ABSTRACT
Background
Nebulizer therapy frequently provokes fear and anxiety in young children, reducing treatment compliance. Although therapeutic play reduces procedural distress in various settings, its use during pediatric emergency nebulization has not been sufficiently investigated.
Methods
This pretest–posttest control group study allocated 102 children (5–8 years) to intervention (n = 51) or control (n = 51). The intervention group received 10–15 min of therapeutic play (toy, mask, stickers) before nebulization; controls received routine care. Outcomes were fear (Children's Fear Scale), anxiety (Children's State Anxiety Scale), and treatment compliance (Pediatric Nebulizer Therapy Follow‐up Questionnaire). Data were analyzed using independent samples t‐tests, Mann–Whitney U tests, and chi‐square tests; effect sizes were calculated with Cohen's d.
Results
The therapeutic play group showed significantly lower fear (parent: p < 0.001, d = 0.97; child: p < 0.001, d = 0.91) and higher treatment compliance (p < 0.001) than controls. Parent‐reported anxiety was lower (p = 0.005, d = 0.58); child‐reported anxiety did not differ significantly.
Conclusions
A brief therapeutic play session before emergency nebulization significantly reduces fear and improves treatment compliance. This low‐cost intervention should be integrated into pediatric emergency care.
Keywords: anxiety, emergency medical services, fear, nebulizers, play therapy
1. Introduction
Emergency department visits are a source of intense psychological stress beyond the physical problem that is being addressed, especially in the case of small children [1]. Children perceive this noisy, unfamiliar, and cold setting to be an uncontrollable threat, heightening feelings of anxiety and potentially laying the groundwork for a future tendency to avoid health services altogether [2, 3, 4]. Under the circumstances, there is a need to emphasize the importance of not only improving medical treatment approaches in the hospital setting, but of ensuring that child‐friendly arrangements that include psychosocial strategies such as using distraction techniques and communication skills are adopted in an integrated model of service [5].
Respiratory tract infections are one of the most common reasons for presenting at the pediatric emergency department. Although nebulizer therapy is the most effective pharmacological method for this population, devices making loud noises, face masks, and the unfamiliar environment reinforce the child's perception of threat, which may lead to anxiety [6]. The ensuing fear can result in the rejection of the treatment and lead to adverse outcomes [7]. Particularly in small children, behaviors such as crying, resistance, and rejection of the mask are common, making compliance with treatment difficult [7, 8]. It is reported in the literature that only 38.9% of children complete their inhalation therapy [9]. While factors such as the type of device used, adaptation to the mask, and the duration of the therapy can affect the intensity of the child's reaction [10, 11], there is a need for psychosocial approaches in addition to pharmacological interventions.
An effective nursing intervention that can address this need is therapeutic play. Therapeutic play aims to ensure not only children's psychological adaptation to the therapy but also improves cooperation by helping children make sense out of the medical procedure, reinforces their feelings of control over the situation, and provides the opportunity for feelings to be expressed [12]. Piaget and Vygotsky and other theorists laid the groundwork for this approach, which can be applied in various formats [13] appropriate to the child's developmental stage in the form of medical toys (make‐believe nebulizers, masks), role‐playing or story‐telling, all aimed at strengthening the sense of trust between nurse and child while encouraging the participation of the family [14].
The literature provides evidence of the effectiveness of therapeutic play in reducing anxiety and fear in the pediatric population.
Studies conducted prior to surgery, during chemotherapy or following liver transplantation show that this practice achieves significant improvement in a child's emotional status and increases behavioral cooperation [2, 15, 16, 17]. In the context of the emergency department, children who are introduced to therapeutic play with make‐believe devices have been shown to display significantly lower levels of anxiety and fear [18]. Similarly, it is reported that playing with medical toys helps the child to perceive medical equipment as less threatening [19]. All these findings indicate that therapeutic play can be a valuable psychosocial intervention in stressful settings such as the emergency department.
The purpose of this study was to assess the effect of therapeutic play on the fear and anxiety levels of children and treatment compliance receiving nebulizer therapy in the emergency department.
