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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE.
PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 NAME AND ADDRESS UNNI KRISHNAN R
OF THE CANDIDATE
1 YEAR MSc. NURSING ,
(in block letters)
SOFIA COLLEGE OF NURSING ,
# 63 , CHOKKANAHALLI ,
YELEHANKA HOBLI, BANGALORE.
SOFIA COLLEGE OF NURSING ,

NAME OF THE
INSTITUTION

# 63 , CHOKKANAHALLI ,
YELEHANKA HOBLI, BANGALORE.

COURSE OF THE
MASTER OF SCIENCE IN NURSING
STUDY AND
IN
SUBJECT
PAEDIATRICS
4 DATE OF ADMISSION 15/10/2010
TO THE COURSE
5 TITLE OF THE TOPIC Assess the effectiveness of play therapy in reducing
PROBLEM
STATEMENT

anxiety level
A DESCRIPTIVE STUDY TO ASSESS THE
EFFECTIVENESS
REDUCING

OF

PLAY THERAPY

ANXIETY

HOSPITALISED

LEVEL

CHILDREN

HOSPITALS AT BANGALORE

IN

IN

AMONG
SELECTED

6.

BRIEF RESUME OF INTENDED WORK


INTRODUCTION
Achild is precious and beautiful,
A source of joy and happiness,
A focus of love and care,
A subject of dream for the future
(Child care)

Hospitalization is stressful for children of all ages. During a serious illness, even older
children have a great need for their parents and can tolerate their absence only for short
periods. They need to know that their parents will be there when they need them most and
that they are loved and missed. 1
Play is an essential part of a childs life and is an important aspect in fostering growth and
development. Toys are the tools of play and provide a more natural environment for a
child. The proper selection and use of toys can reduce the traumatic effects of a
hospitalization experiences and aid in the recovery phase of illness.1
Play is an integral part of the hospitalized childs plan of care. Play offers, the child an
opportunity or creative expression, diversion and effective coping.

In the hospital a

supervised play program provides warm, friendly atmosphere that will help the child continue
to grow and develop. In larger hospitals a child life specialist may coordinate the play
program. A place to play, suitable materials and other children to play with are essential.
Because play is a childs way of learning; toys, materials, and equipment are learning tools.2

Paints modeling clay dolls, blocks, games, books, toys and interactive computer technology
are some of the materials with which children rebuild the world to their size a world they
bring with them of people, special belongings (e.g.: blanket or toys),and feelings. Children
play wherever they are. A childs play is his or her occupation or work. Designing a play
program buffers. The effects of separation from family. feelings of isolation and painful or
frightening experiences such as intensive procedures.3
Play promotes healing and helps the child to cope with stressful experiences. Children Won
fear treatments are helped to release their feelings in their use of falls and other toys. The
attitudes and feelings that children reveal in their play are full of meaning. Every opportunity
should be afforded the hospitalized childe to use play and other expensive activities to lessen
stress, thus promoting healthy resolution of the negative aspects of the hospital experiences.
The child can find acceptable outlets for hostilities through play activities 3. The proper
selection of toys can provide constructive, educational stimulating relaxing, diversional, or
therapeutic value. Play is an essential element in the development of healthy individuals;
childhood play is an integral part of the developmental process in young children. It occurs
spontaneously in children and gives then an important medium for informal learning play is
not a purposeless activity serving only to pass the childhood hours, its a vital factor in
intellectual, social, and emotional development of a child.4

6.1

NEED FOR THE STUDY

Play - when one thinks of play, one immediately thinks of fun and children. But what one
does not realize is the scope of influence it has on the growth and development of a child
stored within its realms. Play happens to be the business for children. Its purposes are
numerous intellectual and motor developments, creativity and development of higher
functions, play has been known to divert childs mind. E.g. A crying child will stop crying
when a toy is given to play. The value of play to a sick child in the hospital has long been
recognized and if the hospital is to meet the physical, mental and emotional need of the child.
It must also provide suitable play activity to the child to reduce the fear and anxiety of
hospitalized children.5
Saucier stated that Play activities can be used in a multitude of setting and in multidisciplinary
fashion Ziegler state that one of every four children will be hospitalized at least once before
reaching school age. The physical and psychosocial stress of hospitalization may be
influences by the child developmental level, causing behavior changes, somatic complaints
and a prolonged hospital stay. Through the use of careful developmental assessments,
preoperative tours and therapeutic play techniques, fear can be allayed misconceptions
correlated emotionally charged issues addressed and appositive self image created. Other
purposes of therapeutic play are helps sick children gradually regain independence through
enjoinment of group experiences.

