2007). The fear of injections may also effectuate a fear of doctors (Brady, Avner and Khine, 2011).

Neonates feel more pain than adults from the same stimulus because their ability to dampen incoming pain signals is immature (Taddio,2008). According to Tansky and Lindberg, infants do perceive and remember pain and have an increased response to painful procedures later in life. They are unable to distract themselves or rub a painful area to stimulate non-nociceptive touch fibers that would block the sensation of pain (2010).

Many parents are overcome with feelings of guilt, helplessness and duplicity for allowing this fearful procedure to happen to their child (Gaskell et al., 2005). The consequence of these parental reactions may be seen in their delaying immunizations for their children (Taddio, 2008). Meyerhoff, Weniger and Jacobs developed a “willingness to pay” study to find out how much parents were willing to pay to avoid their child receiving immunizations. Parents were willing to pay an average of $57 to avoid 2 injections and $80 to avoid 3 or 4 injections (2011). This study attests to the concern that parents have regarding immunization pain in their children.

Studies for physicians are conflicting. Some physicians have concerns about the pain of immunizations and the administration of multiple injections at a visit (Woodin, Lance, Humiston, Carges, Schaffer and Szilagyi,1995). However, in a study by French, Painter and Coury, physicians did not believe the pain of immunizations was severe enough to warrant intervention (1994).

Anxiety over the fear of pain from needle procedures is a nursing problem for several reasons. Nagy states that nurses inflict more pain than other health care providers (1999). According to Ives and Melrose, nurses experience stress when they must administer immunizations to children that resist needle injections (2010). Additionally, nurses find it difficult to inflict pain on young patients (Gaskell et al., 2005). Studies to see how nurses deal with the stress of inflicting painful procedures show that the coping mechanism used most often is to distance themselves from the patient. This emotional detachment can decrease the nurses’ sensitivity to patients and deny the nurses’ satisfaction of patient involvement (Nagy, 1999). Furthermore, Ives and Melrose found that administering injections to needle resistant children creates an ethical and moral dilemma for nurses. Resources to help nurses cope with this are inconsistent (2010).

Another reason that the fear of needle procedures is a nursing problem is that many parents delay immunizations because of the pain experienced by their child.  Not only is this a nursing problem, but it is a public health problem as well. The chances of vaccine preventable disease outbreaks increase when there is an overall reduction of community immunity (Luthy, Beckstrand and Peterson 2009; Taddio, Manley, Potash, Ipp, Sgro and Shah 2008).

Problem statement

The fear of injection pain causes anxiety and distress in patients, parents and health care providers.

Significance

 

The significance of fear of needle procedures is multifaceted. The emotional toll can be seen in many children that are so consumed by the fear of injections that when visiting the clinic or physician’s office, their only thought is “Am I going to receive a shot today?” This fear dominates the visit and prevents the health care provider from building a rapport with the child and addressing other health maintenance issues (Schechter et al., 2007)

Another example of the emotional toll is demonstrated where ten percent (10%) of the population is affected by the recently defined medical condition of needle phobia. Fifty-two percent (52%) of patients with needle phobia report that they can trace the fear to a negative experience at a doctor’s or dentist’s office. These people typically avoid medical and dental care which can cause an impediment in the health care system (Hamilton, 1995).

The monetary cost of decreased immunization levels in the community can be significant also. In 2008, a measles outbreak occurred in San Diego, California among a cluster of intentionally under-vaccinated children. This particular case involved an unvaccinated 7 year old boy returning from Switzerland where he had contracted measles. By the time the outbreak was under control, 12 patients had contracted measles. County and state personnel spent 1,745 person hours on investigation and containment efforts. The total cost to the public sector was $176,980    (Sugarman, Barskey, Delea, Ortega-Sanchez, Bi, Ralston, Rota, Waters-Montijo and LeBaron, 2010).