2. Methods
2.1. Study Design
The quasi‐experimental study, with pre‐ and posttest and controls, was carried out in the pediatric emergency department of a state hospital in western Turkey over the period March 2022–October 2022.
2.2. Study Population and Sample
The study population consisted of children of the ages 5–8 who were receiving nebulizer therapy in the pediatric emergency department of the hospital during the time indicated. A convenience sampling method was used to recruit participants who met the inclusion criteria. The sample size was calculated with G*Power 3.1 based on a one‐tailed t‐test for two independent groups. Although the effect size reported in the reference study was large (Cohen's d = 1.47), a more conservative approach was adopted because this value might indicate a smaller sample size than necessary. Therefore, a medium effect size according to Cohen's classification was used (d = 0.50). Assuming α = 0.05, power = 0.80, and equal group distribution, the minimum total sample size was calculated as 102 [18]. A total of at least 51 participants for each group was calculated (n = 102). To prevent the children from influencing one another, data was collected first from the controls and then from the study group. The age range of 5–8 years was selected because the assessment tools used in this study are validated for children aged 4–10 years, and this range aligns with previous therapeutic play studies in nebulizer therapy [18]. Inclusion criteria were children aged 5–8 years, about to receive nebulizer therapy, having a literate parent, presenting to the emergency department with acute respiratory symptoms (e.g., wheezing, cough, tachypnea, or increased work of breathing), and having an oxygen saturation of ≥ 90% on room air. Exclusion criteria consisted of the child having a physical or cognitive disability, experiencing a serious respiratory problem (defined as oxygen saturation below 90% on room air), having a life‐threatening condition (requiring intubation), and requiring more than one session of nebulizer therapy. Additionally, the child's refusal to participate in therapeutic play and submission of an incomplete data form were also among the exclusion criteria. Each participant was counted only once for the primary reason for exclusion. If a participant met multiple criteria, only the first applicable reason was considered. Thus, the study sample consisted of children aged 5–8 years with a literate parent, who had mild to moderate respiratory distress, and who received a single nebulizer session as part of their acute management. Figure 1 presents the participant flow diagram.
FIGURE 1.
Participant flow diagram.
2.3. Data Collection Instruments
2.3.1. Descriptive Data Questionnaire
This questionnaire contains sociodemographic characteristics of the child and parents and 13 questions on whether the child received preschool education, any admissions to the hospital, applications to the emergency department, and the status of receiving nebulizer therapy. The information was collected from the parents face‐to‐face.
2.3.2. Children's State Anxiety (CSA)
This scale was developed by Ersig et al. [20] and adapted to Turkish by Gerçeker et al. [21]. The CSA is a measure resembling a thermometer that is represented by a lightbulb with horizontal lines going upward at intervals. The children are told, “Imagine that all of your worries and tensions will be reflected in the lightbulb on this thermometer or in the space below,” or “If you are a little worried or tense, your feelings may make the thermometer rise up a little bit. If you are very, very worried or tense, your feelings may go all the way up. Put a mark at the point that shows how worried or tense you feel.” To measure the child's anxiety on the CSA, the children are asked to mark their feelings “at this moment.” In children aged 4–10, scores vary between 0–10; the higher the score, the higher the level of anxiety.
2.3.3. Children's Fear Scale (CFS)
This scale, developed by McMurty et al. [22], was adapted to Turkish by Gerçeker et al. [21]. The range of responses on the CFS is expressed in the form of five face drawings that represent feelings from neutral (0 = no anxiety) to a fearful face (4 = severe anxiety). The scale can be used for children, ages 5–10, prior to, during, and after the procedure [21, 22]. Scores vary between 0 and 4; the higher scores represent increased fear. The content validity index for the scale was 0.89.