Creativity can be developed through playing with toys,

games and group projects during the literature review, the investigator came across studies in
relation to play activity and its effectiveness, in reducing the child anxiety, which are done in
foreign settings. Studies done regarding the relationship between play activities and anxiety

of hospitalized children are very few in India. Thus the investigators were motivated to carry
out this study.6

6.2

REVIEW OF LITERATURE

Review of literature is a systematic identification, location, scrutiny and summary of written


materials that contain information on research problems.
Literature review is based on an extensive survey of books, journals and international
nursing indices. It provides basis for future investigation, justifies the need for the study,
reveals constrains of data collection and establish a comprehensive study of scientific
knowledge in a professional discipline, and from which valid and theories may be developed.
The review of literature is defined as a broad, comprehensive in-depth. Systematic and
critical review of scholarly publications, unpublished scholarly print materials, audiovisual
material and personal communication.
Review of literature is the systematic and critical reviews of the most important published
scholarly literature on a particular topic. This helps the investigator to find what is already
known, and what problems remain to be solved. Since effective research is based upon past
knowledge this exercise provides useful hypothesis and helpful suggestion for significant
investigations
The related studies are presented under the following sub headings.
1. Studies related to anxiety.
2. Studies related to play activities.
3. Studies related Play activities and its therapeutic value in reducing anxiety among the
hospitalized children.

1. Studies Related To Anxiety


.Stress response after pediatric Bone Marrow Transplantation. The study was to assess the
stress response after pediatric bone marrow transplantation. Data were collected during the
pre transplant stage and at 3, 6, 12 months post transplant stage using scale. At the initial
assessment children were found to demonstrate fewer symptoms. The symptoms observed in
the majority of the subject, were the presence of intrusive thoughts demonstrate fewer
symptoms. The symptoms observed in the majority of the subjects were the presence of
intrusive thoughts demonstrated through preservative play with medical equipment and doll
play containing prominent themes of death, mutilation and abandonment set in hospital
rooms. Denial and avoidance of reminders were common and intense. Irritability and sleep
disturbances were common as compared to regressive behaviors, exaggerated startle response
hypervigilence orattentional problems. Scores were not significantly different at 3 months
aftermath (range 60 90, Mean = 78). All scores were 80 100 by months aftertransplant
and remained at the level or improved by 12 months.It is indicated that intensive and for
intrusive procedure like transplant areknown to cause short term psychological morbidity with
acute stress relatedbehavioral and emotional responses in children and their parent. The
resultdocuments the need for children to be restored to a normal life as quickly aspossible,
setting the BMT experience behind them.8
Pereira conducted study to find out the emotional reactions of hospitalisedchildren identified
that anxiety fear, anger more prominent emotional reactionsamong hospitalized preschool
among school aged children Conducted a study on behavioral changes in peadiatric intensive
care units. The trauma ofhospitalization for children is similar in many aspects to the trauma
of a natural disaster such a flood. compared the frequency and severity of behavioral

manifestations of anxiety in peadiatricpatients hospitalized in intensive care unit us ward


setting using a prospective patients series at Arkansan childrens hospital. A sample of 43
subjects aged 6 17 years was consecutively selected for the study. The hospital observed
scale (HOBS) developed for this study was used to describe objectively the subjects
manifestations of anxiety depression, delirium and with drawl subjects in the intensive care
unit exhibited apprehension and withdrawal. Subjects in the intensive care unit exhibited
apprehension. Anxiety, detachment, sadness and weeping more often than did patients in the
ward [P<0.05]. Behavior was significantly influenced by severity of illness [r= 0.39],
[P<0.01], duration of hospitalization [r = 0.42], [P<0.01], number of previous hospitalization
[r = 0.44],[P< 0.01], and presence of a preexisting anxiety and mood disorders [P< 0.05].The
data indicated that critically ill children in the intensive care unit, children with prolonged or
repeated hospitalization and children with preexisting anxiety and mood disorders are at
greater risk than other hospitalized pediatric patients for psychological trauma and for
behavioral problems that many warrant psychiatric intervention. conducted study on factors
influencing the coping of hospitalized school aged children . Indicated that a priority area of
pediatrics nursing intervention is the alleviation of fears and anxieties of hospitalized children
and their parents. Knowing more about the specific stressors and the relationship of the
reaction could provide a rationale. The information comes from investigating childrens
response to hospitalization this will allow nurse to individual supportive interventions for
hospitalized children conducted study on The major anxiety for children are separation
anxiety, loss of control, bodily injury and pain and uncertainty about limits. Separation from
their parents has been long recognized as the greatest source of anxiety for children under 7
years of age. conducted study on coping with unplanned childhood hospitalization effects of

informational interventions on mothers and children. Unexpected hospitalizations of young


children under 6 years.

