Summary The aim of this study is to see if storybooks or hand puppets help reduce fear in children before outpatient surgery. Researchers want to find out which of these two methods works better to help children feel calmer and less upset.

Why is this study being conducted? Going into surgery can be frightening for children. This research is looking for simple and fun ways to reduce a child's fear without using medication.

How will the research be conducted?

The study included 99 children (ages 4-7) undergoing outpatient surgery. The children were divided into three equal groups:

Group 1 (Control): Received standard hospital care.

Group 2 (Storybook): Read an educational book about a character going into surgery.

Group 3 (Puppet): Played with a hand puppet before the procedure.

Researchers measured the children's fear and emotional responses twice: approximately 1 hour before surgery and immediately before entering the operating room. By comparing these scores, the study shows whether it was the storybook or the puppet that helped the children feel better.

The aim of this randomized controlled trial is to evaluate and compare the effectiveness of two different non-pharmacological distraction methods-educational storybooks and hand puppets-on preoperative fear and emotional manifestations in children undergoing day case surgery.

Methodology:

The study was conducted with 99 children, aged 4 to 7, who met the inclusion criteria. Participants were randomly assigned to one of three groups using a 1:1:1 allocation ratio:

Control Group (n=33): Received standard preoperative nursing care, including routine information provided by the hospital staff.

Storybook Group (n=33): In addition to standard care, children were read an educational storybook titled "Elif Ameliyat Oluyor" (Elif is Having Surgery). The book describes the surgical process through a child's perspective to familiarize them with the environment.

Hand Puppet Group (n=33): In addition to standard care, a researcher engaged the child in interactive play using a hand puppet. The puppet was used to simulate the medical procedures in a non-threatening and playful manner.

Data Collection and Outcome Measures:

Two primary tools were used to collect data:

Child Fear Scale (CFS): A self-report scale used to assess the child's level of fear.

Children's Emotional Manifestation Scale (CEMS): An observational scale used by researchers to record behaviors such as crying, facial expressions, and cooperation.

Data were collected at two specific time points:

T1 (Baseline): Approximately 1 hour before the surgical procedure (pre-intervention).

T2 (Final): Immediately before the child was transferred to the operating room (post-intervention).

The study seeks to determine whether these distraction techniques significantly lower fear scores compared to standard care and which method is more effective in a clinical setting.

Inclusion Criteria:

• Children aged between 4 and 7 years.
• Children hospitalized in the pediatric surgery ward.
• Scheduled for elective (planned) surgery.
• Ability to understand and speak Turkish.
• Willingness of both the child and a parent/legal guardian to participate in the study.

Exclusion Criteria

• Children with long-term hospitalization history.
• Participants who received analgesic or sedative medication within the last 24 hours.
• Presence of major trauma, chronic disease, or chronic pain conditions requiring rapid assessment.
• Any physical or cognitive impairment that hinders effective communication (e.g., significant visual, hearing, or speech impairments).
• Presence of diagnosed mental or developmental disabilities.
• History of psychiatric disorders such as Attention Deficit Hyperactivity Disorder (ADHD).
• Participants or parents who wish to withdraw from the study at any stage.

Individual participant data (IPD) will be shared in de-identified form upon reasonable request to the Principal Investigator. Data will be available after publication of the main results and will be provided only for research purposes with appropriate ethical approval.

Surgical procedures were scheduled for wednesdays and fridays. Therefore, the research was conducted on wednesdays and fridays. Wednesday was puppet day and Thursday was storybook day. Consequently, "Due to the nature of the interventions (storybooks=33 and hand puppets=33), participants were completely blinded to the assigned group. However, the research practitioner was dominant in the process, and the nurse was blinded to the study's baseline hypotheses. Furthermore, during the statistical evaluation phase, the other researcher was blinded to group assignments to prevent bias and was not involved in the data collection process." After the experimental groups reached the desired number, control groups =33 were collected.