In 2004, a college student from Iowa returned from India with measles that eventually infected 2 other people. A study by Dayan, Ortega-Sanchez, LeBaron and Quinlisk and the Iowa Measles Response Team demonstrated that this outbreak cost the Iowa public health infrastructure $142,452 and 2,525 hours of personnel time to prevent the spread of the disease. It could cost millions of dollars to contain a community-wide outbreak (2005). In addition to the major cost to public health agencies, rising rates of under vaccination can undermine measles elimination (Sugarman, et al., 2010).

Additionally, California is currently experiencing an epidemic of pertussis. From January 1, 2010 through December 31, 2010, there have been 8,627 confirmed cases with 10 deaths of infants (California Department of Public Health [CDPH], 2011). No one can put a price tag on the pain and heart ache of the parents of these infants. Infants are protected from pertussis by herd immunity; that is, their protection is dependent on successful immunization of those that come into contact with them. Outbreaks in middle and high school can occur when vaccine immunity wanes (CDC, 2011). Intentional under vaccination can only compound the problem.

Meyerhoff et al. state that the deferral of immunizations by parents to avoid pain and emotional distress to the child leads to additional costs and reduced immunoprotection which can lead to increased disease burden. In Meyerhoff’s “willingness to pay” study, the estimated economic value of pain and emotional distress for infants aged 1 ½ to 7 months is $317 million for the US birth age bracket of 3.9 million children. (2011).

Lastly, each year, over 50 million people travel to developing countries where immunizations are recommended. Low immunization rates amongst travelers have been associated with the spread of lethal vaccine preventable diseases internationally such as typhoid and meningococcal disease, just to name a couple (Nir, Paz, Sabo and Potasman, 2003).

Specific Aims

            By applying the theory of unpleasant symptoms, this paper will offer evidence based interventions to decrease the anxiety, fear and pain of administering injections. This could conceivably reduce the number of patients that develop needle phobia and decrease parents’ and patient’s fear which will subsequently increase immunization rates of children and adults.

Theory of unpleasant symptoms

            In 1995, Lenz, Suppe, Gift, Pugh and Milligan collaborated to develop the theory of unpleasant symptoms (TOUS). The purpose of this middle range theory was to design a framework that would help guide research in understanding how to prevent, reduce and make more bearable, those unpleasant symptoms and the negative effects that they potentially can bring about. The three major concepts of the theory are the symptoms, the influencing factors and the performance consequences (Lenz and Pugh, 2008). The theory proposed that the manifestations of an unpleasant symptom were influenced by physiological, psychological and situational factors. The duration, intensity, quality, and distress could vary for each symptom. In their seminal work, Lenz, Suppe, Gift, Pugh and Milligan state that “the theory of unpleasant symptoms can be used to identify preventive interventions to modify some of the factors that produce symptoms or to develop innovative treatments that can be applied across symptoms when they occur.” (1995, p.11).

            In 1997, Lenz, Pugh, Milligan, Gift and Suppe revised the TOUS to demonstrate how the symptoms can be multidimensional, complex and interactive. The original theory model showed the influencing factors flowing in a unidirectional manner to the symptom experience and then to the performance or consequence. The updated version included a visual diagram of how “the performance outcomes can feed back to influence the symptom experience itself.” (Lenz and Pugh, 2008, p. 163).  The revised model allows the patient to experience multiple symptoms simultaneously and those symptoms may exacerbate effects on performance. This symptom interaction allows for a multiplicative phenomenon when more than one symptom is experienced simultaneously (Lenz et al., 1997).

            The TOUS advocates that the dimensions of a symptom are intensity, timing, quality and distress. Each of the dimensions is separate but related and as such, each symptom can be measured separately or in conjunction with other symptoms (Lenz et al., 1997).

            Tyler and Pugh used the TOUS to demonstrate how the physiologic, psychologic and situational factors influenced the symptoms of nausea, fatigue and bloating of a patient that had undergone weight loss surgery. The severity in which the patient felt the unpleasant symptoms drove the core concepts. After the psychological and situational factors were addressed, the physiological symptoms began to improve (2009).

