The Effect of Using a Stress Ball and Watching Cartoons on Fear and Pain Levels During Enemas in Children Aged 6-12

Location and Time of the Study The study is planned to be conducted between September 2026 and May 2027 at the Pediatric Emergency Department of Mersin University Faculty of Medicine Hospital. The Pediatric Emergency Department consists of the following sections: Triage, Green Zone (6 beds), Yellow Zone (8 beds), Red/Critical Zone (3 beds), and Trauma Room (3 beds). The unit is staffed by 1 head nurse and 21 ward nurses. With an average of 220 patient visits per day, the most common reasons for presentation are fever, vomiting, diarrhea, abdominal pain, cough, respiratory distress, and trauma.

Research Variables Dependent variables: fear level, pain level Independent variables: use of a stress ball, showing cartoons

Data Collection The necessary ethics committee and institutional approvals will be obtained before the study begins. The study will be registered as a clinical trial. The study will include children aged 6-12 years who are undergoing enema procedures of the same type and volume at the Pediatric Emergency Department of Mersin University Faculty of Medicine Hospital and who meet the study's sample selection criteria. Children who do not meet the criteria will be excluded from the study. Procedures will be performed on children in all groups by the same nurse.

In line with the literature, researchers have identified distraction methods (cartoon content and the use of stress balls) appropriate for the developmental characteristics of children aged 6-12. To determine which cartoons will be used in the study, a pool of cartoons will be created by asking a total of ten children-five girls and five boys, aged 6-12-about their favorite cartoons. To evaluate the suitability of the cartoon pool, it will be presented to seven experts in the fields of child development, child psychiatry, and pediatric nursing to obtain their expert opinions. Children in Group 2 will use stress balls. The stress balls will be selected to be a size that children can easily grasp and of a soft texture. A pilot study involving 10 children will be conducted to evaluate the suitability of the data collection tools and distraction methods to be used in the study. The children included in the pilot study will not be included in the research sample. The children participating in the study and their parents will be informed about the purpose, content, and implementation process of the study. Written and verbal consent will be obtained from the parents, and verbal consent will be obtained from the children. All children participating in the study will receive routine clinical care.

Routine clinical procedure: Prior to the enema procedure, the child's vital signs are assessed, and the child is informed about the procedure using age-appropriate language.

The child is positioned appropriately (right or left lateral) and the parent is allowed to remain by the child's side during the procedure. During the procedure, the tip of the tube is lubricated and gently inserted into the rectal area, and the enema solution is administered. After the procedure, the child is monitored for potential complications. An informational consent form will be administered to the children included in the study prior to the procedure, and fear and pain levels will be assessed by the nurse, the parent, and the child. Children who meet the sample selection criteria will be randomized into three groups using a computer-generated random number generator.

• Cartoon-viewing group: In addition to standard clinical practice, children in the cartoon-viewing group will be shown an age-appropriate cartoon 1 minute before the procedure begins and will be encouraged to continue watching throughout the procedure.
• Stress ball group: In addition to the standard clinical routine, children in the stress ball group will be given a stress ball 1 minute before the procedure begins and will be encouraged to use it throughout the procedure.
• Control group: No distraction interventions will be applied to children in the control group; only standard clinical care will be provided.

The levels of fear and pain among children in all groups will be assessed immediately after the procedure is completed (before the child gets up from the dental chair). In addition, the satisfaction levels of children in the intervention groups will be assessed. The data collected will be analyzed using statistical methods, and the results will be reported.

Inclusion criteria

Children must:

• Be undergoing their first enema procedure
• Be 6-12 years
• Speak Turkish
• Have no communication difficulties
• Both the child and the parent must be willing to participate in the study

Exclusion criteria

• The patient has a high fever (above 38.3)
• The child has a visual, hearing, intellectual, or physical disability
• The child has genetic-metabolic or chronic diseases
• A parent has an intellectual disability
• Administration of analgesics or sedatives prior to the procedure