RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Name of the Candidate

Mr. PRASHANTH D

Diana College of Nursing

Name of the Institution

No68, Chokkanahalli, Jakkur post,

Yalahanka, Bangalore-64.

Course of study and subject

Master of Science in Nursing

Child Health Nursing

Date of Admission to Course

09 -06-2010

Effectiveness of therapeutic play in

Title of the Topic

reduction of anxiety among pre-operative

children admitted in selected Hospitals,
Bangalore.

BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION
Surgery can be a threatening experience for everyone, especially for
children. Children are more vulnerable due to their lack of knowledge of
procedures, a lack of perceived control, a lack of explanation in childappropriate terms, and a lack of pain management. Hospitalized children may
experience high level of anxiety due to many different factors both physical
and psychological. Hospital setting, medical procedures and experienced
symptoms cause anxiety and fear in children. Especially, surgery is a very
frightening process for children. It appears that the unfamiliarity of the
hospital, the staff and the routine is a major cause of psychological upset.
Furthermore, separation from their mother and a new place (hospital setting)
increase childrens anxiety. Thats why, psychological preparation before
surgery has been effective in decreasing the level of anxiety of children and
providing adaptation to the hospital setting and medical treatment. 1
Pre-operative anxiety in children is a common phenomenon that has been
associated with a number of negative behaviors during the surgery experience
(e.g., agitation, crying, spontaneous urination, and the need for physical
restraint during anesthetic induction). Pre-operative anxiety has also been
associated with the display of a number of maladaptive behaviors post
surgery, including postoperative pain, sleeping disturbances, parent-child
conflict, and separation anxiety. For these reasons, researchers have sought
out interventions to treat or prevent childhood preoperative anxiety and
possibly decrease the development of negative behaviors post surgery. Such
interventions include sedative premedication, parental presence during
anesthetic induction, behavioral preparation programs, music therapy, and
acupuncture.2
During the past few decades, there has been an increase in the use of
therapeutic play to help children cope with the stress of hospitalization in
many Western countries. Therapeutic play is a set of structured activities
designed according to age, cognitive development, and health-related issues
to promote the psycho physiological well-being of hospitalized children. The
central goal of therapeutic play is to facilitate the emotional and physical
wellbeing of hospitalized children. Play may not only allow children to gain
pleasure, but also may help them act out stressful or threatening experiences
when faced with stressful medical procedures and unfamiliar environments.
Numerous case studies have described the benefits of therapeutic play in
hospitalized children, such as identifying the specific psychosocial needs of
pediatric oncology patient, establishing trust between pediatric patients and
healthcare providers during the process of nursing and minimizing negative

emotional behaviors in pediatric patients when undergoing the procedure of

blood sample collection.3
Previous studies have shown that parents also experienced intense stress,
feelings of helplessness, and anticipated difficulties in coping with their
children's surgeries. Parents were very anxious about anesthesia prior to their
children's surgeries. Parents experience high levels of pre-operative anxiety
with their children's surgeries. Parents find difficulty in accepting the role of
helping their children manage the stressful experience of surgery. Indeed, lack
of understanding about the upcoming procedures, unfamiliarity with the
hospital environment, and uncertainty about the illness and its treatment are
the major factors contributing to parental stress. Preparing children and their
parents for pediatric surgery is, therefore, crucial, which has been recognized
as one of the most vital responsibilities of nurses. Moreover, parents should be
encouraged to participate actively in the care of their children whenever
possible, especially in preoperative preparation. 4
The provision of pre-operative information on pre and postoperative care is the
most common method of preparing children for surgery. However, this
approach is mostly focused on providing procedural information, the
psychological needs of children and their parents have seldom been taken into
consideration. 4 Furthermore, in short-term surgical procedures, children are
admitted to the hospital in the morning and will be discharged after operation
in the afternoon and this is challenging for the professionals to perform a
suitable pre operational program for children and parents to reduce their
anxiety. It seems that the therapeutic play may reduce the child's stress and
anxiety. 5