2.3.4. Child Nebulizer Therapy Follow‐Up Questionnaire
This questionnaire was created by Kanık et al. on the basis of the European Respiratory Society Guidelines, the instructions for the nebulizer device and the medicine to be used, and the current literature [23, 24, 25, 26]. The form describes in a total of six steps how to use the nebulizer: “Keep the medicine cup upright until the nebulizer therapy is completed; put the mask on over the mouth and nose so that no medicine can escape; sit in an upright position; don't cry during the procedure; breathe at a normal rate and depth; the procedure should take 5–10 min.” Assessments are made by awarding one point for each correctly performed step; the complete assessment is based on 6 points. The higher the score, the better the level of compliance.
2.4. Data Collection
The researcher invited the parents who met the inclusion criteria. Those who agreed to participate were asked to provide a written consent form; verbal consent was received from the children. The independent variable in this study was therapeutic play; the dependent variables were fear, anxiety, and treatment compliance. The CFS and CSA forms were filled out and received from the children and their parents prior to the nebulizer therapy. Once the pretest was completed, the children in the intervention groups engaged in therapeutic play for 10–15 min prior to the nebulizer therapy. The therapeutic play took place as described below.
The children were shown three different toys that we thought could appeal to both girls and boys (Fluffy Teddy, Maya the Bee, and Momo the Rabbit) and asked to choose one. They were then introduced to the equipment that would be used in the nebulizer therapy (the pediatric nebulizer mask, jet nebulizer). We explained to the children that they would need to keep the mask on the face of the toy for 2–3 min, familiarizing them with what that period of time was by, for example, showing them a clock and turning the minute hand three times for them to see. We told them they could put any sticker they liked on the mask. Some normal saline was put inside the pediatric nebulizer mask. We helped the child put the mask on the toy and turned on the nebulizer, running it for 2–3 min with the mask still on the toy. We answered any questions the child asked and then said that it was now their turn and they could put any stickers they liked on the mask. The parents stood by their children during the therapeutic play. The control group went through routine clinical procedures with no play intervention attempted. The researcher accompanied the child during the nebulizer therapy, recording the proceedings in the pediatric nebulizer therapy follow‐up form. Five minutes after the therapy, both groups of children and their parents filled out the forms once again. During the data collection, there were no losses to follow‐up, discontinuations of the intervention, or exclusions from analysis.
To evaluate the appropriateness of the content of the therapeutic play, academics specialized in Pediatric Nursing (n = 8) were asked for their expert opinions. The content was offered to the experts in list form and each academic was asked to assess each item on the basis of 1–4 points (1: Inappropriate, 4: Very appropriate). The assessments were reviewed using the Davis technique and it was determined that the expert opinion scores varied between 0.83 and 0.92 for each item.
2.5. Ethical Considerations
The approval of the Aydın Adnan Menderes University Faculty of Nursing Noninterventional Clinical Studies Ethics Committee was received (Approval No. 2019/091). The research conforms to the provisions of the Declaration of Helsinki (as revised in Brazil 2013). Permission was obtained for the use of the CFS and CSA‐S instruments from Gülçin Özalp Gerçeker, one of the authors of the relevant validity and reliability study. Authorization for the collection of data was received from the Aydın Provincial Directorate of Health. The parents provided their written, the children their verbal consent. The participants were informed that they could withdraw from the study at any time they wished. All data were encoded and analyzed in line with the principle of confidentiality.
2.6. Data Analysis
Statistical data were analyzed with the SPSS 22.0 program. Distribution of variables were checked with the Kolmogorov–Smirnov test and skewness and kurtosis statistics. Since the data were in normal distribution, parametric tests were employed. Descriptive statistics, x 2, the independent samples t‐test and dependent samples t‐test were used in the evaluation of the data. The level of significance was accepted to be p < 0.05.
3. Results
A review of the descriptive characteristics of the participating children and parents showed that there was no statistically significant difference between the study and control groups. In terms of sex distribution, girls and boys were evenly distributed in both groups, showing no significant difference between the varying groups (p > 0.05). Factors related to the children's past healthcare experiences such as attending nursery school, previously receiving nebulizer therapy, admission to the hospital or to emergency care were also evenly distributed (p > 0.05). A look into the education status of the parents indicated that both mothers and fathers were most commonly middle school and high school graduates; this variable did not demonstrate a significant difference between the groups (p > 0.05). Most of the mothers in the study and control groups were working (74.5% and 70.6%, respectively); the difference was not statistically significant (p > 0.05). A review of total number of children and the mean ages of the children and parents also indicated that the two groups were similar with no significant difference between them (p > 0.05). All of these results demonstrate that the experimental and control groups were initially sociodemographically homogeneous (Table 1).
