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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 24
Working with a Client’s Needle Phobia

CEU Question 24 | CEU Test | Table of Contents | Phobias
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs, Nurse CEUs

Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.

Needle phobia
The term 'phobia' derives from the Greek meaning 'fear' or 'dread'. Stewart (1994) describes phobias as an 'excessive fear of a situation or object that is not in keeping with the actual danger it can or might present… often leading to a desire to avoid and escape an object or situation'. In contrast, Duff (2003) considers fear is a normal response to threatening stimuli, and involves three response systems: physiological arousal, covert feelings and thoughts and overt behaviour reactions. Phobias, however, are described as unreasonable responses to a benign stimulus which results in one of the three elements of fear being excessively and persistently activated (Duff 2003).

Humphrey and Boon (cited in Duff 2003) argue that venepuncture is not a benign stimulus for children, but an unpleasant sensory and emotional experience that threatens 'loss of control. So the child's response is not a fear or phobia of needles but a normal anticipatory fear which involves the distress response. This argument is supported by Duff and Brownlea's finding (cited in Duff 2003) that the fear response is higher prior to needle insertion after which it sharply decreases. They report that this response may be no different if a needle-less system is offered, or if children see needles outside of the context of the procedure.

Despite the lack of clarity around terminology, the term 'needle phobia' will be used in this article as it is commonly used in clinical practice to represent the child's anticipatory fear.

Causes of needle phobia
With advances in medical technology, more children are undergoing venepuncture as part of the diagnostic process. Unfortunately, many children are not provided with sensitive planning and preparation. Topical anaesthetic preparations may be applied, but are not always left for the prescribed time that would ensure optimal effectiveness. Consequently, children may still be restrained whilst venepuncture is performed, resulting in negative experiences and memories for the child and those involved.

It has also been argued that needle phobia may arise not as the result of a personal traumatic experience for the child but from the behaviour of parents who have themselves experienced or witnessed traumatic venepuncture: their fears and anxieties are conveyed to the child (Smalley 1999).

Consequences of needle phobia
A child who is 'needle phobic' will report or be observed to have a long-term fear of needles, which he or she may be able to recognise as unreasonable. When the child is exposed to, or anticipates, a needle insertion, an immediate anxiety response is triggered which may take the form of crying, psychomotor agitation, freezing or clinging.

The ongoing stress response of the impending venepuncture will also result in further hypothalamic stimulation of the sympathetic nervous system and the adrenal medulla. Subsequently, the child's heart rate and blood pressure will continue to increase resulting in vasoconstriction of the blood vessels supplying the skin making venepuncture more difficult. Further effects of sympathetic nervous system stimulation may lead to light-headedness, fainting, nausea and pallor.

Performing venepuncture
The need to prepare children and support them during invasive procedures has been discussed by a number of authors such as Willock et al (2004), Duff (2003), Smalley (1999) and Buckingham (1995). Their views are incorporated into a broader discussion here about support needs when undertaking venepuncture in children who are known or believed to be 'needle phobic'.

The ultimate aim of preparation and support is to obtain and maintain the child's consent to perform the procedure. According to the British Medical Association (BMA 2001), age is not necessarily a major factor in informed consent; if the child or young person is deemed competent, consent should be sought directly from them (DH 200l). Consent can be verbal, written or implied by the child's actions, such as holding out their arm ready for venepuncture. The inclusion of children in all aspects of decision-making makes it more likely that they will give consent; how this is done will need to be tailored to each particular child, taking into consideration their development and previous experiences of medical environments.

This process ensures that the child is listened to and gives control and choice to the child (DH 2003, 2004). Excluding the child can increase their fear and bewilderment (Alderson 1993), which may have a serious impact at a later time. We found that three phases need to be worked through to obtain the child's consent to perform venepuncture: relaxation, control and ultimately graded exposure to the feared stimulus. How long a 'needle phobic' child remains in each stage varies on the individuals and is led by the child and not the nurse (see case studies).

The aim of the first phase is to support the child in being able to relax and consequently reduce their anxiety levels. The child assesses his own anxiety levels on a number line from 0 to 10, with 0 being the least anxious and 10 being the most anxious. We found that just coming to hospital puts the anxiety rating of each needle phobic child between two and three, so this number becomes their baseline. If a child rates his anxiety at higher than three, distraction techniques are employed or the session is halted. Staff spend the initial meeting with the child talking about why he feels that he is 'needle phobic'. The majority of children are able to explain whether it is the result of immunisations, ineffective topical anaesthetic preparation or parental behaviour. This stage helps to build relationships and gives the child the opportunity to develop trust in the staff.

Once the causes of the child's 'needle phobia' have been discussed, the child is taught relaxation. This involves teaching him or her how to gain control over the symptoms of physiological arousal by breathing slowly and deeply and releasing muscle tension. The child may choose to use party blowers, or to blow bubbles to help control breathing. He or she is also helped to develop the necessary skills to perform deep muscle relaxation, a technique that can be used in other stressful situations encountered in daily life.