6.1 NEED FOR THE STUDY

Pre-operative anxiety among children undergoing surgery is a frequent
occurrence and may put children at risk for experiencing maladaptive
behavioral changes post-operatively including general anxiety, nighttime
crying, enuresis, separation anxiety, and temper tantrums. Parents judgments
of their childrens anxiety on the day of surgery are important as they may
determine subsequent interventions. Unfortunately, there is very little
literature on parents perceptions of their childrens pre-operative anxiety. 6
More than 5 million children undergo surgery every year, and it is reported that
up to 50% of these children develop significant behavior stress and anxiety
before their surgery. Although these behavior manifestations cause significant

hardship to children and parents, perhaps of even higher significance is the

impact of these pre-operative behaviour on post-operative recovery. 6
Up to 25% of children have been noted to require physical restraint to facilitate
anesthetic induction a situation that can lead to increased stress in both
children and medical personnel. Based on behavioral and physiological
responses, anesthesia induction appears to be the most stressful procedure
that a child experiences during the pre-or perioperative period. 6
Many studies have shown that post-operative distress and the level of anxiety
are associated with the level of anxiety in pre-operative period and during
induction of anesthesia in children. Further, the post -operative recovery is
more complicated in children with higher preoperative level of anxiety.
6
Children have some developmental limitations in cognitive capacities, selfcontrol, and greater dependency to the caregivers, so they are more
vulnerable to the operational stress and anxiety than adults. 7
Children frequently experience anxiety at the time of separation from their
parents and the time of anesthesia induction. Pediatric anxiety is associated
with a high incidence of post-operation separation anxiety, fear, eating
problems and nightmares. Accordingly, the psychological effects of
anesthesia and surgery is an important concern. Parental presence of preoperational pharmacological regimen and preparation programs are the
current methods that are reutilized to reduce anxiety. 2
Parental presence may increase children's anxiety because parental distress
and anxiety could be uncontrollable during the preoperative period. Preoperation Preparation programs also have some limitations including the time
constrain and the increased cost of preparation programs. On the other hand,
many of these studies have been performed in elective hospitalized children
surgery but recently there is a trend towards day surgery which has shortened
the period between admission and surgery. 2
Several studies have shown that therapeutic play is effective in decreasing
anxiety and fears for children from the time of admission to immediately after
surgery and to the time of discharge. 6Accordingly, in studies where children
were offered therapeutic play, they exhibited greater cooperation during
stressful procedures and were more willing to return to the hospital for further
treatment.4,
The use of puppets in therapeutic play for hospitalized children has been found
to be calming and education. In addition to relieving psychological stress,
therapeutic play is effective in reducing apprehensive physiological responses,
such as palm sweating body movements, escalating pulse rate and high blood
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pressure. In two studies, children who were provided opportunities for

therapeutic play showed less physiological distress, as indicated by lower
blood pressure and pulse rate and shorter time between surgery and first
voiding. They also exhibit less palm sweating than children who did not have
opportunities for therapeutic play. 6
A study indicated that upto 60% of children undergoing surgery may present
with negative behavioural changes at 2 weeks post-operatively. In 2006 over
3.2 million outpatient surgeries were performed in children under the age of 15
years. The increasing incidence of pediatric outpatient surgery has let to a
growing need for pre-operative education programmes such as tours or
medical role play in pediatric surgical settings. 7
A study has shown that children with higher level of pre-operative anxiety were
at 3.5times higher risk for showing immediate post-operative period negative
behavior as compare to less anxious children. 8
A study has shown that at operating centre admission, children above 7 years
of age are more anxious when compared to 4 to 7 years of age children.
However some authors have found in an extensive study with children that
anxiety during induction is not age related. 7
Hence the investigator, keeping the above view in mind felt to undertake this
study on effectiveness of therapeutic play in reduction of anxiety among preoperative children in selected hospitals in Bangalore.

6.2 REVIEW OF LITERATURE:

Review of Literature is the reading and organizing of previously written materials
relevant to the specific problems to be investigated; frame work and methods appropriate to
perform the study.
(Polit D.F and B.P Hunglur)

The purpose of review of literature is to obtain comprehensive knowledge and indepth

information about effectiveness of therapeutic play in reduction of anxiety among preoperative children.
The review of literature in this study will be organized under the following
headings
1. Literature related to anxiety among pre-operative children.
2. Literature related to effectiveness of therapeutic play among preoperative children.
1. Literature related to anxiety among pre-operative children.
A study was conducted to assess child and parents anxiety before
surgery. Children aged 5 to 12 years scheduled to undergone elective surgery
outpatient tonsilectomy and adenoidectomy was selected as samples for the
study. The results showed that anxious children experienced significantly more