In another study using the TOUS, the symptoms of pain, fatigue, anxiety and depression were studied in low-income breast feeding mothers. The authors were able to show that when the physiologic, psychologic and situational factors were addressed, the symptoms decreased and the mothers were able to breastfeed for longer periods of time (Pugh, Milligan and Brown, 2001).

Neither of the preceding studies addresses the interventions that could decrease pain and anxiety of needle procedures specifically. However, they do illustrate that using the TOUS allows positive outcomes to occur when the symptoms of their studies were investigated using the physiologic, psychologic and situational factors.                  

Application of the theory to the clinical problem

           The TOUS can be used as a guide for looking at the symptoms of anxiety, fear and pain from needle procedures common in most patients as well as precipitating factors that influence the symptoms. We can also examine the psychological, physiological and situational factors that can decrease or reduce the effects of the pain perception.

Physiological factors of needle procedures would be the actual act of entry of the needle into the skin and the introduction of the medication through the needle. Those factors would also include any interventions that can alter the “physical” awareness of pain.

Psychological factors would be demonstrated in the fear and anxiety that is brought on by needle procedures. These factors would be those fears and anxieties that the patient brings with them from experiences of previous procedures as well psychological damage that could be inflicted at the current procedure. Patients that are anxious and fearful may perceive their procedure to be highly stressful and are inclined to experience symptoms that are more severe than patients that experience less stress (Pugh and Milligan, 1995). Interventions that fall into the psychological realm will be reviewed.

Situational factors are those aspects of the procedure that are affected by the social and physical environment. In this situation, relevant social support should be a consideration as well as the potential physical environment. 

According to the TOUS, the goals of the nursing interventions are to decrease the intensity, quality, timing and distress of the symptoms of pain, fear and anxiety that is experienced during needle procedures. All of these characteristics are quantifiable. Examples of this would be where the patient experiencing an injection could quantify the intensity of the pain as to severity or amount of pain as well as the quality of the pain as to what the pain feels like. The time dimension could be quantified by measuring the time of the duration of pain from the injection, or the amount of time anxious feelings are experienced. The distress dimension would be a measure of how much a patient is bothered by receiving an injection.

A review of the literature shows many ways to decrease the pain, anxiety and fear of needle procedures. In order to present this information is a logical format, the interventions will be presented according to the TOUS factor that best describes it’s effect on the patient. However, human elements are difficult to confine into a single classification, so some interventions will fall into more than one category.

Physiological 

Physiological factors would include injection techniques and physical interventions. These approaches are commendable choices because they add little or no cost or time to the procedure and are within the scope of nursing interventions.

In order to understand how physiological interventions work to decrease the perception of pain, we must understand the pathophysiology of pain. Nociceptors are unspecialized, sensory nerve endings found in the skin, viscera, muscles, joints and arteries. They respond to chemical, mechanical and thermal stimuli. The relative sensitively to pain is determined by the distribution and nature of the nociceptors. There are two types of nociceptor nerve fibers; the large A delta fibers and the small C fibers (McCance and Huether, 2010). Melzack and Wall discuss the evolution of the gate control theory of pain and explain that pain impulses are transmitted to the brain via the spinal cord by the large A delta fibers and the small C fibers. The fibers conducting both noxious and innocuous stimuli terminate in the substantia gelatinosa located in the dorsal horn of the spinal cord. The cells in the substantia gelatinosa act as a “gate”, regulating the impulses to the central nervous system. When the large A fibers are stimulated, this causes the substantia gelatinosa to “close the pain gate” which will decrease the perception of pain. This theory helps explain how acupuncture works as well as being instrumental in the development of transcutaneous electrical nerve stimulation (TENS) units (Melzack,1996 and Wall, 1996). Therefore, if touch, temperature or vibratory stimuli through the A fibers can exceed the painful nociceptive input, then the gate closes and the pain impulse is stopped or lessened and cannot travel to the brain (Davis, 1993).