Constitute the bulk of pediatric hospital admissions.

Lack of

preparation results in heightened Anxiety and high risk for negative outcomes.9
conducted study on Child Drawing Hospital: An Instrument Designed to Measure the
Emotional Status of Hospitalization School Aged Children.

The degree of anxiety

experienced by any hospitalized child is unknown. The physiological status (temperature,


pulse, respiration, blood pressure etc) can be measured on hospital admission and at routine
intervals. Behavioral indicator of anxiety such as crying or aggression may be recorded. But
children may or may not have the ability or the vocabulary to express their feelings fears,
worries and concerns verbally.10
Conducted study on Child Drawing Hospital: An Instrument Designed to Measure the
Emotional Status of Hospitalization School Aged Children. Stated that anxiety fear and
anger frustration were more prominent emotional reaction among hospitalized scholars than
among school aged children. Stated that school age children experience decreased anxiety
with longer hospital stay. Whereas preschoolers do not show and any changes in the anxiety
status.11
Conducted study on children and illness: psychological aspect of children. Identified the
psychological aspect of hospitalization in children. Hesitated that hospitalization affects body
image and perception, as well as thesocial and family relationship, of children. The resulting
psychological disturbances may influences the course of diseases and the efficiency of the
care conducted a study on anxiety reaction in children during removal of their plaster cast
with a saw inschneider childrens medical center, at Petah Tiqua, Israel.We have had
experience of an 18 months old boy with a cardio my path who died a few minutes after

removal of his cast with a saw, apparently from malignant cardiac arrhythmia triggered by
anxiety. We therefore examined the anxiety to this method of removal of a plaster cast in 20
healthy children; ten were provided with hearing protectors and ten were not. The level of
anxiety was assessed by measuring the heart rate. A known physiological indicators of
anxiety, before, during and five minutes after removal of the cast. The noise level was also
measured. The results showed a mean increase in heart rate during the procedure of 27.9
beats per minute (bum) (26.9%) in the children with no hearing.12
2. Studies Related To play activities:
Conducted an experimental study to explain the effectiveness of Play activities on
development achievement levels of abused children. She defined Play activities as an
opportunity for the child to experience growth and development under the most favorable
conditions. The sample size was 60.There was a significant difference noted between abused
children receiving play and the other children. The result revealed that there is a difference in
the development of the abused children after Play activities.13
Conducted an experimental study to examine the role that play occupies within current
occupational therapy practice with preschoolers. The sample consists of two hundred and
twenty four pediatric occupational therapists completed mail questionnaires designed to
ascertain how they used play in their practice, their used of play assessments, and potential
constrains on their used of play. The results suggested that although respondents indicated that
play was important in motivating children and frequently used play as a treatment modality or
reinforces, they less frequently assessed between school based and non school based
respondents regarding the discipline or model that addresses play in the work setting. He
results suggested a need for increasing the emphasis on play in entry level curricular

continuing education improving clinician access to valid and reliable play assessments, and
designed studies to examine the use and efficiency of play in occupational therapy designed
studies to examine the use and efficiency of play in occupational therapy intervention.14
Conducted experimental comparative study in the effectiveness of Play activities in gaining
the cooperation of the children during painful procedures like blood sampling IV infusions.
Etc. Among the hospitalized children. The sample size was 80 members. The tool used was
observation rating scale to observe to reaction of the children during painful procedure. The
result revealed that there was an effectiveness of play activities in gaining the cooperation of
the children during painful procedures.16
Conducted an experimental study on the effectiveness of Play activities in helping children
between three to twelve years in coping with painful procedures. The findings revealed that
adequate coping ability was shown by62.5% of the children in verbal responses 3.1% in facial
expression 34.4% imposture and 16.9% in physical activities rating scale. Play activities had
helped in improving coping ability of children during painful procedures and children with
Play activities copied better than children without Play activities
Conducted an experimental study concerning effect of play on immobilized children in the
hospital. It aimed to determine whether any difference existed in the perception of time,
social space and self for the two groups of immobilized children in the hospital. Sixty
immobilized children wererandomelly assigned to the experimental and control groups;
children in the control group were exposed to the regular ward stimuli while the experimental
group participated in four periods of planned play. Findings indicated that the immobilized
children exposed to planned play periods expressed more positive feelings towards
themselves than the control group.17

