Pain is a multidimensional and subjective experience that includes emotional, cognitive, behavioral, developmental, spiritual and cultural components [1], [2]. It is one of the undesired and frequent experiences in children due to illness, trauma, or various medical interventions [3], [4], [5]. The most performed painful procedures in the hospital are blood collection, vaccination, peripheral venous access process, and intramuscular applications [6], [7]. Pain experienced during medical procedures often causes fear in children. Reducing pain and fear during painful medical procedures in children is important since mismanagement of pain causes the child and parent to feel anxious, which can have negative long-term consequences and greatly affect adherence to care [8], [9]. In addition, if pain is not adequately managed, it adversely affects quality of life and can bring a significant economic cost to society [10], [11]. It is recommended to provide optimal pain control to prevent future undesirable effects of painful procedures [12], [13]. The management of the fear of medical procedures may provide short- and long-term benefits by increasing adherence to medical care and reducing avoidance behavior [14]. Therefore, in addition to pain management, interventions should be made to reduce fear in children [15].

Numerous pharmacological and non-pharmacological methods have been adopted to reduce pain and fear during medical procedures [3]. Non-pharmacological methods used in children can be classified into three groups as supportive, cognitive-behavioral, and physical [16], [17]. Supportive methods include watching videos, reading books, and having parents with their children during painful procedures [5], [18]. Cognitive-behavioral methods include methods such as relaxation, distraction, and hypnosis [5]. Physical methods include positive touch, positioning, massage, and application of heat and cold [19].

Methods of distraction are used to reduce sensitivity to pain and increase pain tolerance by diverting one's attention from the stimulus causing pain [20]. These methods are classified as active or passive distraction methods. In active distraction, children are encouraged to participate in an activity during the painful procedure. Some of the most commonly used active distraction methods are interactive toys, guided imagery and relaxation, controlled breathing, electronic games, virtual reality, blowing up balloons, and squeezing a soft ball [18], [19]. In passive distraction, the child remains calm and quiet and is given a distracting stimulus. Passive distraction includes methods such as listening to music, watching television, movies or videos [21]. It has been revealed in many randomized controlled studies that pain experienced by children during invasive procedures can be effectively reduced by using distraction methods [22], [23], [24].

During short-term invasive procedures such as phlebotomy, soap bubble blowing and ball squeezing methods seem to reduce children's attention to pain by competing with sensory pain stimuli [18], [25]. It has been reported in the literature that ball squeezing method [24], [25], [26] and bubble blowing method [27], [28], [29], [30] are effective in coping with pain and fear in various invasive procedures. Although there are separate studies on the application of ball squeezing and soap bubble blowing methods, there are limited studies in which two active attention-grabbing methods are discussed together and compared. Limited randomized controlled studies have demonstrated the superiority of one method over the other, which are both active attention-grabbing methods and used in reducing pain and fear during the phlebotomy procedure. In this study, we aimed to examine the effects of ball squeezing and soap bubble blowing on pain and fear experienced by children aged 6–12 years during phlebotomy. It is believed that this randomized controlled and experimental study will contribute to the literature and the nurses in the field.

Study hypotheses.

Hypothesis 1. The methods of ball squeezing and soap bubble blowing used during phlebotomy reduce pain in children.

Hypothesis 2. The methods of ball squeezing and soap bubble blowing used during phlebotomy reduce fear in children.