In a review of physiological interventions, let us first look at those that deal with the actual technique of the procedure. The length of the needle used has shown that longer needles cause less pain to be perceived. Recommendations are 5/8 inch needle for newborns and infants, 1-inch needles for toddlers to adolescents and 1.5 inch needles for large adolescents and adults. The optimal gauge for the needles has been shown to be 23-25 (Taddio, 2008). It has also been shown that rapid injection without aspiration causes less pain and reduces the percentage of infants that cry at the time of immunization (Taddio, 2009). Although this study was done on infants, the findings should be transferable to adults since the procedure and the processing of pain is similar (Hogan, Kikuta and Taddio, 2010). It has also been shown that when administering more than one vaccine, pain scores are significantly lower when administering the least painful vaccine first and the most painful vaccine last (Ipp, Parkin, Lear, Goldblach and Taddio, 2009). Finally, using the Z-track method of administration is thought to decrease pain by decreasing irritation and leakage of medication into the subcutaneous tissue. This technique involves pulling the skin two or three centimeters to the side prior to inserting the needle, then releasing the skin after withdrawing the needle. This creates a disjointed pathway which locks the medication in place (Floyd and Meyer, 2007). 

 In a study by Abbott and Fowler-Kerry, it was shown that 4 to 5½ year old children who received a refrigerant topical anesthetic spray prior to injection reported significantly less pain than those children that received no spray.  It is interesting to note that there was no significant difference between those children receiving the refrigerant topical spray and a placebo water spray. The fact that placebo spray was as effective as the refrigerant spray speaks to the cognitive development of the children and the effects of suggestion (1995). In another study, an ice bag was placed on the skin for three minutes prior to the needle procedure in 6 to 12 year-olds. This procedure was shown to be effective in relieving pain (Movahedi, Rostami, Salsali, Keikhaee and Moradi, 2006).

In studies using vibrators, research indicated that there was significantly less  pain using a combination of vibration and cold in needle procedures in 4 to 18 year-olds (Baxter, Cohen, and von Baeyer, 2011) and adults (Baxter, Leong and Mathew, 2009). In dermatologic needle procedures, it was shown that vibration anesthesia does not eliminate pain completely in adults, but injections are more tolerable (Smith, Comite, Balasubramanian, Carver and Liu, 2004). Nanitsos, Vartuli, Forte, Dennison and Peck found that 73% of adult subjects experienced less injection pain when vibrator stimulus was applied (2009). Berberich and Landman found that using verbal suggestions of diminished sensation and a vibrator on the contralateral arm provided distraction and significant reduction in pain and discomfort (2009).  

In a study by Sparks, it was shown that cutaneous stimulation such as stroking the skin near the injection site before and during the injection decreased pain perception in 4 through 6 year-olds (2001). In another study, it was shown that ten seconds of direct pressure prior to the intramuscular injection decreased the perception of pain in adults (Barnhill, Holbert, Jackson, and Erickson, 1997).

The pain of immunizations in 2 and 4-month olds has been markedly decreased by the administration of 2 ml. of a 24% oral sucrose solution two minutes prior to the procedure. Unfortunately, there is insufficient evidence for this procedure beyond the neonatal period (Hatfield, Gusic, Dyer, and Polomano, 2008).

Psychological

The psychological component of the TOUS encompasses the patient’s mental state, mood, pre-conceived reaction and knowledge of the procedure. Patients that are anxious are more likely to experience more fear and pain than those that experience less stress (Lenz, et al., 1997). The gate control theory also addresses psychological factors such as past experiences and attention (Melzack and Wall, 1965). Distraction techniques work by competing with the attention needed to process the physical, emotional, and evaluative components of pain perception (Cassidy, Reid, McGrath, Finley, Smith, Morley, Szudek and Morton, 2002).