TABLE 1.
Comparison of the groups' descriptive characteristics.
| Variable | Study group n (%) | Controls n (%) | Test value (χ2) | p |
|---|---|---|---|---|
| Sex | ||||
| Female | 26 (51.0) | 25 (49.0) | 0.039 | 0.500 |
| Boy | 25 (49.0) | 26 (51.0) | ||
| Preschool education | ||||
| Yes | 35 (68.6) | 40 (78.4) | 1.259 | 0.185 |
| No | 16 (31.4) | 11 (21.6) | ||
| Experience with nebulizer therapy | ||||
| Yes | 46 (90.2) | 44 (86.3) | 0.378 | 0.380 |
| No | 5 (9.8) | 7 (13.7) | ||
| History of hospital admission | ||||
| Yes | 20 (39.2) | 23 (45.1) | 0.362 | 0.344 |
| No | 31 (60.8) | 28 (54.9) | ||
| History of emergency department admission | ||||
| Yes | 50 (98.0) | 49 (96.1) | 0.343 | 0.500 |
| No | 1 (2.0) | 2 (3.9) | ||
| Mother's education | ||||
| Primary school | 11 (21.6) | 11 (21.6) | 1.143 | 0.887 |
| Middle school | 16 (31.4) | 12 (23.5) | ||
| High school | 12 (23.5) | 16 (31.4) | ||
| University | 11 (21.6) | 11 (21.6) | ||
| Graduate degree | 1 (2.0) | 1 (2.0) | ||
| Father's education | ||||
| Primary school | 12 (23.5) | 13 (25.5) | 0.565 | 0.967 |
| Middle school | 13 (25.5) | 10 (19.6) | ||
| High school | 14 (27.5) | 16 (31.4) | ||
| University | 11 (21.6) | 11 (21.6) | ||
| Graduate degree | 1 (2.0) | 1 (2.0) | ||
| Mother employed? | ||||
| Yes | 38 (74.5) | 36 (70.6) | 0.197 | 0.412 |
| No | 13 (25.5) | 15 (29.4) | ||
| Father employed? | ||||
| Yes | 48 (94.1) | 49 (96.1) | 0.210 | 0.500 |
| No | 3 (5.9) | 2 (3.9) | ||
| Total number of children | ||||
| 1 | 13 (25.5) | 12 (23.5) | 2.512 | 0.473 |
| 2 | 26 (51.0) | 20 (39.2) | ||
| 3 | 11 (21.6) | 18 (35.3) | ||
| 4 | 1 (2.0) | 1 (2.0) | ||
| Mean ± SD | Mean ± SD | |||
| Child's age (months) | 74.920 ± 10.840 | 75.730 ± 9.571 | 0.692 | |
| Mother's age | 32.750 ± 6.542 | 32.430 ± 6.920 | 0.814 | |
| Father's age | 35.960 ± 6.270 | 36.530 ± 5.863 | 0.637 | |
Table 2 represents a comparison of the study and control groups before and after therapeutic play in terms of the fear scores of the children and their parents. We determined that following therapeutic play the fear scores of the parents in the study group were significantly lower than those of the parents in the control group (t a = −4.871, p < 0.001). This signifies a large effect size (d = 0.97, 95% CI: −1.60, −0.67).
TABLE 2.