Muscle relaxation involves the child sitting with their feet on the floor and then clenching or curling the toes for fifteen seconds and then slowly releasing. The child is then encouraged to undertake this clenching and releasing with their calf muscles and then their thigh muscles. The ultimate goal is to enable the child to relax in the previous anxiety-provoking situation, until the phobia gradually disappears (Stewart 1994). In conjunction with relaxation training, the child may choose to use some toy which they can play with -- for example a Rubics cube -- to keep the hands occupied and reduce anxiety. The child is also offered the opportunity to undertake guided imagery, which involves encouraging him or her to evoke pleasant imagery and engage in fantasy 'scenes' (Duff 2003), actively gaining a sense of internal control over their reactions. However, this has not proven to be a popular option to date.

While teaching the child ways to relax, staff need to be aware of the child's verbal and non-verbal cues. Each child's body language is unique and it is through observation that staff become aware of increasing anxiety levels. One of the more obvious non verbal cues is increased fidgeting.

From the start of relaxation training, it is important that the child is given control through choices. The first choice involves letting the child decide the environment in which they will be prepared for venepuncture. Very few children choose the treatment room, preferring instead an environment which is comfortable, relaxed and child-friendly. The child is also given the choice of where they will sit in the room, who they want to be included and, dependent on age, if they want to sit on a parent's lap.

The importance given to choice arises from the discovery that the cause of children's 'needle phobia' may be the result of being ignored when concerns were expressed about the readiness of the topical anaesthetic preparation. Loss of trust in health professionals (and in the efficacy of topical anaesthetic preparations) needs to be rebuilt. Children are encouraged to try a topical anaesthetic preparation at home, safe in the knowledge that there is no one available to perform venepuncture and that they are in control of the situation.

Graded exposure
This is achieved by establishing successive approximations of the procedures which build to full behavioural rehearsals. From a psychological perspective, graded exposure involves counter-conditioning, in which the situation encountered is connected with new responses incompatible with fear, such as relaxation (Wolpe 1985, cited in Stewart 1994).

The process of graded exposure commences with the introduction of a cotton wool ball, placed in the doorway of the room. The child is asked 'how scary is this' which usually elicits a laugh. Gradually, the cotton wool ball is brought closer until, eventually, the child holds it in their control. The next stage is when the nurse holds the cotton wool ball. This usually raises the child's anxiety levels as they no longer have control. When the child's anxiety levels increase, they are encouraged to employ breathing techniques and any other forms of relaxation they have chosen to use. Next, an alcohol wipe is introduced. The child is given the opportunity to touch the packaging, and the packet is then opened, as we found that it is the smell of an alcohol wipe that increases the child's anxiety levels.

Once the child feels comfortable with an alcohol wipe, a syringe is introduced and then, finally, a needle. The syringe and needle are initially in their packaging so that the child can be reassured they are not for use until he or she is ready. To reinforce the counter-conditioning, and in negotiation with the parents, the child is given the opportunity to take the needle and syringe home within the packaging so as to become accustomed to these items. Throughout the process of graded exposure, the child is regularly reminded that venepuncture will not be undertaken until he or she is ready. Staff also ensure that when a child has attended for graded exposure they do not go home with an anxiety level higher than their baseline.

Following the process of graded exposure, the child's readiness and choices for venepuncture are considered in greater depth. This includes whether they will rest their hand on a pillow; if someone will hold their hand; if they will sit next to a parent, or on their lap; will they read a book or perhaps watch a video so that they do not observe the procedure. Then, a signal is agreed to indicate that the child is ready for the venepuncture to be performed, such as the child's turning the head a certain way or nodding at a parent. What is imperative is that the undertaking of the signal is led by the child, because they must have the courage and trust to say yes, knowing that venepuncture will not be performed until the definitive signal is given. To date, apart from one mother who would not bring her child any more, all the children have been able to build a trusting relationship with the staff. Following venepuncture, the child is sent a star card to congratulate them on their achievement and are told they are welcome to contact the unit if they need to in the future.

Anticipatory fear of needles is not an uncommon problem. All nurses need to be aware of this kind of negative outcome of not listening to children. The aim of the intervention described in this article is to equip the child and their family with appropriate coping strategies so that venepuncture may be performed in other establishments at other times. Evidence-based, effective, client-focused care is possible, if those working with children have the right skills and the creative thought to use them for the benefit of each child
- Thurgate C, Heppell S.; Needle phobia- Changing venepuncture practice in ambulatory care;  Paediatric Nursing; Nov. 2005; Vol. 17, Issue 9

Personal Reflection Exercise #10
The preceding section contained information regarding working with a client’s phobia of needles. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 24
Why is treating a needle phobia important? Record the letter of the correct answer the CEU Test.

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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

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