10

Conducted an experimental study on children with leukemia and found that day undergo
painful procedures such as lumbar puncture and bone marrow aspiration. To overcome pain,
certain units offer total anesthesia. Others offer generic supports: others offer no preparation
at all. Since September 1997, we have provided leukemia children with Play activities a non
verbal and creative modality that develops coping skills. Our goal is to prevent anxiety and
fear during painful interventions as well prolonged emotional distress. We treated 32children
aged 2 14 years. The modes of Play activities before, during and after the punctures were as
follows: clinical dialogue to calm children and help them.18
Cope with painful procedures; visual imagination to activate alternative sensitivity
Gate; medical play to clarify structured drawing to contain anxiety by offering a structured,
predictable reality (the drawing) that was controllable by children; free drawing to allow
children to externalize confusion and fears: and dramatization to children expect and reconcile
themselves body changes. The results revealed children hospitalized before September 1997,
exhibited resistance and anxiety during and after painful procedures.
3. Studies Related Play activities and its Therapeutic Value in Reducing
Anxiety among the Hospitalized Children.
Conducted a study on therapeutic play and hospitalized child. It has long been recognized that
there are many and varied definitions of play. This article briefly reviews normative play theory,
differentiating it.

from its counterpart, therapeutic play.

Three forms of therapeutic play

(emotions outlet play, instructional play, and physiologically enhancing play) are described and
clinical examples are given.19

11

Conducted a study on the effect of the use of therapeutic play by the pediatric nurse on the
behavior of recently hospitalized children. This work describes the realization and the results of
one experimental research accomplished with children from 3 to 5 years age, recently hospitalized using the therapeutic play. The results showed that it helped children behave more
according to what is expected of this 3 5 age group, as well as show signs that they had adapted
or presented ego strength.17
Conducted a study on medical play and preparation: question and issues. Medical play and
preparation have become increasingly visible components of psychosocial programming for
children in health care settings. Each strategy varies to the extent to which adults structure and
direct, which may influence childrens responses and post hospital adjustment. Medical play and
preparation represent different philosophies and theories on childrens learning. Adaptation, and
development, the ever changing medical environment may currently favor adult- directed
experiences over those that are spontaneous or child initiated, with potentially differing impacts
on children.

6.3 Statement of problem


A descriptive study to assess the effectiveness of play therapy in reducing anxiety level among
hospitalized children in selected hospitals in Bangalore.

6.4 Objectives
1. To assess level of anxiety among hospitalized children before administering
Play activities in experimental and control group.
2. To determine the effectiveness of play activities among hospitalized children
12

In experimental group.
3. To find out the association in anxiety level among hospitalized children with selected
demographic variables.
Hypotheses
H1: There will be a significant difference between the pre test and post test level of anxiety
among hospitalized children after play activities.
H2: there will be a significant association in the pretest level of anxiety with the selected
demographic variables.

Assumption
The study was based on the following assumptions:

It will highlight those areas in childrens development which require genuine care and

support.
Identification of reaction will motivate the health team to create a healthy care encounter

with children.
It will help the team members to understand hospitalized children as unique & whole and

therefore provide them improved quality care.


It will promote sensitive care in order to meet effectively the needs of ill and hospitalized
children and thus promote more positive health outcomes.

DELIMITATIONS
13

The study is delimited to

Hospitalized ill children and their mothers who are willing to participate in the study.
Observation of the children by the investigator is limited only to day time.
Children who are admitted in general pediatric unit and during the period of data

collection.
The children whose mothers can speak Kannada.

Operational definition
1. Children:
Refers to children admitted to the medical ward in age groups of 3-6 both
Male and female children were included in the study.
2. Effectiveness:
Effectiveness is defined in term of reduction in anxiety offer the
Intervention through Play activities.
3. Play activities:
Play activities is the process for treatment where the concept of

14

Play is used as diversion. It includes the opportunity provided for children to manipulate create
draws interact and involve themselves with selected activities or object. The following types of
play were include in Play activities i.e. toys, balls, paints, drawing materials building blocks,
videogames and snake and ladder.
4. Anxiety:
A chronic state of tension, which effects both mind and body.
5. Hospitalization:
Admission in to an institution providing medical and surgical
Treatment and nursing care for sick or injured people [oxford dictionary, 1994] in this study it
refers to the admission of the child to the pediatric medical unit of the hospital for treatment
7. MATERIALS AND METHODS;
7.1 SOURCE OF DATA;
Hospitalized preschool children admitted in medical ward in India Gandhi Institute of Child
Health at Bangalore will be selected through convenient sampling technique through non
probability sampling technique
INCLUSIVE CRITERIA:

Children admitted in hospital during June 2005


Children admitted in medical ward
Children who could understand Kannada.