Comparison of groups' fear scores before and after therapeutic play.
| Therapeutic play group (n = 51) | Control group (n = 51) | t a | p | d [95% GI] | |
|---|---|---|---|---|---|
| M ± SD | M ± SD | ||||
| CFS—parent‐reported | |||||
| Before | 1.840 ± 1.065 | 1.820 ± 1.584 | 0.073 | 0.942 | 0.01 [−0.51, 0.55] |
| After | 0.430 ± 0.944 | 1.570 ± 1.375 | −4.871 | 0.000 | 0.97 [−1.60, −0.67] |
| t b | 12.163 | 3.765 | |||
| p | 0.000 | 0.000 | |||
| d [95% GI] | 1.70 [1.18, 1.65] | 0.53 [0.12, 0.39] | |||
| CFS—self‐reported | |||||
| Before | 1.530 ± 1.102 | 1.470 ± 1.302 | 0.246 | 0.806 | 0.05 [−0.42, 0.53] |
| After | 0.410 ± 0.726 | 1.270 ± 1.115 | −4.631 | 0.000 | 0.91 [−1.23, −0.49] |
| t b | 12.849 | 2.854 | |||
| p | 0.000 | 0.006 | |||
| d [95% GI] | 1.80 [0.94, 1.29] | 0.40 [0.06, 0.33] | |||
Abbreviations: t a, independent groups t‐test; t b, dependent groups t‐test.
Similarly, we found that the fear scores of the children in the study group after the intervention had significantly fallen compared to the control group (t a = −4.631, p < 0.001). Effect size was large (d = 0.91, 95% CI: −1.23, −0.49). In the intragroup comparisons, a pronounced and very significant fall was seen in the fear scores reported by the parents and children in the study group after therapeutic play (parents: d = 1.70; children: d = 1.80; p < 0.001); in the control group, the size of this decrease remained small‐medium.
A review of the anxiety scores reported by the parents showed that there was a significant decrease in the study group after therapeutic play compared to the controls (t a = −2.908, p < 0.001). This difference exhibited a medium effect size (d = 0.58, 95% CI: −1.79, −0.33). The children's anxiety scores, however, did not display a statistically significant difference between the groups at the posttest (p > 0.05), but in the intragroup analyzes, anxiety in both groups decreased after the intervention. The effect size of this decrease was larger in the study group (Table 3).
TABLE 3.
Comparison of groups' anxiety scores before and after therapeutic play.
| Therapeutic play group (n = 51) | Control group (n = 51) | t a | p | d [95% GI] | |
|---|---|---|---|---|---|
| M ± SD | M ± SD | ||||
| CSA—parents | |||||
| Before | 3.450 ± 2.427 | 3.390 ± 3.001 | 0.109 | 0.914 | 0.02 [−1.01, 1.13] |
| After | 1.530 ± 1.391 | 2.410 ± 2.376 | −2.908 | 0.005 | 0.58 [−1.79, −0.33] |
| t b | 8.162 | 2.591 | |||
| p | 0.000 | 0.012 | |||
| d [95% GI] | 1.14 [1.58, 2.61] | 0.36 [0.22, 1.74] | |||
| CSA—children | |||||
| Before | 3.060 ± 2.731 | 3.100 ± 2.633 | −0.074 | 0.01 [−1.09, 1.02] | |
| After | 1.530 ± 1.391 | 2.160 ± 1.922 | −1.889 | 0.38 [−1.29, 0.03] | |
| t b | 6.511 | 2.590 | |||
| p | 0.000 | 0.013 | |||
| d [95% GI] | 0.91 [−1.06, 2.00] | 0.36 [0.21, 1.67] | |||
Abbreviations: t a, independent groups t‐test; t b, dependent groups t‐test.
The mean score we registered during the nebulizer therapy in terms of the child's treatment compliance was significantly higher in the experimental group (5.27 ± 1.02) compared with the controls (3.92 ± 2.30) (t = 3844; p < 0.001).
We observed during the treatment that 94.1% of the children in the therapeutic play group and 60.8% of those in the control group held the nebulizer cup in an upright position. We also observed during the treatment that 98% of the children in the therapeutic play group and 72.5% of those in the control group put the masks on correctly. Additionally, 94.1% of the children in the therapeutic play group and 62.7% of those in the control group did not cry during the treatment. We observed that 98% of the children in the therapeutic play group and 68.6% of those in the control group breathed at a normal rate and depth during the treatment. There was a statistically significant difference between the two groups in terms of the factors of holding the cup upright, applying the mask correctly, sitting upright, and crying and breathing normally (p < 0.001) (Table 4). Both groups were similar in that the procedure took about 5–10 min (p > 0.05) (Table 4).
