The Effect of Two Different Types of Hourglasses on Pain, Fear, and Anxiety During Blood Collection in Children: A Randomized Controlled Trial

Pain, fear, and anxiety experienced by children during medical procedures constitute a significant clinical and psychosocial concern. Venipuncture, particularly common among invasive procedures performed on children aged 5-10 years, can trigger strong emotional reactions in this age group. These reactions may negatively affect not only the procedure itself but also children's long-term trust in the healthcare system, treatment adherence, and tolerance of future procedures.

Failure to effectively manage the anxiety and fear that arise during invasive procedures in children may lead to movement, increased pain, delays in the procedure, and challenges in terms of staff safety. Moreover, children who experience high levels of fear and anxiety may later avoid similar procedures, which poses a serious risk for access to healthcare services and adherence to treatment. Therefore, identifying and optimizing non-pharmacological, low-cost, and feasible methods used during invasive procedures is of utmost importance.

One of the non-pharmacological strategies used to reduce pain, fear, and anxiety during invasive procedures in children is active and passive distraction. Active distraction methods involve the child's engagement in surrounding activities such as playing games, crafts and coloring, tablet/computer games, role-play, and storytelling. These methods require the child to use hand-eye coordination, cognitive skills, or imagination and often reduce pain and anxiety more effectively. Passive distraction methods rely on the child's observation or listening to an activity and include watching videos/cartoons, listening to music or stories, and observing visual toys (e.g., sand timers). These methods provide visual and auditory stimuli that help redirect attention away from painful cues and are generally easy to implement. In summary, while active methods involve the child's active participation in the process, passive methods rely solely on focusing on an external stimulus. Studies in the literature indicate that both methods play an important role in reducing pain, fear, and anxiety experienced by children during invasive procedures.

Among passive distraction methods, sand timers are used as visual toys. The reason for selecting two different types of sand timers for children is the potential for their visual and cognitive stimulus properties to influence levels of pain, fear, and anxiety differently. The traditional sand-based timer offers a simple visual stimulus by displaying the natural flow of sand and is familiar and calming for most children. In contrast, liquid gel-based timers provide a more dynamic and attention-grabbing stimulus through colorful liquid and varying flow speeds. These differing characteristics may influence how effectively children's attention can be diverted from painful cues during venipuncture. However, the literature on the effectiveness of visual distractors such as sand timers remains limited. Sand timers are simple, portable, and low-cost tools to capture children's attention, but differences between sand-based (traditional) and liquid gel-based versions-such as visual effects, flow speed, and color variations-have not been fully explored regarding their impact on pain, fear, and anxiety. This gap creates uncertainty about which type is more effective in clinical practice.

Systematically evaluating the effects of liquid gel-based and traditional sand timers on children's experience during invasive procedures may provide valuable evidence for nursing practice and pediatric care protocols. If simple and low-cost tools such as sand timers can reduce pain, fear, and anxiety during venipuncture, their widespread use may enhance children's procedural experiences and improve their cooperation and morale. Lower levels of pain and fear may help children move less during the procedure, increasing the safety of both the child and healthcare staff and supporting their compliance with future procedures. Furthermore, compared with medication- or device-based interventions, sand timers offer economic and logistical advantages; their ease of application in clinical settings and minimal training requirements make them highly feasible for practice.