Taste, suckling and skin-to-skin contact are three components that are comforting and analgesic to infants. It has been shown that breastfeeding is effective when used as a distraction by decreasing the pain and discomfort of immunizations. It is theorized that the 3 components of breastfeeding “close the gate” by using distraction to stimulate the non-nociceptive nerve fibers (Tansky and Lindberg, 2010). In another study by Abdel Razek and  El-Dein, crying was reduced 83% in babies that were breast fed during their immunizations (2009).

Skin-to-skin contact or “kangaroo care” alone has been shown to decrease pain perception. Babies that are wearing only a diaper, and are held against the chest of their mother experience less pain (Kashaninia, Sajedi, Rahgozar, and Noghabi, 2008). A similar behavior is belly-to-belly, where a clothed parent holds a clothed infant close to their body and facing the parent. This activity was shown to reduce crying and infant distress rapidly (Blount, Devine, Cheng, Simons and Hayutin, 2008).

 Children feel less fear when they are sitting up as opposed to lying down. Immobilization can increase distress in children and cause psychological trauma (Taddio et al., 2009). In order to avoid restraining or holding a child down, it is recommended that a “comfort restraint” be utilized. It helps to steady and control the limb without overpowering the child. The child is held in the parent’s lap with the child’s legs between the parent’s legs. The parent’s arms embrace the child during the procedure (California Department of Health Services., 2001).

Another distraction technique that has been shown to be successful is the “cough trick”. The patient gives a “warm-up” cough followed by another cough that coincides with the needle stick. 76% of the children in the study felt that the “cough trick” helped with their injection pain (Wallace, Allen, Lacroix, and Pitner, 2010). Ahmed, Ahmed, Imran and Ahmed attribute this phenomenon to an increase in blood pressure at the time of the cough which lowers pain perception, as well as providing a distraction for the patient (2004).

There are several studies using breathing techniques for distraction. A simple diversion technique for children with mild to moderate levels of stress is party blowers. In addition to being a distraction, it has been theorized that when engaging in play behavior with toys, the child may not be aware of the brief shot pain (Bowen and Danmeyer, 1999). In another study, it was shown that when a child was told to take a deep breath and blow and blow and blow (blow the pain away) until the experimenter told them to stop, the child exhibited significantly fewer pain behaviors (French, Painter, and Coury, 1994). Lastly, in a study by Sparks, bubble blowing was shown to significantly reduce pain perception in children aged 4 to 6 years old (2001).

  In a study to determine the effectiveness of distraction on infants, it was found that prompting parents to use their usual coping strategies to help lessen infants’ distress helped the infant recover more quickly from the pain experienced by immunizations than did the distraction technique (Cramer-Berness and Friedman, 2005). Cassidy, et al. recommends distraction analgesia be used in combination with other interventions (2002).

Finally, children that were informed of the importance of the immunization and preparing them for the painful intervention experienced less pain than non-informed children (Boivin, Poupon-Lemarquis, Iraqi, Fay, Schmitt and Rossignol, 2008). According to Gaskell, Binns, Heyhoe and Jackson, “young people should be given the opportunity to understand the procedure and to be empowered to make choices about their treatment.” (2005, p.26).

Situational

Situational factors that influence the outcomes of the TOUS are elements of the social and physical environment that might effect the patient’s experience. In the immunization situation, potentially relevant considerations are social and emotional support of parents, siblings and health care providers. Other environmental variables that might influence the outcomes are noise and light (Lenz, et al., 1997).

According to Gaskell et al., the immunization session needs to take place in a “calming and child-friendly environment” (2005, p. 26). Patient comfort can be enhanced by manipulating the surrounding environment by decreasing noise and increasing ambiance (Kolcaba, 2001). Taddio et al. suggest a comfortable room free of distress inducing acoustic or visual stimuli. Private exam rooms in offices accomplish this and in school based clinics, a room separated from peers should be instituted in order to avoid and minimize stress. Anticipatory fear and a chaotic environment have been shown to increase the pain and distress during the procedure (2009).

When children were coached to watch cartoons during the procedure, their coping behaviors increased and pain perception decreased.  Additionally, it was shown in this study that nurses and parents showed less distress promoting behaviors and more coping promoting behaviors while coaching the child (Cohen, Blount and Panopoulus, 1997).