TABLE 4.
Percentages of adherence to the items on the Pediatric Nebulizer Therapy Follow‐up Form in each group during treatment.
| Therapeutic play group (n = 51) | Control group (n = 51) | χ2 | p | |||
|---|---|---|---|---|---|---|
| n | % | n | % | |||
| Holding the cup upright | ||||||
| Yes | 48 | 94.1% | 31 | 60.8% | 16.223 | 0.000 |
| No | 3 | 5.9% | 20 | 39.2% | ||
| Holding the mask to the face without allowing medication to escape | ||||||
| Yes | 50 | 98.0% | 37 | 72.5% | 13.209 | 0.000 |
| No | 1 | 2.0% | 14 | 27.5% | ||
| Sitting in an upright position | ||||||
| Yes | 48 | 94.1% | 41 | 80.4% | 4.320 | 0.000 |
| No | 3 | 5.9% | 10 | 19.6% | ||
| Not crying | ||||||
| Yes | 48 | 94.1% | 32 | 62.7% | 14.836 | 0.000 |
| No | 3 | 5.9% | 19 | 37.3% | ||
| Breathing at normal rate and depth | ||||||
| Yes | 50 | 98.0% | 35 | 68.6% | 15.882 | 0.000 |
| No | 1 | 2.0% | 16 | 31.4% | ||
| Procedure taking 5–10 min | ||||||
| Yes | 25 | 49.0% | 24 | 47.1% | 0.039 | 0.500 |
| No | 26 | 51.0% | 27 | 52.9% | ||
Abbreviation: χ2, Chi‐squared analysis.
4. Discussion
In this study, we explored the effect of engaging in short and structured therapeutic play ahead of receiving nebulizer treatment in the emergency department on the fear and anxiety levels and the treatment compliance of 5–8‐year‐old children.
Our findings indicated that an intervention of therapeutic play prior to the treatment significantly reduced post‐procedural fear levels in children with a large effect size and substantially increased children's treatment compliance scores. We also found that the parents reported that the therapeutic play resulted in a moderate decrease in the child's level of anxiety. On the other hand, the reduction observed in the children's self‐reported state anxiety (CSA) scores did not display a statistically significant difference between the groups.
According to the feedback received from both the children and parents, we found that therapeutic play significantly diminished the children's post‐procedural fear levels with a large effect size. The diminishing effect of therapeutic play on fear is consistent with the literature [18, 27, 28, 29, 30]. Fear is generally accepted to be a basic behavioral response to a concrete, momentary and specific danger (e.g., the sound of a device, the look of a mask) [22]. Therapeutic play may have effectively alleviated the fear reaction because the toys provided the children with the opportunity to experience, control and become familiar with the specific stimuli they were to encounter in the procedure. Similar to our findings, Kırkan and Kahraman reported that therapeutic play with a toy nebulizer and mask significantly reduces children's fear levels [18]. It has also been demonstrated that using a child‐friendly nebulizer produced with 3D printing technology is more effective in preventing children's crying and fear behavior than standard devices [27]. The fast pace of the emergency room setting, the unfamiliar faces and emergency interventions may cause children to feel a deep sense of desperation and loss of control [1]. The chance given to the children in the therapeutic play initiated in our study to choose their own toys and stickers, the opportunity to observe the procedure by means of the make‐believe equipment, and the child's active participation when the time came for the real procedure may have been the factors that reinforced the sense of gaining back control.
Following the therapeutic play, the anxiety scores of the study group children, although lower than in the control group, did not point to a statistically significant difference. Yanık and Ayyıldız found that familiarizing children aged 3–6 with a make‐believe nebulizer significantly reduced their anxiety scores compared to the control group [25]. Some studies have also shown that therapeutic play initiated in the emergency department is effective in diminishing children's anxiety [18, 31].