pain both during the hospital stay and over the first 3 days at home. The study
concluded that pre-operative anxiety in young children undergoing surgery is
associated with a more painfull post-operative recovery and a higher incidence
of sleep and other problems.8
A study was conducted to assess the level of anxiety among children before
surgery. 110 boys aged 3 to 6 years old who have to undergone
circumcisionwas studied. The children were assigned to one of two groups,
depending on their attitude: the anxious and calm group. The study concluded
that 20 out of 27 boys in the anxious group showed significantly greater
incidence of problematic behavior when compared to 5 of 79 in the calm
group.9
A study was conducted to explore the potential association between preoperative anxiety and post-operative nausea and vomiting in children. The
study included 51 pre-medicated children 5 to 16 years old undergo surgery,
under standardized general anesthesia. Anxiety of children was assessed and
the results showed that, children who experienced nausea or vomiting in the
post-anesthesia care unit did not differ significantly in their anxiety before
surgery.10
A study was conducted to assess the anxiety level in parents prior to their
child being admitted for outpatient surgery. The sample consisted of 100
parents of children under the age of 13 years. The Leeds Self Assessment
Questionnaire was used to measure anxiety levels of parents.The study reveal
that 42 parents were anxious, compare to 58 parents who were not anxious.
Those parents who were anxious identified factors such as separation from
their children, concept of surgery, anesthesia and post-operative pain. 7
A study was conducted to assess the anxiety among hospitalized latency age
children. 50 latency age children and their parents were studied anxiety was
measured by self report, parental report, nurses report and direct observation.
The findings revealed that both parents and children had increased anxiety
levels during hospitalization. 11

2. Literature related to effectiveness of therapeutic play among preoperative children.

A study was conducted to assess whether medically related
therapeutic play was more effective than medically unrelated therapeutic play.
The authors examined the effects of pre-operative preparation on stress
reduction in 45 children aged 3 and 4 years. The children were randomly

assigned into one of three groups: a control group, a medically unrelated play
therapy group and a medically related play therapy group. The medically
related play included providing information to the child and parent and a role
play that resembled actual medical procedures with hospital toys. Results from
the study concluded that children in this group were more cooperative and less
upset than children in the other two groups, which suggests that medically
related play can be more effective in alleviating stress than unrelated play .2
A study was conducted to compare the effects of play on the psychosocial
adjustment of 46 children, aged 5 to 10 years, who were hospitalized for an
acute illness. They randomly assigned the children to one of four groups:
therapeutic play, diversionary play, verbal support and no treatment. The
therapeutic play studies have shown that therapeutic play produces benefits
not evidenced which consisted of playing with medical and non-medical
materials as well as puppets, dolls and toy animals. During this non-directive
play, the facilitator encouraged re-enactments of experiences while allowing
the child to reflect and interpret feelings. The results showed that children who
engaged in therapeutic, non-directive play showed a significant reduction in
self-reported hospital fears in comparison with children from other groups. 12
A study was conducted to examine the effects of therapeutic play on
outcomes of children undergoing day surgery. Two hundred and three children
admitted for day surgery were invited to participate in a randomized controlled
trial. The experimental group received therapeutic play and the control group
received routine information preparation. Children in the experimental group
reported significantly lower state anxiety scores in pre- and postoperative
periods and exhibited fewer negative emotions at induction of anesthesia than
children in the control group. No significant differences were found between
the two groups in post operative pain. The study provided some evidence that
therapeutic play is effective in pre-operative period as opposed to postsurgical
management of children.14
A study was conducted to investigate the effectiveness of guided medical
play in reducing anxiety in latency-age children. Fifty children, aged 5 to 9
years, were randomly assigned to the control group, where the child watched
TV with a recreational therapist for 20 minutes, or the experimental group,
where a recreational therapist facilitated medically-oriented play with the
child. This study found that although the mean levels of anxiety of children in
the experimental group decreased more than children in the control group, the
difference was not sufficient to reach statistical significance. 13
A study examined 91 children aged 1 to 7 years undergoing day surgery.
Preoperative anxiety was found to be an independent predictor of the

development of postoperative negative behavior, where postoperative

negative behaviors were measured via parental report. Specifically, a child
who displayed elevated anxiety prior to surgery was 3.5 times more likely to
be at risk for the development of negative postoperative behavior changes in
comparison to a child who displayed lower levels of anxiety. 6
A study was conducted to compare the effect of play activities on the level of
anxiety after surgery in an intervention and control group of Iranian children.
75 Children aged 5 to 12 years were enrolled in intervention and the control
group. The anxiety symptoms were assessed using State Trait Anxiety
Inventory for children, childrens Manifest Anxiety Scale and Yale Pre-operative
Anxiety Scale. The result showed that anxiety score was lowered in the
intervention group when compared to the control group and was statistically
significanct. The study concluded that attending play rooms and using play
activities may reduce the anxiety level induced by surgical procedure. 15
A study was conducted to assess the effects of pre-operative anxiety on
pediatric patients. The intervention group consisted of children between the
ages of 5 to 12 years old who were having otolaryngology surgery. The non
intervention group included 62 childrens between the same ages. The
intervention group received a tour of the surgical area and was encouraged to
manipulate medical equipment, while the non intervention only received
general pre-operative information. The study found that those children in the
intervention group were less anxious prior to and before surgery than those in
the nonintervention group. The study concluded that children who received
more intense pre-operative education exhibited lower level of anxiety postoperatively. 3