Parental anxiety has a direct effect on the child’s stress and coping abilities. It has been shown that enlisting the parent’s assistance in providing distraction techniques to the child indirectly helps to lower the stress level of the parent (Cohen et al., 1997). When the parents are calm and use strategies to help the child cope such as distraction, non-procedural talk and coaching, the child’s pain is reduced. Conversely, when parents reassure to excess, criticize or apologize, it transmits parental anxiety to the child by focusing the child’s attention to the procedure. The interaction between the nurse, child and parent is crucial and cues both parent and child how the immunization process should be conducted (Plumridge, Goodyear-Smith and Ross, 2009, Taddio, et al., 2009).

In a study of “small-talk’ or reassurance and comfort talk, it was shown that talking baby-talk to the child by the nurse and parent sends the message that there is nothing to be worried about (Plumridge et al., 2009). In another study, non-procedural talk during the procedure was shown to result in a reduction of stress due to distraction or attentional redirection (Blount et al., 2008). 

Weisenberg, Tepper and Schwarzwald found that humor used as distraction significantly increased pain tolerance. It was reasoned that catecholamine levels were increased after mirth which lead to an increase in endorphins thereby decreasing pain (1995). In their study, humorous films were used, however, in the immunization setting, perhaps jokes could be told.

Applying knowledge to practice

Current health care agencies require best practices to be evidence based. However, in the case of pain management when administering immunizations, it is not the norm. One of the significant barriers to pain management is lack of awareness about effective interventions. There has been significant research on strategies to employ to decrease pain, fear and anxiety but little research on ways to disseminate that evidence and information into the practice arena. Educational opportunities for vaccinators and parents are sorely needed in order that they are armed with the knowledge needed for pain reduction strategies for children experiencing needle procedures (Taddio, Ipp and Shah, 2009).

The interventions investigated do not have an “all or none effect”. Most outcomes in the studies are described as “decreased pain perception” rather than “no pain perceived”. In order to have more anesthetic effect, it is recommended that the interventions be used concomitantly (Taddio, et al., 2009). The “multifaceted” approach would enable the nurse to choose several interventions simultaneously thereby increasing the pain reduction effect. Lastly, it is important that the nurse choose age appropriate interventions for the patient.

Summary and Conclusions

Immunizations are a necessary part of our lives.  The fact that these very important immunization procedures can keep members of our society healthy is often times overshadowed by the fear, anxiety and pain that is experienced by the patient. The pain experienced with needle procedures for immunizations is brief, but very real. The anxiety and fear regarding the injections is often long lived (Brady et al., 2011). This fear can lead to needle phobia and avoidance of needle procedures. There is an emotional price to pay for patients, their parents and the nurses that perform the procedures. More than half of the 10 % of the population that developed needle phobia can trace the origin of that phobia to childhood needle procedures.   This avoidance can also lead to lower immunization rates and subsequently outbreaks of vaccine preventable illnesses.  Disease outbreaks can cost our health care system thousands of dollars monetarily. The psychological cost to the needle phobic patient is immeasurable. Using the theory of unpleasant symptoms and evidence based research, the influencing factors that relate to the physiological, psychological and situational interventions have been explored. Using a combination of these interventions, the elements of duration, intensity, quality, and distress can be decreased in the symptoms of pain, fear and anxiety. When these symptoms have been lessened, there should be positive performance consequences with outcomes of higher immunization rates and fewer cases of needle phobia. Patients expect nursing care that is competent. Using available interventions to make the patient more comfortable increases the perception of competency thereby achieving better results for the patient and the agency or institution. This leads to enhanced patient satisfaction and positive financial viability of the health care organization (Kolcaba, 2001). If interventions for pain management are employed with every injection, patients and parents will learn how to manage pain, remain calm during needle procedures and develop trusting relationships with nurses and health care providers (Taddio, et al., 2009).

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