The Effects of Finger Painting as an Intervention During Nebulization Therapy on Fear and Anxiety Levels in Children: A Randomized Controlled Trial

The nurse assessments of the children in the study and control groups were conducted by the same nurse evaluator for all children throughout the study. Prior to the data collection process, the primary researcher provided the nurse evaluator with standardized training on the purpose of the study, the data collection process, and the administration of the measurement instruments.

The primary researcher is a master's student in Pediatric Nursing and has been working as a nurse in pediatric clinics for approximately three years. She has also received training in therapeutic play and holds a certificate in this field.

Before nebulization treatment, the children's levels of fear and anxiety were evaluated by the child, the parent, the evaluating nurse, and the primary researcher using the CFS and CAS-SA. In addition, parents completed the Parent Information Form. After the completion of the nebulization treatment, the children's levels of fear and anxiety were reevaluated by the same evaluators. Throughout the study, the primary researcher did not participate in the delivery of clinical care; she was responsible only for data collection and the implementation of the intervention.

The nurse assessments of the children in the study and control groups were conducted by the same nurse evaluator for all children throughout the study. Prior to the data collection process, the primary researcher provided the nurse evaluator with standardized training on the purpose of the study, the data collection process, and the administration of the measurement instruments.

The primary researcher is a master's student in Pediatric Nursing and has been working as a nurse in pediatric clinics for approximately three years. She has also received training in therapeutic play and holds a certificate in this field.

Before nebulization treatment, the children's levels of fear and anxiety were evaluated by the child, the parent, the evaluating nurse, and the primary researcher using the CFS and CAS-SA. In addition, parents completed the Parent Information Form. After the completion of the nebulization treatment, the children's levels of fear and anxiety were reevaluated by the same evaluators. Throughout the study, the primary researcher did not participate in the delivery of clinical care; she was responsible only for data collection and the implementation of the intervention.

The nurse assessments of the children in the study and control groups were conducted by the same nurse evaluator for all children throughout the study. Prior to the data collection process, the primary researcher provided the nurse evaluator with standardized training on the purpose of the study, the data collection process, and the administration of the measurement instruments.

The primary researcher is a master's student in Pediatric Nursing and has been working as a nurse in pediatric clinics for approximately three years. She has also received training in therapeutic play and holds a certificate in this field.

Before nebulization treatment, the children's levels of fear and anxiety were evaluated by the child, the parent, the evaluating nurse, and the primary researcher using the CFS and CAS-SA. In addition, parents completed the Parent Information Form. After the completion of the nebulization treatment, the children's levels of fear and anxiety were reevaluated by the same evaluators. Throughout the study, the primary researcher did not participate in the delivery of clinical care; she was responsible only for data collection and the implementation of the intervention.

Finger-Painting Intervention Administered to the Study Group Finger painting is an art-based therapeutic play activity used in pediatric care to distract children and encourage their active participation (Coyne, 2006; Koller \& Goldman, 2012; Li \& Lopez, 2008). In the present study, the finger-painting intervention was administered to the children in the study group during nebulization therapy.

Immediately before the nebulization therapy began, the procedure was explained to the children. The children were given blank paper and single-use, non-toxic, water-based finger paints in six primary colors, suitable for pediatric use. The children were allowed to choose the colors they wanted, mix colors or use them separately, and carry out the painting process according to their own preferences. No guidance was provided regarding the number of fingers used, the painting technique, or pattern creation during the painting process.

The finger-painting activity was initiated simultaneously with nebulization therapy, and the children were allowed to paint freely in their beds. The activity lasted approximately 5-10 minutes and concluded upon completion of the nebulization therapy. After the activity, the children's hands were washed with their parents' assistance in accordance with standard clinical practices. Children performing the finger-painting activity during nebulization therapy and the finger-painting materials used in the study (Picture 1).

Interventions to the Control Group No distraction methods or additional interventions were used for the children in the control group during nebulization therapy. The children received nebulization therapy solely as part of routine clinical care.

• the finger-painting (Other): Before nebulization therapy, the children were provided with finger paints and shown how to use them. They were then asked to engage in finger painting during the nebulization therapy.

Primary outcomes

• assessing fear during nebulization therapy [3-5 minutes.]: Children's Fear Scale: The scale was developed by McMurtry et al. to find out the anxiety levels of children between 4 and 10 years of age (McCarthy et al., 2010). There are five face pictures in the scale. Anxiety level is scored between "0 and 4". 0 indicates "no anxiety", while a scared face is scored 4 and indicates "too much anxiety". After the nebulization therapy ended, a researcher and parents filled Children's Fear Scale separately and independently to find out fear experienced by the child during the procedure.

Secondary outcomes

• assessing anxiety during nebulization therapy [3-5 minutes.]: Children's Anxiety Scale-State Anxiety was developed by Ersig et al. (2013); the Turkish validity and reliability study was conducted by Gerçeker et al. (2018) (Gerceker Özalp et al., 2018; Ersig et al, 2013). The scale is used to evaluate the levels of state anxiety in children aged 4-10. The scale, which is in the form of a thermometer, is rated on a scale where 0 means "calm, not tense or anxious" and 10 means "very tense or anxious." After the nebulization therapy ended, a researcher and parents filled Children's Anxiety Scale separately and independently to find out fear experienced by the child during the procedure.

Sex: All, ages: 3 Years to 6 Years

Inclusion Criteria:

* For children:
* Being between 3 and 6 years of age.
* Being accompanied by a parent.
* Being able to communicate in Turkish.
* Having no allergy to chemical dyes, according to parental reports.
* Having no mental or physical disabilities.
* Having no history of chronic nebulizer use.

For parents:

* Being able to communicate in Turkish.
* Being literate.
* Having no mental or physical disabilities.

Exclusion Criteria:

* For children:
* Failing to complete the finger-painting intervention.
* Having previously participated in a finger-painting intervention.
* Having motor or functional impairments affecting the hands or fingers.

For parents:

\- Having a mental health issue.