EXCLUSIVE CRITERIA:

15

Who are critically ill children?


Children who were treated as our patients
Children with complications.

DEPENDENT VARIABLE:
Anxiety level of hospitalized children
INDEPENDENT VARIABLE:
Structured teaching programmed
STUDY DESIGN:
One group pre and post test approach will be used for the study.

7.2 METHOD OF COLLECTION OF DATA;

Closed ended questionnaire

Interview methods

7.3 DOES THE

STUDY REQUIRE ANY INVESTIGATION

OR

INTERVENTIONS TO BE CONDUCTED PATIENTS OR OTHER HUMANS


OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY:
The study will be done on mothers with hospitalized children who are willing to participate.

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR


INSTITUTION?

16

Ethical clearance has been done by obtaining permission from the principal of

Sophia College of nursing, from hospital administrative, ward in charge and the participants of
the mothers with hospitalized children.

17

8. LIST OF REFERENCE
1. Ingalls, saleroom. Maternal and child health nursing. 9th edition. Network: Mosby; 1999.
2. Sadler C. childs play nurses times. 1990; 86 (11): 16 17.
3. Saucier Bl... Play activities a nursing intervention. Advanced clinical care. 1989
4. Ziegler Debbie Michelle. Preparation for surgery and adjustment to
Hospitalization. Nurses clinician of North America. 1994; 29 (4):655-59.
5.

Denise F. Polite, Bernadette P. Hunger. Nursing research principles and methods.

2ndedition. Philadelphia: Lippincott publishers; 1999.


6. Mariner. A nursing theorists and their work. 1st edition. Toronto C.V. Company
1986.
7. Chirstense P.J, Kenny. J.N. Nursing process. Application of conceptual framework. 1 st
edition. Philadelphia: Mosby. 1989.
8. Nancy Burns, Susan K Grove. Understanding nursing research 1 st edition.
Philadelphia: saunders publishers : 2002.
9. Laura A Talbot. Principles and practice of nursing research. 1 st
edition Missouri:Mosby publishers: 1995.
10. Denise F. Polit, Cheryl tatano Beck. Nursing reaserach priniciples and methods.
7 th edition. Philadelphia: Lippincott publishers; 2003.
18

11. Basavanthappa BT. Nursing research 1 st edition. Bangalore: Jaypee Brothers


medical publishers; 2003.
12. Stuber M.L, Nader K D S W, Yasuda P, Pynoos R S, Cohen S. Stress responses
after paediatric bone marrow transplantation: preliminary results of a prospective longitudinal
study. Journal of American academy of child- Adolescent psychiatry. 1991: 30 (6):952 957.
13. Perelra, M.A. A study to find out the emotional reactions of hospitalized children.
Published dissertation SNDT Womens University Mumbai 1992
14. Jones S M, Fiser H.D, Living Stone R. L. Behaviour changes in paediatrics intensive care
units. American journal of disease children. 1992; 146 : 375 379.
15. Bossert E. Factors influencing the coping of hospitalized school aged children.
Journal of paediatrics nursing. 1994; 9(5): 299-306.
16. Zingler Debbie Michelle. Preparation for surgery and adjustment to
hospitalization. Nurse clinician or North America. 1994; 29 (4) : 65559.
17. Melynk. M.B. Coping with unplanned child hood hospitalization effects of informational
interventions on mothers and children. Nursing research. 1994; 43(1): 5055.

18. Clatworthy S, Simon K, Tiedman M E. Child drawing hospital. An instrument

19

designed to measure the emotional status of school aged children. Journal of Paediatric Nursing.
1999; 14 (1): 2 18.
19. Bastin T. Children and illness psychological aspect of children. Archieves of paediatrics.
2000; 7 (4): 405 9.
20. Katz K, Fogelman R, Attias J, Baron E, Soudry M. Anxiety reaction in children during
removal of their plaster cast. Journal of bone joint surgery. 2001; 83 (3):
388 90.
21. Bonnie N. The effectiveness of play therapy on development achievement level
so of abused children. IPT journal . 2000;14(2):6-8.
22. Couch. Promoting Play activities . I PT Journal. 1999; 347 349.

20

SIGNATURE OF THE

10

STUDENT
REMARKS OF THE GUIDE

it is a seasible study

11 NAME AND DESIGNATION Professor in pediatrics


11. GUIDE
1
11. SIGNATURE
2
11. HEAD OF THE
3
DEPARTMENT
11. SIGNATURE
4
12. REMARKS OF THE PRINCIPAL
1

use full in

findings of the study will be

reducing anxiety level using play therapy

12. SIGNATURE
2
21

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