6.3 STATEMENT OF THE PROBLEM.

Effectiveness of therapeutic play in reduction of anxiety among pre-operative children
admitted in selected Hospitals, Bangalore.
6.4 Objectives:

 To assess the level of anxiety among pre-operative children in experimental and

control group.
To compare the before and after intervention anxiety scores among pre

operative children in experimental and control group.

To assess the effectiveness of therapeutic play among pre-operative
children in

experimentalgroup by comparing the after intervention

anxiety scores between experimental and control group.

To find out the association between the after intervention anxiety scores of pre
operative children and selected demographic variables in experimental and control
group.

6.5 Operational Definitions:

Effectiveness
It refers to the response of pre operative children by therapeutic play in significant reduction of

anxiety as measured by State Anxiety Scale for children.

Therapeutic play
It refers to a structured form of play to relieve psychological stress and anxiety through
activities such as orientation of operationtheater and doll demonstration of procedures as taught by
the investigator.

Anxiety
It refers to the psychological fear that pre-operative children face due to
lack of understanding about the surgical procedures, unfamiliarity with the
hospital environment and separation from parents.

Pre-operative children
It refers to children within the age group of 5-12 years, currently admitted in
the Pediatric surgical unit for an elective surgery.

6.6 Assumptions:
1. Anxiety is common in pre-school and school going children.

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2. Therapeutic play may help to reduce pre-operative anxiety among

children.

6.7 Hypothesis:
H1: There will be a significant difference in the level of anxiety among preoperative children in the experimental and control group.
H2: There will a significant difference in the level of anxiety among pre-operative
children receiving therapeutic play in the experimental group.
H3: There will be a significant association between after intervention anxiety scores
among pre-operative children and their selected demographic variables in the experimental
and control group.

7. Materials and Methods:

7.1. Sources of Data:

Research approach

Quasi experimental approach

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Research Design

Pre test post test with control group design will be used for the
study.

Setting for the Study

Pediatric Surgical ward of selected hospitals, Bangalore will be

the setting for the study.

Population

Children admitted for elective day surgery along with their

parents will be the population for the study.

Sample

Pre operative children admitted in Pediatric Surgical Ward of

selected hospitals, will be the samples for the study.

Sample Size

60 pre operative children are selected as samples for the study. 30

children will belong to the experimental group and the other 30
children will belong to control group

Sampling Technique Purposive sampling technique will be used to select the children
from Pediatric Surgical Ward
Criteria for selection of
samples
Inclusion criteria

The study will include, children

1. between 5-12 years only
2. able to speak and understand kannada or English
3. accompanied by parents (either father or mother) on
the pre-operative assessment day and on the day of surgery.
4. willing to participate in the study.

Exclusion criteria

The study will exclude, children

1. undergoingemergency surgery.
2. who have cognitive or learning problems identified
during health assessment.

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3. with previous surgical experiences.

Tool

The tool will be divided into following sections:

Section A

Deals with demographic variables of pre-operative

children
Section B

1) State anxiety scale for children to assess the anxiety level of

children.
2) State anxiety scale for parents to assess the anxiety level of
parents
3) Post operative Parents Satisfaction Questionnaire (PPSQ) to
assess the parents perception of opinion of therapeutic play
received pre-operatively.

Data collection

Prior to the data collection period, the investigator will obtain

permission from concerned authority and parents of selected hospitals.
The investigator will assess the level of anxiety of pre operative
children in experimental and control group.
The investigator himself will provide therapeutic play intervention for
children in the experimental group only.
Again the investigator will reassess the level of anxiety after
intervention among pre operative children in experimental and control
group.

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Data analysis and

presentation

The data will be organized by,

1. Descriptive statistics: Frequency distribution, Percentage,
Mean, Mode, Median statistics and standard deviation will be
used to assess the demographic variables.
2. Inferential statistics: Pairedt test will be used to compare the
before and after intervention anxiety scores of pre-operative
children.
3. Chi square test will be used to determine the association of
after intervention anxiety score with selected demographic
variables of per-operative children in experimental and control
group.
4. The analysis data will be presented in the form of tables,
diagrams and graphs based on findings.