There are other studies reporting that therapeutic interventions do not have an impact on anxiety. It has also been asserted that children who come in for nonemergency visits and do not need invasive procedures as determined through triage do not display significantly diminished anxiety following hospital “clown” interventions [32]. By the same token, researchers report that lively musical games that engage the children in the emergency room are not effective in reducing their anxiety [33]. Our findings are consistent with the literature.
Anxiety is more common than fear, less concrete an emotion and may contain worries about the future [34]. It would therefore be expected that a short intervention, while reducing the apprehension about the procedure, may not affect general state anxiety to the same degree. We found that the 10–15‐min therapeutic play we initiated in our study was sufficient to familiarize the children with the device and the procedure, thus lessening their palpable fear. However, a longer time frame or an integrated approach that would allow an adjustment to be made to the physical setting may be needed to alleviate the more common emotion of fear [35].
We observed that the children in the therapeutic play group taking nebulizer therapy exhibited significantly higher compliance scores than the controls, displaying a markedly higher percentage in terms of willingness to put the mask on correctly and in terms of overall treatment compliance. The literature reveals that fear and resistance displayed during nebulizer treatment significantly reduces the dose of the medicine reaching the lungs [36, 37]. It is reported that crying and screaming during the treatment can reduce the collection of medication in the lungs by five‐fold compared to children who are calm during the procedure [36]. In our study, 94.1% of the children in the therapeutic play group were calm and did not cry during the nebulizer therapy. Additionally, keeping the mask away from the face by only 1–2 cm can result in a 50%–80% loss of the inhaled medication dose [37, 38]. Our results show that 98.0% of the children in the therapeutic play group kept the mask close to their face so that no medication would be lost.
It can therefore be said that achieving increased compliance with therapeutic play does not only facilitate the procedure itself but also directly optimizes the clinical efficiency of the treatment. This finding is consistent with the studies of Çelik et al., and Suryawanshi et al., who demonstrated that play‐based interventions increase children's compliance to medical procedures by reducing their stress [23, 29]. Chen et al. have also reported an increase in children's treatment compliance in aerosol therapy following therapeutic play [9].
The intervention of conducting a short therapeutic play session ahead of nebulizer therapy in the emergency room noticeably reduced the children's fear and markedly increased clinical efficacy by significantly improving treatment compliance. Therapeutic play is an evidence‐based and valuable nursing intervention that integratively addresses a child's psychosocial and physical needs. We recommend that this simple but important intervention be included in routine pediatric care protocols, even in the stressful environment of the emergency department.
This study has a few limitations. First, it was carried out at a single site and therefore the generalizability of the findings may be limited. Second, the sample comprises only children of the ages 5–8; an evaluation of effectiveness in younger or older children was not made. It may be suggested that future studies are designed for different age groups and developmental stages and at multiple sites. The lack of information on long‐term effects (e.g., behavior displayed at the next visit) is another limitation of our study.
In conclusion, this study demonstrates that a brief, structured therapeutic play intervention (10–15 min) prior to emergency department nebulization significantly reduces fear and improves treatment compliance in children aged 5–8 years, with large effect sizes. Integrating therapeutic play into routine pediatric emergency protocols is a low‐cost, evidence‐based strategy to enhance both psychosocial outcomes and clinical efficiency for young children undergoing stressful procedures.
Author Contributions
H.Y. contributed to the conception or design of the work. H.Y. F.K.D., and H.E., contributed to the acquisition, analysis, or interpretation of data. F.K.D. and H.E., wiriting the manuscript. H.Y. critically revised the manuscript and gave final approval of the version to be published. All authors agree to be accountable for all aspects of the work ensuring integrity and accuracy.
Funding
The authors have nothing to report.
Disclosure
This study was a single‐center, quasi‐experimental therapeutic play intervention conducted within routine clinical practice and was not initially considered a clinical trial requiring prospective registration; the authors acknowledge current policies and will register future studies accordingly.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors sincerely thank the children and their families who participated in this study. We are grateful to the staff of the Pediatric Emergency Department for their support and cooperation during data collection.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.