7.3 Does the study require any investigation or intervention to be conducted on

patients or other human beings?
- Yes, study will be conducted on pre operative children admitted in Pediatric surgical ward
at selected hospitals, Bangalore.

7.4 Has Ethical clearance been obtained from your institution?

Yes, informed consent will be obtained from concerned authority of Institution and
parents prior to study. Privacy, confidentiality and anonymity will be guarded. Scientific
objectivity of the study will be maintained with honesty and impartiality.

7.5 Ethical committee

Title of the topic

Effectiveness of therapeutic play in the reduction of

anxiety in pre operative children admitted in
selected Hospitals, Bangalore.

14

Name of the candidate

Mr. Prashanth. D

Course and the subject

Master of Science in Nursing.

Child Health Nursing.

Name of the guide

M/s Elizabeth Dora

Professor
Department of Child Health Nursing
Diana College of Nursing
Bangalore 64.

Ethical committee

Approved

Members of Ethical committee:

1. Prof. Veda Vivek

Principal and HOD

Department of Community Health Nursing
Diana College of Nursing
Bangalore 64.

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2. Prof. Elizabeth Dora

Head of the Department
Department of Child Health Nursing
Diana College of Nursing
Bangalore 64.
3. Prof. Kalaivani
Head of the Department
Department of Obstetrics and Gynecological Nursing
Diana College of Nursing
Bangalore 64.
4. Prof. Vasantha Chithra.D
Head of the Department
Department of Medical Surgical Nursing
Diana College of Nursing
Bangalore 64.
5. Prof. Kalai Selvi.S
Head of the Department
Department of Psychiatric Nursing
Diana College of Nursing
Bangalore 64.
6. Prof. Rangappa
Biostatistician,GKVJ.
Jakkur International Airport

8. List of References
1. Darbyshire P. Guest editorial: From research on children to research with
children. Neonatal, Paediatric and Child Health Nursing.2000;3(1):2-3.
2. Schwartz BH, Albino JE, Tedesco LA. Effects of psychological preparation on
children hospitalized for dental operations. Journal of
Pediatrics.2003;102(4):634-638.
3. Vessey JA, Mahon MM. Therapeutic play and the hospitalized child. Journal of
Pediatric Nursing. 2006;5(5):328-331.

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4. Ellerton M-L, Caty S, Ritchie JA. Helping young children master intrusive

procedures throughplay. Children's Health Care.1985;13(4):167-173.

5. Zahr, l,k.(2004). Therapeutic play for hospitalized preschool in lebanon.
Pediatric nursing, 23(5), 449-454
6. Cassell S. Effect of brief puppet therapy upon the emotional responses of
children undergoing cardiac catheterization. Journal of Consulting
Psychology.2003;29(1):1-8.
7. Morrow V, Richards M. The Ethics of Social Research with Children: An
Overview, Children & Society. 6 2008:10(2):90-105.9
8. Ho Cheung William Li Journal of clinical nursing. "The effectiveness of two
preoperative nursing interventions and ex..." 11/2007; 16(10):1919-26.
9. Johnson PA, Stockdale DF. Effects of puppet therapy on palmar sweating on
Hospitalized children. TheJohns Hopkins Medical Journal.2005;137:1-5.
10. Jouranal of Development and Behavioural Pediatrics. Anxiety among
hospitalized latency age children. Dec2000 volume iii Issues 6.
11. Alderson P. Children's consent to surgery. Buckingham [England]: Open
University Press;2006.
12. Fosson A, Martin J, Haley J. Anxiety among hospitalized latency-age
children.Developmental and Behavioral Pediatrics.2004; 11(6):324-327.
13. Young MR, Fu VR. Influence of play and temperament on the young child's
response to pain. Children's Health Care.2005;16(3):209-215.
14. Javid Mahomedi Etal. Effect of pre-operative play intervention on post
surgery anxiety. Iran jouranal of Psychiatry 2008.3: 20-24
15. ciatworthy s.Therapeutic play: Effects on hospitalized children. Journal of
Association for care of childrens health.2000:99 (4) 108-113

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9. Signature of the Candidate

10. Remarks of the Guide

11. Name and Designation of

Guide

M/s Elizabeth Dora

Department of Child Health Nursing
Diana College of Nursing
Bangalore - 64

11.2 Signature

11.5 Head of the Department

M/s Elizabeth Dora

Head of the Department
Diana College of Nursing
Bangalore - 64

Signature

12.1. Remarks of the Chairman &

Principal

Signature

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